2. Case History
65 year old post-menopausal woman presented
with complaints of
• abdominal distention
• spotting P/V intermittent for 6 month.
3. Clinical Examination
• P/A – Mass palpable the size of that of 28
weeks of gravid uterus occupying the
umbilical, hypogastric right and left lumbar
and iliac regions.
• Mass is non-tender, no warmth with regular
borders,surface smooth with variable
• Cervix, vagina – looks healthy.
4. • US Abdomen – A large abdominopelvic complex cystic
lesion - ? Mucinous Cystadenocarcinoma. Advised CECT
Abdomen for further evaluation.
• CECT Abdomen – Ovarian Solid Cystic Lesion likely to
represent Carcinoma Ovary.
• Tumor markers –
– CEA – 9.89 ng/mL (non-smokers upto 3.0 , smokers upto 5.0 )
– CA-125 – 34.09 U/ml ( < 35 U/ml)
• PAP Smear (G720/17) – Candidiasis and was Negative for
Intraepithelial Lesion and Malignancy.
• Patient underwent Staging Laprotomy under
SA and EA.
Patient underwent Total Abdominal
Hysterectomy with bilateral salpingo-
ophrectomy, Infracolic omentectomy was also
6. SPECIMEN - GROSS EXAMINATION
• Received a container labelled
right ovarian tumor with right
Fallopian tube (984/17) -
– Partially cut open ovarian mass
measuring 19 x 14.5 x 14.5 cm
with attached stretched out
Fallopian tube measuring 2cm in
– The external surface of the mass
– The cut sections showed
• multiloculated cyst (predominantly
cystic and partially solid areas
measuring 6 x 2.3 cm)
• 20-30 ml of mucinous fluid was
• Lumen of tube identified.
10. Specimen - Gross Examination
• Also received a container labelled uterus with cervix with
left ovary and left tube (985/17) .
– atrophic uterus with cervix measuring 8 x 4 x 3 cm with
attached tube measuring 4.5 cm and ovary measuring 2.5 x 1
– The external surface of uterus and cervix are unremarkable.
– The cut section of uterus and cervix shows
• Endocervical canal measuring 1.5 cm showing a Nabothian Cyst
• Endometrial canal measuring 2.5 cm occupied by a polyp measuring 1
x 0.5 cm. The endometrial thickness measured 0.5 cm and
endomyometrail thickness measured 1.5 cm on both sides.
– The cut section of tube and ovary shows
• Lumen of tube identified.
• Ovary shows corpus albicans.
11. Specimen - Gross Examination
• Also received container labelled omental
– Received single linear fibrofatty mass measuring
– No lymph nodes were identified
12. Specimen - Examination
• Also received peritoneal fluid for examination
• Examination of peritoneal fluid (NGC 110/17)
showed acellular smear
20. Microscopy (984/17)
• Sections studied from the cyst (A-E)showed multiloculated cyst
lined by intestinal type of columnar epithelium with underlying
subepithelium stroma consisting of ovarian stroma.
• Sections studied from thickened fibrous wall of cyst or solid areas
(F-K) comprises of predominantly solid nests of transitional
epithelium with occasional microcystic spaces containing
eosinophilic secretions in the background of fibrous stroma. The
individual tumor cells have moderate clear to eosinophilic
cytoplasm, vesicular nuclei with some nuclear grooves surface lined
by intestinal type of epithelium mainly. Foci of mucin secreting
columnar epithelium also seen.
• Sections studied from (Right) Fallopian tube (attached to ovarian
cyst) showed normal histology.
21. Microscopy (985/17)
Sections studied from
– Cervix (A,B) reveal endocervix showing chronic papillary
endocervicitis with squamous metaplasia and Nabothian
– Endomyometrium (C,D) reveal
– Endometrium showing polyp and features of
– Myometrium showing adenomyosis.
– (Left) tube showing normal histology.
– (Left) ovary showing corpus albicans.
27. SEROUS CYSTADENOMA
• Generally benign, most commonly seen in reproductive age group.
• Most common subtype of surface epithelial tumors.
• Bilateral – 10%
• Risk of malignancy : 10 – 15 % borderline malignant
20 -25% malignant
• GROSS : unilocular cyst with fibrous stroma , papillary components.
• MICRO : low columnar epithelium with cilia.
• Characteristic psammoma bodies (end products of degeneration of
papillary implants)are found.
• Associated fibrosis may lead to “cystadenofibroma”
• Lesions without cystic component - adenofibromas
29. MUCINOUS CYSTADENOMA
• Round to ovoid unilateral multiloculated masses with smooth
capsules that are usually translucent or bluish to whitish gray.
• Have tendency to become large masses (upto 50cm)
• Interior divided by discrete septa into loculi containing clear ,
• Epithelium – tall, pale staining, secretary with basal nuclei and
• 5 – 10% are malignant.
