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Diseases Of Ovary

Ovarian lesions present either with pain due to inflammation or swelling of the organ, or with the remote effects of an endocrine secretion.

Ovarian Cysts
Ovarian cysts may be non-neoplastic or neoplastic; many ovarian tumours are partially cystic. The various types of non-neoplastic cysts are:
  • Mesothelial-lined
  • Epithelial inclusion
  • Follicular
  • Luteinised follicular
  • Corpus luteum
  • Corpus albicans
  • Corpus luteum cyst of pregnancy
  • Endometriotic.
Inclusion cysts occur in the ovarian cortex probably as a result of surface trauma at the time of ovulation;

They may be lined by original peritoneal mesothelium or metaplastic epithelium. 

Ovarian Neoplasms
  1. May be solid or cystic, benign or malignant
  2. Borderline lesions have low risk of malignant behaviour
  3. Nomenclature based on cellular origin
  4. Some produce oestrogens
  5. Commonest fatal gynaecological malignancy in many countries
  6. Ovarian tumours may be divided into five broad categories: 
    1. Epithelial
    2. Germ cell
    3. Sex-cord stromal
    4. Metastatic
    5. Miscellaneous. 
1. Epithelial tumors
  1. They  are believed to arise from the mesothelial cell layer covering the peritoneal surface of the ovary and associated inclusion cysts.
  2. This mesothelium has the propensity to undergo metaplasia to Müllerian epithelium, as, indeed, does the entire mesothelial lining of the peritoneal cavity.
  3. Thus, differentiation may take place to resemble tubal mucosa (serous tumours), endocervical mucosa (mucinous tumours) or endometrium (endometrioid tumours).
  4. Transitional cell tumours do not fit neatly into this histogenetic theory as they resemble the transitional epithelium of the bladder.
  5. Each of these tumours may be benign or malignant.
  6. But there is a third category of borderline tumour.
  7. These tumours show some of the features associated with malignancy, such as irregular architecture, nuclear stratification and pleomorphism and mitotic activity, but lack the most important criterion of invasion.
  8. Their biological behaviour is intermediate between that of clearly benign and overtly malignant tumours.
  9. Aneuploid tumours are more likely to behave in a malignant manner.
  10. A significant proportion of mucinous tumours, particularly in the borderline category, contain intestinal-type rather than endocervical-type epithelium.
  11. These tumours may be complicated by peritoneal implants.
    1. Benign mucinous and serous tumours are commonly smooth-walled and cystic,
    2. While benign transitional cell (Brenner) tumours are solid but may show cystic areas.
    3. Endometrioid tumours of the ovary may show the full range of mixed Müllerian neoplasia already referred to in the context of uterine tumours, such as endometrioid adenofibroma and malignant mixed Müllerian tumours.
2. Germ Cell Tumours
A potentially confusing range of tumours may arise from germ cells in the ovary. These may be benign or malignant. 

  1. The fundamental or undifferentiated female ovarian germ cell tumour is the dysgerminoma, which is the exact counterpart of the seminoma arising in the male testis.
  2. It is a rare malignant tumour arising predominantly in young females; it is usually confined to one ovary and has a fleshy cut surface. Q
  3. Histologically, it shows a uniform appearance of germ cells admixed with lymphocytes. Occasional giant cells containing human chorionic gonadotrophin may be present, but these do not imply a poorer prognosis.
  4. These tumours are highly radiosensitive. 
Teratomas are divided into three categories:
  1. Mature (benign):
  1. Most benign teratomas are cystic and are known as dermoid cysts.
  2. These neoplasms are presumably derived from the ectodermal differentiation of totipotent cells.
  3. They are bilateral in 10% to 15% of cases.
  4. Characteristically, they are unilocular cysts containing hair and cheesy sebaceous material. On section, they reveal a thin wall lined by an opaque, gray-white, wrinkled, apparent epidermis.
  5. Generally, in one area of the cyst wall, a solid prominence is seen known as Rokitansky 's protuberance where tissue elements such as tooth, bone, cartilage & various other odd tissues are present.
  6. On histologic examination, the cyst wall is composed of stratified squamous epithelium with underlying sebaceous glands, hair shafts, and other skin adnexal structures. In most cases, structures from other germ layers can be identified, such as cartilage, bone, thyroid tissue, and other organoid formations.
  7. Dermoid cysts are sometimes incorporated within the wall of a mucinous cystadenoma.
  8. About 1 % of the dermoids undergo malignant transformation of anyone of the component elements (but most commonly, squamous cell carcinoma).
  1. Monodermal or Specialized Teratomas
  1. The rare group of tumors, the most common of which are struma ovarii and carcinoid.
  2. They are always unilateral, although a contralateral teratoma may be present.
  3. Struma ovarii is composed entirely of mature thyroid tissue. Interestingly, these thyroid neoplasms may hyperfunction, causing hyperthyroidism.
  4. The ovarian carcinoid, which presumably arises from intestinal epithelium in a teratoma, might in fact be functioning, particularly in large tumors, producing 5-hydroxytryptamine and the carcinoid syndrome.
  1. Immature Malignant Teratomas
  1. These are rare tumors that differ from benign teratomas in that the component tissue resembles that observed in the fetus or embryo rather than in the adult.
  2. The tumor is found chiefly in prepubertal adolescents and young women.
  3. These grow rapidly and frequently penetrate the capsule with local spread or metastases.
  4. On microscopy, there are varying amounts of immature tissue differentiating toward cartilage, glands, bone, muscle, nerve, and others.
  5. An important risk for subsequent extraovarian spread is the histologic grade of tumor, which is based on the proportion of tissue containing immature neuroepithelium.
3. Extraembryonic germ cell tumours
  1. Differentiation of germ cells may take place along extraembryonic (as opposed to embryonic) lines to form the neoplastic counterparts of the non-fetal parts of the conceptus (the primitive yolk sac and the trophoblast of the placenta).
  2. These elements may give rise to yolk sac tumours (also known as endodermal sinus tumours because of their resemblance to the endodermal sinuses of Duval .
Yolk Sac Tumours
  1. Yolk sac tumours usually affect young females below the age of 30 years.
  2. The tumours are cystic and solid and often haemorrhagic.
  3. Histologically, characteristic structures (Duval-Schiller bodies), composed of central vessels with a rosette of tumour cells, may be seen.
  4. Alpha-fetoprotein may be demonstrated immunohistologically and is used as a serum marker. Intra-abdominal metastasis occurs, and the prognosis for untreated patients is poor.


