Difference between revisions of "Ovarian tumours"

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[[Image:Ovarian carcinoma.JPG|thumb|250px|right|[[Gross pathology|Gross]] photo of a [[malignant]] ovarian tumour. (WC/Doc James)]]
The article examines '''ovarian tumours''' including '''ovarian cancer'''.   
The article examines '''ovarian tumours''' including '''ovarian cancer'''.   


An introduction to the ovary is in the ''[[ovary]]'' article, which also deals benign cysts.   
An introduction to the ovary is in the ''[[ovary]]'' article, which also deals benign cysts.   
What was labeled "ovarian cancer" in the past may really arise from [[fallopian tube]].<ref name=pmid19574767>{{Cite journal  | last1 = Hirst | first1 = JE. | last2 = Gard | first2 = GB. | last3 = McIllroy | first3 = K. | last4 = Nevell | first4 = D. | last5 = Field | first5 = M. | title = High rates of occult fallopian tube cancer diagnosed at prophylactic bilateral salpingo-oophorectomy. | journal = Int J Gynecol Cancer | volume = 19 | issue = 5 | pages = 826-9 | month = Jul | year = 2009 | doi = 10.1111/IGC.0b013e3181a1b5dc | PMID = 19574767 }}</ref> The label ''tubo-ovarian cancer''
has been advocated to address this change.  These tumours are dealt with in this article.


=Clinical=
=Clinical=
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*There are two versions.<ref name=ukguide>URL: [http://www.sign.ac.uk/guidelines/fulltext/75/section3.html http://www.sign.ac.uk/guidelines/fulltext/75/section3.html]. Accessed on: 16 September 2011.</ref>  
*There are two versions.<ref name=ukguide>URL: [http://www.sign.ac.uk/guidelines/fulltext/75/section3.html http://www.sign.ac.uk/guidelines/fulltext/75/section3.html]. Accessed on: 16 September 2011.</ref>  


Elements & points (RIM 2):<ref name=ukguide>URL: [http://www.sign.ac.uk/guidelines/fulltext/75/section3.html http://www.sign.ac.uk/guidelines/fulltext/75/section3.html]. Accessed on: 16 September 2011.</ref>  
====Definition====
:<math>RMI\ score = ultrasound\ score\ *\ menopausal\ score\ *\ CA125\ level\ [U/ml].</math>
 
====Elements====
Elements & points (RMI 2):<ref name=ukguide>URL: [http://www.sign.ac.uk/guidelines/fulltext/75/section3.html http://www.sign.ac.uk/guidelines/fulltext/75/section3.html]. Accessed on: 16 September 2011.</ref>  
#Ultrasound features.  
#Ultrasound features.  
#*Significant findings: multilocular cyst, solid component, bilateral lesions, ascites, suspected intra-abdominal [[metastases]] (one finding=1 point, two or more findings=4 points).
#*Significant findings: multilocular cyst, solid component, bilateral lesions, ascites, suspected intra-abdominal [[metastases]] (one finding=1 point, two or more findings=4 points).
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#CA-125 (blood test) in ''U/ml''.
#CA-125 (blood test) in ''U/ml''.


<math>RMI\ score = ultrasound\ score\ x\ menopausal\ score\ x\ CA125\ level\ [U/ml].</math>
====Interpretation====
 
Interpretation:
*RMI > 200 -- predicts malignancy.
*RMI > 200 -- predicts malignancy.


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Surface epithelial tumours:
Surface epithelial tumours:
# Serous.
# [[Serous carcinoma of the ovary|Serous carcinoma]].
# Endometrioid.
#* High-grade serous carcinoma. †
# Mucinous.
#* Low-grade serous carcinoma.
# Transitional cell tumours<ref name=Ref_WMSP401>{{Ref WMSP|401}}</ref> ([[Brenner tumour]]).
# [[Endometrioid carcinoma of the ovary|Endometrioid carcinoma]].
# Clear cell carcinoma.
# [[Mucinous carcinoma of the ovary|Mucinous carcinoma]].
# [[Clear cell carcinoma of the ovary|Clear cell carcinoma]].
# [[Brenner tumour]].
 
Note:
* † Transitional cell tumours<ref name=Ref_WMSP401>{{Ref WMSP|401}}</ref> are now grouped with high-grade serous carcinoma.<ref name=pmid23681072>{{Cite journal  | last1 = Takeuchi | first1 = T. | last2 = Ohishi | first2 = Y. | last3 = Imamura | first3 = H. | last4 = Aman | first4 = M. | last5 = Shida | first5 = K. | last6 = Kobayashi | first6 = H. | last7 = Kato | first7 = K. | last8 = Oda | first8 = Y. | title = Ovarian transitional cell carcinoma represents a poorly differentiated form of high-grade serous or endometrioid adenocarcinoma. | journal = Am J Surg Pathol | volume = 37 | issue = 7 | pages = 1091-9 | month = Jul | year = 2013 | doi = 10.1097/PAS.0b013e3182834d41 | PMID = 23681072 }}</ref><ref name=pmid23018212>{{Cite journal  | last1 = Ali | first1 = RH. | last2 = Seidman | first2 = JD. | last3 = Luk | first3 = M. | last4 = Kalloger | first4 = S. | last5 = Gilks | first5 = CB. | title = Transitional cell carcinoma of the ovary is related to high-grade serous carcinoma and is distinct from malignant brenner tumor. | journal = Int J Gynecol Pathol | volume = 31 | issue = 6 | pages = 499-506 | month = Nov | year = 2012 | doi = 10.1097/PGP.0b013e31824d7445 | PMID = 23018212 }}</ref>


