In Malaysia Ovarian Cancer

• 4th most common cause of

cancer deaths in women in UK
(5th most common in US and
Singapore)
• Malaysia: 4.1% of all female
cancers are ovarian
• 47% of all deaths from cancers
of the female genital tract are
caused by ovarian cancer
Silent and deadly
 Pathogenesis Two main theories

1. Incessant ovulation theory 2. Excess gonadotrophin

Suggests that any factors which reduce the secretion (FSH, LH)
number of ovulations during a woman’s life
will reduce the risk of ovarian CA developing Promotes higher levels of oestrogen which in
turn leads to epithelial proliferation and
malignant transformation of the ovarian
epithelium
 Protective Factor
1. Multiparity
2. Breastfeeding
3. Anovulation
4. Oral contraceptive pills
5. Tubal ligation
6. Hysterectomy
Risk Factor
1. Age: 45 – 60 years old
2. Nulliparous or of low parity
3. Previous PCOS or on tamoxifen
4. High calorie, high fat diet
5. Genetic predisposition BRCA-1 & BRCA-2 genes
6. Late menopause, early menarche
7. Breast & gastrointestinal cancer
8. Prolonged HRT in menopausal woman
9. IVF
 Classification
Ovarian tumour is not a single entity, but a complex wide spectrum of
neoplasms involving a variety of histological tissues
4 types of ovarian tumours
 Non-neoplastic Neoplastic
Benign Malignant
Follicular Follicular cyst Epithelial Serous cystadenoma Epithelial Serous cystadenocarcinoma
Corpus luteal cyst tumor Mucinous cystadenocarcinoma
Mucinous Endometriod
cystadenoma Clear cell
Theca-lutein cyst Brenner tumor Undifferentiated
Inflammatory Tubo-ovarian Sex cord Fibroma Sex cord Granulosa cell
abscess stromal stromal tumor Sertoli-Leydig
Thecoma Gynandroblastoma
Endometrioma Germ Mature teratoma Germ cell Immature teratoma
cell tumor Choriocarcinoma
Endodermal sinus (Yolk sac)
Dysgerminoma
Mixed
Metastatic (Krukenberg tumors)
 Epithelial Tumor
Types
1. Serous type 75% 50% undergo malignant transformation

2. Mucinous type 20% 5% undergo malignant transformation

Invasive cancers
seen in women of 3. Endometrioid 2%
aged 50-70 y/o
4. Brenner tumor < 1%

5. Clear cell carcinoma < 1%

6. Undifferentiated < 1%

Borderline Tumor
• 10- 20% of these tumors  Low malignant potential
• Remain confined to the ovaries
• Predominantly occur in premenopausal age group (30-50 y/o)
• Good prognosis
 1. Serous Cystadenoma
• Most
Serous common
cystadenoma
epithelial Malignant
1. ovarian tumor
Cystic (filled with serous 1. Solid, inner surface nodular
• Resemble
fluid), inner surface tube liningwith papillary structure
fallopian
glistening
(ciliated 2. Coarse papillary growth
columnar epithelium)
2. Papillary growth: spread to peritoneal
• 50% of cases bilateral
delicate papillary surfaces and paillary friable
• 30% are malignant
outgrowth within loculi 3. Loculi contained blood
• Account
3. for 50serous
Loculi contain – 80% of all stained
straw color
ovarian fluid
tumor 4. Low columnar cell, loss of
4. Lining
1. 60of– tumor is single
70% benign cilia, stratification,
layer tall columnar multilayered
2. 15%cell,
ciliated borderline
cystic spaces 5. Cellular atypia > 4 cell layer
3. 20 –atypia
5. Cellular 25% malignant
< 4 cell thickness
layer thickness 6. Stromal invasion
6. No stromal invasion 7. Pasammoma bodies
 2. Mucinous Tumor
• 30 – 60 years old • Can grow to a large size and often weight 5 to 10 kg
• Appearance • May be combined with a dermoid cyst or a brenner
1. Have glistening surface tumour
2. Multiloculated cysts lined • Usually unilateral
by mucus producing • 5 – 10% become malignant
columnar epithelium  • 10 – 15% low malignant potential (LMP)
resemble endocervical
3. Loculi filled with mucinous
contents
4. Cut surface shows
multiloculi and honeycomb
appearance
5. Often pedunculated
 3. Endometrioid Tumor
• 20 % of all malignant ovarian neoplasm
• Resemble endometrium (columnar
epithelium)
• Malignant
• Usually bilateral
• 10% associated with endometriosis
• 20% associated with primary
endometrial cancer of the uterus
• Gross: large solid, cystic mass,
haemorrhage & necrosis
• Histology: resemble endometrial CA
 4. Mesonephroid Tumor
• Also known as clear cell carcinoma
• Uncommon
• Highly malignant tumor
• Composed of cuboidal epithelial cells
with clear cytoplasm characteristically
forming tubules, gland, small cystic
spaces lined by Hobnail cells (clear
cells showing large dark nuclei
protruding into lumen)
 5. Brenner Tumor
• Uncommon
• Gross: Resembles fibroma of
ovary
• Histology: Background fibrous
tissue, interspersed within it are
nests of transitional epithelium
(Walthard cell rest)
• Its cut surface appears gritty and
yellowish grey
• Unilateral
• Small-moderate size
• Seen in women around
menopause
 Germ cell tumors
• Mainly in young women Mature Immature
• Composed of mixture of • Also derived from the three
• Incidence tissues of at least 2 germ layers germ layers but have primitive
1. 15 – 20% of all ovarian (ectoderm, mesoderm, immature cells (mostly,
endoderm) neuroectodermal tissues)
tumors • Solid, malignant, rare
2. 95% are benign cystic Mature teratoma/ benign cystic • Tumors are graded 1 to 3 by
teratoma/ dermoid cyst the amount of immature
teratomas (dermoids) 1. Ectodermal structures are neural tissue they contain.
predominant: skin, hair, teeth, • Grow rapidly and can cause
Type sweat and serbaceous gland, pain early
neural tissue
Teratoma 2. Mesodermal structures: bone,
Immature cartilage, muscle
Mature 3. Endodermal structures: lining
Monodermal/ highly specialized of respiratory and digestive
tract
Dysgerminoma
 Teratoma
Mature Immature Highly specialized
• Eg: Dermoid cyst • Eg: Solid teratoma • Eg Struma Ovarii
• 5-10% • Very rare • Consists entirely of thyroid
• Usually unilocular with smooth • Solid part contains cartilage tissue similar to that of a
surface and bones. It also can contain thyroid adenoma.
• Diameter: > 15cm muscle, brain tissue, glia, pia • The tumor is solid
• It contains sebaceous glands mater • To the naked eye, the tumour
and hair follicles • Cystic spaces contain hair & resembles a small mucinous
• Teeth, bone, cartilage, thyroid sebaceous material cystadenoma
tissue & bronchial mucus • Mostly malignant
membrane are also found
 Dysgerminoma
• Corresponds to seminoma of the testis
• 3 – 5% of all ovarian tumors
• Usually arises in young women / children (average
= 20 years old)
Gross Histology
Solid elastic rubbery consistency, smooth Consist of large cells arranged in bunches
& firm capsule or alveoli, appearance of large dark
– Cut surface is yellow/ grey with staining nuclei with clear cytoplasm and
lymphocyte infiltration of fibrous septa
areas of degeneration &
(diagnostic)
hemorrhage
– Usually unilateral

• Tumor is neutral, not secrete sex hormone

• Secrete placental alkaline phosphatase (PLAP), LDH
and BhCG