Pathology of the ovaries 2

During peak fertile years, only ________ malignant; ratio becomes 1 in 3 after age 40.

-1 in 15 -40

Sonographic Evaluation of the ovaries

-Any change in ovarian echogenicity or volume of more than 20 ml should be considered suspicious. -In postmenopausal women, ovaries become atrophic and often do not have follicles. -Only women receiving hormone replacement therapy continue to have normal-sized ovaries. -Abnormal ovaries suggestive of malignancy defined as enlarged echogenic ovaries

Sonographic Findings of carcinoma of the fallopian tube

-Appears as sausage-shaped, complex mass, with cystic and solid components often with papillary projections -Clinical and sonographic findings similar to those of ovarian carcinoma

Which genes is Ovarian Carcinoma primarily related to?

-Appears primarily related to genetic mutations in BRCA1 and BRCA2 genes **Less commonly in MSH2 and MLH1 genes

Fibroma cont.

-Associated ascites along with pleural effusion -Referred to as Meigs syndrome; occurs in 1% to 3% of patients with fibroma -Not specific; it can occur with other ovarian neoplasms as well -Found in postmenopausal women

other sonographic appearance of Mucinous Cystadenocarcinoma

-Bilateral -May occur in menopausal women (10%) -Large, likely to rupture—ascites

Diagnosing Ovarian Carcinoma

-Blood chemistry test CA 125 helpful in some patients; disappointing as screening test because of inability to detect many cases of ovarian cancer -Has many false-positive and false-negative results; elevated levels found in only 50% of patients with stage III ovarian cancer

Fibroma and Thecoma

-Both fibroma and thecoma tumors arise from ovarian stroma; are pathologically similar -Tumors with abundance of thecal cells called thecomas, and those with abundance of fibrous tissue called fibromas -Thecomas usually benign and unilateral, comprising 1% of all ovarian neoplasms; 70% occur in postmenopausal women -Frequently show signs of estrogen production

Dermoid Cysts

-Classified as a Germ Cell tumor -Represent 10-20% of benign ovarian cysts -Contain derivatives of all three germ layers -8-15% of Dermoid cysts are bilateral -Composed of varying tissue composition making them the ultrasound chameleon of ovarian tumors -Most commonly contain: skin, hairs, and sebaceous glands. -They may also contain fat, cartilage, nerve tissue, bone , respiratory tissue, teeth and gastrointestinal tissue

Clinical symptoms of Germ cell tumors

-Clinical symptoms include pelvic and/or abdominal pain and palpable mass (average diameter 15 cm) -Usually unilateral; 40% of tumors will calcify -Ranges in texture from homogeneously solid (3%), predominantly solid (85%), to predominantly cystic (12%)

Clinical symptoms of Granulosa

-Clinical symptoms of estrogen production may include precocious puberty or vaginal bleeding and full breasts -Pain, pressure, fullness may also be present -May twist on itself to cause torsion or rupture, leading to Meigs syndrome -Malignant transformation rare, but when it occurs, lesion spreads via lymphatics and bloodstream

clinical evaluation of fibroma

-Compromise 4% of ovarian neoplasms -Rarely associated with estrogen production -Clinical signs include lack of symptoms if tumor small -If large, increasing pressure and pain apparent -Ascites has been reported in up to 50% of patients with fibromas >5 cm in diameter

Sonographic Evaluation of Ovarian Neoplasms

-Doppler examination shows low-resistive pattern -Extension beyond ovary into omentum or peritoneum and liver metastases should be evaluated. -Malignant ascites may be present. -Unilocular or thinly septated cysts more likely to be benign

Endodermal Sinus Tumor sonographic appearance

-Endodermal sinus tumor has poor prognosis. -Second most common malignant ovarian germ cell neoplasm after dysgerminoma -Sonographic appearance similar to dysgerminoma

Endodermal Sinus Tumor (yolk sac tumors)

-Endodermal sinus tumors rare rapidly growing tumors also called yolk sac tumors. -Usually occurs in women <20 years of age; is almost always unilateral -Increased serum AFP may be seen.