Sex cord stromal tumours:
Sex cord stromal tumours:
#[[Granulosa cell tumour]] (adult type, juvenile type).
#[[Granulosa cell tumour]] ([[Adult granulosa cell tumour|adult type]], [[Juvenile granulosa cell tumour|juvenile type]]).
#[[Sertoli cell tumour]].
#[[Sertoli cell tumour]].
#[[Leydig cell tumour]].
#[[Leydig cell tumour]].
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*Silverberg grading system,<ref>{{cite journal |author=Silverberg SG |title=Histopathologic grading of ovarian carcinoma: a review and proposal |journal=Int. J. Gynecol. Pathol. |volume=19 |issue=1 |pages=7-15 |year=2000 |month=January |pmid=10638449 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0277-1691&volume=19&issue=1&spage=7}}</ref> aka ''universal grading system''.
*Silverberg grading system,<ref>{{cite journal |author=Silverberg SG |title=Histopathologic grading of ovarian carcinoma: a review and proposal |journal=Int. J. Gynecol. Pathol. |volume=19 |issue=1 |pages=7-15 |year=2000 |month=January |pmid=10638449 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0277-1691&volume=19&issue=1&spage=7}}</ref> aka ''universal grading system''.
*Based on ''pattern'', ''cytologic atypia'' and ''mitotic rate''.
*Based on ''pattern'', ''cytologic atypia'' and ''mitotic rate''.
*System somewhat similar to [[breast]] grading, which can be remembered as: ''TMN'' (tubular formation, mitotic rate, nuclear atypia).
*System somewhat similar to [[breast]] grading, which can be remembered as: ''TNM'' (tubular formation, [[nuclear atypia]], mitotic rate).


===Silverberg system===
===Silverberg system===
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*Grade III = 8-9.
*Grade III = 8-9.


Note 1:
Note:
*Most resident microscopes have an eyepiece diameter of 22 mm.  Thus, the approximate field diameter is 0.55 mm (22 mm/40 X = 0.55 mm), at highest magnification, and the field area is 0.23758 mm^2 (pi*(0.55/2)^2=0.23758 mm^2).  
*Most resident microscopes have an eyepiece diameter of 22 mm.  Thus, the approximate field diameter is 0.55 mm (22 mm/40 X = 0.55 mm), at highest magnification, and the field area is 0.23758 mm^2 (pi*(0.55/2)^2=0.23758 mm^2).  
*The number of HPFs should be adjusted if the area per field is different than 0.345 mm^2.
*The number of HPFs should be adjusted if the area per field is different than 0.345 mm^2.
**If the field diameter is 0.55 mm and the sample area is 3.45 mm^2, this is equivalent to 14.52 HPFs (3.45 mm^2 / 0.23758 mm^2 = 14.52); thus, it would be appropriate to use 15 HPFs and the cut points above.
**If the field diameter is 0.55 mm and the sample area is 3.45 mm^2, this is equivalent to 14.52 HPFs (3.45 mm^2 / 0.23758 mm^2 = 14.52); thus, it would be appropriate to use 15 HPFs and the cut points above.


Note 2:
===Predictive power of Silverberg grading===
*A not-so-good alternative is to adjust the number of mitotic counts a keep the number of HPFs (10) constant.
**If the mitotic rate per area is held constant, and the cut points are 9, 10 and 24, the equivalent mitoses per area are:
***0-4 mitoses/((HPF of 0.345 mm^2) x 10) = 1.
***5-11 mitoses/((HPF of 0.345 mm^2) x 10) = 2.
***12+ mitoses/((HPF of 0.345 mm^2) x 10) = 3.
 
===Value of Silverberg...===
Good correlation with five year survival (rounded values):<ref name=pmid12496698>{{cite journal |author=Sato Y, Shimamoto T, Amada S, Asada Y, Hayashi T |title=Prognostic value of histologic grading of ovarian carcinomas |journal=Int. J. Gynecol. Pathol. |volume=22 |issue=1 |pages=52-6 |year=2003 |month=January |pmid=12496698 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0277-1691&volume=22&issue=1&spage=52}}</ref>
Good correlation with five year survival (rounded values):<ref name=pmid12496698>{{cite journal |author=Sato Y, Shimamoto T, Amada S, Asada Y, Hayashi T |title=Prognostic value of histologic grading of ovarian carcinomas |journal=Int. J. Gynecol. Pathol. |volume=22 |issue=1 |pages=52-6 |year=2003 |month=January |pmid=12496698 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0277-1691&volume=22&issue=1&spage=52}}</ref>
*Grade I = 90%.
*Grade I = 90%.
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==Peritoneal implants==
==Peritoneal implants==
===General===
===General===
*In the setting of [[serous borderline tumour]]s there is much ado about implants.
Applies only to:
*[[Serous borderline tumour]].
*[[Seromucinous borderline tumour]].


====Classification====
====Classification====
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===IHC===
===IHC===
*Elastin stain.
*Elastin stain.
=Staging of ovarian cancer=
*The CAP protocol talks of in the pelvis and outside the pelvis - pT2 versus pT3.
*Omental involvement is considered outside the pelvis; it is pT3.<ref>URL: [http://ovariancancer.about.com/od/testsdiagnosis/a/FIGO_stages.htm http://ovariancancer.about.com/od/testsdiagnosis/a/FIGO_stages.htm]. Accessed on: 8 July 2013.</ref>


=Surface epithelial tumours=
=Surface epithelial tumours=
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'''Where to start when considering a malignant (epithelial) tumour of the ovary:'''
'''Where to start when considering a malignant (epithelial) tumour of the ovary:'''
{| class="wikitable"
{| class="wikitable sortable"
| || '''Serous''' || '''Endometrioid'''  || '''Mucinous'''
!Features
! Serous
! Endometrioid
! Mucinous
|-
|-
|Characteristics || cilia, columnar cells<br>psammoma bodies, papillary arch. || gland forming, endometrium-like || mucinous glands, colon-like
|Histology
| low grade: cilia, columnar cells, [[psammoma bodies]], papillary arch.; high grade: marked nuclear pleomorphism, prominent [[red nucleoli]], [[psammoma bodies]]
| gland forming - esp. cribriforming, endometrium-like
| mucinous glands, colon-like
|-
|-
|Differentiators || cilia, psammoma bodies || squamous metaplasia || mucin, lack of necrosis
|Differentiators
| cilia, [[psammoma bodies]]
| squamous metaplasia
| mucin, often lack of [[necrosis]]
|-
|-
|Associations || atrophy || endometriosis, endometrial hyperplasia || (?)
|Associations
| atrophy
| [[endometriosis]], [[endometrial hyperplasia]]
| (?)
|-
|-
|Typical age || usually 60s+ || 40-60 || varies (?)
|Typical age
| usually 60s+
| 40-60
| varies (?)
|-
|-
|Grade || typically high grade || typically low grade || often low
|Grade
| typically high grade
| typically low grade
| often low
|-
|-
|IHC || p53 +ve (diffuse), WT-1 +ve, CA-125 +ve, D2-40 +ve || WT-1 -ve || CK7 +ve, CK20 +ve (other tumours CK7 +ve, CK20 -ve)
|IHC
| p53 +ve (diffuse), WT-1 +ve, CA-125 +ve, D2-40 +ve
| WT-1 -ve
| CK7 +ve, CK20 +ve (other tumours CK7 +ve, CK20 -ve)
|-
|-
|Main DDx || poorly diff. endometrioid  || serous || metastatic tumour (usually GI)
|Main DDx
| poorly diff. endometrioid   
| serous
| metastatic tumour (usually GI)
|-
|-
|}
|}


