Institute of Pathology First Faculty of Medicine Charles University. Ovary

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1 Ovary

2 Barrett esophagus ph in vagina between 3.8 and 4.5 ph of stomach varies from 1-2 (hydrochloric acid) up to 4-5 BE probably results from upward migration of columnar cells from gastroesophageal junction (GEJ) GEJ cells are also origin of gastric-type metaplasia in distal esophagus It is unclear whether gastric-type metaplasia is a precursor to intestinal type metaplasia or whether they are separate entities

3 Diseases of the ovary nonneoplastic lesions - pelvic inflammatory disease - ovarian cysts - endometriosis ovarian tumors - epithelial (surface epithelial-stromal) - sex cord-stromal - germ cell - germ cell sex-cord stromal

4 Nonneoplastic inclusion functional endometrioid Ovarian cysts Cystic tumors epithelial tumors - cystadenoma (benign, borderline) - cystadenocarcinoma germ cell tumors - dermoid cyst

5 Nonneoplastic cysts inclusion cysts - inclusions of the surface epithelium - inclusions from fimbrial epitehlium functional cysts - follicular cyst - corpus luteum cyst - hemorrhagic cyst endometrioid cyst

6 Nonneoplastic cysts inclusion cysts - inclusions of the surface epithelium - inclusions from fimbrial epitehlium functional cysts - follicular cyst - corpus luteum cyst - hemorrhagic cyst - simple unilocular cysts - up to 1 cm in diameter - larger cyst - cystadenoma endometrioid cyst

7 Nonneoplastic cysts - unilocular thin walled cysts inclusion cysts - more than 3 cm in diameter - inclusions of the surface epithelium - content: serous, serosanguineous, - inclusions from fimbrial epitehlium clotted blood functional cysts - follicular cyst - corpus luteum cyst - hemorrhagic cyst endometrioid cyst

8 Nonneoplastic cysts inclusion cysts - thick and fibrotic wall - up to 15 cm in diameter - cyst content: semifluid, chocolate-colored functional cysts material - inclusions of the surface epithelium - inclusions from fimbrial epitehlium - follicular cyst - corpus luteum cyst - hemorrhagic cyst endometrioid cyst

9 Ovarian tumors

10 Classification of ovarian tumors epithelial tumors sex cord-stromal tumors germ cell tumors germ cell sex cord-stromal tumors

11 Classification of epithelial tumors according to their gross features: - cystadenoma (cystadenocarcinoma) - cystadenofibroma - adenofibroma (adenocarcinofibroma) - surface papilloma (surface papillary carcinoma) according to their histogenesis

12 Classification of epithelial tumors according to their gross features: - cystadenoma (cystadenocarcinoma) - cystadenofibroma - adenofibroma (adenocarcinofibroma) - surface papilloma (surface papillary carcinoma) according to their histogenesis!!!

13 Epithelial tumors benign borderline malignant serous - low grade - high grade endometrioid clear cell mucinous

14 Surface epithelial tumors benign borderline Tumors of müllerian origin malignant Müllerian (paramesonephric) ducts will give rise to: - upper vagina - cervix - uterus - Fallopian tube serous - low grade - high grade endometrioid clear cell mucinous

15 Benign epithelial tumors can be large (especially mucinous tumors the world s biggest tumor weighted 136 kilos) symptoms and signs usually nonspecific: - pelvic pain - discomfort - an asymptomatic pelvic mass up to 25% of tumors bilateral

16 Benign serous cystadenoma

17

18 Benign mucinous cystadenoma

19 Borderline tumors increased epithelial proliferation do not display invasion usually behave in a benign fashion but behavior can be malignant clinical features similar to those for benign tumors

20 Serous borderline tumor

21 Serous borderline tumor

22 Borderline tumor vs. carcinoma Borderline tumor Median age % of tumor in stage I 5-year survival % % rate for stage I 5-year survival % % rate for stage II 5-year survival % % rate for stage III metastatic spread rare common Invasive caricnoma

23 Ovarian cancer about 30% of all cancers of the female genital tract incidence rates are highest in the economically advanced countries (most frequent cause of death due to gynecological cancer) epithelial carcinomas account for 90% of these cancers in North America and Western Europe in some Asian countries, including Japan, germ cell tumours account for a significant proportion (20%) of ovarian malignancies

