Ovarian cyst

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Ovarian cyst Dr. Hatem Al-Nuaimi Consultant
pathologist MB.Ch.B, F.I.C.MS-Path European
board-histopathology-MB.Ch.B-EBP-Path Head of
Department of Pathology
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Epidemiology of Ovarian Cysts?

• Many types.
• Different causes.
• Many women will have cysts during their
  childbearing years.
• Most are asymptomatic.
• Some types can cause serious health problems.

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Questions ????????

• .1-classification
• 2-causes.
• 3-Diagnosis.

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Ovarian Cysts
Non Neoplastic - Physiological(Functional)
Follicular. Corpus Luteum. Theca
Lutein. - Pathological Endometriotic.
PCOS. - Inflammatory
Neoplastic - Epithelial. - Sex Cord.
- Germ Cell. - Others ( Metastatic.)
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Causes(pathogenesis)

• The exact cause of ovarian cysts is not known,
  but they tend to form when the ovary produces too
  much of the hormone estrogen
• Some ovarian cysts are caused by a hormonal
  irregularity called polycystic ovarian syndrome
  in which the entire ovary is filled with numerous
  cysts that are causing abnormal amounts of
  hormonal production. 
• Other times cysts can be caused by tumors, which
  can be either benign or cancerous. 
•  .

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Functional cyst- Follicular cysts

• Follicular cysts are the most commonly seen
  ovarian cysts.
• They occur in reproductive life and can be
  confused with neoplastic lesions. Each egg forms
  in a tiny structure inside the ovary called a
  follicle. The follicle contains fluid to protect
  the egg as it grows and it bursts when the egg is
  released.
• Sometimes a follicle does not release an egg, or
  it does not shed its fluid and shrink after the
  egg is released. If this happens, the follicle
  can get bigger as it swells with fluid. The
  fluid-filled follicle becomes a follicular
  ovarian cyst.
• Usually, only one cyst appears at a time and it
  will often disappear without treatment after a
  few weeks

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Cont- Follicular Cyst

• Most follicular cysts are unilateral and measure
  1 - 10 cm.
• The maximum measurement of a normal follicular
  cyst is 2.5cm.

luteinized follicular cyst of the ovary. HE
stain.
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2- Corpus Luteum

• Occurs when the dominant follicle ruptures
  successfully.
• In the absence of a pregnancy, the corpus luteum
  normally collapses and becomes the corpus
  albicans.
• Unusual continued growth and / or hemorrhage may
  create a cyst.
• Measure 1.5 - 2.5 cm in diameter and may contain
  internal blood.
• - Less common than follicular cysts.
• - Rupture leading to hemoperitoneum(acute abd).
• - Most ruptures occur on cycle days 20 26

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3- Corpus Luteum of Pregnancy

• In the presence of hCG, the ruptured follicle
  undergoes cystic enlargement.
• This structure usually regresses spontaneously by
  the 12th week.

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Microscopically
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4- Theca Luteum

• Cystic enlargement of atretic follicles.
• Most commonly are associated with hydatidiform
  mole and other types of gestational trophoblastic
  disease.
• The least common.
• - Bilateral.
• - Size quite large (30cm), multicystic,
  regress spontaneoustly.

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Neoplastic cyst
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Cystadenomas

• Cystadenomas are common cystic epithelial tumors
  occurring on the ovary.
• These cysts may grow very large and are most
  frequently seen in women between 50 - 60 years of
  age.
• It is impossible to differentiate histologic
  types sonographically.
• Septations and papillary excrescences may be
  seen.
• Three histologic types exist
• 1- Serous Cystadenomas.
• 2- Mucinous Cystadenomas.
• 3- Cystadenofibroma

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1- Serous Cystadenoma

• A unilocular or multilocular cyst lined by
  epithelium similar to the fallopian tube.
• Contains serous fluid.
• They are the most common benign epithelial tumors
  and form 20 of all ovarian neoplasm.
• In about 10 of cases they are bilateral.
• It is uncommon to find them large than a fetal
  head.
• More common in women 40 - 50 y.

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Serous Cystadenoma
Serous cystadenoma, ovary
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2- Mucinous Cystadenoma

• A unilocular or multilocular cyst of ovary lined
  by tall columnar epithelium resembling that of
  the cervix or large intestine.
• It is usually large and may reach immense
  proportions, occupying the whole peritoneal
  cavity and compressing other organs.
• It may occur at any age but more common in women
  30 - 50 years of age.
• Contains thicker mucinous fluid.
• Rarely bilateral (5 - 7).
• Low malignant potential.
• Only 1 in 7 become malignant.
• 20 of epithelial tumors.

• Rupture may occur and seeding of the
  epithelium on the peritoneal surface may cause
  pseudomyxoma peritonei.

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Mucinous Cystadenoma
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Cystadenofibroma

• Variant of serous type.
• Unilateral.
• Partly cystic and partly solid.

Ovarian Cystadenofibroma
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Pseudomyxoma Peritonei

• This rare condition occasionally but not
  inevitably follows the rupture of a mucinous
  cystadenoma.
• The epithelial cells implant on the peritoneum
  and continue to secrete a gelatinous pseudomucin
  which is not absorbed, or secretion is faster
  than absorption.
• The abdominal cavity is eventually filled with
  the jelly, while the secreting cells spread over
  the parietal and visceral peritoneum.