Granulosa

-Feminizing neoplasm composed of cells resembling graafian follicle -Most common hormone-active estrogenic tumor of ovary -More common after menopause (50%) -Also seen in reproductive ages (45%) and in adolescence (5%)

Fibroma

-Fibromas are very rare type of ovarian tumor. -They are benign and most often unilateral. -They are most prevalent in the perimenopausal age group. -Ovarian fibroma appears sonographically as a sharply circumscribed, solid oblong tumor with relatively low-level, homogenous internal echo pattern.

Germ Cell Tumors

-Germ cell tumors derived from primitive germ cells of embryonic gonad -Account for 15% to 20% of ovarian neoplasms, with approximately 95% being benign cystic teratomas -Besides teratomas, germ cell tumors include dysgerminoma, embryonal cell carcinoma, choriocarcinoma, and transdermal sinus tumor -Often occur as mixed tumors with elements of two or three varieties of germ cell tumors

Epithelial Tumors

-Gynecologic tumors that arise from surface epithelium and cover ovary and underlying stroma are called surface epithelial-stromal tumors. -Account for 65% to 75% of all ovarian neoplasms and 80% to 90% of all ovarian malignancies -Most common types are serous and mucinous tumors -Mixed solid to cystic ovarian masses typical of all epithelial ovarian tumors

Immature and Mature Teratomas

-Immature teratomas uncommon; occur in girls and young women 10 to 20 years of age -Rapidly growing, solid malignant tumors with many tiny cysts -AFP elevated in 50% of patients -Unilateral and small in size; may grow to larger dimension

Sonographic Findings of Mucinous Cystadenoma

-In 75% of patients with mucinous tumors, ultrasound examination shows simple or septate thin-walled multilocular cysts -Contain internal echoes with compartments differing in echogenicity caused by mucoid material in dependent portions

Sonographic finidings (continuation)

-In advanced disease, ascites and omental masses may be palpated. -Can present as either complex, cystic, or solid mass -More likely predominantly cystic -As many as 20% bilateral

Carcinoma of the Fallopian Tube

-Least common (<1%) of all gynecologic malignancies -Adenocarcinoma most common histological finding -Occurs most frequently in postmenopausal women with pain, vaginal bleeding, pelvic mass -Usually involves distal end; may involve entire length of tube

Sonographic Findings of Mucinous Cystadenocarcinoma

-Malignant cysts tend to have thick, irregular walls and septations with papillary projections and echogenic material. -Generally have sonographic appearance similar to serous cystadenocarcinomas

Spreading of Epithelial Tumors

-Metastatic spread primarily intraperitoneal -Direct extension to surrounding structures and lymphatics not uncommon -Hematogeneous spread usually occurs late in course of disease.

Mucinous Cystadenomas

-More complex internal echo pattern than serous cystadenomas -Contain fine medium level echoes -Contain coarse echoes of relatively high amplitude -May become very large tumors and can only be appreciated with a transabdominal sonogram.

Mucinous Cystadenoma characteristics

-Most common cystic tumor -Usually unilateral -Cyst filled with sticky, gelatin-like material -Multilocular cystic spaces -Benign type more common than malignant **Clinical findings: Pressure, pain, increased abdominal girth

Mucinous Cystadenocarcinoma

-Most frequently occurs in women 40 to 70 years old -Accounts for 5% to 10% of all primary malignant ovarian neoplasms -15% to 20% bilateral when malignant - 10% occur in menopausal women -Can also become very large and more likely than benign form to rupture -If tumor ruptures, associated with pseudomyxoma peritoneum -Causes loculated ascites with mass effect

Sonographic evaluation of Epithelial tumors

-One fourth bilateral; most occur in women >40 Large and often fill pelvic cavity -Ovary with volume twice that of opposite side generally considered abnormal -When solid mass found, care taken to identify connection with uterus to differentiate ovarian lesion from pedunculated fibroid -Color Doppler helpful by using color to identify vascular pedicle between uterus and mass, as can often be identified with pedunculation

Metastatic Disease

-Ovaries more involved with metastatic disease than any other pelvic organ -Metastases often mimic appearance of advanced stage II to III primary ovarian cancer -Approximately 5% to 10% of ovarian neoplasms are metastatic in origin. -The liver is a frequent site of metastasis for cancers of the breat uterus, ovaries and gastrointestinal tract.