31. DERMOID CYST
• Often bilateral (15 -25%)
• GROSS: thick, opaque , whitish wall.
• CONTENTS: hair, bone, cartilage, and a large amount of greasy sebaceous
• MICROSCOPICALLY : all the three germ layers (ectoderm, mesoderm and
• Malignant change occurs in 1-3%. Usually of a squamous type.
• Risk of torsion is 15%
• An ovarian cystectomy is almost always possible, even if it appears that
only a small amount of ovarian tissue remains
• Most common benign, solid neoplasms of the ovary.
• Compose approx 5% of benign ovarian neoplasms and 20% of all solid
tumors of the ovary.
• Frequently seen in middle-aged women.
• Characterized by their firmness and resemblance to myomas
• Misdiagnosed as exophytic fibroids or primary ovarian malignancy
• Not hormonally active
• Fibromas may be associated with ascites or hydrothorax as a result of
increased capillary permeability thought to be a result of VEGF
• Meig’s syndrome (ovarian fibromas, ascites and hydrothorax) is
uncommon and usually resolves after surgical excision.
• Solid fibromatous lesions that show varying degrees of yellow or
• Almost always confined to one ovary
• Usually >40 years, 65% after menopause
• May be hormonally active and hence associated with estrogenic or
occasionally androgenic effects.
• Luetinised thecoma – younger, sclerosing peritonitis and ascites
• Leydeig cell thecoma – ass. with Reinke crystals
• Rarely malignant
37. BRENNER TUMOR
• Uncommon tumor grossly identical to fibroma
• .90% are unilateral
• Arise from Walthard cell rests ,also from surface epithelium, rete ovarii and
• Grossly, they are solid, sharply circumscribed and pale yellow-tan in colour.
• On microscopy – markedly hyperplastic fibromatous matrix interspersed with
nests of epithelial cells showing coffee bean pattern
• Considered uniformly benign,but scattered reports of malignant Brenner’s is
• Endocrinologically inert, but could be associated with virilization and
39. Differential Diagnosis for Brenner’s tumor
Benign Brenner tumors are generally resembles
other solid ovarian masses such as
• Pedunculated leiomyoma
40. Mixed Brenner-Mucinous Tumors
• Tumors containing both Brenner and mucinous components
are more common than previously appreciated.
• Believed to be variants of Brenner tumor and can be classified
as metaplastic Brenner tumor or mixed Brenner–mucinous
• 1/4th of benign ovarian epithelial tumors that have a
mucinous component also contain a Brenner component.
• Conversely, 16% of tumors with a Brenner component contain
a mucinous component.
Notas del editor
1. Benign epithelial tumors of the ovary can reach massive proportions. The serous cystadenoma seen here fills a surgical pan and dwarfs the 4 cm ruler
2.Here is a benign serous cystadenoma that demonstrates multiloculation. Note that the inner surface is, for the most part, smooth, with only a solitary papillation at the upper right.
3. Ultrasound imaging
4. Histopathological section: With few papillary projections from the surface
1.Cut open section of mucinous cystadenoma..
2. Histological section showing tall epithelial lining with pale staining nuclei at the basal pole.
3. Variable echogenicity in the contents of an adnexal multilocular cyst
The photo below shows a well-developed tooth arising from the right side of the mural nodule ("Rokitansky nodule") that contains most of the solid teratomatous elements. The central portion of the nodule contains mostly cutaneous tissues (skin, sweat glands, and hair follicles), while the neural tissues extend into the wall toward the left.
1. Mature cystic teratoma with typical long hyperechogenic lines and bright prominent spots representing hair in fluid.
2. Mature cystic teratoma with Rokitansky nodule or 'dermoid plug'(arrow) with posterior acoustic shadowing.
grayish white and firm
Microscopically – stellate or spindle shaped cells arranged in fusiform pattern. Hyalinisation is frequent. The elongated fibroblastic tumor cells have spindle-shaped nuclei and may contain small amounts of lipid in their cytoplasm
Benign lesions can be managed by simple excision.
t/t of malignant brenner tumours is unsettled, various forms of chemotherapy have been used with little success.
Walthard cell rests are a benign cluster of epithelial cells most commonly found in the connective tissue of the Fallopian tubes, but also seen in the mesovarium, mesosalpinx and ovarian hilus. solid, sharply circumscribed and pale yellow-tan in colour. 90% are unilateral (arising in one ovary, the other is unaffected). The tumours can vary in size from less than 1 centimetre (0.39 in) to 30 centimetres (12 in). Borderline and malignant Brenner tumours are possible but each are rare.
Hyperplastic fibromatous matrix interspersed with nests of epitheloid cells
On high magnification, they exhibit characteristic coffee bean nuclei (clearly visible in image). On low magnification, they resemble urothelial cell nests.