Pathology of an Ovary and the Fallopian Tube

Question 1

Describe the features of a normal fallopian tube

Answer 1

• It is a tubal structure with a muscular wall covered by peritoneum.
• It has a fimbrial end with finger like projections. The epithelium of these projections is in continuity with the lining of the tube.
• Internal aspect of the tube has a complex arrangement of plical folds which are covered by serous epithelium which contains cuboidal cells with cilia and secretory cells.

Question 2

Describe the appearence of the normal ovary

Answer 2

Peripheral cortex contains numerous follicles containing ova (germ cells)
- Corpora lutea and corpora albicantes are seen during menstruation in peripheral cortex.
- Corpus albicantes remain in post menopausal women.
- There is a central medulla containing stroma, blood vessels and sometimes leydig cells.
- Stroma contains spindle shaped cells and colloagen fibres.
- Mesothelial cells form a peritoneal covering.

Question 3

Explain the development of the fallopian tubes

Answer 3

• Germ cells originate from the yolk sac and by 5-6 weeks of gestation migrate to the urogenital ridge.
• Mesodermal epithelium of this ridge then forms the epithelium and stroma of the ovary in which the germ cells are embedded.
• At 6 weeks, invagination and fusion of the coelomic epithelium forms the mullerian ducts which grown down into the pelvis. They fuse and the fused portions become the uterus and vagina. The unfused portion becomes the fallopian tubes

Question 4

Name the non neoplastic ovarian cyst types

Answer 4

• Follicular cysts and luteal cysts which are part of the normal menstrual cycle.
• Inclusion cysts,
• Polycystic ovarian disease: where the ovary contains a large number of follicular cysts, many of which lack a central oocyte. Patients have irregular periods, androgen excess and fertility problems

Question 5

What is ovarian stromal hyperplasia?

Answer 5

• Uniform enlargement of the ovary
• Stromal hyperplasia so no luteinising cells, however if they are present then it is termed stromal hyperthecosis.
• Ill defined white/yellow nodules macroscopically.
• Microscopically replacement of cortex and medulla by ovarian stroma

Question 6

What is pelvic inflammatory disease and tubo-ovarian abscess?

Answer 6

• tubo-ovarian abscess is part of the PID spectrum. There is fusion of tubal plicae which increases risk of infertility and ectopic pregnancy.
• Underlying cause is STI such as chlamydia trachomatis/Neisseria gonorrhoea. These cause cervical inflammation which can ascend to cause salpingitis
• Microscopically have aggregates of neutrophils

Question 7

How does PID present?

Answer 7

Abdominal/pelvic pain, adnexa; tenderness, fever and vaginal discharge. Requires antibiotic therapy

Question 8

Describe features of endometriosis

Answer 8

• Endometrial constituents occur outwith endometrial cavity.
• Ovarian endometriosis can cause formation of blood filled cysts termed endometriomas
  -The abnormally located endometrium continues to bleed and can result in scarring and adhesion formation in the adjacent tissue.

Question 9

What are some different types of ovarian neoplasia

Answer 9

Tumours can arise from: surface epithelium (most common), germ cells, ovarian stroma or metastasis from other primary tumours.

Question 10

What are the symptoms of ovarian neoplasms

Answer 10

-If the tumour does not secrete hormones then it can be asymptomatic until they reach a large size.
- Symptoms can include abdominal distention, urinary symptoms and GI symptoms (due to compression)
- Large neoplasms can result in torsion causing severe abdo pain.

Question 11

Describe features of benign serous cystadenoma

Answer 11

• Cyst with thin walls which are lined by epithelium which resembles normal fallopian tubes,
• Epithelium is one cell thick so there are no tufts, papillary areas or solid growth, so only the removal of the cyst is required.
• Borderline serous tumours have more complex growth patterns compared to benign, they will have some cytological atypia. Can develop into carcinomas

Question 12

Describe features of a low grade serous carcinoma

Answer 12

• Rare which is slowly progressive with recurrences following excision.
• Does not respond well to chemotherapy
• Seen in areas which also have borderline serous tumours.
• Molecular abnormalities: BRAF or KRAS mutations present.
• Absence of BRCA mutation or p53 mutation

Question 13

Describe features of high grade serous carcinomas

Answer 13

• Most common ovarian carcinoma which occurs in post/peri-menopausal women but can be seen in younger patients with BRCA mutation.
• Late presentation so tumour has usually spread past ovary.
• Treated with surgery and chemotherapy depending on extent.
• Though to originate from precursor - serous tubal intraepithelial carcinoma
• Molecular abnormalities: p53 mutation present.

Question 14

Describe features of clear cell carcinomas

Answer 14

• More than 90% of clear cell tumours are carcinomas. They can be associated with endometriosis.
• Treatment is usually surgery as there is some resistance to platinum based chemo.
• Microscopic features include: high grade tumour with many different growth patterns, don’t always have clear cytoplasm. Can be hard to differentiate from high grade serous carcinomas but the clear cell carcinomas do not have p53 mutations

Question 15

Describe features of endometrioid carcinomas of the ovary

Answer 15

• associated with endometriosis and resembles endometrioid carcinoma of the endometrium.

Question 16

Name some germ cell tumours

Answer 16

• Most common is benign teratomas.
• Dysgerminoma,
• Embryonal carcinoma
• Yolk sac tumour,
• Choriocarcinoma

Question 17

Describe features of mature teratomas

Answer 17

• Can occur in al ages but most commonly women of reproductive age.
• Consists of mature tissues derived from one or more embryonic germ layers - ectoderm, endoderm, and mesoderm
• Most are cystic but can have solid areas such as hair, greasy sebaceous material and sometimes cartilage, bone and teeth.
• Microscopically different mature tissues can be identifies, eg, GI, thyroid, adipose.
• Requires thorough sampling as immature teratomas are regarded as malignant

Question 18

What are sex cord/stromal tumours?

Answer 18

These are tumours which develop from; cells surrounding the germ cells (granulosa or theca cells), sertoli or leydig cells, and fibroblasts within the stroma.
- Commonest is fibroma (benign) and adult granulosa cell tumour (low grade malignancy)

Question 19

Describe features of ovarian fibroma

Answer 19

• They are benign, solid, firm masses which vary in size which are white with a lobulated surface.
• Some patients develop Meig’s syndrome where an ovarian fibroma is associated with ascites and pleural effusion (resolves with removal of effusion).
• Microscopy shows small bland spindle shaped cells and collagen
• Present with non specific symptoms of abdominal pain

Question 20

What are adult granulosa cell tumours?

Answer 20

• Oestrogen secreting tumours resulting in abnormal vaginal bleeding, menorrhoea, amenorrhoea or post menstrual bleeding.
• Occasionally secrete progesterone.
• Low grade malignancy
• Usually unilateral and confined to ovary.
• Require long follow up period