Fallopian tubes and ovaries path Flashcards
what are the most common disorders affecting the fallopian tubes
infections and associated inflammatory conditions
what does Anexa mean
just means parts adjoining an organ . . the fallopian tube and ovary collectively referred to as this
organisms that cause suppurative salpingitis
- may be caused by any pyogenic organism
- Gonococcus (60%)
- Chlamydiae many of remaining
- Tuberculous salpingitis rare but important cause of infertility in other areas
What are the most common primary lesion of the fallopian tubes
minutes .1 - .2 cm translucent cysts filled with clear serous fluid called paratubal cysts
Larger paratubal cysts are found near the fimbriated end of the tube or in the broad ligaments and are referred to as what
hydatids of Morgagni
paratubal cysts are lined with benign serous epithelium and are presumed to arise from what
remnants of the mullerian duct
stain for tuberulosis
- Ziehl-Neelson
- Acid fast
Lymphogranuloma venereum
Chlamydia trachomatis
chancroid
Haemophilus ducreyi
Granuloma inguinale (donovanosis)
Klebsiella granulomatis
What are the fallopian tube tumors
- benign adenomatoid tumor (mesothelial tumors)
- primary adenocarcinoma
Adenocarcinoma of the fallopian tube usually presents as what?
others come to attention how?
- dominant tubal mass detected on pelvic exam
- abnormal discharge, bleeding NOT RELATED TO CYCLE or occasionally abnormal cells in pap smear
Adenocarcinoma of fallopian tube affects who`
postmenopausal caucasians
progression and severity of adenocarcinoma of fallopian tube
-40% dead within 5 years
how do you treat adenocarcinoma of the fallopian tube
ovarian cancer chemo protocols
link of fallopian tube adenocarcinoma to ovarian serous cancer
a subset of serous ovarian cancer is thought to arise from epithelium of the fallopian tube
what are the most common lesion encountered in the ovary
functional or benign cysts and tumors
Neoplastic disorders of the ovary can be grouped according to their origin from each of the three main ovarian cell types. what are these 3 cell types
- mullerian epithelium
- germ cells
- sex cord-stromal cells
these originate from unruptured graafian follicles or in follicles that have ruptured and immediately sealed
cystic follicles
morphology box for cystic follicles of ovary
- up to 2 cm . .if bigger then called follicle cyst
- filled with clear serous fluid
- lined by a gray glistening membrane
- very common and incidental . . may be palpable and cause pelvic pain
Describe a luteal cyst
- present in normal ovaries of women of reproductive age
- lined by a rim of bright yellow tissue containing luteinized granulosa cells
- occasionally rupture and cause a peritoneal reaction . . might be hard to distinguish between this and endometriotic cyst
complex endocrine disorder characterized by hyperandrogenism, menstrual abnormalities, polycystic ovaries, chronic anovulation, and decreased fertility
polycystic ovarian syndrome (PCOS) . . formerly called Stein Leventhal syndrome
PCOS is associated with what disorders
- obesity
- type 2 diabetes
- premature atherosclerosis
PCOS affects who
6-10% of reproductive age females
PCOS is marked by what
- dysregulation of enzymes involved in androgen biosynthesis
- excessive androgen production . . . central feature
- also insulin resistant and altered adipose tissue metabolism
what is increased in women with PCOS (besides androgens) and what does this cause
- increase in free serum estrone
- leads to increased risk for endometrial hyperplasia and carcinoma
This disorder is characterized by uniform enlargement of the ovary which has a white to tan appearance. usually bilateral and shows hypercellular stroma and luteinization of stroma cells
Stromal hyperthecosis, also called cortical stromal hyperplasia
what is a disorder that overlaps with PCOS but is often seen in postmenopausal women
stromal hyperthecosis
Clinical presentation of stromal hyperthecosis
similar to PCOS but virilization may be even more striking
a physiologic condition mimicking PCOS and stromal hyperthecosis but in response to pregnancy hormones
theca lutein hyperplasia of pregnancy
symptoms of PCOS
- Amenorrhea
- Acne
- Hirsutism or male pattern baldness
- aconthosis nicricans
- deepening voice
about 80% of ovarian tumors are ______ and occur mostly in young women between what ages?
