• Grossly will appear as ovoid, smooth or nodular surface with a dense, white fibrotic cut surface +/- small simple cysts

• Should see ovarian follicles & dense spindled stroma

• Often will see corpus luteum or corpora albicantia (left over from previous menstrual cycles)

INTRODUCTION

Normal Ovarian  Histology

• The ovary is the most common site of EM. Breakdown of the hemorrhagic material results in the "chocolate cyst" appearance on gross examination

• Typical histology

  • Endometrial glands​

  • Dense stroma surrounding glands

  • Extravasated RBCs

  • +/- hemosiderin

​

View Virtual Slide

Endometriosis/ Endometrioma

• Twisting of the ovary (especially large, cystic ovaries) can disrupt the blood supply

• Doppler will show decreased/no blood flow to the ovary

• Medical emergency! Must operate immediately & untwist the ovary to reduce ischemia. May require removal (oophorectomy)

• Grossly, the ovary will be dark & dusky with hemorrhagic

Gross Examination

Ovarian Torsion

• Small, atrophic, not properly developed ovaries --> DEC estrogen

• Associated with Turner Syndrome (45 XO)

  • Streak ovaries (seen left)

  • Cystic Hygroma​ (web neck)

  • Lymphangiectasia

  • Coarctation of the aorta

• Delayed puberty & Premature menopause​

• Histology: Lack of follicle development - will not see ova (eggs/follicles) in the ovarian stroma

Gross Examination

Streak Ovaries

• Multiple cysts (often, but not required for clinical diagnosis)

• Clinical= Obesity, Hirsutism, Diabetes/Insulin resistance, secondary amenorrhea

  • Infertility from anovulatory cycles

• Histology: Thick capsule, multiple follicular cysts +/- luteinization ​

• Stein Leventhal syndrome

Learn More...

Polycystic Ovaries

• Bilateral theca lutein cysts are seen in patients with choriocarcinoma of the uterus

Large

cysts -->

Theca Lutein Cysts

• Most often in fallopian tube, but could occur in ovary

• Clinical pic= +/- hx of PID, Amenorrhea, Vaginal bleeding, Pain

• Diagnosis =  elevated/abnormal HCG levels & ultrasound

• D&C (of endometrium) would NOT have fetal parts

• Requires emergency surgery 

​​

<-- Click to examine this slide demonstrating an ectopic tubal gestation. Notice the chorionic villi present and abundant hemorrhage from rupture of the tube.

View Virtual Slide

Ectopic Pregnancy

• Most common type (65-70%)

• Avg patient = OLDER (>20 years old)

• Types:

  • Serous​

  • Mucinous

  • Endometrioid

  • Clear Cell

  • Brenner

​​

- See Section Below - 

Surface Epithelial Tumors

• 2nd most common (15-20%)

• Avg patient age = YOUNGER (0-25) 

• Types:

  • Cystic Teratoma

  • Small cell carcinoma

  • Dysgerminoma

  • Yolk Sac Tumor
  • Embryonal Carcinoma
  • Polyembryoma
  • Choriocarcinoma
  • Gonadoblastoma
  • Gynandroblastoma

Germ Cell

Tumors

• Least common primary tumor (10%)

• Affects ALL ages

• Types:

  • Granulosa Cell Tumor​

  • Juvenile Granulosa Cell Tumor

  • Fibroma/Thecoma​

  • Sertoli Cell Tumor

  • Leydig Cell Tumor

  • Carcinosarcoma

Sex Cord-

Stromal Tumors

• TYPICAL CHARACTERISTICS

  • ​LOWER GRADE Tumors

  • Relatively benign course

  • Often arise from precursor lesion

  • Large cystic masses, often unilateral

• CLASSIFICATION

  • Benign​

  • Borderline

  • Invasive

• TYPES

  • LOW GRADE serous or endometrioid CA,

  • Mucinous CA

  • Clear cell CA (some)

• MOLECULAR

  • KRAS, BRAF, ARIDIA​

  • Rarely BRCA1, BRCA2 or TP53

Type 1  Surface Epithelial Tumors

• TYPICAL CHARACTERISTICS

  • HIGH GRADE​ Tumors

  • More aggressive

  • Typically present in advanced stages

  • Can be from tubal origin

• TYPES

  • HIGH GRADE Serous

    • Primary ovary= HG Serous CA ovary​

    • Fallopian tube CA or 

    • Primary peritoneal/ Pelvic

  • HIGH GRADE Endometrioid CA

  • Carcinosarcoma (MMMT)

