Germ Cell Tumours

Ans. is b i.e. Dysgerminoma

“Dysgerminoma is the most common malignant germ cell tumour accounting for about 40% of all ovarian cancers of germ cell origin.”                                                                              

“Dysgerminomas are the most common malignant germ cell tumours of the ovary and have been considered the female – equivalent of seminoma.”

Most common germ cell tumour of ovary is dermoid cyst (mature teratoma). It is benign in nature.

Dysgerminoma

• Commonest malignant germ cell tumour° of ovary.
• Primarily affect young women (average age of incidence is 20 years°).
• Usually unilateral° but they are the only germ cell malignancy with a significant rate of bilateral ovarian involvement – 15 to 20%.
• Can be found at gonadal as well as extra gonadal sites.°

Pathologically it is a solid neoplasm with areas of softening° due to degeneration.

• They are the most common ovarian malignancy detected during pregnancy.
• Histologically as in seminoma, it mimics the pattern of primitive gonad, lymphocytic infiltration may be seen (good prognostic sign).°
• Clinically as with all germ cell tumours most dysgerminoma are diagnosed at an early stage.
• Unlike other germ cell tumours it does not secrete AFP and HCG is only rarely secreted, however it secretes LDH and placental alkaline phosphate, which are used as tumour marker of dysgerminoma.
• Although dysgerminoma is most radio sensitive tumouty²treatment of choice is surgery (unilateral salpingo oophorectomy) followed by Bleomycin, Etoposide and Cisplatin (BEP) based chemotherapy as fertility can be preserved.
• They have the best prognosis of all malignant ovarian germ cell variants.
• Tumours associated with it : – Immature teratoma

–                         Choriocarcinoma

–                         Endodermal sinus tumour.

Dysgerminomas are also seen in phenotypic females with abnormal gonads like :

1. • Pure gonadal dysgenesis (46XY with bilateral streak gonads, swyer syndrome)
   • Mixed gonadal dysgenesis
   • Testicular feminization syndrome (46XY)
   • Klinfelter syndrome
   • For patients in whom karyotype reveals Y chromosome, both ovaries should be removed although uterus may be left in situ for possible future embryo transfer.

Ans. is b i.e. Germ cell tumour

“Below the age of 20 years 60% of the tumours are of germ cell origitf~in gift under the age of 10 years almost 85% are of germ cell origin and are invariably malignant.”

Remember :

• Most common ovarian tumour (over all) – Epithelial cell tumour.
• Most common tumour in young woman is – Germ cell tumour.                                        
• Most common malignant tumour of ovary – Serous cystadenocarcinoma.
• Most common benign tumour of ovary (over all) – Dermoid cyst.                                       
• Most common benign epithelial tumor of ovary – Serous cystadenoma.                                         
• Most common germ cell tumour – Mature teratoma (Dermoid cyst).
• Most common malignant GCT – Dysgerminoma.
• Most common ovarian tumour in pregnancy (but in remains undiagnosed) – Serous cystadenoma.
• Most Common benign tumour diagnosed in pregnancy – Dermoid cyst.
• Overall most common ovarian tumour diagnosed in pregnancy – Dermoid cyst.
• Most common malignant ovarian tumor detected during pregnancy – Dysgerminoma.
• Most common ovarian tumour to undergo torsion during pregnancy – Dermoid cyst.
• Most common ovarian tumour to involve opposite ovary by metastasis – Granulosa cell tumour.
• Most radiosensitive ovarian tumour – Dysgerminoma..
• Most rapidly growing ovarian tumour – Yolk sac Tm.
• Most connective tissue tumour – Fibroma.