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Polycystic Ovaries

• An endocrine disease that results in the
  over-production of cysts within the ovaries is
  known as PCO or Stein-Levinthal Syndrome.
• Most commonly found in adolescent girls and young
  women (teens - twenties).
• Diagnosis of PCO is actually a clinical /
  serological diagnosis and not necessarily a
  sonographic diagnosis.
• Clinical Findings
• Obesity
• Oligomenorrhea or amenorrhea
• Hirsutism
• Infertility

Polycystic Ovary Disease (Stein-Leventhal
Syndrome)
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Serous Cystadenocarcinoma

• This is by far the commonest primary carcinoma,
  accounting for 60 of all cases, and in over half
  the cases it is bilateral.
• The cysts are always of papillary type and the
  epithelium burrowing through the capsule produces
  papillary processes on the serous surface.
• Extension of the growth to the pelvis and
  adjacent organs fixes the tumor.
• Ascites is always present.

Serous cystadenocarcinoma, ovary
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• Serous papillary cystic tumor of borderline
  malignancy.
• There is extensive, orderly invagination of the
  neoplastic glands, most with intraluminal
  papillae, into the stromal component of the
  neoplasm. The stroma is unaltered in appearance.

Serous papillary cystic tumor of borderline
malignancy. White polypoid excrescences that
were soft arise from the lining of the cyst.
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Mucinous Cystadenocarcinoma

• This is only a third as common as the serous
  variety.
• Malignancy in a mucinous cyst is characterized by
  the formation of areas of solid carcinoma in the
  wall.
• The cells are columnar, show mitoses and tend to
  form glandular structures.

Mucinous cystadenocarcinoma - papillary
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• Multilocular mucinous cystic tumor.

Mucinous cystic tumor of borderline malignancy.
Edematous papillae have a prominent inflammatory
cell infiltrate.
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Mucinous Cystadenocarcinoma
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Endometrioid Carcinoma of the Ovary

• Usually the lesion is cystic and chocolate brown
  in color.
• If such a cyst ruptures spontaneously, malignancy
  should be suspected.
• The histology varies as in uterine carcinoma.
• It may be a well-differentiated adenocarcinoma,
  an adeno-acanthoma, mucinous adenocarcinoma or
  clear-celled carcinoma.

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• Serous, mucinous, endometrioid, and clear cell
  tumors of the ovary are for the most part cystic
  lesions, and aspirates usually yield some fluid.
• The most common neoplasm is the serous type,
  which yields groups of cells in papillary,
  acinar, and single forms.
• Psammoma bodies may be encountered in aspirates,
  but this feature is present in only a minority of
  cases

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Differences Between Benign Malignant
Benign Malignant
Unilateral Bilateral
Cystic Solid component
Unilocular Multilocular
Stable over time Growth
No ascites Ascites
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Teratomas

• Cystic teratomas are the most common benign tumor
  of the ovary and usually occur in women ages 20
  30 and frequently they are bilateral.
• These masses are also frequently referred to as
  dermoids but a distinction between dermoids and
  teratomas exists.
• Dermoids (derived from two germ cell layers) are
  always benign, teratomas (derived from three germ
  cell layers) maintain a malignant potential.
• Teratomas are ovoid and unilocular and as they
  mature they may form teeth, hair and glandular
  tissue.
• The wall consists of dense fibrous tissue lined
  by stratified squamous epithilium.
• Thick yellow sebacious material fill the cyst.
• Many teratomas are located superior to the fundus
  of the uterus making them a potential easy miss
  with sonographic evaluation.

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Benign cystic teratoma, ovary
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Stromatous Tumours Germ Cell Tumours

• .Fibroma or sarcoma.
• .Dysgerminoma.
• .Teratoma.
• .Gonadoblastoma.
• .Yolk sac tumour.
• .Carcinoid
• .Thyroid tumour Choriocarcinoma

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Hormone-Producing Tumors

• Estrogen-producing
• Granulosa cell tumour.
• Thecoma.
• Androgen-prodicing
• Sertoli-Leydig cell tumour (Arrhenoblastoma).
• Hilar cell tumour.
• Lipoid cell tumour.

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Krukenberg Tumour

• There is one well-known secondary tumour of the
  ovary, the krukenberg tumour, a secondary of a
  stomach carcinoma.

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CA-125

• CA-125 (cancer antigen 125 or carbohydrate
  antigen 125) also known as mucin 16 or MUC16 is a
  protein that in humans is encoded by the MUC16
  gene. MUC16 is a member of the mucin family
  glycoproteins. CA-125 has found application as a
  tumor marker or biomarker that may be elevated in
  the blood of some patients with specific types of
  cancer, or other benign conditions.

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As a biomarker

• CA-125 is clinically approved for following the
  response to treatment and predicting prognosis
  after treatment. It is especially useful for
  detecting the recurrence of ovarian tumor. Its
  potential role for the early detection of ovarian
  cancer
• In April 2011 the UK's National Institute for
  Health and Clinical Excellence (NICE) recommended
  that women with symptoms that could be caused by
  ovarian cancer should be offered a CA-125 blood
  test. The aim of this guideline is to help
  diagnose the disease at an earlier stage, when
  treatment is more likely to be successful. Women
  with higher levels of the marker in their blood
  would then be offered an ultrasound scan to
  determine whether they need further tests.

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