Pathology of the fallopian tube and ovary

Question 1

Endometrial pathology

Answer 1

• Most are estrogen related: can be metaplasia, hyperplasia, adenoCA
• Hyperplasia may be +/- atypia, the presence of atypia predicts the development of CA
• Endometrial adenoCA: can be low grade (more glandular, better prognosis), or high grade (more solid pattern)
• Non-estrogen related (poor prognosis): serous endometrial CA, clear cell CA, carcinosarcomas, leiomyosarcoma, endometrial stromal sarcoma

Question 2

Acute and chronic salpingitis

Answer 2

• Usually due to neisseria gonorrhea or chlamydia
• Acute: hyperemia and congestion of the fallopian tubes, which will progress to an abscess (either in the tube or w/in the lumen)
• If not treated will result in progressive destruction and obstruction of the tube
• Chronic salpingitis (due to repeated bouts of infection) results in partial or complete obliteration of the lumen, often resulting in infertility (also increases chance of getting ectopic pregnancy)

Question 3

Ectopic tubal pregnancy

Answer 3

• Since the tube cannot sustain a full term pregnancy it will eventually rupture, causing massive intraperitoneal hemorrhage
• Pts can present w/ severe abd pain and hypovolemic chock
• Pregnancy tests are often positive, there may be a tender adnexal mass
• Uterus will not be the appropriate size for the gestational age
• Other sites: ovary, peritoneal structures

Question 4

Non-neoplasic ovarian cysts 1

Answer 4

• Usually arise from coelomic epithelium or ovarian follicle, may be functional (producing E+P) or non-functional
• Follicular cyst: extremely common, often involutes but may persist and result in hyperestrinism (manifests as endometrial hyperplasia)
• Corpus luteal cyst: may result in persistent progesterone production, causing delayed menstruation followed by prolonged uterine bleeding
• Theca lutein cyst: usually associated w/ elevated levels of gonadotropins, as seen in gestational trophoblastic diseases (hydatidiform mole, choriocarcinoma)

Question 5

Non-neoplasic ovarian cysts 2

Answer 5

• Polycystic ovary: usually associated w/ luteinization of the cysts and cortical storm, resulting in clinical manifestations depending on the hormone being produced
• Can produce estrogen (hyperestrinism), can lead to virilism, can lead to stein-leventhal syndrome (triad of secondary amenorrhea, polycystic ovary, and virilism)
• Endometrial cyst: will undergo cyclic bleeding and result in blood-filled cyst that will fibrose (can cause tubo-ovarian adhesions)
• Tubo-ovarian adhesions are a risk factor for sterility and ectopic pregnancies
• Women w/ endometrial cysts will often have Fe-def anemia

Question 6

Primary epithelial neoplasms of the ovary

Answer 6

• Thought to be due to bits of fallopian tube falling into ovary when it ruptures during ovulation (epithelium proliferates w/in ovary)
• Benign neoplasms are more common and usually seen in young women, malignant neoplasms are generally seen in older women (peak age 62)
• They are often incidental findings, may present w/ abd discomfort, ascites can be seen particularly in malignant neoplasms
• The neoplasms can be benign, borderline, or malignant based on micro and macroscopic appearance (degree of nuclear atypia, complexity of glanduals architecture, presence of absence of invasion)
• Benign neoplasms have a good prognosis and malignant ones have poor (borderline neoplasms are in the middle)

Question 7

Types of primary neoplasms of the ovary

Answer 7

• Tubal (serous): resembles ciliated epithelium of fallopian tube
• Endocervical (mucinous): resembles mucinous columnar epithelium of endocervical canal
• Urothelial: resembles transitional epithelium of urinary bladder
• Endometrioid
• Clear cell

Question 8

Appearance of benign, borderline, and malignant ovarian neoplasms

Answer 8

• Benign: majority are cystic (except urothelial and adenofibromas)
• Lining resembles nl structures (single cell layer lining)
• Borderline: increased architectural complexity, cellular proliferation, nuclear atypia, but do not invade stroma tho do have ability to met (>90% 10 yr survival)
• Borderline neoplasms often demonstrate papillae, w/ linings 2-4 cells thick
• Malignant ovarian epithelial tumors: extreme architectural complexity, nuclear atypia, destructive invasion of stroma, high met potential
• Cell lining >4 cells thick, key thing is invasion of the stroma

Question 9

Germ cell tumors 1

Answer 9

• A disease of the young- peak in 2nd decade of life
• Mature teratomas (most common benign): cystic and solid masses, contain sebum, teeth (contains endoderm, mesoderm, and ectoderm), may be bilateral (most common tissues are skin, nerves, and adipose)
• Immature teratomas are malignant
• Dysgerminoma (most common malignant): marked elevation of LDH, radiosensitive, solid/lobulated w/ necrotic and hemorrhagic areas

Question 10

Germ cell tumors 2

Answer 10

• Micro: uniform, primitive cells, fibrovascular cords + sheets of lymphocytes, focal areas w/ syncytiotrophoblasts
• Endodermal sinus (yolk sac) tumor: 2nd most common malignant GCT, elevated AFP is hallmark, unilateral pelvic mass in 20yo
• Mass is large, lobulated, solid + necrosis, radioresistant
• Micro: characteristic rosetting around small venues (schiller-duval bodies), hyaline globules of AFP

Question 11

Ovarian sex-cord and stream tumors 1

Answer 11

• Usually seen in older women, after 6th decade
• Fibroma: benign solid tumors that occasionally produce steroid hormones (usually E), occasionally produce a pleural effusion
• Micro: spindled cells look like fibroblasts, rare mitoses
• Granulosa cell tumor: low grade malignant tumor that frequently produces estrogen (presents as uterine bleeding, endometrial hyperplasia, endometrial adenoCA)

Question 12

Ovarian sex-cord and stream tumors 2

Answer 12

• Micro: often see call-exner bodies; ring of granulosa cells around a space filled w/ amorphous pink material (resembling primordial follicles)
• Sertoli-leydig tumors: clinically significant when they produce androgens and cause virilization (occur in women of all ages)
• Micro: sertoli cells arranged in tubules (looks like seminiferous tubules) w/ leydig cells scattered in small clusters around tubules (discolored patches of cells are leydig cells- they produce the androgens)

Question 13

Endometrial carcinoma of the endometrioid type

Answer 13

• Is related to unopposed estrogen and is usually anteceded by endometrial hyperplasia
• Endometrial bleeding leads to early detection, and hysterectomy is curative if caught early enough
• Gross: irregular thickening of the endometrium, followed by necrosis and hemorrhage
• Micro: back to back glands lined by malignant cells, w/ less differentiated types containing fewer glands and more sheets of cells

Question 14

Leiomyosarcoma and leiomyomas of the uterus

Answer 14

• Leiomyomas are benign SmM tumors that are thought to be E-related
• They can produce abnormal uterine bleeding, pelvic discomfort, and can cause infertility
• Gross: well-circumscribed spherical nodules
• Micro: disorganized bundles of SmM cells
• Leiomyosarcoma: malignant counterpart, composed of malignant SmM cells
• Micro: highly atypical cytology, coagulate necrosis and high mitotic index