Ovarian Tumour :

Causing :

• Pseudomyxoma peritonei    – Mucinous cystadenoma.
• Meig’s syndrome                      – Ovarian fibroma
• Pseudomeig’s syndrome :   – Brenner’s tumour

–                          Granulosa cell tumour

–                          Thecoma

• Ovarian tumour associated with hyperpyrexia and hypercalcemia – Mesonephroid tumour.
• Ovarian tumour arising from epithelium of urinary tract – Brenner Tm 4
• Call exner body seen in                     Granulosa cell Tm
• Schiller duval body seen in – Endodermal sinus Tm
• Feminizing tumours :                   – Granulosa cell tumour

– Theca cell tumour

–   Fibromas

• Virilising tumour :                     – Androblastoma                                       – Hilus cell Tm

Gynadroblastoma                               – Adrenal cortical tumour

• Largest benign ovarian Tm – Mucinous cyst adenoma
• Mucinous tumours are associated with             Dermoid cyst (MBD)

– Brenner’s tumour

• Tumour with lymphocytic infilteration : – Dysgerminoma.

Ans. is c i.e. Embryonal cell carcinoma

Friends, this is one of those type of questions where we will derive a correct answer by ruling out other options. Let see,

Option ‘a’ : Dysgerminoma

• “They are bilateral in about 10% of cases”.                                                                                      

Option ‘b’ : Immature teratoma

• “In a premenopausal patient whose lesion appears to be confined to a single ovary, unilateral oophorectomy and surgical staging should be performed. For a postmenopausal patient, a total abdominal hysterectomy and bilateral salpingo-oophorectomy may he performed. Contralateral involvement is rare, and routine resection or wedge biopsy of the contralateral ovary is unnecessary.”                                                                                                
  

Coming on to Option ‘c’ with embryonal cell carcinoma. It is a rare type of Germ cell tumor and so is the information available on at. The only information I could lay my hands was :

Options ‘c’: Embryonal cell carcinoma

The primary lesions tend to be large, and about two thirds are confined to one ovary at the time of diagnosis

Option ‘d’ : Endodermal Sinus Tumour (EST)

• It is unilateral in 100% of cases.
•  Considering all above options I choose embryonal cell carcinoma as the option of choice I have provided you with all related references, you are free to have your opinion.

Option b and c both

Arrhenoblastoma is a sex cord stromal tumour.                                                                                    

Brenner tumour and serous cystadenoma are epithelial tumours.                                      

Germ cell tumours of ovary are :

Mnemonic : YES PCT

• Yolk sac Tumor (Endodermal sinus Tm)

E                Embroyonal carcinoma

S                Seminoma = Dysgerminoma

P                Polyembryoma

C                Choriocarcinoma

T                 Teratoma : – Mature (Benign)

–                          Immature (Malignant)

–                          Carcinoid – Thyroid carcinoma

Ans. is a i.e. CA – 125

Brenner’s tumour

Granulosa theca cell tumour

Germ cell tumour

Granulosatheca cell tumour

Totipotent cells

10% are B/L & malignant

CEA REF: Harrison’s 17^th ed p. 551

CEA is not a testicular tumor marker

Teratoma is a non seminomatous tumor of testis.

Malignant REF: Robbin’s ^7th ed p. 1044

In children differentiated mature teratoma may be benign

In post pubertal males all teratoma are regarded as malignant and capable of metastasis regardless the elements may be immature or mature.

metastatic germ cell tumor [Ref: Computed body tomography by Lee Sagel 4/e p1207; CT and MRI of the whole body by Haagu 5/e p2006, 2007; Harrison I7/e p601J

“Testicular tumors tend to metastasize via the lymphatic system. In general, the testicular lymphatics, which follow the course of the testicular arteries/veins, drain directly into the lymph nodes in or near the renal hilus. After involvement of these sentinel nodes, the lumbar paraaortic nodes become involved (unilaterally or bilaterally), followed by spread to the mediastinal and supraclavicular nodes or hematogenous dissemination to the lungs, liver and brain.”- Lee Sagel

• This necrotic retroperitoneal mass represents necrotic lymphnodes.
• Necrotic lymphnodes usually suggest malignant metastasis; however benign inflammatory diseases may also cause necrotic lymphadenopathy.
• Lymphoma though a common cause of retroperitoneai lymphadenopathy usually does not show necrosis, and is thus ruled out.
• Metastases to retroperitoneal lymphnodes may come from virtually any abdominal or pelvic neoplasm, but the most common ones are testicular, prostatic, cervical, endometrial, and renal.
• Carcinomas of the bladder, prostate, cervix, and uterus initially spread to the pelvic nodes.
• Testicular, ovarian, and fallopian tube malignancies spread first to the retroperitoneal nodes adjacent to or near the renal hila but may involve the pelvic nodes by retrograde spread.
• Testicular neoplasms are the most common solid tumor in men 15 to 34 years old. (Ref: Lee Sagel)

Extragonadal germ cell tumors:

80% of ovarian masses are benign cystic teratomas or dermoid cysts. It mainly occur during the reproductive years, but have a wider age distribution.

