Ovarian Pathology

Question 1

peak age of ovarian cancer?

Answer 1

75

Question 2

are there precursor lesions in ovarian cancer?

Answer 2

no

Question 3

most common type of primary ovarian tumour?

Answer 3

epithelial (arise from surface epithelium)

Question 4

what is the main risk factor for ovarian cancer?

Answer 4

the number of times the woman ovulates

therefore COCP, several pregnancies and breastfeeding reduces risk

Question 5

genetic predisposition to ovarian cancer?

Answer 5

1 first degree relative under 50 = 5% risk
2 first degree relatives under 50 = 25% risk
HNPCC (lynch syndrome)
BRCA1 and BRCA2 = 10-50% risk

Question 6

how is BRCA risk managed?

Answer 6

women with these genes should attend regular screening and may be offered bilateral oophrectomy once their family is complete

Question 7

what are the 4 categories of ovarian tumour?

Answer 7

epithelial
sex-cord/stromal tumours
germ cell tumours
metastatic tumours

Question 8

5 types of epithelial ovarian tumour?

Answer 8

endometrioid
mucinous
serous (most common ovarian cancer)
clear cell
brenner

Question 9

two types of serous tumour with precursor lesions?

Answer 9

high grade serous carcinoma (precursor = serous tubal intra-epithelial carcinoma (STIC))
low grade serous carcinoma (precursor = serous borderline tumour)

Question 10

can serous tumour be benign?

Answer 10

yes
serous cystadenomas
make up 20% of benign ovarian tumours

Question 11

which epithelial ovarian tumours are associated with lynch syndrome?

Answer 11

endometrioid

clear cell

Question 12

which epithelial ovarian tumour is associated with endometrial cancere?

Answer 12

endometrioid
histologically similar to endometrioid cancer
30% of women will also have a co-existent primary endometrial cancer

Question 13

which epithelial ovarian cancer is associated with ovarian endometriosis?

Answer 13

clear cell

Question 14

what is brenner tumour?

Answer 14

type of epithelial ovarian tumour
AKA urothelial like
tumour of transitional type epithelium

Question 15

3 types of sex cord/stromal tumour?

Answer 15

granulosa cell
thecoma/fibroma
sertoli/leydig cell

Question 16

describe granulosa cell tumours?

Answer 16

low grade but all are potentially malignant
75% secrete hormones (oestrogen)
contain cells with coffee bean nuclei and gland like spaces called call-exner bodies

Question 17

symptoms of granulosa cell tumours?

Answer 17

precocious pseudopuberty
abnormal menstrual bleeding
post-menopausal bleeding
(all due to oestrogen secretion)

Question 18

describe thecoma/fibroma?

Answer 18

usually benign

contain variety of cells such as theca cells or fibroblastic-type cells

Question 19

symptoms of thecoma/fibroma?

Answer 19

may produce oestrogen causing uterine bleeding

can cause meigs syndrome (ascites and pleural effusion)

Question 20

how is meigs syndrome managed?

Answer 20

removal of tumour

Question 21

describe sertoli/leydig tumour?

Answer 21

rarest type
occur in young women (20s)
usually unilateral
usually non-functional but can be androgenic
stroma-derived fibroblasts may be seen if tumour contains leydig cells

Question 22

4 types of germ cell tumour?

Answer 22

teratoma
dysgerminoma
endodermal sinus/yolk sac tumour
choriocarcinoma

Question 23

who usually gets germ cell tumours?

Answer 23

20-25% of all ovarian neoplasms

usually affects children/young women

Question 24

describe teratoma?

Answer 24

common
usually benign
contain elements from all 3 germ layers

Question 25

what is a mature teratoma?

Answer 25

type of teratoma which may contain hair, teeth, epithelium, sebum etc AKA dermoid cyst 95% of all germ cell tumours (immature teratomas are rare)

Question 26

most common malignant germ cell tumour?

Answer 26

dysgerminoma

Question 27

what is dysgerminoma associated with?

Answer 27

gonadoblastoma in gonadal dysgenesis | increased HCG level

Question 28

how does yolk sac tumour usually present?

Answer 28

sudden pelvic mass | 20% of woman also have a teratoma

Question 29

tumour markers in yolk sac tumour?

Answer 29

raised AFP | HCG usually normal

Question 30

what does choriocarcinoma secrete?

Answer 30

HCG | therefore may present with precocious pseudopuberty

Question 31

prognosis of choriocarcinoma?

Answer 31

poor prognosis | doesnt respond to chemo

Question 32

what cancers often metastasise to ovary?

Answer 32

endometrium breast pancreas GI

Question 33

how do ovarian cancers spread?

Answer 33

trans-coelomically can seed into peritoneal cavity para-aortic lymph nodes death results from intestinal blockage and cachexia

Question 34

how might ovarian cancer present?

Answer 34

usually present late with non-specific symptoms only have GI symptoms in late stage often have abdominal distension (due to ascites or mass itself)

Question 35

what is RMI?

Answer 35

risk of malignancy index | tool used to separate benign and malignant lesions

Question 36

how is RMI calculated?

Answer 36

RMI = US X menopausal score X CA125

Question 37

what is done if RMI is high?

Answer 37

CT/MRI is performed | US better for imaging cysts, CT/MRI done for malignant masses

Question 38

suspicious US findings on ovarian mass?

Answer 38

``` complex mass with solid + cystic area multi-loculated thick septations associated ascites bilateral disease ```

Question 39

how is CA125 used in ovarian cancer?

Answer 39

sensitive but not that specific raised in 80% of ovarian cancers but also raised in other things to its a better indicator of disease progression at follow up than for diagnosis

Question 40

what else can cause raised CA125?

Answer 40

``` endometriosis peritonitis pregnancy pancreatitis ascites other malignancies ```

Question 41

what other tumour markers are used in ovarian cancers?

Answer 41

CEA may be raised in ovarian cancer (esp in mucinous), mainly used to exclude mets from a GI primary cancer 65% of germ cell tumours produce HCG and AFP so these can be used to indicate response to treatment

Question 42

how is ovarian cancer staged?

Answer 42

FIGO system 1A = tumour limited to one ovary 1B = tumour limited to both ovaries 1C = cancer involving ovarian surface/rupture/surgical spill/tumour in washings 2A = extension or implants on uterus/fallopian tubes 2B = extension to other pelvic intraperitoneal 3A = retroperitoneal lymph node metastasis or microscopic extrapelvic peritoneal involvement 3B = macroscopic peritoneal metastasis beyond pelvis up to 2cm in dimension 3C = macroscopic peritoneal metastasis >2cm in dimension 4 = distant metastasis

Question 43

how are benign ovarian tumours managed?

Answer 43

excision or drainage | often cant distinguish between benign and malignant so diagnosis occurs after surgery

Question 44

how are epithelial ovarian tumours managed?

Answer 44

``` usually surgery + chemo - surgery = debulking - chemo = usually adjuvant to surgery chemotherapy can be used as first line therapy if unfit for surgery chemo treatment of choice in relapse ```

Question 45

how are non-epithelial ovarian tumours managed?

Answer 45

fertility preservation important as these often occur in younger women many are sensitive to chemo limited surgery and chemotherapy can produce good results in many cases

Question 46

mean survival in ovarian cancer?

Answer 46

5 year survival is 40% | germ cell survival is better at 75%