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Fifth stage
Gynecology
Lec-5
د. احمد جاسم
6/4/2016
Surface epithelial-stromal tumor
Tumors of Surface Epithelium form 90% of ovarian tumors
Surface epithelial-stromal tumors are a class of ovarian neoplasms that may be
benign or malignant. Neoplasms in this group are thought to be derived from the
ovarian surface epithelium (modified peritoneum) or from ectopic endometrial or
Fallopian tube (tubal) tissue. This group of tumors accounts for the majority of all
ovarian tumors. Serum CA-125 is often elevated but is only 50% accurate so it is not a
useful tumour marker to assess the progress of treatment.
Classification
Epithelial-stromal tumors are classified on the basis of the epithelial cell type, the
relative amounts of epithelium and stroma, the presence of papillary processes, and
the location of the epithelial elements. Microscopic pathological features determine
whether a surface epithelial-stromal tumor is benign, borderline, or malignant
(evidence of malignancy and stromal invasion). Borderline tumors are of uncertain
malignant potential.
This group consists of serous, mucinous, endometrioid, clear cell, and brenner
(transitional cell) tumors, though there are a few mixed, undifferentiated and
unclassified types.
Serous tumors
These tumors vary in size from small and nearly imperceptible to large, filling the
abdominal cavity.
Benign, borderline, and malignant types of serous tumors account for about 30% of
all ovarian tumors.
75% are benign or of borderline malignancy, and 25% are malignant
The malignant form of this tumor, serous cystadenocarcinoma, accounts for
approximately 40% of all carcinomas of the ovary and are the most common
malignant ovarian tumors.
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• Serous Tumors
– Incidence – 30-50% of ovarian neoplasms
• Serous cystadenoma:
– Age group: 20 – 30 yrs
– Bilateral in 15%
– Malignant transformation in 20 – 30 %
• Serous cystadenocarcinoma:
– Age group: 40 – 60 yrs
– Bilateral in 30%
– 5 year survival rate: 30 – 50 %
– Features:
• Contain fibrous walled cysts with papillary excrescences
• Locules contain straw-colored fluid
• Psammoma bodies=concentric calcification in papillary process
– Usually fine sand-like calcification frequently difficult to see on
plain radiographs
• Benign and borderline tumors are most common between the ages of 20 and 50
years.
• Malignant serous tumors occur later in life on average, although somewhat earlier in
familial cases.
• 20% of benign, 30% of borderline, and 66% of malignant tumors are bilateral (affect
both ovaries).
• Components can include:
• cystic areas
• cystic and fibrous areas
• predominantly fibrous areas
• The chance of malignancy of the tumor increases with the amount of solid areas
present, including both papillary structures and any necrotic tissue present.
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Pathology
• lined by tall, columnar, ciliated epithelial cells
• filled with clear serous fluid
• the term serous which originated as a description of the cyst fluid has come to be
describe the particular type of epithelial cell seen in these tumors
• may involve the surface of the ovary
• the division between benign, borderline, and malignant is ascertained by assessing:
– cellular atypia (whether or not individual cells look abnormal)
– invasion of surrounding ovarian stroma (whether or not cells are infiltrating
surrounding tissue)
– borderline tumors my have cellular atypia but do NOT have evidence of
invasion
– the presence of psammoma bodies are a characteristic microscopic finding of
cystadenocarcinomas.
Prognosis
• The prognosis of a serous tumor, like most neoplasms, depends on
• degree of differentiation
– this is how closely the tumor cells resemble benign cells
– a well-differentiated tumor closely resembles benign tumors
– a poorly differentiated tumor may not resemble the cell type of origin at all
– a moderately differentiated tumor usually resembles the cell type of origin, but
appears frankly malignant
• extension of tumor to other structures
– in particular with serous malignancies, the presence of malignant spread to the
peritoneum is important with regard to prognosis.
• The five year survival rate of borderline and malignant tumors confined to the ovaries
are 100% and 70% respectively. If the peritoneum is involved, these rates become
90% and 25%.
• While the 5-year survival rates of borderline tumors are excellent, this should not be
seen as evidence of cure, as recurrences can occur many years later.
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Mucinous tumors
• Closely resemble their serous counterparts
• Somewhat less common, accounting for about 25% of all ovarian neoplasms
• Occur principally in middle adult life and are rare before puberty and after
menopause
• 80% are benign or borderline and about 15% are malignant
• Mucinous cystadenocarcinomas (the malignant form of this tumor) are relatively
uncommon and account for only 10% of all ovarian cancers .