It is associated with a 15% risk of torsion, and is the most common type of ovarian cyst to undergo torsion.

Other complications associated with it are, cystic rupture resulting in acute peritonitis and chronic leakage of teratoma contents resulting in granulomatous peritonitis.

Ref: Textbook of gynecology by D C Dutta 4th edition  Page 273-5, 352.

Well-formed teeth are commonly seen in mature cystic teratoma and not in any of the other lesions.

Dysgerminoma is the most common malignant germ cell malignancy of the ovary, accounting for about 40% of all ovarian cancers of germ cell origin.

Ref: Multimodality Therapy in Gynecologic Oncology By BU. Sevin, 1996, Page 137

Complications associated with mature cystic teratoma are torsion, rupture, infection, hemolytic anemia and development of malignancy. Torsion and rupture of teratoma are more likely to occur during pregnancy.

Ans. is ‘d’ i.e., Teratoma

o All Tumors, benign or malignant, have two basic components -*

1. Proliferative neoplastic cells —> constiture parenchymes.
2. Supportive stroma                    —> made up of connective tissue and blood vessels.

o The name of tumor is usually based on the cell, e.g. smooth muscle cell tumor —> leiomyoma or leiomyosarcoma, skeletal muscle cell tumor rhabdomyosarcoma.

o Benign tumors

         In general, benign tumors are designed by attaching the suffix – oma, e.g tumor of fibroblasts —> fibroma, tumor of cartilagenous cells —> chondroma.

o Malignant tumors

         Malignant tumors arising in mesenchymal cell origin are usually called sarcoma, e.g. fibrosarcoma, liposarcoma, leiomyosarcoma, rhabdomyosarcoma.

         Malignant tumors of epithelial cell origin are called carcinoma.

         Carcinoma may be further classified one with glandular growth pattern, i.e. adenocarcinoma and the other one producing recognizable squamous cells of epithelium, i.e. squamous cell carcinoma.

o Germ layers and tumor

         Great majority of the neoplasm are composed of cells representative of a single germ layer.

         Teratomas, in contrast, are made up of a variety ofparenchymal cell types representative of more than one germ layer, usually all three.

They arise from totipotent cells and so are principally encountered in the gonads. These totipotent cells differentiate along various germ lines, that can be identified as skin, fat, muscle, tooth structure, hair or any other tissue of the body. Example is dermoid cyst of ovary is a benign teratoma (note –> mature teratoma is benign, while immature teratoma is malignant).

Note-There are some exceptions to above general rules, i.e. malignant neoplasms with suffix – oma –> Melanomas, seminoma, hepatoma (hepatocellular Ca), mesotheloma, lymphoma.

Ans. is ‘a & c’ Teratoma & endodermal sinus tumor

o Serum alpha feto proetin level is elevated in non seminomatous testicular tumors.

o Non seminomatous testicular tumors include

(a)          Yolk sac or endodermal sinus tumor

(b)          Embryonal carcinoma

(c)          Teratomas

Ans. is ‘a’ i.e., Yolk sac tumor; ‘c’ i.e., teratoma

Ans. is ‘b’ i.e., Leydig cell tumor

Testicular tumor

o Testicular tumors are divided into two major catogaries : ‑

Germ cell tumors

o Seminoma     o Embryonal carcinoma   o Yolk sac (endodermal sinus) tumor

• Spermatocytic seminoma                   o Choriocarcinoma             o Teratoma

Sex cord tumors

• Leydig cells tumor                             o Sertoli cell tumor

o Approximately 95% of testicular tumors are germ cell tumors.