==Serous tumours==
==Serous tumours - overview==
===General===
===General===
*Most common malignant ovarian tumour.
*Most common malignant ovarian tumour.
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**Columnar.
**Columnar.
*Papillae.
*Papillae.
*[[Psammoma bodies]] (concentric calcifications).
*[[Psammoma bodies]] (concentric [[calcification]]s).


Note:  
Note:  
*In ''serous borderline tumours'', ''micropapillae'' are thought to have significance -- assoc. with increased risk of distant recurrence<ref>LAE. 19 February 2009.</ref><ref name=pmid15897738>URL: [http://www.ncbi.nlm.nih.gov/pubmed/15897738 http://www.ncbi.nlm.nih.gov/pubmed/15897738]. Accessed on: 7 April 2011.</ref><ref>{{cite journal |author=Piura B, Rabinovich A, Yanai-Inbar I |title=Micropapillary serous carcinoma of the ovary: case report and review of literature |journal=Eur. J. Gynaecol. Oncol. |volume=21 |issue=4 |pages=374–6 |year=2000 |pmid=11055486 |doi= |url=}}</ref> - though is disputed.<ref>{{cite journal |author=Prat J, De Nictolis M |title=Serous borderline tumors of the ovary: a long-term follow-up study of 137 cases, including 18 with a micropapillary pattern and 20 with microinvasion |journal=Am. J. Surg. Pathol. |volume=26 |issue=9 |pages=1111-28 |year=2002 |month=September |pmid=12218568 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0147-5185&volume=26&issue=9&spage=1111}}</ref>
*In ''serous borderline tumours'', ''micropapillae'' are thought to have significance -- assoc. with increased risk of distant recurrence<ref>LAE. 19 February 2009.</ref><ref name=pmid15897738>URL: [http://www.ncbi.nlm.nih.gov/pubmed/15897738 http://www.ncbi.nlm.nih.gov/pubmed/15897738]. Accessed on: 7 April 2011.</ref><ref>{{cite journal |author=Piura B, Rabinovich A, Yanai-Inbar I |title=Micropapillary serous carcinoma of the ovary: case report and review of literature |journal=Eur. J. Gynaecol. Oncol. |volume=21 |issue=4 |pages=374–6 |year=2000 |pmid=11055486 |doi= |url=}}</ref> - though is disputed.<ref>{{cite journal |author=Prat J, De Nictolis M |title=Serous borderline tumors of the ovary: a long-term follow-up study of 137 cases, including 18 with a micropapillary pattern and 20 with microinvasion |journal=Am. J. Surg. Pathol. |volume=26 |issue=9 |pages=1111-28 |year=2002 |month=September |pmid=12218568 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0147-5185&volume=26&issue=9&spage=1111}}</ref>
*Psammoma bodies may be seen in [[endosalpingiosis]].<ref name=pmid1774734>{{cite journal |author=Hallman KB, Nahhas WA, Connelly PJ |title=Endosalpingiosis as a source of psammoma bodies in a Papanicolaou smear. A case report |journal=J Reprod Med |volume=36 |issue=9 |pages=675–8 |year=1991 |month=September |pmid=1774734 |doi= |url=}}</ref>
*Psammoma bodies may be seen in [[endosalpingiosis]].<ref name=pmid1774734>{{cite journal |author=Hallman KB, Nahhas WA, Connelly PJ |title=Endosalpingiosis as a source of psammoma bodies in a Papanicolaou smear. A case report |journal=J Reprod Med |volume=36 |issue=9 |pages=675–8 |year=1991 |month=September |pmid=1774734 |doi= |url=}}</ref>
==Serous carcinoma of the ovary==
*[[AKA]] ''ovarian [[serous carcinoma]]''.
{{Main|Serous carcinoma of the ovary}}


==Serous cystadenoma of the ovary==
==Serous cystadenoma of the ovary==
*[[AKA]] ''ovarian serous cystadenoma''.
*[[AKA]] ''ovarian serous cystadenoma''.
===General===
*Related to ''adenofibroma'' and ''serous cystadenofibroma''.
*Benign.
{{Main|Serous cystadenoma of the ovary}}
*Very common.
*'''Not''' related to the [[serous cystadenoma of the pancreas]].


===Gross===
==Ovarian serous borderline tumour==
*Usually unilocular.
*[[AKA]] ''serous borderline tumour of the ovary''.
*[[AKA]] ''serous tumour of low malignant potential of the ovary'', abbreviated ''SLMP''.<ref name=pmid10836293>{{Cite journal  | last1 = Seidman | first1 = JD. | last2 = Kurman | first2 = RJ. | title = Ovarian serous borderline tumors: a critical review of the literature with emphasis on prognostic indicators. | journal = Hum Pathol | volume = 31 | issue = 5 | pages = 539-57 | month = May | year = 2000 | doi =  | PMID = 10836293 }}</ref><ref name=pmid10881733>{{Cite journal  | last1 = Dietel | first1 = M. | last2 = Hauptmann | first2 = S. | title = Serous tumors of low malignant potential of the ovary. 1. Diagnostic pathology. | journal = Virchows Arch | volume = 436 | issue = 5 | pages = 403-12 | month = May | year = 2000 | doi =  | PMID = 10881733 }}</ref>
{{Main|Serous borderline tumour}}


===Microscopic===
==Mucinous ovarian tumours==
Features:
*Simple epithelium with cilia - '''key feature'''.
**Cell morphology: columnar, cuboidal or flatted.