- benign
- 20 and 45
age for borderline ovarian tumors?
malignant?
- slightly older than benign
- b/t 45 and 65
Why does ovarian cancer account for a disproportionate number of deaths from cancer of the female genital tract
most have spread beyond the ovary by the time of diagnosis
what are the most common symptoms from ovarian tumors
- abdominal pain and distention
- urinary and GI symptoms due to compression or invasion
- vaginal bleeding
Which ovarian tumors have a high tendency to be bilateral
- malignant serous (65%)
- endometroid (40%)
- metastatic (>50%)
Most primary ovarian neoplasms arise from what
mullerian epithelium
what are the 3 histological types of epithelial ovarian tumors
- serous
- mucinous
- endometrioid
each histological variant of the epithelial ovarian tumors is further broken down into what types
- benign
- borderline
- malignant
benign epithelial ovarian tumors are even further broken down into what types
- cystic areas (cysadenomas)
- cystic and fibrous (cystadenofibromas)
- predominantly fibrous (adenofibromas)
borderline and malignant epithelial ovarian tumors can also have a cystic component and when malignant are sometimes referred to as what?
cystadenocarcinomas
2 types of ovarian carcinomas . . tell what each arises from
type I: low grade, associated with borderline tumors or endometriosis (low grade serous, endometrioid, and mucinous) . . . from serous borderline tumors
type II: high grade serous that arise from serous intraepithelial carcinoma (STIC) . . from in situ lesion in the fallopian tube fimbriae or from serous inclusion cyst within the ovary
most common malignant ovarian tumor
serous
What are the known risk factors for malignant serous ovarian carcinomas
- nulliparity
- family history
- heritable mutations
- higher frequency in women with low parity
Who has a decreased risk of developing ovarian cancer
-women 40-59 who have taken oral contraceptives or undergone tubal ligation
What is the genetic risk factor associated with serous ovarian carcinoma
BRCA1 and 2
what is the prophylactic surgery not for women at high risk for ovarian carcinoma (BRCA mutation carriers and women with a strong family history of breast/ovarian cancer)
salpingo-oophorectomy (used to be oophorectomy)
morphology of a benign serous ovarian tumor
- smooth glistening cyst wall with no epithelial thickening or only small papillary projections.
- CILIA
morphology of borderline serous ovarian tumor
- increased number of papillary projections
- stratification of epithelium
- mild nuclear atypia but invasion of stroma is not seen
- the delicate papillary pattern referred to as “micropapillary carcinoma” which is thought to be a precursor to LOW GRADE SEROUS CARCINOMA
how are high grade serous ovarian tumors distinguished from low grade
- more complex growth patterns
- widespread infiltration or frank effacement of the underlying stroma
- marked nuclear atypic, including pleomorphism, atypical mitotic figures, multinucleation
what buzz word characterizes a serous ovarian tumors but is not specific for this neoplasm
concentric calcifications . . psammoma bodies
Ovarian serous tumors both low and high grade have a propensity to spread where?
commonly associated with the presence of what?
to peritoneal surfaces and omentum
-ascites
What feature of a serous ovarian tumor makes it more likely to spread to peritoneal surfaces
unencapsulated
age for mucinous ovarian tumors
- middle adult life
- rare before puberty and after menopause
majority of mucinous ovarian tumors are what type
benign or borderline
what is a consistent genetic alteration in mucinous tumors of the ovary
KRAS
what characteristics about mucinous ovarian tumors is different than serous
- surface of ovary rarely involved
- most are not bilateral
morphology highlights of mucinous ovarian tumors
- lack cilia
- filled with sticky, gelatinous fluid rich in glycoproteins
- majority demonstrate gastric or intestinal type differentiation
ovarian mucinous carcinomas characteristically demonstrate what
confluent glandular growth that is now recognized as a form of “expansile” invasion
describe a mucinous carcinoma that has spread beyond the ovary
- usually fatal but uncommon
- must be distinguished from metastatic mucinous adenocarcinoma
This is a clinical condition marked by extensive mucinous ascites, cystic epithelial implants on the peritoneal surfaces, adhesions, and frequent involvement of the ovaries
pseudomyxoma peritonei
if pseudomyxoma peritonei is extensive it may cause what
intestinal obstruction and death
What is the cause of pseudomyxoma peritonei
appendix
Because the majority of primary mucinous ovarian tumors are unilateral, bilateral presentation of mucinous tumors always requires what?