Ans. is ‘c’ i.e., Seminoma

o Among the given options only options c & d are germ cell tumors. Seminoma is malignant while dermoid cyst is benign.

Germ cell tumors

o Malignant – Germinoma (seminoma, dysgerminoma), embryonal carcinoma, endodermal sinus tumor (yolk sac tumor), choriocarcinoma, immature teratoma.

• Benign – Mature teratoma, dermoid cyst.

Ans. is ‘a’ i.e., Cryptorchidism; ‘b’ i.e., Testicular feminising syndrome; ‘c’ i.e., Klinefelter syndrome

The predisposing factor of germ cell tumors of testes are :

1. Cryptorchidism

2. Testicular feminisation syndrome

3. Klinefelter syndrome

4. Excess 12P copy number either in the term of i(12P) or increased 12P an aberranthy banded marker chromosome.

o In most large testicular tumour approximately 10% associated with Cryptorchidism.

o Abdominal cryptorchid testes are higher risk than inguinal cryptorchid testes.

o Early orchiopexy before puberty reduced the risk of GCT.

o Klinefeleter’s syndrome is associated with mediastinal GCT.

o An ischromosome of short arm of chromosome 12[i(12P)]. is pathognomic of GCT in all histological types.

Ans. is ‘d’ i.e., Testis

Extragonadal germ cell tumors occur at :‑

Mediastinum                 —->     M.C. site.                    3. Sacrococcygeal region        —–>     Sacrococcygeal teratoma.

Retroperitoneum           —->           2nd M.C. site.       4. Pineal gland

Ans. is ‘d’ i.e., Mediastinum

Ans. is ‘b’ i.e., Teratoma

Teratoma

o Teratomas are divided into three categories:

(1) Mature (benign):

           Most benign teratomas are cystic and are known as dermoid cysts.

           These neoplasms are presumably derived from the ectodermal differentiation of totipotential cells.

           They are bilateral in 10% to 15% of cases.

           Characteristically, they are unilocular cysts containing hair and cheesy sebaceous material. On section, they reveal a thin wall lined by an opaque, gray-white, wrinkled, apparent epidermis.

           Generally, in one area of the cyst wall, a solid prominence is seen known as Rokitansky’s protuberance where tissue elements such as tooth, bone, cartilage & various other odd tissues are present.

On histologic examination, the cyst wall is composed of stratified squamous epithelium with underlying

sebaceous glands, hair shafts, and other skin adnexal structures. In most cases, structures from other germ layers can be identified, such as cartilage, bone, thyroid tissue, and other organoid formations.

           Dermoid cysts are sometimes incorporated within the wall of a mucinous cystadenoma.

           About 1% of the dermoids undergo malignant transformation of any one of the component elements ( but most commonly, squamous cell carcinoma).

(2) Monodermal or Specialized Teratomas

           The rare group of tumors, the most common of which are struma ovarii and carcinoid.

           They are always unilateral, although a contralateral teratoma may be present.

           Struma ovarii is composed entirely of mature thyroid tissue. Interestingly, these thyroidal neoplasms may hyperfunction, causing hyperthyroidism.

           The ovarian carcinoid, which presumably arises from intestinal epithelium in a teratoma, might in fact be functioning, particularly in large tumors, producing 5-hydroxytryptamine and the carcinoid syndrome.

(3) Immature Malignant Teratomas

           These are rare tumors that differ from benign teratomas in that the component tissue resembles that observed in the fetus or embryo rather than in the adult.

           The tumor is found chiefly in prepubertal adolescents and young women.

           These grow rapidly and frequently penetrate the capsule with local spread or metastases.

           On microscopy, there are varying amounts of immature tissue differentiating toward cartilage, glands, bone, muscle, nerve, and others.

           An important risk for subsequent extraovarian spread is the histologic grade of tumor, which is based on the proportion of tissue containing immature neuroepithelium.