Other Pelvic Masses

-Pelvic kidneys -Omental cysts -Distended impacted feces in rectosigmoid colon -Distended bladder -Hydroureters -Colonic cancer or masses -Diverticular abscesses -Retroperitoneal masses -Ectopic pregnancy

Clinical evaluations of Mucinous Cystadenocarcinoma

-Pelvic pressure; pain when ruptured -Sonographic Findings: Ascites appears as hypoechoic fluid with bright punctate echoes; thick, irregular walls and septations

Dysgerminoma

-Rare malignant germ cell tumor bilateral in 15% of cases -Mass constitutes 1% to 2% of primary ovarian neoplasms and 3% to 5% of ovarian malignancies -Entirely solid ovarian mass in woman <30 years of age usually dysgerminoma -Dysgerminoma and serous cystadenoma are two most common ovarian neoplasms seen in pregnancy

Symptoms and sonographic findings of Ovarian Carcinoma

-Relative absence of symptoms early in disease -Commonly not detected until advanced, having spread beyond capsule but still within pelvis (stage II) or into abdomen (stage III) -Adnexal finding on physical examination variable, ranging from almost "normal" to slightly enlarged firm irregular ovaries to pelvic masses

Stages of cancer

-STAGE I: Limited to ovary -STAGE II: Limited to pelvis -STAGE III: Limited to abdomen -STAGE IV: Hematogenous disease

Serous Cystadenoma

-Second most common benign tumor of ovary (after dermoid cyst) -Represents 20% to 25% of all benign ovarian neoplasms -Is usually unilateral; 20% are bilateral

Stromal Tumors

-Sex cord-stromal tumors typically solid adnexal masses that arise from sex cords of embryonic gonadal and/or ovarian stroma -Includes granulosa cell tumor, thecoma, fibroma, and Sertoli-Leydig cell tumors (androblastoma and arrhenoblastoma) -Accounts for 5% to 10% of all ovarian neoplasms and 2% of all ovarian malignancies

Secondary follicles

-Similar to primary follicles in many ways, however they are larger (approx. 200 µm in diameter) and have more developed theca folliculi. -they now consist of an inner layer (theca interna) and outer layer (theca externa). Only a few primary follicles develop into secondary follicles.

Teratoma: Dermoid Tumors

-Size ranges from small to 40 cm -Unilateral, round to oval mass -Contains fatty, sebaceous material, hair, cartilage, bone, teeth

Risk Factors for OC

-Strongest risk factor is family history of ovarian or breast cancer -Women with carcinoma of breast have increased risk of developing ovarian cancer; women with ovarian cancer 3 to 4 times more likely to develop breast cancer **Other risk factors include -increasing age, -nulliparity, -infertility, -uninterrupted ovulation, -and late menopause.

Mucinous Cystadenoma

-Type of epithelial tumor lined by mucinous elements of endocervix and bowel -Constitutes 20% to 25% of all benign ovarian neoplasms -Is usually found in woman between ages of 13 and 45 years old -80% to 85% of mucinous tumors benign -Can be very large, measuring 15 to 30 cm in diameter, and weighing more than 100 pounds

Sonographic appearance of Serous Cystadenoma

-Usually unilateral -Smaller than mucinous cysts -Multilocular cysts with septations Clinical: Pelvic pressure, bloating Sonographic Findings: Multilocular cyst; may have nodule

Sonographic Findings of Fibroma

-Usually unilateral (90%) -Size ranges from small to melon size, with variable sonographic appearance -Hypoechoic mass with posterior attenuation seen from homogeneous fibrous tissue -Larger tumors pedunculated and prone to torsion, edema, and cystic degeneration

