Pathology of Ovary and Tube

Question 1

3 major disorder of fallopian tubes include:

Answer 1

• inflammations (gonococcus, chlamydiae, TB)
• paratubal cysts (benign, common)
• tumors (uncommon; serous carcinomas arise here and met to ovary)

Question 2

2 major disorders and 3 major tumor types of ovaries include:

Answer 2

• cysts (follicular and luteal)
• PCOS
• epithelial tumors: serous, mucinous, clear cell, brenner, MMMT, metastatic
• Sex cord stromal tumors: granulosa cell tumors, fibromas, fibrothecomas, sertoli-leydig cells tumors
• germ cell tumors: teratoma, dysgerminoma, yolk sac tumor, mixed

Question 3

Follicular cyst

Answer 3

ovarian cyst:

• granulosa cells may line it or they may be atrophied if pressure is high
• outer theca cells may be conspicuous 2/2 inc. amounts of pale cytoplasm

Question 4

Corpus luteal cysts

Answer 4

ovarian cyst:

• lined by bright yellow tissue containing luteinized granulosa cells
• present in normal repro-age ovaries; may rupture and cause peritoneal rcn

Question 5

Classification of ovarian epithelial tumors

Answer 5

• benign
• borderline
• malignant

Question 6

Serous ovarian tumor

Answer 6

• made of malignant epithelial cells; most common malignant tumor of the ovary
• assoc’d with germline BRCA1 and 2 mutations; bilaterality is common
• where do LGSC come from: benign serous cystadenoma –> borderline tumor (epithelial cell stratification but no invasion) –> low grade serous carcinoma
• where do HGSC come from: a serous tubal intraepithelial carcinoma (STIC) of the fimbrae breaks off some malignant cells which somehow get uptaken into the ovary, grow and cause a high grade serous carcinoma

Question 7

How to distinguish between low and high grade serous carcinomas?

Answer 7

• high grade have more complex growth patterns and widespread infiltration or frank effacement of underlying stroma (recall its origin from STIC in fimbrae)
• low grade defined by complex micropapillary serous carcinoma (recall its development from benign cystadenoma)

Question 8

Mucinous tumor

Answer 8

• cystic multilobular tumors of the ovary with smooth lining of epithelium; the mucin is produced by goblet cells
• assoc’d with KRAS mutation (proto-oncogene)
• also commonly a metastasis to the ovary from a mucinous tumor in the GI tract

Question 9

Pseudomyxoma peritonei

Answer 9

• a clinical condition - “jelly belly” - that arises when the abdomen has been seeded by mucin-producing tumors
• pt will have mucinous ascites, cystic epithelial implants on the peritoneal surfaces, adhesions
• frequently involves ovaries
• source thought to be extra-ovarian, and is often appendiceal – so if this is found, check the appendix for a malignant mucinous tumor as well (appendiceal mucinous tumors often look benign)

Question 10

Endometrioid adenocarcinoma

Answer 10

• adenocarcinoma associated with endometrial tissue
• 15-20% of cases coexist with endometriosis
• micro looks a lot like endometrial carcinoma but arises near ovary instead of in endometrial cavity
• can exist at the same time as an endometrial carcinoma (which makes sense because if you’re predisposed and get the trigger, it triggers the cells to proliferate in both places)

Question 11

Transitional cell tumor

Answer 11

(Transitional cells now called urothelium)

• tumors containing neoplastic epithelial cells resembling and mimicking urothelium
• when in the ovary these are called Brenner tumors
• arranged in classic epithelial nests within stroma (well-demarcated cellular islands) on histology
• usually benign, malignant are exceedingly rare

Question 12

Metastatic tumors found on the ovary

Answer 12

• the most common are derived from Mullerian origin (uterus, tube, ovary, pelvic peritoneum)
• most common extra-Mullerian origins are breast and GI tract
• pseudomyxoma peritonei also included in this group because this commonly comes from appendiceal mucinous tumor

Question 13

Krukenberg tumor

Answer 13

• classic metastatic GI (most often stomach) cancer to the ovaries
• bilateral metastases composed of mucin-producing cancer cells

Question 14

Granulosa tumors

Answer 14

• tumor composed of granulosa cells of ovary - so they do what granulosa cells do
• Important features to remember:
  1. produce estrogen - because that’s what granulosa cells do; this inc. risk of uterine/breast cancer
  2. behave like low-grade malignancies
  3. Call-Exner bodies - granulosa cells also try to recapitulate follicles, so these bodies are follicle-like structures
  4. looks like coffee beans (has grooves)
  5. stains positively for inhibin

Question 15

Meigs syndrome

Answer 15

• combination of findings including ovarian tumor, hydrothorax, and ascites
• unknown genesis
• associated with fibromas, fibrothecomas, thecomas

Question 16

Sertoli-Leydig cell tumors

Answer 16

often functional, producing testosterone and masculinization or defeminization; some can have estrogenic effects as well;

Question 17

Sex cord stromal tumor

Answer 17

• these include tumors derived from ovarian cells including granulosa cells, fibromas, fibrothecomas, thecomas, Sertoli-leydig cells

Question 18

Teratoma

Answer 18

• tumor of embryonic tissue layers that differentiated into different structures
• 3 categories:
  1. mature (benign)
  2. immature (malignant, resemble embryonic tissue; the higher fraction of immature neuroepithelium present the higher the risk of extraovarian spread)
  3. monodermal or highly specialized (struma ovarii)
• malignancy potential depends on histological staging, which is based on the proportion of tissue that is immature neuroepithelium

Question 19

Dysgerminoma

Answer 19

• a tumor of stem cells (unknown type); named differently based on the location:
  males–>seminoma;
  brain/mediastinum–>germinoma
• cell have a fried egg appearance with prominent nucleoli; lymphocytes present in tissue (will clinch the dx)
• cells express the RTK KIT and ~1/3 have activating mutation in KIT gene

Question 20

Yolk sac tumor

Answer 20

• tumors found in young people made of germ cells, aka endodermal sinus tumor
• these cells produce α-fetoprotein, and contain hyaline droplets within the cell that stain positive for AFP
• Schiller-Duval bodies will be seen as the malignant cells crowd around a vessel, ends up looking like a glomerulus

Question 21

What is the clinical utility of CA-125?

Answer 21

• watching for recurrence - if a woman has an epithelial ovarian tumor removed, CA-125 drops, then rises again if the tumor recurs
• not useful as a screening tool because it’s not very specific or sensitive