Ans. is ‘d’ i.e., Seen in teratoma

o Psammoma bodies represent a process of dystrophic calcification.

o Single necrotic cells may constitute seed crystals that become encrusted by the mineral deposits. The progressive acquisition of outer layers may create lamellated configurations, called psammoma bodies because of their resemblance to grains of sand.

o Psammoma bodies are seen in : papillary cancer of thyroid, meningioma, papillary serous cystadenocarcinoma of ovary.

Ans. is ‘b’ i.e., Leydig cell tumor

Germ cell tumors

o Germ cell tumors, as the name suggests, arise from Primordial germ cells (Precursor germ cells or gametocytes),

o Germ cells develops early in life. In growing fetus, germ cells migrate from their point of origin to the gondal area. o Germ cells that still have to reach the gonads are called primordial germ cells.

o After reaching to gonads these become mature germ cells and the end products of germ cell cycle are the egg or sperm.

o Germ cell tumors arise from primordial germ cells.

o Therefore germ cells tumor may be :

Gonadal (In testis or ovary)

ii) Extragonadal : – When primordial germ cells fail to reach the right location and divide at the site of arrest. Extra-gonadal germ cell tumors may occur at mediastinum (most common site), retroperitonium (2nd most common site), brain, pineal gland, sacrococcygeal region.

o Germ cell tumor are :

Seminoma/dysgerminoma   

Embryonal carcinoma         

Yolk/sac (endodermal sinus) tumor

Choriocarcinoma                  

Teratoma

Non-germ cell gonadal tumors

o These tumors occur in adults. These may occur very rarely in children and occur predominantly in ovary. Tumors are : –

i) Surface epithelial tumors : – Serous tumor, mucinous tumor, Brenner tumor etc.

ii) Sex cord stromal tumors : – Granulosa-theca cell tumor, Sertoli-Leydig cell tumor.

A i.e. Teratoma

In teratoma, there may be presence of tooth & other calcified bodies giving rise to radio-opaque shadows.

Ans is ‘a’ i.e. Cryptorchidism; ‘b’ i.e. Testicular Feminization syndrome; ‘c’ i.e. Klinefelter’s syndrome

• Predisposing factors for testicular GCTs are

a)          Cryptorchidism

b)          Testicular feminization syndrome

c)          GCT of one testis is a risk factor for the other testis

d)          Testicular Ca in a sibling

e)          Klienfelter syndrome – is associated with mediastinal GCT

f)           Administration of estrogens (eg DES) to the mother during pregnancy is associated with increased incidence of testicular Ca in male offspring.

• Some points are worth mentioning about cryptorchidism
• Of the predisposing factors, cryptorchidism has the strongest association with testicular Ca.
• Increased risk is seen for both the testis i.e. the cryptorchid testes as well as the normally descended testes
• Abdominal cryptorchid testes are at a higher risk than inguinal cryptorchid testes.
• Seminoma is the most common type of testicular cancer seen in a cryptorchid testes
• Remember this : Placement of the cryptorchid testis into the scrotum (orchipexy) does not alter its malignant potential, however it facilitates examination and tumor detection [Ref: Campbell’s Urology 8/e, p 2882;

Smith’s Urology I7/e, p3751 (Note that Harrison (17/e, p601) contradicts the above statement but we should follow what Campbell & Smith say)

Answer is ‘a’ i.e. Seminoma; ‘b’ i.e. Teratoma 

Ans is b  ie. dysgerminoma 

lntratubular germ cell neoplasia (ITGCN) is regarded as the preinvasive stage of testicular germ cell tumors (also k/a carcinoma in situ of testis )

It is the precursor of all germ cell tumors except‑

–  pediatric yolk sac tumors and teratomas and

–  adult spermatocytic seminomas.

ITGCN can be found in testicular tissue adjacent to GCTs in approximately 90 percent of adult cases.

ITCGN is encountered with a high frequency in the following conditions, listed in order of increasing risk: cryptorchidism, prior germ cell tumors, strong family history of germ cell tumor, androgen insensitivity syndrome, and gonadal dysgenesis syndrome.