  1. Pure choriocarcinoma of the ovary is extremely rare and is associated with beta human chorionic gonadotrophin (βhCG) production.
  2. Theoretically, it could occur either as a germ cell tumour or as a primary or secondary gestational neoplasm, in which case the tumour would contain the paternal haplotype on chromosomal analysis.
  3. When choriocarcinoma is seen, it is more usually one component of a malignant mixed germ cell tumour.
4. Sex-cord stromal tumours
  1. During the fourth month of fetal life and onwards cell cords grow down from the surface epithelium of the ovary to surround the primordial follicles.
  2. Sex-cord stromal tumours comprise a range of ovarian neoplasms which frequently produce steroid hormones and are considered to arise from the cells which are the adult derivatives of these primitive sex cords in the fetal ovary.
  1. Thecoma is the commonest sex-cord stromal tumour. It presents in the reproductive years as an abdominal mass, and is a benign tumour of the ovarian stroma.
  2. It is usually unilateral and well-circumscribed with a pale, fleshy cut surface.
  3. Histologically, it is a cellular, spindle-celled tumour containing abundant lipid.
Granulosa cell tumour
  1. Granulosa cell tumours can occur at any age and all cases are potentially malignant, although there is a close correlation between large size at presentation and malignant behaviour.
  2. It is particularly associated with oestrogenic manifestations.
  3. It should, however, be remembered that granulosa cells do not synthesise oestrogens, but merely convert hormonal precursors to oestrogens.
  4. They present as unilateral multicystic tumours that may be focally haemorrhagic or necrotic. Histologically, they are composed of nests and cords of granulosa cells with characteristically grooved nuclei.
  5. Often, cells surround a central space containing eosinophilic hyaline material; this structure is called the Call-Exner body.
5. Sertoli-Leydig cell tumours
  1. Sertoli-Leydig cell tumours are rare tumours composed of a variable mixture of cell types normally seen in the testis.
  2. Pure Sertoli and Leydig cell tumours may also occur.
  3. The tumours may be well, moderately or poorly differentiated and may present with androgenic signs and symptoms.
  4. Leydig cells may be identified by the presence of Reinke's crystals within their cytoplasm. 
  1. Gonadoblastoma is a rare lesion, which may not be a true neoplasm, in which primitive germ cells and sex-cord stromal derivatives are present.
  2. The latter usually resemble immature Sertoli cells and granulosa cells.
  3. These lesions typically develop in the dysgenetic streak gonads of phenotypic females carrying a Y chromosome.
  4. The germ cell component may undergo malignant change, usually to form a dysgerminoma.
 Steroid cell tumours
  1. Steroid cell tumours are uncommon and are usually benign and unilateral.
  2. In many cases the patient presents with virilisation due to androgen production.
  3. Microscopically, the tumour is well circumscribed and composed of cells that resemble adrenal cortical cells and contain abundant intracellular lipid. 
6. Metastatic tumours
  1. Tumour metastatic to the ovary may be genital or extra-genital.
  2. Endometrial adenocarcinoma may spread to the ovary, but it should be remembered that primary endometrial adenocarcinoma may co-exist with primary endometrioid adenocarcinoma of the ovary and be associated with a favourable prognosis.
  3. Large intestine, stomach and breast adenocarcinomas are the most important extra-genital tumours.
  4. Metastatic colonic adenocarcinoma may be confused with primary mucinous cystadenocarcinoma or endometrioid adenocarcinoma.
  5. The term 'Krukenberg tumour' refers to bilateral ovarian neoplasms composed of malignant, mucin-containing, signet ring cells, usually of gastric origin.
  6. Breast carcinoma frequently metastasises to the ovary, but usually these metastases do not manifest themselves clinically.
  7. Metastatic malignant melanoma may first present as an ovarian tumour.

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