Ovarian cyst Dr. Hatem Al- Nuaimi Consultant pathologist MB.Ch.B, F.I.C.MS-Path

1. 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

3. 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.

4. Questions ???????? .1-classification 2-causes. 3-Diagnosis.

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

6. 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.  •  .

7. 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

8. 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. H&E stain.

9. 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

10. 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.

11. Microscopically

12. 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.

13. Neoplastic cyst

14. 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

15. 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.

16. Serous Cystadenoma Serous cystadenoma, ovary

17. 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.

18. Mucinous Cystadenoma

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

20. Pseudomyxoma Peritonei • This rare condition occasionally but not inevitably follows the rupture of a mucinouscystadenoma. • 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.

21. 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)

22. 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

23. 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.

24. 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

25. Multilocular mucinous cystic tumor. Mucinous cystic tumor of borderline malignancy. Edematous papillae have a prominent inflammatory cell infiltrate.

26. Mucinous Cystadenocarcinoma

27. 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, mucinousadenocarcinoma or clear-celled carcinoma.

29. 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

30. Differences Between Benign & Malignant

32. 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 squamousepithilium. • 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.

33. Dermoid Cyst Benign cystic teratoma, ovary

34. StromatousTumours Germ Cell Tumours .Fibroma or sarcoma. .Dysgerminoma. .Teratoma. .Gonadoblastoma. .Yolk sac tumour. .Carcinoid .Thyroid tumour Choriocarcinoma

35. Hormone-Producing Tumors • Estrogen-producing: • Granulosa cell tumour. • Thecoma. • Androgen-prodicing: • Sertoli-Leydig cell tumour (Arrhenoblastoma). • Hilar cell tumour. • Lipoid cell tumour.

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

37. 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 MUC16gene. 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.

38. 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.

39. ovarian cyst US Unilocular Multilocular - Heterogeneous -Thick walls -vegetation -Homogenous -Thin walls -No vegetation C.A. 125 <35 >35 Observe 2 months Laparoscopy or laparotomy Stable or <5cm >5cm Aspiration by U.S. Observe 6 months Cytology Suspicious Benign