Untreated ITGCN progresses to invasive germ cell tumor in approximately 50% of cases over 5 years of follow-up and it has also been proposed that practically all patients with ITGCN eventually develop invasive tumors.

If ITGCN is identified, it is treated by low-dose radiotherapy, which destroys the germ cells yet maintains the androgen production of the Leydig cells.

Answer is ‘c’ ie They are often associated with raised levels of serum AFP and HCG

Ans is (c) i.e., alpha-feto protein is markedly raised in all germ cell tumors 

Ans. is ‘a’ i.e., Chemotherapy 

Chemotherapy of extragonadal GCT utilizes BEP regimen; a combination of Bleomycin &

Etoposide

– Cisplatin (Platinol)

Ans is ‘b’ i.e. Seminomas are radio sensitive 

Seminomas are well known to be one of the most radiosensitive tumors

About other options

• Option (a) : Commonest malignancy in older males is —> Prostate cancer
• Option (c) : Stage I Nonseminomas (including teratomas) are t/t by surgery alone and show a high cure rate (>95%)

[Stage I seminomas are t/t by surgery + retroperitoneal radiotherapy and show —98% cure rate]

• Option (d) : Chemotherapy shows a good response in advance stage testicular tumors.

Ans. is ‘c’ i.e., Sacro-coccygeal teratoma 

In meningocele there will be cough impulse

Ans is ‘a’ i.e. metastatic germ cell tumor

“Testicular tumors tend to metastasize via the lymphatic system. In general, the testicular lymphatics, which follow the course of the testicular arteries/veins, drain directly into the lymph nodes in or near the renal hilus. After involvement of these sentinel nodes, the lumbar paraaortic nodes become involved (unilaterally or bilaterally), followed by spread to the mediastinal and supraclavicular nodes or hematogenous dissemination to the lungs, liver and brain.”- Lee Sagel

• This necrotic retroperitoneal mass represents necrotic lymphnodes.
• Necrotic lymphnodes usually suggest malignant metastasis; however benign inflammatory diseases may also cause necrotic lymphadenopathy.
• Lymphoma though a common cause of retroperitoneal lymphadenopathy usually does not show necrosis, and is thus ruled out.
• Metastases to retroperitoneal lymphnodes may come from virtually any abdominal or pelvic neoplasm, but the most common ones are testicular, prostatic, cervical, endometrial, and renal.
• Carcinomas of the bladder, prostate, cervix, and uterus initially spread to the pelvic nodes.
• Testicular, ovarian, and fallopian tube malignancies spread first to the retroperitoneal nodes adjacent to or near the renal hila but may involve the pelvic nodes by retrograde spread.
• Testicular neoplasms are the most common solid tumor in men 15 to 34 years old. (Ref: Lee Sagel)

Ans. C: Hemorrhoidectomy

Internal hemorrhoids are classified by the degree of tissue prolapse into the anal canal:

• First-degree – hemorrhoids that bleed but do not prolapse
• Second-degree – hemorrhoids that prolapse with straining or defecating and retract on their own
• Third-degree – hemorrhoids that prolapse and require manual reduction
• Fourth-degree – hemorrhoids that chronically prolapse and, if reducible, fall out again

Management:

• Rubber band ligation – A rubber band is placed around the base of the hemorrhoid inside the rectum. The band cuts off circulation, and the hemorrhoid withers away within a few days.
• Sclerotherapy is one of the oldest forms of treatment. A chemical solution is injected directly into the hemorrhoid or the area around it. This solution causes a local reaction that interferes with blood flow inside the hemorrhoid, making the hemorrhoid shrink.
• Laser or electro-coagulation techniques – Both techniques use special devices to burn hemorrhoidal tissue.

– Cryotherapy uses cold temperatures to obliterate the veins and cause inflammation and scarring. It is more time consuming, associated with more posttreatment pain, and is less effective than other treatments. Therefore, this procedure is not commonly used.