Sonographic Findings of Serous Cystadenoma

-Usually unilocular or multilocular with thin septations -Smaller than mucinous cysts (up to 20 cm); borders irregular with loss of capsular definition -Multilocular cysts contain small amount of solid tissue in chambers of varying size with occasional internal septum or mural nodules

Sonographic Findings of Granulosa

-Variable appearance -Mass without torsion -Similar to endometrioma or cystadenoma, with low-level homogeneous echoes -If torsion occurs, multilocular cyst containing blood or fluid seen -Solid masses may have echogenicity similar to uterine fibroids

Mucinous tumors

-account for 20% to 25% of ovarian neoplasms. -less frequently bilateral than are serous type

Differential diagnosis of Ovarian Carcinoma

-endometriosis -hemorrhagic ovarian cyst -ovarian torsion -PID -benign ovarian neoplasms

Sertoli-Leydig cell tumor

-is a rare cancer of the ovaries. -The cancer cells produce and release a male sex hormone.Sertoli-Leydig cell tumor is an androgen producing ovarian tumor that is most prevalent between 20 and 25 years of age. -It may occur at any age, however, heavy androgen production by the tumor incites a rapidy progessive virilization, with hirsutism, acne, clitoral hypertrophy, deepen of the voice, and an increas in muscle. Srum testosterone levels are markedly elevated. -considered types of testicular cancer

Signet ring cell carcinoma

-is an epithelial malignancy characterized by the histologic appearance of signet ring cells. -It is a form of adenocarcinoma, and it is most often found in the glandular cells of the stomach, but it may develop in other areas of the body such as the prostate, bladder, gallbladder, breast, colon, ovarian stroma and testis.

Ovarian Carcinoma

-kills more women than cancer of uterine cervix and body combined and is the fourth leading cause of cancer death. -Approximately 1 in 70 women develop the disease. -60% of ovarian malignancies occur in women between 40 and 60 years of age.

Serous tumors

-most common; comprise 30% of all ovarian neoplasm -cystadenoma and cystadenocarcinoma

Endodermal Sinus Tumor /Yolk sac tumors (YSTs

-occurs rarely in older women -associated with a variety of ovarian epithelial tumors elevated serum levels of α-fetoprotein that roughly correlate with the amount of the YST component. -should be suspected in postmenopausal women with an ovarian mass and elevated serum levels

Any fluid present in pelvis can be used to outline dependent portions of pelvic organs by ____________ patient, using ______________ approach, or both

-tilting -transvaginal

Sonographic Findings of Metastatic disease

-to ovaries frequently bilateral and often associated with ascites -Metastases usually completely solid or solid with "moth-eaten" cystic pattern that occurs when necrotic

Krukenberg tumors

-tumor is a special metastatic form arising from signet-ring cell- forming gastric carcinoma, appear as large, solid, bilateral ovarian lesions with a nonhomogenous echo pattern caused by extensive necrosis and intratumoral hemorrhage -"drop" metastases to ovaries from GI tract, primarily from stomach, but also from biliary tract, gallbladder, pancreas

Clinical symptoms of OC

-vague abdominal pain -swelling, indigestion -frequent urination -constipation -weight change (ascites). **Over 70% of women first seen by doctors are in advanced stages of disease

Sonographic patterns of Teratoma

A. completely cystic mass B. cystic mass with very echogenic nodule along mural wall representing "dermoid plug" C. fat-fluid level D. high-amplitude echoes with shadowing (e.g., teeth or bone) E. complex mass with internal septations

The cortex of the ovary

After puberty, the cortex forms most of the volume of the ovary. It is composed of a series of stromal cells arranged in 'whorls', together with a network of collagen fibers. It houses the developing gametes in structures known as ovarian follicles.

