1. Academic Review
By
Dr.Varughese George
12/5/2017

2. Case History
65 year old post-menopausal woman presented
with complaints of
• abdominal distention
• breathlessness
• 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
consistency
• 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.
Investigations

5. Procedure
• Patient underwent Staging Laprotomy under
SA and EA.
Patient underwent Total Abdominal
Hysterectomy with bilateral salpingo-
ophrectomy, Infracolic omentectomy was also
done.

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
length.
– The external surface of the mass
was smooth.
– 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
drained.
• Lumen of tube identified.

7. Specimen - Gross Examination

8. Specimen - Gross Examination

9. Specimen - Gross Examination

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
cm.
– 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
biopsy (986/17)
– Received single linear fibrofatty mass measuring
37 cm.
– No lymph nodes were identified

12. Specimen - Examination
• Also received peritoneal fluid for examination
• Examination of peritoneal fluid (NGC 110/17)
showed acellular smear

13. Microscopy

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
cyst.
– Endomyometrium (C,D) reveal
– Endometrium showing polyp and features of
secretory phase.
– Myometrium showing adenomyosis.
– (Left) tube showing normal histology.
– (Left) ovary showing corpus albicans.

22. Microscopy (986/17)
• Section studied showed fibrofatty tissue with congested blood
vessels.

23. Impression
Mixed Epithelial Tumor of Right Ovary
(Combined Benign Brenner’s Tumor and Mucinous cystademona)

24. DISCUSSION

26. Benign ovarian tumors
• Serous cystadenoma
• Mucinous cystadenoma
• Dermoid cyst
• Fibroma
• Thecoma
• Brenner’s tumor

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 ,
viscid fluid.
• Epithelium – tall, pale staining, secretary with basal nuclei and
goblet cells
• 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
material.
• MICROSCOPICALLY : all the three germ layers (ectoderm, mesoderm and
endoderm)
• 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

34. FIBROMA
• 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.

36. THECOMA
• Solid fibromatous lesions that show varying degrees of yellow or
orange discoloration
• 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
ovarian stroma.
• 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
available
• Endocrinologically inert, but could be associated with virilization and
endometrial hyperplasia

39. Differential Diagnosis for Brenner’s tumor
Benign Brenner tumors are generally resembles
other solid ovarian masses such as
• Fibroma
• Fibrothecoma
• 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
tumor.
• 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.