DDx:
==General==
*Serous cystadenoma fibroma.
*Common.
 
*Tumours may be heterogenous; benign appearing epithelium may be beside clearly malignant epithelium.
==Seromucinous borderline tumor of the ovary==
*Good sampling of mucinous tumours, i.e. many blocks, is important to lessen the chance of undercalling them.
===General===
*Rare.
===Gross===
*Mucin-filled cysts.
 
Image:
*[http://alf3.urz.unibas.ch/pathopic/e/getpic-fra.cfm?id=009520 Seromucinous borderline tumor of the ovary (unibas.ch)].
 
===Microscopic===
Features:
#Simple mucinous epithelium - endocervical type.<ref>{{Cite journal  | last1 = Shappell | first1 = HW. | last2 = Riopel | first2 = MA. | last3 = Smith Sehdev | first3 = AE. | last4 = Ronnett | first4 = BM. | last5 = Kurman | first5 = RJ. | title = Diagnostic criteria and behavior of ovarian seromucinous (endocervical-type mucinous and mixed cell-type) tumors: atypical proliferative (borderline) tumors, intraepithelial, microinvasive, and invasive carcinomas. | journal = Am J Surg Pathol | volume = 26 | issue = 12 | pages = 1529-41 | month = Dec | year = 2002 | doi =  | PMID = 12459620 }}</ref>
#*Tall columnar epithelium with apical pale cytoplasm.
#Simple serous epithelium - with cilia.
 
==Mucinous tumours==
*May arise in [[endometriosis]].<ref name=Ref_PBoD1097>{{Ref PBoD |1097}}</ref>
 
===Gross===
Features:
*Multiloculated.
*Sticky, gelatinous fluid (glycoprotein).
 
===Microscopic===
Features:
*Tall [[columnar cell]]s in glands.
**Apical mucin.
**May vaguely resemble colorectal adenocarcinoma.
*Glands have mucin.
*+/-Nuclear atypia.
*NO [[cilia]].


===Subtypes===
===Subtypes===
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Comparison of mucosa:
Comparison of mucosa:
*Normal endocervical mucosa: [http://pathology.mc.duke.edu/research/Histo_course/endocx.jpg endocervical mucosa].
*Normal endocervical mucosa: [http://pathology.mc.duke.edu/research/Histo_course/endocx.jpg endocervical mucosa (duke.edu)].
*Normal colonic mucosa: [http://cellbio.utmb.edu/microanatomy/epithelia/00004493.jpg colonic type mucosa].
*Normal gastric mucosa: [http://commons.wikimedia.org/wiki/File:Normal_gastric_mucosa_intermed_mag.jpg gastric mucosa (WC)].


===Classification===
===Classification===
*Benign. (Dx: mucinous cystadenoma ''or'' mucinous adenofibroma ''or'' mucinous cystadenofibroma)
*Benign. (Dx: [[Mucinous_cystadenoma_of_the_ovary|mucinous cystadenoma]] ''or'' mucinous adenofibroma ''or'' mucinous cystadenofibroma)
**Single layer of cells.
**Single layer of cells.
*Borderline. (Dx: ''mucinous tumour of uncertain malignant potential'' or ''borderline mucinous tumour'')
*Borderline. (Dx: ''mucinous tumour of uncertain malignant potential'' or ''borderline mucinous tumour'')
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**Usually intestinal subtype.
**Usually intestinal subtype.


Note:
==Seromucinous borderline tumour of the ovary==
*Tumours may be heterogenous; benign appearing epithelium may be beside clearly malignant epithelium.   
*[[AKA]] ''endocervical-type mucinous and mixed cell-type tumour''.<ref name=pmid12459620>{{Cite journal | last1 = Shappell | first1 = HW. | last2 = Riopel | first2 = MA. | last3 = Smith Sehdev | first3 = AE. | last4 = Ronnett | first4 = BM. | last5 = Kurman | first5 = RJ. | title = Diagnostic criteria and behavior of ovarian seromucinous (endocervical-type mucinous and mixed cell-type) tumors: atypical proliferative (borderline) tumors, intraepithelial, microinvasive, and invasive carcinomas. | journal = Am J Surg Pathol | volume = 26 | issue = 12 | pages = 1529-41 | month = Dec | year = 2002 | doi = | PMID = 12459620 }}</ref>
*Good sampling of mucinous tumours, i.e. many blocks, is important to lessen the chance of undercalling them.
 
==Ovarian endometrioid carcinoma==
===General===
===General===
*Associated with [[endometriosis]], i.e. people with endometriosis are more likely to have 'em.
*Rare.
*Associated with [[endometriosis]].
===Gross===
*Mucin-filled cysts.


===Microscopic===
Image:
*Tubular glands.  
*[http://alf3.urz.unibas.ch/pathopic/e/getpic-fra.cfm?id=009520 Seromucinous borderline tumor of the ovary (unibas.ch)].
**Cribriform pattern common.
* May see mucinous secretion.<ref name=pmid18580313>{{cite journal |author=Baker P, Oliva E |title=A practical approach to intraoperative consultation in gynecological pathology |journal=Int. J. Gynecol. Pathol. |volume=27 |issue=3 |pages=353-65 |year=2008 |month=July |pmid=18580313 |doi=10.1097/PGP.0b013e31815c24fe |url=}}</ref>
* May have squamous differentiation/squamous metaplasia (useful for differentiating from sex-cord stromal tumours and germ cell tumours).<ref name=pmid18580313/> - very useful feature.
 
==Clear cell carcinoma of the ovary==
*[[AKA]] ''ovarian clear cell adenocarcinoma''.
*[[AKA]] ''ovarian clear cell carcinoma''.
*[[AKA]] ''clear cell adenocarcinoma of the ovary''.
 