exclusion of a nonovarian origin
factoids about endometrioid ovarian tumors
- carcinoma accounts for 10-15% of ovarian cancers
- benign and borderline are uncommon
- 15-20% arise with ENDOMETRIOSIS and these occur a decade earlier than those that arise without
- 15-30% are accompanided by UTERINE ENDOMETRIAL CARCINOMA
what is a benign endometrioid ovarian tumor called
endometrioid adenofibroma
endometrioid tumors are distinguished from serous and mucinous tumors by the present of what?
-tubular glands resembling benign or malignant endometrium
molecular studies of endometrioid ovarian carcinomas that are similar to endometrial carcinoma
- increase in PI3K/AKT (PTEN, PIK3CA, ARID1A, KRAS)
- CTNNB1 (beta catenin)
- TP53 in poorly differentiated
morphology for endometrioid ovarian tumors
- solid and cystic
- 40% bilateral
- bilaterality implies extension of neoplasm beyond the genital tract
- glandular patterns
these tumors contain neoplastic epithelilial cells resembling urothelium and are usually benign
-transitional cell tumors
what type of tumors are Brenner tumors
transitional cell tumor
Brenner tumors are often detected incidentally and even when large the behave how
in a benign fashion
All ovarian carcinomas produce similar clinical manifestations, most commonly what?
lower abdominal pain and abdominal enlargement
malignant ovarian carcinomas tend to cause what symptoms
- progressive weakness
- weight loss
- cachexia
if ascites occurs with ovarian carcinoma, the fluid is filled with what?
exfoliated tumor cells
describe the peritoneal pattern of spread with ovarian carcinoma
-all serosal surfaces are diffusely seeded with .1 to .5 cm nodules of tumor that only rarely invade deeply into underlying parenchyma
describe metastatic pattern for ovarian carcinoma
- regional nodes often involved
- liver, lungs, and GI
- across midline to other ovary in about half . . progressive downhill course and death within a few months or years
Most women with ovarian carcinoma present with what stage
high stage
what is used in patients with known ovarian carcinoma to monitor disease recurrence/progression
CA-125
-HE4 . .newer
what are most germ cell tumors of the ovary
benign cystic teratomas
What are the 3 categories of teratomas
- mature (benign)
- immature (malignant)
- monodermal or highly specialized
Most benign teratomas are cystic and are often referred to as what
dermoid cysts because they are almost always lined by skin like structures
Cystic teratomas are usually found in what age
young women during the active reproductive years
Benign cystic teratomas may be discovered incidentally but are occasionally associated with what clinically important syndromes
paraneoplastic syndrome such as inflammatory limbic encephalitis
morphology of benign teratomas
- characteristically unilocular cysts containing hair and sebaceous material
- thin wall lined by an opaque gray white wrinkled epidermis, frequently with protruding hair shafts
- maybe grossly evident tooth and areas of calcification
about 1% of dermoids (benign teratomas) undergo malignant transformation, most commonly to what?
squamous cell carcinomas but also to other cancers like thyroid carcinoma and melanoma
Karyotype of almost all benign ovarian teratomas
46, XX
what are the most common types of monodermal or specialized teratomas
- struma ovarii
- carcinoid
monodermal or specialized teratomas are always bilateral or unilateral?
