219. Pathology of Ovary, Fallopian Tubes, Adnexal Masses

Question 1

Histo/Layers of Fallopian Tube

Answer 1

Serosa: outer mesothelium
Myosalpinx (muscular wall)
Lamina Propria (fibrous c.t.)
Mucosa with plicae: epithelium of ciliated cells and secretory cells

Question 2

Non-Neoplastic Path

• Inflammatory Disorders: histo of acute salpingitis, chronic salpingitis, hydrosalpinx
• Ectopic Pregnancy: RFs, Path
• Paratubal Cysts: what are they, special feature

Answer 2

Acute Salpingitis: due to bacteria (gonorrhea), distended plicae with acute/chronic inflammatory cells
Chronic Salpingitis: resolution of acute salpingitis, risk infertility and ectopic pregnancy, fused fibrotic plicae creating cyst-like spaces
Hydrosalpinx: dilated tube lumen, flattened lining, due to salpingitis, filled with serous fluid

Ectopic Pregnancy: RFs - prior ectopic, tube sterilization, PID, salpingitis
Path: choiroinic villi and fetal tissue in fallopian tube, implants in fallopian tube, hemosalpinx (dilated with blood)

Paratubal Cysts: benign cysts lined by different types of epithelium
Hydatid of Morgagni: cyst arising in fimbriated end from MULLERIAN/WOLFFIAN DUCT remnants

Question 3

Fallopian Tube Neoplasia
Serous Tubal Intraepithelial Carcinoma (STIC)
- epidemiology
- precursor
- origin
- mutations
- tx
- complication
- histo

Answer 3

Epi: most common ovarian cancer, probable origin of most high grade serous ovarian carcinomas
Origin: secretory tubal epithelial cells (usually from fimbriae)
genes: BRCA1/2 mutation carriers, p53 mutations
tx: remove fallopian tubes with ovaries (BSO - bilateral salpingo-oopherectomy)
Complication: STIC cells slough off and implant on ovarian surface = ovarian cancer

Histo: Atypical tubal epithelium - large, round nuclei with prominent nucleoli, loss of polarity, atypical mitoses

Question 4

Normal Ovary Histo

• what do the layers of ovary look like
• what do parts of follicle look like
• what does CL look like

Answer 4

Layers

• Cortex: outer layer (surface mesothelial lining), cellular ovarian stroma (spindle cells - cartwheel pattern; scant cytoplasm, reticulin fibers, some collagen)
• Medulla: loose fibrous c.t. and blood vessels
• Hilum: where vessels and nerves exit/enter

Follicles

• theca externa - more spindled, blend to stroma
• theca interna - spindled, pink
• Granulosa cells - dyscohesive, minimal cytoplasm

CL: convoluted border, luteinized GCs (more pink cytoplasm)

Question 5

Non-neoplastic Path

• Follicular/Corpus Luteum Cysts: what they are, risks
• Polycystic Ovaries: cause, path

What are the most common categories of primary ovarian neoplasms (top 3)?

Answer 5

Follicular/CL Cysts: dilated follicles with clear fluid <2cm, can rupture and cause peritonitis

PCOS: high androgens = anovulatory infertility, numerous cystic/atretic follicles

1. Epithelial (65-70%)
2. Germ Cell (15-20%)
3. Sex Cord Stromal (5-10%)

Question 6

Benign Epithelial Tumors

• Cystadenomas: what they are, types, path
• Mucinous Cystadenoma: what they are, path

Borderline Epithelial Tumors

• what they are, subtypes
• unique features
• prognosis

Answer 6

Cystadenomas: cystic neoplasm lined by benign epithelial cells, serous/mucinous most common

Mucinous Cystadenomas: multilocular cyst with smooth lining, can be very large (<30cm), contains mucoid/viscous fluid; usually unilateral
Path: simple mucinous lining cells filled with mucin (like gastric/intestinal mucinous cells)

Borderline Epithelial Tumors

• atypical proliferative tumor with low malignant potential (without invasion)
• subtypes: serous, mucinous
• unique: extraovarian “deposits” in peritoneum or LNs (NOT mets because NOT malignant)
• prognosis: generally very good unless transform to carcinoma, conservative tx acceptable

Question 7

Ovary: Malignant Epithelial tumor
Type I vs. Type 2
- origins
- behaviors
- genes

High Grade Serous Carcinoma

• type
• origin
• gross
• histo

Clear Cell Carcinoma

• type
• origin
• histo

Answer 7

Type 1 = Clear Cell Carcinoma

• origin: stepwise from benign to borderline to malignant
• behavior: indolent, low stage at dx
• genes: variety: KRAS/BRAF, Wnt, PI3K, PTEN

Type II = High Grade Serous Carcinoma

• origin: arise de novo from tubal epithelium (STIC)
• behavior: aggressive, high stage at dx
• genes: p53!! (BRCA1/2, Akt2)

High Grade Serous Carcinoma (TII)

• aggressive neoplasm presenting at high stage, most common ovarian carcinoma (50%)
• originate from STIC
• gross: solid tumor, variegated cut surface
• histo: markedly atypical nuclei, numerous mitoses

Clear Cell Carcinoma (TI)

• originates from endometriosis
• histo: HOBNAILING: bulbous protrusion of nuclear portion of cell into lumen, variable nuclear atypia, clear cytoplasm

Question 8

Ovarian: Germ Cell Tumors
- origin

Teratoma
- mature vs. immature (signs, gross, histo)

Yolk Sac Tumor

• biochemical marker
• pathognomonic finding

Answer 8

GCT: derived from pluripotent stem cells

Teratoma
Mature: most common ovarian germ cell tumor, almost always cystic and BENIGN, derivatives from multiple germ cell layers
- gross: cysts filled with hair and sebaceous material
- histo: stuctures from any organ (ecto, meso, endoderm)
Immature: at least focal immature/embryoid tissue, malignant ones can grow rapidly, metastasize or recur

Yolk Sac Tumor
MALIGNANT GCT
- produces AFP (high in serum)
- SCHILLER-DUVAL BODY: central blood vessel, surrounding tumor cells, space, tumor cells lining space

Question 9

Sex Cord Stromal Tumors (Ovary)
- origin

Fibrothecoma

• components
• assoc
• gross
• histo

Granulosa Cell Tumor

• adult type: malignant potential, production, histo
• juvenile type

Answer 9

Origin: ovarian stroma/sex cords or both

Fibrothecoma: BENIGN, solid well-circumscribed mass

• Fibroblasts w/ collagenous stroma, Theca Cells (plump spindle cells containing lipids)
• assoc: MEIG’S SYNDROME - ovarian tumor (fibroma) + ascites + hydrothorax (due to high VEGF)
• gross: solid yellow tumor (more theca), solid white tumor (more fibroblasts)
• histo: fibroblasts (spindled pink cytoplasm, collagen), theca cells (plump round abundant pale cytoplasm due to lipid)

Granulosa Cell Tumor
Adult type: usually post-mp age, more common, LOW malignant potential (can mets and recur), produces ESTROGEN (endometrial hyperplasia)
- histo: small round ovoid tumor cells, little cytoplasm
- KEY: CALL EXNER BODIES (small circular space lined by tumor cells with pink material)
Juvenile type: young patients

Question 10

Mets to ovary

- from where?

Answer 10

Most common from other GTN: uterus, cervix, fallopian tube, other ovary

GI Tract: colon appendix stomach pancreas biliary tract

Breast