===General===
* Thought to be related to endometrioid carcinoma.<ref name=Ref_PBoD1098>{{Ref PBoD |1098}}</ref>
** Increased risk of CC adenoca in people with endometriosis.
* Worse prognosis vs. other surface epithelial tumours<ref>{{cite journal |author=Hauptmann S, Köbel M |title=[Prognostic factors in ovarian carcinoma] |language=German |journal=Verh Dtsch Ges Pathol |volume=89 |issue= |pages=92-100 |year=2005 |pmid=18035678 |doi= |url=}}</ref>


===Microscopic===
===Microscopic===
Features:
Features:
*Cystic/tubular architecture - important low power feature.
#Simple mucinous epithelium - endocervical type.<ref>{{Cite journal  | last1 = Shappell | first1 = HW. | last2 = Riopel | first2 = MA. | last3 = Smith Sehdev | first3 = AE. | last4 = Ronnett | first4 = BM. | last5 = Kurman | first5 = RJ. | title = Diagnostic criteria and behavior of ovarian seromucinous (endocervical-type mucinous and mixed cell-type) tumors: atypical proliferative (borderline) tumors, intraepithelial, microinvasive, and invasive carcinomas. | journal = Am J Surg Pathol | volume = 26 | issue = 12 | pages = 1529-41 | month = Dec | year = 2002 | doi =  | PMID = 12459620 }}</ref>
*Clear cells - cytoplasm is clear - '''key feature'''.
#*Tall columnar epithelium with apical pale cytoplasm.
*[[Hobnail morphology]] - apical surface larger than basal surface.<ref>URL: [http://www.pathologyoutlines.com/ovary.html http://www.pathologyoutlines.com/ovary.html]. Accessed on: 8 February 2011.</ref>  
#Simple serous epithelium - with cilia.
**"Nuclei bulge into the lumen".
*Hyaline droplets -- common, as in ''[[clear cell renal cell carcinoma]]''.
**Eosinophilic bodies within lumen.
*Nucleoli - prominent.


Note:
==Mucinous cystadenoma of the ovary==
*Clear cell adenocarcinoma does not have to have clear cells. Yes, this is stupid; it is like ''[[papillary thyroid carcinoma]]'' -- which often isn't papillary -- see ''[[no truth in names]]''.
*[[AKA]] ''ovarian mucinous cystadenoma''.
**The ''hobnail morphology'' is important if this is the case.
{{Main|Mucinous cystadenoma of the ovary}}
 
==Mucinous borderline tumour of the ovary==
*[[AKA]] ''ovarian mucinous borderline tumour''.
*[[AKA]] ''ovarian mucinous tumour of low malignant potential''.<ref name=pmid21464732>{{Cite journal  | last1 = Khunamornpong | first1 = S. | last2 = Settakorn | first2 = J. | last3 = Sukpan | first3 = K. | last4 = Suprasert | first4 = P. | last5 = Siriaunkgul | first5 = S. | title = Mucinous tumor of low malignant potential (borderline or atypical proliferative tumor) of the ovary: a study of 171 cases with the assessment of intraepithelial carcinoma and microinvasion. | journal = Int J Gynecol Pathol | volume = 30 | issue = 3 | pages = 218-30 | month = May | year = 2011 | doi = 10.1097/PGP.0b013e3181fcf01a | PMID = 21464732 }}</ref>
{{Main|Mucinous borderline tumour of the ovary}}


Images:
==Mucinous adenocarcinoma of the ovary==
*[[WC]]:
*[[AKA]] ''ovarian mucinous adenocarcinoma''.
**[http://commons.wikimedia.org/wiki/File:Ovarian_clear_cell_carcinoma_-a-_very_high_mag_-_cropped.jpg Clear cell carcinoma - very high mag. - cropped (WC)].
*[[AKA]] ''ovarian mucinous carcinoma''.
**[http://commons.wikimedia.org/wiki/File:Ovarian_clear_cell_carcinoma_-a-_intermed_mag.jpg Clear cell carcinoma - intermed. mag. (WC)].
{{Main|Mucinous adenocarcinoma of the ovary}}
**[http://commons.wikimedia.org/wiki/File:Ovarian_clear_cell_carcinoma_-_low_mag.jpg Clear cell carcinoma - low mag. (WC)].
*www:
**[http://path.upmc.edu/cases/case343.html Clear cell carcinoma of the ovary - several images (upmc.edu)].


===IHC===
==Endometrioid carcinoma of the ovary==
*HNF-1beta +ve.<ref>{{Cite journal  | last1 = Tsuchiya | first1 = A. | last2 = Sakamoto | first2 = M. | last3 = Yasuda | first3 = J. | last4 = Chuma | first4 = M. | last5 = Ohta | first5 = T. | last6 = Ohki | first6 = M. | last7 = Yasugi | first7 = T. | last8 = Taketani | first8 = Y. | last9 = Hirohashi | first9 = S. | title = Expression profiling in ovarian clear cell carcinoma: identification of hepatocyte nuclear factor-1 beta as a molecular marker and a possible molecular target for therapy of ovarian clear cell carcinoma. | journal = Am J Pathol | volume = 163 | issue = 6 | pages = 2503-12 | month = Dec | year = 2003 | doi =  | PMID = 14633622 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892387/?tool=pubmed }}</ref><ref name=omim189907>{{OMIM|189907}}</ref>
*[[AKA]] ''endometrioid ovarian carcinoma''.
**Usu. -ve in serous carcinoma.
*[[AKA]] ''endometrioid adenocarcinoma of the ovary''.
*WT-1 -ve.
*[[AKA]] ''ovarian endometrioid adenocarcinoma''.
**Usu. +ve in serous carcinoma.
{{Main|Endometrioid carcinoma of the ovary}}


Panel for high grade serous vs. clear cell:<ref name=pmid18830127>{{cite journal |author=Köbel M, Kalloger SE, Carrick J, ''et al.'' |title=A limited panel of immunomarkers can reliably distinguish between clear cell and high-grade serous carcinoma of the ovary |journal=Am. J. Surg. Pathol. |volume=33 |issue=1 |pages=14–21 |year=2009 |month=January |pmid=18830127 |doi=10.1097/PAS.0b013e3181788546 |url=}}</ref>
==Clear cell carcinoma of the ovary==
*ER, HNF-1beta, WT-1.
*[[AKA]] ''ovarian clear cell adenocarcinoma'', abbreviated ''OCCC''.
*[[AKA]] ''ovarian clear cell carcinoma''.
*[[AKA]] ''clear cell adenocarcinoma of the ovary''.
{{Main|Clear cell carcinoma of the ovary}}