unilateral, although a contralateral teratoma may be present
what type of monodermal or specialized teratomas are composed entirely of mature thyroid tissue, which may be functional and cause hyperthyroidism
struma ovarii
The ovarian carcinoid (monodermal or specialized teratoma) presumably arises from what
intestinal tissue found in teratomas
if an ovarian teratoma is large (>7cm) they can produce what
5-hydroxytryptamine to cause carcinoid syndrome even in the absence of hepatic metastases
Primary ovarian carcinoid must be distinguished from metastatic intestinal carcinoid, which is virtually always what?
bilateral
what % of carcinoids in teratomas metastasize
2%
how do immature malignant teratomas differ from benign teratomas
the component tissues resemble embryonal and immature fetal tissue
immature malignant teratomas are found chiefly in who
prepubertal adolescents and young women, mean age being 18 years
with immature malignant teratomas, an important risk for subsequent extraovarian spread is the histologic grade of the tumor which is based on what
proportion of tissue containing immature neuroepithelium
morphology of immature teratomas that differs from benign
- bulky and solid (not cystic)
- areas of necrosis and hemorrhage
What is the ovarian counterpart of testicular seminoma
Dysgerminomas
Age for dysgerminomas
may occur in childhood but 75% occur in second and third decades
Some dysgerminomas occur in what special people
-patients with gonadal dysgenesis, including pseudohermaphroditism
endocrine function of dysgerminomas
most have none
A few dysgerminomas produce elevated levels of what
chorionic gonadotropin, a finding that correlates with the presence of syncytiotrophoblastic giant cells
what transcription factors do dysgerminomas express
- OCT-3
- OCT- 4
- NANOG
- also KIT . . . may be therapeutic target
morphology box for dysgerminomas
- most unilateral
- Large vesicular cells having a clear cytoplasm, well defined cell boundaries, and centrally placed regular nuclei
dysgerminomas and malignancy?
- all are malignant
- but degree of histologic atypia is variable, and only about 1/3 are aggressive
a unilateral dysgerminoma that has not broken through the capsule or spread outside the ovary has what prognosis
excellent (96%) cure rate
yolk sac tumors are also called what
endodermal sinus tumor
yolk sac tumors are thought to be derived from what
malignant germ cells that are differentiating along the EXTRAEMBRYONIC yolk sac lineage
what do yolk sac tumors elaborate
alpha-fetoprotein
what is the characteristic histologic features of a yolk sac tumor
-glomerulus like structure composed of a central blood vessel enveloped by tumor cells within a space that is also lined by tumor cells . . (Schiller-Duval body)
Conspicuous intracellular and extracellular hyaline droplets are present in what tumors
yolk sac tumors . . . and some of these droplets stain for alpha-fetoprotein by immunoperoxidase
describe who has yolk sac tumors and what they present with
-most children or young women presenting with abdominal pain and a rapidly growing pelvic mass usually a single ovary
origin of choriocarcinoma
- placental
- along with yolk sac tumors it is an example of extraebryonic differentiation of malignant germ cells
Most ovarian choriocarcinomas exist in combination with what
other germ cell tumors
choriocarcinomas are histologically identical to what
more common placental lesions
describe the nature and spread of choriocarcinomas
- aggressive
- usually metastasized hematogenously to the lungs, liver, bone, and other sites by time of diagnosis
choriocarcinomas elaborate high levels of what
chorionic gonadotropins
how is choriocarcinoma of the ovary different from that of placenta
it is unresponsive to chemo and often fatal
what are the germ cell tumors
- teratomas
- dysgerminoma
- yolk sac tumor
- choriocarcinoma
what are the sex cord stromal tumors of the ovary
- Granulosa cell tumors
- fibromas, thecomas, and fibrothecomas
- Sertoli-leydig cell tumors
Granulosa cell tumors are divided into what two types?
Adult (95%) and juvenile
age for Granulosa cell tumors
any age for 2/3 in postmenopausal women
morphology for granulosa cell tumor
- usually unilateral
- those hormonally active have yellow color due to intracellular lipids
- Call Exner Bodies
describe the call exner bodies of granulosa cell tumors
distinctive glandlike structures filled with an acidophilic material
What are the 2 reasons why granulosa cell tumors are of clinical importance
- they elaborate large amounts of estrogen
- they may behave like low grade malignancies
Functionally active granulosa cell tumors in prepubertal girls (juvenile type) may produce what?
in adult women?