• Mucinous Tumors
– Incidence – 30% of ovarian neoplasms
• Mucinous cyst adenoma
– Commonest tumor
– Age group: 30-50 yrs
– Bilateral in 10%
• Mucinous cystadenocarcinoma
– Age group: 40-60 yrs
– Bilateral in 10 %
– Features
• Large multilocular pedunculated cyst
• Rare complication may occur with involvement of the peritoneum
– Psedomyxoma peritonei (jelly belly)
• May produce coarse calcifications in primary or metastases
• Mucinous tumors are characterized by more cysts of variable size and a rarity of
surface involvement as compared to serous tumors
• Also in comparison to serous tumors, mucinous tumors are less frequently bilateral,
approximately 5% of primary mucinous tumors are bilateral.
• May form very large cystic masses, with recorded weights exceeding 25kg
• Appear as multiloculated tumors filled with sticky, gelatinous fluid
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Pathology
• Benign mucinous tumors are characterized by a lining of tall columnar epithelial cells
with apical mucin and the absence of cilia, similar in appearance with benign cervical
or intestinal epithelia. Cystadenocarcinomas (malignant tumors) contain a more solid
growth pattern with the hallmarks of malignancy: cellular atypia and stratification,
loss of the normal architecture of the tissue, and necrosis. The appearance can look
similar to colonic cancer. Clear stromal invasion is used to differentiate borderline
tumors from malignant tumors.
Prognosis
• 10-year survival rates for borderline tumors contained within the ovary, malignant
tumors without invasion, and invasive malignant tumors are greater than 95%, 90%,
and 66%, respectively. One rare but noteworthy condition associated with mucinous
ovarian neoplasms is pseudomyxoma peritonei. As primary ovarian mucinous tumors
are usually unilateral (in one ovary), the presentation of bilateral mucinous tumors
requires exclusion of a non-ovarian origin.
Endometrioid tumors
• Endometrioid tumors account for approximately 20% of all ovarian cancers and are
mostly malignant (endometroid carcinomas). They are made of tubular glands
bearing a close resemblance to benign or malignant endometrium. 15-30% of
endometrioid carcinomas occur in individuals with carcinoma of the endometrium,
and these patients have a better prognosis. They appear similar to other surface
epithelial-stromal tumors, with solid and cystic areas. 40% of these tumors are
bilateral, when bilateral, metastases is often present.
• Endometrial tumors
– Incidence – 20% of ovarian tumors
– Morphology:
• Tumors containing solid and cystic areas
• Filled with hemorrhagic fluid
• Lined by glandular epithelium
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Pathology
• Glands bearing a strong resemblance to endometrial-type glands
– Benign tumors have mature-appearing glands in a fibrous stroma
– Borderline tumors have a complex branching pattern without stromal invasion
– Carcinomas (malignant tumors) have invasive glands with crowded, atypical
cells, frequent mitoses. With poorer differentiation, the tumor becomes more
solid.
Prognosis
• Prognosis again is dependent on the spread of the tumor, as well as how
differentiated the tumor appears. The overall prognosis is somewhat worse than for
serous or mucinous tumors, and the 5-year survival rate for patients with tumors
confined to the ovary is approximately 75%.
Clear cell tumors
• Clear cell tumors are characterized by large epithelial cells with abundant clear
cytoplasm and may be seen in association with endometriosis or endometrioid
carcinoma of the ovary, bearing a resemblance to clear cell carcinoma of the
endometrium. They may be predominantly solid or cystic. If solid, the clear cells tend
to be arranged in sheets or tubules. In the cystic variety, the neoplastic cells make up
the cyst lining.
• Clear Cell (mesonephroid tumor)
– Incidence: uncommon
– Age group: 50 – 60 yrs
– Morphology:
• Unilocular cysts with small cystic spaces
Prognosis
• These tumors tend to be aggressive, the five year survival rate for tumors confined to
the ovaries in approximately 65%. If the tumor has spread beyond the ovary at
diagnosis, the prognosis is poor.
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Brenner tumor
• Brenner tumors are uncommon surface-epithelial stromal cell tumors in which the
epithelial cell (which defines these tumors) is a transitional cell. These are similar in
appearance to bladder epithelia. The tumors may be very small to very large, and
may be solid or cystic. Histologically, the tumor consists of nests of the
aforementioned transitional cells within surrounding tissue that resembles normal
ovary. Brenner tumors may be benign or malignant, depending on whether the
tumor cells invade the surrounding tissue.
• Brenner tumor:
• Incidence: 1- 2%
• Occur commonly in perimenopausal women
Treatment
• For advanced cancer of this histology, the US National Cancer Institute recommends
a method of chemotherapy that combines intravenous (IV) and intraperitoneal (IP)
administration.Preferred chemotherapeutic agents include a platinum drug with a
taxane.