==Transitional cell carcinoma of the ovary==
==Transitional cell carcinoma of the ovary==
===General===
{{Main|Transitional cell carcinoma of the ovary}}
*Rare.
*Fits into the ''transistional cell tumours'' category - in the surface epithelial group of ovarian tumours.<ref name=Ref_WMSP401>{{Ref WMSP|401}}</ref>
 
===Microscopic===
Features:<ref name=pmid15087664>{{Cite journal  | last1 = Eichhorn | first1 = JH. | last2 = Young | first2 = RH. | title = Transitional cell carcinoma of the ovary: a morphologic study of 100 cases with emphasis on differential diagnosis. | journal = Am J Surg Pathol | volume = 28 | issue = 4 | pages = 453-63 | month = Apr | year = 2004 | doi =  | PMID = 15087664 }}</ref>
*Cystic spaces:
**Small - punched-out border - very common.
**Large.
*Papillae, usu. large, blunt.
**Occasionally small and filiform.
*+/-Bizarre giant cells (35%)
*+/-Gland-like tubules.
*+/-Squamous differentiation.
*+/-[[Psammoma bodies]].
*Cells:
**Moderate basophilic cytoplasm and little intervening stroma.
**Marked nuclear pleomorphism.
**Mitoses - common.
 
Notes:
#Resembles [[urothelial carcinoma]].<ref name=pmid21073751>{{Cite journal  | last1 = Tazi | first1 = EM. | last2 = Lalya | first2 = I. | last3 = Tazi | first3 = MF. | last4 = Ahellal | first4 = Y. | last5 = M'rabti | first5 = H. | last6 = Errihani | first6 = H. | title = Transitional cell carcinoma of the ovary: a rare case and review of literature. | journal = World J Surg Oncol | volume = 8 | issue =  | pages = 98 | month =  | year = 2010 | doi = 10.1186/1477-7819-8-98 | PMID = 21073751 }}</ref>
#'''No''' Brenner tumour component (benign or malignant) should be present.<ref name=pmid21073751/>
 
Images:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Transitional_cell_carcinoma_of_the_ovary_-_very_low_mag.jpg TCC - very low mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Transitional_cell_carcinoma_of_the_ovary_-_intermed_mag.jpg TCC - intermed. mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Transitional_cell_carcinoma_of_the_ovary_-_very_high_mag.jpg TCC - very high mag. (WC)].
 
===IHC===
Features:<ref name=pmid21073751>{{Cite journal  | last1 = Tazi | first1 = EM. | last2 = Lalya | first2 = I. | last3 = Tazi | first3 = MF. | last4 = Ahellal | first4 = Y. | last5 = M'rabti | first5 = H. | last6 = Errihani | first6 = H. | title = Transitional cell carcinoma of the ovary: a rare case and review of literature. | journal = World J Surg Oncol | volume = 8 | issue =  | pages = 98 | month =  | year = 2010 | doi = 10.1186/1477-7819-8-98 | PMID = 21073751 }}</ref>
#Vimentin +ve,
#CA-125 +ve.
#WT1 +ve.
#CK20 -ve.
#Thrombomodulin -ve.
#Uroplakin III -ve.
 
Notes:
*1-6 usu. opposite pattern in urothelial cell carcinoma.


==Brenner tumour==
==Brenner tumour==
===General===
{{Main|Brenner tumour}}
*Fits into the ''transistional cell tumours'' category - in the surface epithelial group of ovarian tumours.
 
====Epidemiology====
*Mostly benign clinical course.
*Thought to arise from [[Walthard cell rest]].
*Frequently an incidental finding, i.e. oophorectomy was done for another reason.
 
===Gross===
Features:
*Solid.
 
===Microscopic===
Features:
*Nests of transitional epithelium.<ref name=Ref_PBoD1098>{{Ref PBoD|1098}}</ref>
*"[[Coffee bean nucleus]]".
**Elliptical shape (nucleus).
**Nuclear grooves.<ref name=pathout_brenner>URL: [http://www.pathologyoutlines.com/ovarytumor.html#brennergen http://www.pathologyoutlines.com/ovarytumor.html#brennergen]. Accessed on: 8 February 2011.</ref>
*Distinct nucleoli.<ref name=pathout_brenner/>
 
Notes:
*DDx of Coffee bean nucleus = granulosa cell tumour.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Brenner_tumour_high_mag.jpg "Coffee bean" nuclei (WC)].
*[http://commons.wikimedia.org/wiki/File:Brenner_tumour_intermed_mag.jpg Brenner tumour - intermed. magnifiction (WC)].


=Germ cell tumours=
=Germ cell tumours=
Line 507: Line 435:


=Metastatic ovarian tumours=
=Metastatic ovarian tumours=
{{Main|Metastases}}
{{Main|Ovarian metastasis}}
==Generally==
* Mostly Muellerian origin (uterus, fallopian tube) or pelvic peritoneum.
 
==Extramuellerian metastatic tumours==
DDx:
* [[Breast]].
* [[Gastrointestinal pathology|Gastrointestinal (GI) tract]].
** Pseudomyxoma peritonei, usu. [[appendix|appendiceal]] origin.
** Krukenberg tumour = [[signet ring cell]] cancer with mucin production of GI origin.
 
===Microscopic===
Features:
*Predominantly surface involvement and nodular at low power.
*Signet ring cells (suggestive of GI or breast primary).
*Lymphovascular invasion.
 
===Mucinous carcinoma - [[GI tract]] metastasis vs. primary ovarian===
====Gross====
Features favouring metastatic disease:<ref name=pmid18162780>{{Cite journal  | last1 = Yemelyanova | first1 = AV. | last2 = Vang | first2 = R. | last3 = Judson | first3 = K. | last4 = Wu | first4 = LS. | last5 = Ronnett | first5 = BM. | title = Distinction of primary and metastatic mucinous tumors involving the ovary: analysis of size and laterality data by primary site with reevaluation of an algorithm for tumor classification. | journal = Am J Surg Pathol | volume = 32 | issue = 1 | pages = 128-38 | month = Jan | year = 2008 | doi = 10.1097/PAS.0b013e3180690d2d | PMID = 18162780 }}</ref>
*Bilaterality -- both ovaries involved.
*Small unilateral tumour size -- <10 cm = metastatic.
**>13 cm = primary ovarian.
 
