Histology

Ovarian germ cell tumors comprise a number of different histologic types (Table 11-5). In terms of incidence, dysgerminomas are the most common malignant ovarian germ cell tumors (Fig. 11-8), followed by immature teratomas (Fig. 11-9) and endodermal sinus tumors (Fig. 11-10), although mixed varieties containing disparate tumor components also exist. Other histologic types such as embryonal carcinomas, nongestational choriocarcinomas, struma ovarii, and so on, are more rare. Surveillance, Epidemiology and End Results (SEER) Program data from 1973 to 2002 identified 1262 cases of ovarian germ cell tumors: 414 (32.8%) dysgerminomas, 449 (35.6%) immature teratomas, and 362 (28.7%) mixed histologies.93 For simplicity, these tumors may be divided into two broad categories: dysgerminomas (the counterpart to the male seminoma) and nondysgerminomas.94

II. Biphasic or triphasic teratoma

A. Immature teratoma

B. Mature teratoma

1. Solid

2. Cystic a. Dermoid cyst b. Fetiform teratoma (homunculus)

II. Biphasic or triphasic teratoma

A. Immature teratoma

B. Mature teratoma

1. Solid

2. Cystic a. Dermoid cyst b. Fetiform teratoma (homunculus)

III. Monodermal teratoma and somatic-type tumors associated with group II (above)

A. Thyroid (struma ovarii)

B. Carcinoid

C. Neuroectodermal

D. Carcinoma

E. Melanocytic

F. Sarcoma

G. Sebaceous

H. Pituitary type I. Others

Adapted from World Health Organization classification of tumors.

Dysgerminoma
Figure 11-8. A, Gross picture of dysgerminoma. B, Micrograph of dysgerminoma. C, High-power micrograph of dysgerminoma. (Courtesy of Dr. Kristen Atkins, Department of Pathology, University of Virginia Health System.)
Dysgerminoma Tumor Ovary

Grossly, dysgerminomas are fleshy, solid tumors that have a gray-white appearance. At histologic examination, they are composed of sheets of vesicular cells separated by fibrous stroma.95 Immature teratomas are generally bulky tumors with a smooth surface. Microscopically, they are characterized by areas of necrosis and hemorrhage. As in their benign counterparts, bone, cartilage, hair and sebaceous

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Figure 11-10. Endodermal sinus tumor demonstrating characteristic Schiller-Duval body. Present in nearly 50% of endodermal sinus tumors, Schiller-Duval bodies are pathognomonic for this tumor and are said to resemble a glomerulus (H&E, x400). (Courtesy of Dr. Kristen Atkins, Department of Pathology, University of Virginia Health System.)

Figure 11-10. Endodermal sinus tumor demonstrating characteristic Schiller-Duval body. Present in nearly 50% of endodermal sinus tumors, Schiller-Duval bodies are pathognomonic for this tumor and are said to resemble a glomerulus (H&E, x400). (Courtesy of Dr. Kristen Atkins, Department of Pathology, University of Virginia Health System.)

Table 11-6. Differential Expression of Tumor Markers in Malignant Ovarian Germ Cell Tumors

Tumor

Tumor Marker

AFP b-hCG LDH

Dysgerminoma Usually normal Usually normal Elevated

Immature teratoma Usually normal Usually normal —

Endodermal sinus tumor Elevated Normal —

Embryonal carcinoma Elevated Elevated —

Nongestational choriocarcinoma Normal Elevated —

Dysgerminoma Usually normal Usually normal Elevated

Immature teratoma Usually normal Usually normal —

Endodermal sinus tumor Elevated Normal —

Embryonal carcinoma Elevated Elevated —

Nongestational choriocarcinoma Normal Elevated —

material may be present. The immature components are typically glandular, bone, muscle or nervous tissue. 95 Endodermal sinus tumors (yolk sac tumors) have pathognomonic structures that resemble a renal glomerulus, the Schiller-Duval body (see Fig. 11-10).

Based on the underlying histologic makeup of the germ cell tumor, specific blood proteins (tumor markers) may be elevated (Table 11-6). Classically, dysgerminomas and pure immature teratomas have no specific tumor markers, but dysgerminomas may have an elevated lactate dehydrogenase. Endodermal sinus tumors usually have an elevated AFP, which may correlate with disease burden, but a normal P-human chorionic gonadotropin (P-hCG). Choriorcarcinomas have the opposite picture with an elevated P-hCG and a normal AFP. Embryonal carcinomas usually have elevations in both AFP and P-hCG. Tumors of mixed histology may have elevations in some or all of these tumor markers, depending on the cell types present.

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