– Hemorrhoidectomy – Occasionally, extensive or severe internal or external hemorrhoid may require removal by surgery known as hemorrhoidectomy. This is the best method for permanent removal of hemorrhoid

Hemorrhoidectomy is the treatment for:

• Severe third-degree and fourth-degree hemorrhoids.
• Second degree hemorrhoids that have not been cured with conservative measures.
• Fibrosed hemorrhoids
• Interno-externo hemorrhoids when the external hemorrhoid is well defined.

beta HCG (Tumour shown: Sacrococcygeal teratoma

Sometimes, remnants of the primitive streak persist in the sacrococcygeal region. These clusters of pluripotent cells proliferate and form tumors, known as sacrococcygeal teratomas that commonly contain tissues derived from all three germ layers. This is the most common tumor in newborns, occurring with a frequency of one in 37,000. These tumors may also arise from primordial germ cells that fail to migrate to the gonadal ridge 

This cyst is dermoid cyst

Ans. is a. b, and c i.e. It is teratoma; Frequently undergo torsion; X-ray is diagnostic; and Contains sebaceous material and hairs

Dermoid cyst (mature teratoma) :

• Most comon benign ovarian neoplasm.
• Mostly affect women of reproductive age group.
• Morphologically dermoid cyst is unilocular with smooth surface.
• On cross section — cysts are unilocular and typically contain are area of localised growth that prottectes into the cystic cavity called as Rokintansky protuberance / dermoid process.
• It contains sebaceous material and hair with teeth. bone, cartilage, thyroid tissue.
• If teeth or bone are seen in X-ray in adnexal mass, this finding is pathognomic for teratoma.
• Dermoid cyst are bilateral in 12% to 15% and frequently arise in association with mucinous cystadenomas.

Ans:B.)Teratoma.

Image shows:Mature cystic teratoma (dermoid cyst) of the ovary. A ball of hair (bottom) and a mixture of tissues are evident.

OVARIAN TUMORS

• Tumors may arise from epithelium,sex cord–stromal cells, or germ cells.

• Epithelial tumors are the most common malignant ovarian tumors and are more common in women older than 40 years of age.

• The major types of epithelial tumors are serous,mucinous, and endometrioid. Each has a benign, malignant, and borderline (low malignant potential) counterpart.

• Sex cord–stromal tumors may display differentiation toward granulosa, Sertoli, Leydig, or ovarian stromal cell type. Depending on differentiation, they may produce estrogens or androgens.

• Germ cell tumors (mostly cystic teratomas) are the most common ovarian tumor in young women; a majority are benign.

• Germ cell tumors may differentiate toward oogonia (dysgerminoma), primitive embryonal tissue (embryonal), yolk sac (endodermal sinus tumor), placental tissue (choriocarcinoma), or multiple fetal tissues (teratoma).

TERATOMA

Benign (Mature) Cystic Teratomas .

• Almost all benign (mature) cystic teratomas are marked by the presence of mature tissues derived from all three germ cell layers: ectoderm, endoderm, and mesoderm.
• Usually these tumors contain cysts lined by epidermis replete with adnexal appendages—hence the common designation dermoid cysts.
• Most are discovered in young women as ovarian masses or are found incidentally on abdominal radiographs or scans because they contain foci of calcification produced by tooth-like structures contained within the tumor. About 90% are unilateral, with the right side more commonly affected.
• Rarely do these cystic masses exceed 10 cm in diameter.
• On cut section, they often are filled with sebaceous secretion and matted hair that, when removed, reveal a hair-bearing epidermal lining.
• Sometimes there is a nodular projection from which teeth protrude. Occasionally, foci of bone and cartilage, nests of bronchial or gastrointestinal epithelium, and other tissues also are present.

Immature Malignant Teratomas .

• Malignant (immature) teratomas are found early in life, the mean age at clinical detection being 18 years.
• They differ strikingly from benign mature teratomas insofar as they often are bulky, predominantly solid on cut section, and punctuated by areas of necrosis; uncommonly, cystic foci are present that contain sebaceous secretion, hair, and other features similar to those of mature teratomas.
• On microscopic examination, the distinguishing feature is presence of immature elements or minimally differentiated cartilage, bone, muscle, nerve, or other tissues.

Ans. is ‘b’ i.e., Leydig cell tumor