====IHC====
Ovarian tumours:
*Dipeptidase 1 (DPEP1) +ve.<ref name=pmid21076463>{{Cite journal  | last1 = Okamoto | first1 = T. | last2 = Matsumura | first2 = N. | last3 = Mandai | first3 = M. | last4 = Oura | first4 = T. | last5 = Yamanishi | first5 = Y. | last6 = Horiuchi | first6 = A. | last7 = Hamanishi | first7 = J. | last8 = Baba | first8 = T. | last9 = Koshiyama | first9 = M. | title = Distinguishing primary from secondary mucinous ovarian tumors: an algorithm using the novel marker DPEP1. | journal = Mod Pathol | volume = 24 | issue = 2 | pages = 267-76 | month = Feb | year = 2011 | doi = 10.1038/modpathol.2010.204 | PMID = 21076463 }}</ref>
*CK7 +ve.


=Sex cord stromal tumours=
=Sex cord stromal tumours=
Line 551: Line 452:
*Abbreviated ''SCTAT''.
*Abbreviated ''SCTAT''.
*'''NOT''' ''sex cord tumour with angulated tubules''.
*'''NOT''' ''sex cord tumour with angulated tubules''.
 
{{Main|Sex cord tumour with annular tubules}}
===General===
*Associated with [[Peutz-Jeghers syndrome]].<ref name=pmid7358344>{{Cite journal  | last1 = Purohit | first1 = RC. | last2 = Alam | first2 = SZ. | title = Sex cord tumour of the ovary with annular tubules (SCTAT). | journal = Histopathology | volume = 4 | issue = 2 | pages = 147-54 | month = Mar | year = 1980 | doi =  | PMID = 7358344 }}
</ref>
**Large tumours more likely sporadic.
**Small tumours more likely Peutz-Jeghers syndrome and incidental.
 
===Microscopic===
Features:
*Well-circumscribed nests of cells with nuclei at the periphery.
*Annular tubules (ring-shaped tubules) with dense hyaline material.
 
Notes:
*''Annular'' = shape of a ring.<ref>URL: [http://dictionary.reference.com/browse/annular http://dictionary.reference.com/browse/annular]. Accessed on: 6 August 2011.</ref>
 
DDx:
*Sertoli-Leydig tumour - has double palisading with overlap of the layers.
*[[Granulosa cell tumour]] - have Call-Exner bodies, which don't have a well-defined/solid content.
*[[Brenner tumour]] - [[coffee-bean nuclei]].
 
Images:
*[http://www.gfmer.ch/selected_images_v2/detail_list.php?cat1=10&cat2=120&cat3=1015&cat4=3&stype=n SCTAT - image collection (gfmer.ch)].
*[http://www.pathology.cn/bbs/forum.php?mod=viewthread&tid=57445 Possible SCTAT (pathology.cn)].


==Juvenile granulosa cell tumour==
==Juvenile granulosa cell tumour==
===General===
{{Main|Juvenile granulosa cell tumour}}
*May secrete estrogen.
**May present with endometrial pathology, e.g. [[endometrial hyperplasia]] ''or'' endometrioid [[endometrial carcinoma]].
*May arise in males.<ref>URL: [http://path.upmc.edu/cases/case631.html http://path.upmc.edu/cases/case631.html]. Accessed on: 26 January 2012.</ref>
 
===Gross===
*Classically solid.
 
===Microscopic===
Features:
*Microcystic spaces.
*Moderate-to-marked nuclear atypia.
*Cuboidal-to-polygonal cell in sheets or stands or cords.
*Basophilic cytoplasm.
 
Notes:
*Juvenile variant of GCT has more nuclear pleomorphism.
 
Images:
*[[WC]]:
**[http://commons.wikimedia.org/wiki/File:Juvenile_granulosa_cell_tumour_-_intermed_mag.jpg Juvenile granulosa cell tumour - intermed. mag. (WC)].
**[http://commons.wikimedia.org/wiki/File:Juvenile_granulosa_cell_tumour_-_very_high_mag.jpg Juvenile granulosa cell tumour - very high mag. (WC)].
 
===IHC===
* Inhibin positive.<ref name=Ref_PBoD1102>{{Ref PBoD|1102}}</ref>
** Inhibin negative in ''[[Brenner tumour]]''.
*Calretinin +ve.


==Adult granulosa cell tumour==
==Adult granulosa cell tumour==
*[[AKA]] ''granulosa cell tumour''.
*[[AKA]] ''granulosa cell tumour''.
**Should not be confused with ''[[juvenile granulosa cell tumour]]''.
**Should '''not''' be confused with ''[[granular cell tumour]]''.
 
**Ideally, it should be called ''adult granulosa cell tumour'' to avoid confusion with ''[[juvenile granulosa cell tumour]]''.
===General===
{{Main| Adult granulosa cell tumour}}
*May secrete estrogen.
**May present with endometrial pathology, e.g. [[endometrial hyperplasia]] ''or'' endometrioid [[endometrial carcinoma]].
 
===Gross===
*Classically solid.
 
===Microscopic===
Features:
* Classic appearance includes gland-like structures filled with acidophilic material (Call-Exner bodies).
* Small cuboidal to polygonal cell in sheets or stands or cords.
* Nuclear grooves.
 
Note:
*There is a "10% rule" -- if less than 10% of a SCST is granulosa cells... it isn't granulosa cell tumour.
*Juvenile variant of GCT has more nuclear pleomorphism.
 
DDx:
* [[Urothelial cell carcinoma]] (UCC).
** UCC usually has extensive necrosis.
* [[Brenner tumour]].
* [[Sertoli cell tumour]].
 
===IHC===
* Inhibin positive.<ref name=Ref_PBoD1102>{{Ref PBoD|1102}}</ref>
** Inhibin negative in ''[[Brenner tumour]]''.
*Calretinin +ve.