24 Risk factors age reproductive factors - early menarche, late menopause high socioeconomic status - lower fertility BRCA1/2 mutation (5-10% hereditary) Ovarian cancer Protective factors increased parity oral contraceptive use surgically induced: - hysterectomy - tubal ligation - bilateral salpingooophorectomy

25 Ovarian cancer: age-standardised (world) incidence and mortality rates per (all ages) in 18 world regions Sankaranarayanan R, Ferlay J. Worldwide burden of gynaecological cancer: the size of the problem. Best Pract Res Clin Obstet Gynaecol Apr;20(2):

26 Incidence and mortality Czech Republic 2006 Incidence Mortality 1074 cases 764 deaths 20,4 / women 14,5 / women 6,1%

27 high grade serous (70%) y ne og ci ol di th Me Pa of ity of ty rs te ul ive itu ac n st F U In rst les Fi har low grade serous (<5%) C surface epithelialstromal tumors endometrioid (10%) clear cell (10%) mucinous (3%)

28 y ne og ci ol di th Me Pa of ity of ty rs te ul ive itu ac n st F U In rst les Fi har C surface epithelialstromal tumors high grade serous (70%) Supposed origin of surface epithelial-stromal tumors according lowwho: grade serous (<5%) to mesothelial surface lining of the ovaries endometrioid (10%) and/or invagination of this lining into the ovarian cortex (inclusion cysts) clear cell (10%) mucinous (3%)

29 1) intraepithelial carcinoma in the tubal fimbriae 2) endosalpingiosis (inclusions from fimbrial epithelium) 3) inclusions from surface epithelium high grade serous (70%) low grade serous(<5%) precursor lesion: serous borderline tumor Epithelial tumors Precursor lesions and origin: unknown Putative precursor lesions: 1) endometriosis 2) mucinous metaplasia of Walthard nests 3) some can be of germ cell origin endometrioid (10%) clear cell (10%) mucinous (3%) precursor lesion: endometriosis precursor lesion: endometriosis

30 High grade serous carcinoma

31 High grade serous carcinoma y ne og ci ol di th Me Pa of ity of ty rs te ul ive itu ac n st F U In rst les Fi har C

32

33

34 y ne og ci ol di th Me Pa of ity of ty rs te ul ive itu ac n st F U In rst les Fi har C

35 Clear cell carcinoma

36 Clear cell carcinoma y ne og ci ol di th Me Pa of ity of ty rs te ul ive itu ac n st F U In rst les Fi har C

37

38 Prognostic factors C y ne og ci ol di th Me Pa of ity of ty rs te ul ive itu ac n st F U In rst les Fi har histologic subtype histologic grade stage advanced cancer: - macroscopic absence of residual tumor after primary surgery

39 Sex cord-stromal tumors C y ne og ci ol di th Me Pa of ity of ty rs te ul ive itu ac n st F U In rst les Fi har about 8 % of all ovarian tumors composed of: granulosa cells theca cells fibroblasts of stromal origin Sertoli cells Leydig cells singly or in various combinations

40 Sex cord-stromal tumors (adult or juvenile type) C y ne og ci ol di th Me Pa of ity of ty rs te ul ive itu ac n st F U In rst les Fi har about 8 % of all ovarian tumors composed of: granulosa cells theca cells fibroblasts of stromal origin Sertoli cells Leydig cells granulosa cell tumor singly or in various combinations thecoma fibroma fibrosarcoma Sertoli cell tumor Leydig cell tumor

41 Germ cell tumors different tumor types derived from the primitive germ cells of the embryonic gonad represents: - about 30% of all ovarian tumors (up to 95 % are mature cystic teratomas) - about 3 % of all ovarian cancers (western world) - up to 20 % of all ovarian cancers (Asia)

42 Germ cell tumors - histogenesis Dysgerminoma Germ cell Tumors of totipotential cells Embryonal carcinoma Embryonal carcinoma Extraembryonic structures Embryonic structures Yolk sac tumor Choriocarcinoma Teratoma

43

44

45 y ne og ci ol di th Me Pa of ity of ty rs te ul ive itu ac n st F U In rst les Fi har C

46 y ne og ci ol di th Me Pa of ity of ty rs te ul ive itu ac n st F U In rst les Fi har C

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3 cell types in the normal ovary Ovarian tumors 3 cell types in the normal ovary Surface (coelomic epithelium) the origin of the great majority of ovarian tumors (neoplasms) 90% of malignant ovarian tumors Totipotent germ cells Sex cord-stromal

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