Ovary and Fallopian Tube Pathology 1

Question 1

List the four major types of ovarian tumors.

Answer 1

• Surface epithelial neoplasms
• Sex-cord stromal tumors
• Germ cell tumors
• Metastatic tumors

Question 2

What are the major non-neoplastic ovarian cysts?

Answer 2

• Follicular cyst
  
  • common lesions of Graafian follicle origin
  • usually multiple and <2cm
  • may produce increased estrogen if theca component is luteinized
    
    • increased serum estrogen, pain, or hemoperitoneum
  • consist of granulosa and theca cells
  • polycystic ovarian syndrome
• Corpus lutein cysts (CLC)
  
  • non-pregnant CLC
  • pregnancy CLC
    
    • corpus luteum may appear as ovarian neoplasm
  • rupture may cause peritoneal inflammation
• Non-neoplastic epithelial cysts
  
  • ovarian surface epithelial cyst
  • ciliate tubal inclusion cyst/Paratubal cyst
  • remnant cyst

Question 3

What is the clinical presentation, pathophysiology, histology, and long-temr sequelae of PCOS?

Answer 3

• Clinical
  
  • 5% of reproductive age women
  • obese
  • hirsute (rarely virilized)
  • diabetic (insulin-resistant)
• Pathophysiology
  
  • persistent anovulation
  • oligomenorrhea
  • high level of LH & estrogen
    
    • LH and insulin result in overproduction of androgens that are converted in peripheral tissue to estrogen
• Histology
  
  • multiple follicles
  • fibrosis
  • absence of corpus luteum
• Long-term sequelae
  
  • endometrial hyperplasia/carcinoma

Question 4

What are the common sources of ovary/FT surface epithelial tumors?

Answer 4

• Glands of endometriosis
• Remnants: rete ovary, walthard and mesonephric ducts (secondary Mullerian system)
• Endosalpingiotic, paraovarian, and paratubal cysts
• The fimbriated end of secretory epithelia (FTE)
  
  • gives rise to significant percentage of hihg-grade serous carcinomas
  • fimbria responsible for deposition of neoplastic cells on the surface of the ovary
• Ovarian surface epithelia?

Question 5

What are the sources of “sex-cord” stromal tumors?

Answer 5

• Stroma of the ovary: fibroblasts and myofibroblasts
• Sex cord: the non-germ cell elements of the Graafian follicle

Question 6

What are the common sources off germ cell neoplasias?

Answer 6

germ cells within the follicle are the progenitor cells

Question 7

What are the major epithelial ovarian tumor classifications?

Answer 7

• Serous:
  
  • epithelium of tumor resembles fallopian tube epithelium , the most common neoplasms in ovary
• Mucinous:
  
  • resembles endocervical (associated with endometriosis and teratoma) or colonic mucosa
• Endometrioid:
  
  • resembles proliferative endometrial glands; 30% associated with endometriosis
• Clear Cell:
  
  • similar histology at all sites; ~50% to 70% associated with endometriosis
• Transitional:
  
  • Brenner tumor most common type; cells resemble transitional (urothelial) cells

Question 8

What is the detection rate and death rate of ovarian carcinoma?

Answer 8

• Accounts for 50% of female genital tract deaths; The death rate for OC has not changed in the past 50 years.
• 75% of OC are detected in late stages and 50% are high grade serous carcinoma
• Recent studies, however, have raised a compelling hypothesis that fallopian tube secretory epithelial cells (FTSECs) may harbor a cell of origin for most high grade serous carcinoma.

Question 9

What are the major subdivisions of serous epithelial tumors and what are the major features of each?

Answer 9

• Benign (60%):
  
  • serous Cystadenoma and Cystadenofibroma
• Borderline or Low Malignant Potential (15%)
  
  • intraepithelial proliferation
  • 30% to 40% have extra-ovarian spread, called “implants” in omentum, peritoneum or lymph nodes
• Malignant: Invasive (25%)
  
  • 50% bilateral; represents 50-60% of all malignant ovarian tumors
  • can be divided into low grade and high grade

Question 10

Describe the histology of serous cystadenoma.

Answer 10

• Multiple cysts with smooth lining
• Showing serous cyst adenofibroma (top) and cyst adenoma with simple papillary architecture (bottom).
  