Teratoma: Dermoid Tumors clinical symptoms

Asymptomatic to abdominal pain, enlargement and pressure; pedunculated; subject to torsion

adenoma

Benign or low-malignancy potential form of tumor

Sonographic Findings of Serous Cystadenocarcinoma

Cystic structure with septations and/or papillary projections; internal and external papillomas usually present

Sonographic Findings of Teratoma: Dermoid Tumors

Cystic/complex/solid mass; echogenic components; acoustic

Serous Cystadenocarcinoma

External papillary mass adhesions and infection lead to bilateral involvement Loss of capsular definition and tumor fixation; calcifications Peritoneal implants; ascites; metastases to omentum, lymph nodes, liver, and lungs Clinical: Pelvic fullness, bloating

Epithelium of mucinous tumors tubal in type; may be one or multiple cysts.

Fasle - serous tumors are tubal in type & may consist of one or multiple cysts

STAGE IV

Hematogenous disease (liver parenchyma)/spread beyond abdomen

primary follicle

The follicles begin developing multi-layers of cuboidal supporting cells, known as granulosa cells. -These secrete follicular fluid within the interstitial space.

theca folliculi

The stromal cells surrounding the follicle start to condense to form the theca folliculi

Adjustments in equipment features with auto optimization may help the sonographer to better determine the thickness of the septations within the large ovarian mass.

True

Approximately 6% of ovarian carcinomas are metastatic.

True

Germ Cell Tumors is associated with elevated alpha-fetoprotein (AFP) and hCG levels.

True

More sonographically complex the tumor, more likely to be malignant, especially if associated with ascites.

True

Well-defined anechoic lesions more likely to be benign; lesions with irregular walls, thick irregular septations, mural nodules, and solid echogenic elements favor malignancy

True

Yolk sac tumors (YSTs) can be seen in males and females, involving the testis, ovary, and other sites, such as the mediastinum.

True

STAGE II

a. Involvement of uterus/fallopian tubes b. Extension to other pelvic tissues c. Positive peritoneal lavage (ascites)

STAGE I

a. Limited to 1 ovary b. Limited to 2 ovaries c. Positive peritoneal lavage (ascites)

fibroma

added if tumor is more than 50% fibrous

Follicular or stromal cells

are a single layer of flat supporting cells that surround oocytes present in the cortex of the ovary. They support the oocyte and nourish it.

classified under Sertoli-Leydig cell tumour

arrhenoblastoma and androblastoma

Masses <5 cm in longest axis more likely to be ___________ However, masses >10 cm more likely to be ______________.

benign malignant **Increasing patient age correlates with increased incidence of malignancy.

Incidence of ovarian cancer greatly increased in women who have had ______________ & _____________ cancer.

breast and colon

Lymphoma involving the ovary is usually ___________ & __________ and also frequently bilateral

diffuse and disseminated ** Sonographically, the mass appears as solid hypoechoic tumor similar to lymphoma elsewhere in body.

STAGE III

intraabdominal extension outside pelvis/retroperitoneal nodes/extension to small bowel/omentum

Meigs' syndrome

is the triad of ascites, pleural effusion and benign ovarian tumor (fibroma, Brenner tumour and occasionally granulosa cell tumour) **Bilateral ovarian fibromas accompanied by ascites and hydrothorax are observed in Meigs syndrome

Metastatic cancer can arise from breast, upper GI tract, and other pelvic organs by direct extension or by___________ ___________.

lymphatic spread

Multilocular, thickly septated masses and masses with solid nodules are more likely to be ____________.

malignant

adenocarcinoma

malignant form of tumor

Lavage

means the irrigation or washing out of an organ as the stomach or bowel 2. to wash out or irrigate

In postmenopausal woman, ovaries enlarged; if mass is seen, may be ____________ ____________ to ____________ with papillae within.

mixed texture to solid

In advanced stages, _____________ ____________ with malignant ascites and peritoneal implants can be seen.

peritoneal carcinomatosis

Obvious signs of malignancy, such as sonolucent liver metastases or nodular peritoneum outlined by ascites, assist in __________ ____________.

preoperative assessment

Distinguish solid ovarian masses from pedunculated myomas by identifying ____________ ____________ and searching for ovary

uterine connection