Ovarian Cancer

Ovarian Surface Epithelial Tumors

Serous Tumors of the Ovary

Benign Serous Cystadenoma

Histology: ciliated/non-ciliated columnar cells
- single layer (no mucin)
- note: serous adenofibroma has broad shaped papillae

Borderline Serous Tumors

Histology: epithelium is stratification, mild-moderate atypia, free floating buds
- no stromal invasion
- can have overlying mesothelial hyperplasia
- microinvasion – clusters of tumor cells in stroma < 10 mm2

Borderline Serous Implants

Non-invasive Implants

1. epithelial: non-invasive papillary epithelial cells, stroma normal, “stuck on” or “berween lobules of fat”
2. desmoplastic: tumor nodules have more abundant cytoplasm, inflammation and granulation tissue

Invasive Implants

- infiltrative pattern of growth into fat (some desmoplasia), irregular margins
- have retraction artifact

Malignant Serous Cystadenocarcinoma

Histology: high grade, obvious stromal invasion
- branching papillae with no stromal support
- slit like spaces
- psammoma bodies often seen
Immunohistochemistry: WT-1 positive
Differential diagnosis from mucinous cystadenocarcinoma: CEA negative and CK7+/CK20-

Micropapillary serous carcinoma

- filigree pattern of branching, no stromal invasion

Mucinous Tumors of the Ovary

Benign Mucinous Cystadenoma

Histology:endocervical-type lining, minimal stratificaton and minimal atypia
- can arise in a dermoid cyst

Borderline Mucinous Tumor

Endocervical-type Borderline Mucinous Tumor

- 90% of mucinous borderline tumors
Histology: complex papillae, mild atypia, nuclear stratification, no stromal invasion
i. with microinvasion or with microinvasive carcinoma
- single cells, glands, clusters, cribriform nests < 10mm2
ii. with pelvic or abdominal implants

Intestinal-type Borderline Mucinous Tumor

- 10% of mucinous borderline tumors
Histology: intestinal type epithelium with goblet cells and Paneth cells
- stratification, mild to moderate atypia, no stromal invasion
i. with IEC (intraepthelial carcinoma)
- grade 3 nuclei
ii. with microinvasion or with microinvasive carcinoma
- single cells, glands, clusters, cribriform nests < 10mm2

Malignant Mucinous Cystadenocarcinoma

Histology: atypia, stratification
i. Expansile type: no destructive stromal invasion but back to back complex malignant glands and > 10mm2
ii. Infilatrative type: obvious stromal invasion

Immunohistochemistry

CEA positive and CK7+/CK20+ (50%)

Other Mucinous Tumor Variants:
Mucinous cystic tumor with mural nodules
Mucinous cystic tumor with pseudomyxoma peritonei

Endometrioid Tumors of the Ovary

Gross appearance: solid and cystic with hemorrhagic contents

Benign Endometrioid Tumors

Histology

- like endometrial cyst but no endometrial stroma or hemorrhage   – rare

Borderline Endometrioid Tumors

- cytologically malignant endometrioid cells without obvious invasion
Microinvasion: nests < 10mm2

Malignant Endometrioid Tumor

Associations: 50% squamous differentiation, 20% endometriosis, 20% associated with concurrent uterine endometrial carcinoma

How to determine the primary with 2 endometrial tumors in ovary and uterus?

1. Pre-existing lesion: endometrial hyerplasia
2. Size
3. Angiolymphatic invasion
4. Grade
5. Surface involvement of ovary
6. Bilateral favors endometrium primary

Other tumors:
-adenocarcinoma, carcinosarcoma, adenosarcoma, endometrial stromal sarcoma, undifferentiation ovarian sarcoma

Clear Cell Tumors of the Ovary

Histology: STP pattern, eosinophilic hyaline globules (PAS +), hobnail pattern, dense hyalinized cores in papillae

Differential diagnosis:

- dysgerminoma
- metastatic renal cell carcinoma
- yolk sac tumor
- Krukenberg tumor (signet ring)
- steroid cell tumor
- Arias stella reaction change

Transitional Cell Tumors of the Ovary

Benign Brenner Tumor of the Ovary

Gross appearance: solid white whorled tumor mass < 2 cm
Histology: sharply demarcated nests of round, polygonal cells with oval-shaped nuclei with grooves, hyalinization in nests, dystrophic calcification

Borderline Brenner Tumor

- endocervical-lined microcysts +/- papillary TCC

Malignant Transitional Cell Carcinoma

TCC only

Malignant Brenner Tumor

Brenner (benign/bordeline) tumour + TCC

Squamous Cell Tumors

- epidermoid cyst
- SCC

MIXED EPITHELIAL TUMOURS

UNDIFFERENTIATED CARCINOMA

GRADING OVARIAN CANCER

For all tumors, except endometrioid and mucinous (see Uterus section)

Pattern

1 – glandular
2 – papillary
3 – solid

Nuclear

1 – variation in size <2:1
2 – variation in size 2-4
3 – variation in size >4:1

Mitoses

1 – <10 mitoses
2 – 10-24 mitoses
3 – >25 mitoses

Grade 1= 3,4,5 (well-differentiated)
Grade 2 = 6,7 (moderately-differentiated)
Grade 3 = 8,9 (poorly-differentiated)

OVARIAN CANCER STAGING

a    b    c

T1    Single ovary    Both ovaries    ruptured capsule, surface, + cells in wash/ascites

T2    Ovary(ies) + Pelvic extension
uterus or tube    other pelvic tissues    pelvic extn + cells in wash/ascites

T3    microscopic peritoneal mets    macroscopic peritoneal mets <2cm    macroscopic peritoneal mets <2cm OR reg. nodes

GROSSING OVARIAN CANCER

1. ink outer surface over irregular areas
2. open all cysts
3. if suspicion of malignancy submit 1section.1cm of cyst
4. describe cyst and contents

KEY POINTS
? benign tumor ? unilateral BSO
? borderline tumor ? BSO only if young, otherwise TAH
? carcinoma ? TAH/BSO + omentectomy + pelvic lymphadenopathy + washings/ascites collection + peritoneal biopsies