  • high-power (right) showing fallopian tube-like epithelium
• Lesion usually lined with a pseudostratified row of tall ciliated columnar cells - resembles fallopian tube epithelium

Question 11

Describe the histology of serous papillary “borderline” tumors.

Answer 11

• Gross
  
  • solid and cystic mass
  • yellow tan papillary fronds
• Typical Histology
  
  • intraepithelial proliferation
  • pseudo- and true stratified
  • tufting
  • mild to moderate nuclear atypia
  • non or microinvasive
  • hierarchical papillary/micropapillary epithelial proliferation
  • 30-40% have “implants” of serous tumor on extra-ovarian peritoneal surfaces
• Progression to low-grade invasive serous adenocarcinoma on recurrance has high mortality rate

Question 12

In serous “borderline” tumors what are important considerations for involvement of extra-ovarian sites?

Answer 12

• Implants vs Metastasis
  
  • common in omentum, pelvic sidewall, diaphragm and uterine serosal surface
  • can be found in pelvic lymph node
  • can progress to low grade serous carcinoma

Question 13

What are some features of malignant serous tumors?

Answer 13

• Solid component with invasion into ovarian stroma
• Increased cellular proliferation with cytologic atypia
• Cytologic atypia and psamomma bodies
• High-grade serous carcinomas can also come from mucosa lining fibriated end of the fallopian tube
  
  • spread diffusely throughout peritoneal cavity

Question 14

What are some important features of ovarian mucinous tumors?

Answer 14

• Middle-aged adults
  
  • rare before puberty / after menopause
• Three groups:
  
  • endocervical
    
    • usually benign
    • cystic neoplasms lined by talkk mucin-filled cells
    • associated with endometriosis
  • intestinal
    
    • maybe benign, LMP, or malignant
    • usually large and multicystic
    • lined by intestinal-type mucosa with goblet cells
  • Mullerian
• Can be heterogeneous and consist of benign borderline and malignant components with on tumor
• Malignant tumors are more solid and complex with stromal invasion
• Must exclude appendiceal or colonic metastasis!

Question 15

What are the major histologic findings of mucinous cystadenocarcinoma?

Answer 15

• Major histologic features:
  
  • columnar cells with abundant intracytoplasmic mucin and cytologic atypia
  • Stromal invasion;
  • more solid growth, loss of glandular architecture,
  • necrosis
• Differentiation:
  
  • glands are mostly intestinal type
  • endocervical type usually
• Carcinoma often merges with borderline or benign mucinous tumors

Question 16

What are the major histologic findings of clear cell carcinoma?

Answer 16

• Less common
• 50-70% associated with foci of endometriosis in ovaries or pelvis
• Microscopically characterized by presence of pleomorphic cells with clear, glycogen-rich or lightly eosinophilic cytoplasmic arranged as:
  
  • tubular glands
  • solid nests
  • papullary structures
• Clinically agressive

Question 17

What are the major features of endometrioid tumors?

Answer 17

• Common (20% of all ovarian cancers)
• Grossly, solid and cystic neoplasms with tubular glands resembling endometrium
  
  • histologically identical to those arising in the endometrium
• 30% associated with foci of endometriosis
• co-existing uterine endometrioid carcinoma in 15-30%

Question 18

What are the important histological features of Brenner cell tumors?

Answer 18

• Presents in middle-aged or older adults
• Commonly, an incidental finding (tumor < 2cm.).
• 10% to 25% of tumors associated with mucinous cystadenoma
• Rare “borderline” tumors resemble papillary transitional cell tumors of the bladder
• Nests of epithelial cells (resembling urothelial cells) with bland, “grooved” nuclei in a cellular fibrous stroma (red arrows)

Question 19

What are the common histologic features of small cell carcinoma of the ovary?

Answer 19

• High-grade carcinoma; affects patients <40 years of age
• Small pleomorphic cells
• Nearly 50% are bilateral.
• About 2/3s of tumors are associated with hypercalcemia.
• Poor prognosis

Question 20

Describe the FIGO staging of ovarian cancer.

Answer 20

• Stage 1 - Tumor limited to ovaries
• Stage 2 - Involvement of one or both ovaries with pelvic extension in pelvis
• Stage 3 - Involvement of one or both ovaries with extension beyond the pelvis
• Stage 4 - Involvement of one or both ovaries with distant metastases