  • Undifferentiated CA

  • Clear cell CA (some)

• MOLECULAR​

  • BRCA1 OR BRCA2​

  • TP53

Type 2 Surface Epithelial Tumors

• CYSTadenoFIBROma

  • CYSTic 

  • ADENO (glands)

  • FIBRO(us tissue)

  • -OMA = benign (non-invasive)

• Thick, bulbous, bulky protrusions​

• View the virtual slide of this cystadenofibroma with a bonus Brenner tumor​

Cystadenofibroma

​

• Over 95% are benign

• Histology

  • Transitional epithelium

  • Moderate cellularity

  • Sheets of cells

  • Can see "coffee-bean" nuclear grooves

    • POP QUI​Z- What other GYN tumor has nuclear grooves??Granulosa Cell Tumor​​

• Differential Diagnosis​​

  • Metastatic Renal Cell Carcinoma​

• View the virtual slide that contains both endometrioid adenocarcinoma & clear cell adenocarcinoma!

Brenner Tumor

• Most common type (25-50%)

• Unicystic or Multilocular Cysts filled with serous fluid

  • Look for/sample any solid areas

  • Look for any papillary projections

  • Is there surface involvement?

    • Higher chance of LN or spread​

• Clues on Histology:

  • Psammoma bodies​

• Spectrum of Disease (click to open virtual slide):

  • Serous cystadenoma​ (70%)

    • Benign, simple cyst​

    • Low grade, single cell layer, no atypia

  • Borderline/ Low malignant potential (5-10%)

    • Overgrowth, Branching, Tufting​

    • Microinvasion= <5mm2

  • Micropapillary Serous CA​

    • Low grade nuclei

    • Bilateral​ ovaries involved

    • Surface involvement + omental spread common

    • Invasive vs desmoplastic type

  • Cystadenocarcinoma (20-25%)

    • Low vs. High grade

    • Clue on low power= clearing around the invasive component​

Serous Tumors

• Looks just like endometrial carcinoma of the uterus (or colon ADC too)

• Histology

  • Tall columnar cells, "pencil" nuclei

  • Microacini​/Glandular

  • Mitosis & apoptosis

  • ​Squamous differentiation

    • CLUE: Seeing squamous portions helps DDx endometrial from colon CA​

    • Colon CA also has "dirty necrosis"

Endometrioid Carcinoma

• Can grow VERY large

• Lined by mucinous epithelium

  • Intestinal-type

    • Goblet cells or Paneth cells​

    • More aggressive

    • View Virtual Slide of this Intestinal Type (Borderline) Mucinous tumor 

  • Mullerian-type

    • endocervical-like glands

    • a/w endometriosis

• Spectrum of Disease​​ (Click each entity to open virtual slide)

  • Mucinous cystadenoma​

  • Mucinous Borderline tumor/ low malignant potential ​​

  • Mucinous carcinoma

• Other mucinous tumors​

  • Pseudomyxoma peritonei​

  • Krukenburg tumor (Mucinous ADC of appendix)

Mucinous Tumors

• Associated with endometriosis

• Histology

  • Clear, vacuolated cytoplasm

  • Papillary structures have thicker, wider fibrous core lined by "hobnailing" cells

  • Can have hyaline (dense pink) cytoplasmic inclusions 

  • Pleomorphic macronucleoli​

• Differential Diagnosis​​

  • Metastatic Renal Cell Carcinoma​

• View the virtual slide that contains both endometrioid adenocarcinoma & clear cell adenocarcinoma!

Clear Cell Carcinoma

• 2nd most common (15-20%)

• Avg patient age = YOUNGER (0-25) 

• Types:

  • Cystic Teratoma

  • Small cell carcinoma

  • Dysgerminoma

  • Yolk Sac Tumor

  • Embryonal Carcinoma

  • Polyembryoma

  • Choriocarcinoma

  • Gonadoblastoma

  • Gynandroblastoma

Germ Cell

Tumors

• Least common primary tumor (10%)

• Affects ALL ages

• Types:

  • Granulosa Cell Tumor​

  • Juvenile Granulosa Cell Tumor

  • Fibroma/Thecoma​

  • Sertoli Cell Tumor

  • Leydig Cell Tumor

  • Carcinosarcoma

Sex Cord-

Stromal Tumors