==Fibroma-thecoma group==
==Fibroma-thecoma group==
Line 641: Line 468:


Note:
Note:
*Some discourage the use of the term ''fibrothecoma'' and sugguest calling tumours in the fibrom-thecoma group ''fibroma'' unless there are lipid-laden cells and more than minimal alpha-inhibin positivity.<ref name=pmid16810055/>
*Some discourage the use of the term ''fibrothecoma'' and sugguest calling tumours in the fibroma-thecoma group ''fibroma'' unless there are lipid-laden cells and more than minimal alpha-inhibin positivity.<ref name=pmid16810055/>


==Ovarian fibroma==
==Ovarian fibroma==
===General===
{{Main|Ovarian fibroma}}
*May be a part of:
*#Meigs syndrome (mnemonic ''FAR'': fibroma, [[ascites]], right pleural [[effusion]]).
*#[[Nevoid basal cell carcinoma syndrome]] (NBCCS), AKA ''Gorlin syndrome''.<ref name=Ref_PBoD1103>{{Ref PBoD |1103}}</ref>
*#*In NBCCS classically - calcified and bilateral.<ref name=pmid6385289>{{Cite journal  | last1 = Tytle | first1 = T. | last2 = Rosin | first2 = D. | title = Bilateral calcified ovarian fibromas. | journal = South Med J | volume = 77 | issue = 9 | pages = 1178-80 | month = Sep | year = 1984 | doi =  | PMID = 6385289 }}</ref>
*Very rarely transform to [[adult fibrosarcoma|fibrosarcoma]] <1%.<ref>URL: [http://brighamrad.harvard.edu/Cases/bwh/hcache/353/full.html http://brighamrad.harvard.edu/Cases/bwh/hcache/353/full.html]. Accessed on: 4 October 2011.</ref>
 
===Microscopic===
Features:<ref>[http://www.pathologyoutlines.com/ovarytumor.html#fibroma http://www.pathologyoutlines.com/ovarytumor.html#fibroma]</ref><ref name=pmid16810055/>
*Spindle-shaped cells.
*Central nuclei.
*Stainable lipid - minimal or none.<ref name=pmid16810055/>
 
Images:
*[http://commons.wikimedia.org/wiki/File:Ovarian_fibroma_-_intermed_mag.jpg Ovarian fibroma - intermed mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Ovarian_fibroma_-_high_mag.jpg Ovarian fibroma - high mag. (WC)].
 
===IHC===
*Inhibin -ve (~75%).<ref name=pmid16810055/>


==Thecoma==
==Thecoma==
===General===
{{Main|Thecoma}}
*Associated with compression & atrophy of ovarian cortex, thought to arise from medulla.<ref name=pmid18164409/>
*Approx. 50% have symptoms related to estrogen secretion.<ref name=pmid16810055/>
**May also be viralizing.
 
===Microscopic===
Features:<ref name=pmid16810055/>
*Nuclei with oval to spindle morphology.
*Abundant cytoplasm that is pale, vaculolated -- '''key feature'''.
 
Images:
*[http://commons.wikimedia.org/wiki/File:Thecoma_low_mag.jpg Thecoma - low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Thecoma_high_mag.jpg Thecoma - high mag. (WC)].
 
===IHC===
*Alpha-inhibin +ve (90%+).<ref name=pmid16810055/>


==Sertoli-Leydig cell tumour==
==Sertoli-Leydig cell tumour==
*[[AKA]] ''androblastoma''.
*[[AKA]] ''androblastoma''.
{{Main|Sertoli-Leydig cell tumour}}
==Hilus cell tumour==
{{Main|Leydig cell tumour}}
*[[AKA]] ''Leydig cell tumour''.<ref name=pmid19697637>{{Cite journal  | last1 = Zafrakas | first1 = M. | last2 = Venizelos | first2 = ID. | last3 = Theodoridis | first3 = TD. | last4 = Zepiridis | first4 = L. | last5 = Agorastos | first5 = T. | last6 = Bontis | first6 = JN. | title = Virilizing ovarian hilus (Leydig) cell tumor with concurrent contralateral hilus cell hyperplasia: a rare diagnosis. | journal = Eur J Gynaecol Oncol | volume = 30 | issue = 3 | pages = 338-40 | month =  | year = 2009 | doi =  | PMID = 19697637 }}</ref>
===General===
===General===
*Sertoli and leydig cells are normal in the [[testis]].
*Rare.<ref name=pmid19697637/>
*Poorly differentiated tumours have sarcomatous features.<ref name=Ref_PBoD1103>{{Ref PBoD|1103}}</ref>
*May cause virilization.
**Development of male (sexual) characteristics in a female.
*Arise from [[hilus cells]].


===Microscopic===
===Microscopic===
Features:
Features - see ''[[Leydig cell tumour]]'':
# Sertoli ''or'' Leydig cells.<ref name=Ref_PBoD1103>{{Ref PBoD|1103}}</ref>
*Moderate eosinophilic cytoplasm.
#* Leydig cells:
*+/-Reinke crystalloids (cytoplasmic inclusions).
#** Abundant solid eosinophilic cytoplasm.
#** Round nuclei with fine chromatin and a small or indistinct [[nucleolus]].
#** Often in small clusters ~ 5-25 cells/cluster.
#* Sertoli cells:
#** Pale/clear vacuolated cytoplasm.
#** Irregular nuclei with irregular/vacuolated-appearing chromatin.
#** Architecture: tubules, cords or sheets.
# Stroma.
# +/- Sarcomatous features (mucinous glands, bone, cartilage).


Images:
DDx:
*[[WC]]:
*Hilus hyperplasia.
**[http://commons.wikimedia.org/wiki/File:Sertoli-Leydig_cell_tumour_-_intermed_mag.jpg Sertoli-Leydig cell tumour - intermed. mag. (WC)].
*[[Sertoli-Leydig tumour]].
**[http://commons.wikimedia.org/wiki/File:Sertoli-Leydig_cell_tumour_-_very_high_mag.jpg Sertoli-Leydig cell tumour - very high mag. (WC)].
*www:
**[http://path.upmc.edu/cases/case270/micro.html Sex cord stromal tumour with Sertoli-Leydig component - several images (upmc.edu)].
 
==Pure Leydig cell tumour==
===General===
*AKA ''Hilus cell tumour''.
 
===Microscopy===
*Reinke crystalloids - in the cytoplasm of Leydig cells - ''[[testis]] article''.


=Benign=
=Benign=
Michael
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