- precocious sexual development
- proliferative breast disease, endometrial hyperplasia, and endometrial carcinoma
Granulosa cell tumors produce what
- estrogen
- occasionally adrogens, masculinizing the patient
granulosa cell tumors and malignancy
all are potentially malignant
-pursue an indolent course in which local recurrences may be amenable to surgery
Granulosa cell tumors and recurrence
-Recurrences within the pelvis and abdomen may appear 10-20 years after removal of original tumor
Elevated tissue and serum levels of inhibin are found in what tumors
granulosa cell tumors
What gene mutation is found in granulosa cell tumors
FOXL2 but interestingly only common in adult form
Tumors arising in the ovarian stroma that are composed of fibroblasts?
plump spindle cells with lipid droplets?
- fibromas
- thecomas
- a mixture is a fibrothecomas
are fibromas hormonally active?
thecomas?
- inactive
- active
characteristics of fibromas
- unilateral in 90%
- usually solid, spherical or slightly lobulated, encapsulated, hard, gray-white masses
- covered by glistening intact werosa
- histology: well differentiated fibroblasts and a scant interspersed collagenous stroma
Fibromas usually come to attention as what?
what 2 odd associations
a pelvic mass sometime accompanied by pain
- Ascites (40%) . . tumors measure more than 6 cm . .uncommonly also hydrothorax on right site
- Basal cell nevus syndrome
combination of ovarian tumor, hydrothorax, and ascites is what syndrome
Meigs syndrome
vast majority of fibromas, fibrothecomas, and thecomas are benign but rarely have mitotic activity and increased nuclear to cytoplasmic ratio and pursue malignant couse . . termed what
fibrosarcomas
These tumors are often functional and commonly produce masculinization or defeminization, but few have estrogenic effects
sertoli-Leydig cell tumors
age for sertoli leydig cell tumors
- all ages
- peak at second and third decade
Gene mutation in over half of sertoli Leydig cell tumors
DICER1 . . gene that encodes an endonuclease and essential for proper processing of microRNAs
Sertoli leydig cell tumors may block normal female sexual development in children and may cause defeminization of women, manifested by what?
- atrophy of breasts
- amenorrhea
- sterility
- loss of hair
- may progress to striking virilization (hirsutism) associated with male distribution of hair, hypertrophy of clitoris, and voice changes
Reinke Crystalloids
Hilus cell tumors (pure leydig cell tumors)
these are rare unilateral tumors derived from cluster of polygonal cell arranged around hilar vessels and comprised of large lipid laden leydig cells with distinct border and characteristic cytoplasmic structures called Reinke crystalloids
Hilus cell tumors (pure leydig cell tumors)
women with hilus cell tumors present with what
masculinization in form of hirsutism, voice changes, and clitoral enlargement
-milder than those with sertoli-leydig cells tumors
what do hilus cell tumors produce
testosterone
a rare tumor that closely resemble the corpus luteum of pregnancy and may produce virilization in pregnant patients and their female infants
pregnancy luteoma
an uncommon tumor composed of germ cells and sex cord stroma derivative resembling immature sertoli and granulosa cells that occurs in individuals with abnormal sexual development and in gonads of indeterminate nature
Gonadoblastoma
The most common metastatic tumors of the ovary of derived from what
mullerian origin:
- uterus
- fallopian tube
- contralateral ovary
- pelvic peritoneum
The most common extra mullerian tumors that metastasize to the ovaries are what
- carcinomas of the breast
- GI: colon, stomach, and biliary tract and pancreas
bilateral ovarian metastasis composed of mucin-producing, SIGNET RING cancer cells, most often of gastric origin
Krukenberg tumor
features of ovarian torsion
- infrequent but significant cause of acute lower abdominal pain
- reproductive age median of 28 . . second peak postmenopausal
- tube often involved
- if not considered, delay can lead to vascular compromise of adnexa and subsequent infarction
- 5th most common cause of gynecologic surgical emergency
