Pathology of the Myometrium, Placenta, Tube and Ovary

Question 1

Myometrium

What are the lesions which may be find within the myometrium

Answer 1

Benign: Leiomyoma

Malignant: Leiomyosarcoma

Question 2

Leiomyoma

Answer 2

A leiomyoma is a type of smooth muscle benign tumor which is found within the myometrium of the uterus.

Very common tumour.

Women 40 – 50 years.

Up to 20% of women develop uterine leiomyomas.

Question 3

Pathology of a Leiomyoma:

Macroscopic

Answer 3

Macroscopic:

Subserosal, intramural or intramucosal.-Usually multiple.

0,2 – 20cm diameter.
On sectioning solid, white with a whorled appearance.

Large lesions often contain areas of dystrophic calcification, cystic change, hyalinisation or red degeneration

Question 4

Pathology of a Leiomyoma:

Microscopic

Answer 4

Monomorphic spindle cells looking like smooth muscle.

Pauicellular with fewer that 5 mitoses per 10 high power fields

Question 5

What are the effects of a Leiomyoma

Answer 5

Decreased fertility.

Abnormal haemorrhage.

Obstructive labour.

Urinary frequency and sometimes infections.

Abdominal distention when the tumours are massive

Question 6

Leiomyosarcoma

Answer 6

Malignant tumour with smooth muscle differentiation.
Rare, usually elderly women

Recur after excision or haematogenous dissemination.

Poor prognosis.

Question 7

Pathology of a Leiomyosarcoma:

Macroscopic

Answer 7

Bulky, fleshy tumour, poorly circumscribed

Question 8

Pathology of a Leiomyosarcoma:

Microscopic

Answer 8

Highly cellular spindle cell tumour containing 10 or more mitoses per 10 h.p.f, necrosis and pleomorfism.

Question 9

Compare the characteristic of a Leiomyoma and a Leiomyosarcome

Answer 9

Small                                    
Well demarcated 
Slow growing 
Noninvasive 
Non-metastatic 
Well differentiated

Large
Poorly demarcated
Rapidly growing with hemorrhage and Necrosis
Locally Invasive
Metastatic
Poorly differentiated

Question 10

Adenomyosis

Answer 10

Common finding in hysterectomy specimens

Presence of endometrial glands and stroma
deep within the myometrium

Peri-menopausal, multiparous women

Can be regarded as a form of “diverticulosis”

Question 11

Endometriosis

Answer 11

Endometrial stroma and glands outside the
uterus;

❖ovary
❖serosal surface of the fallopian tube
❖pouch of douglas
❖intestinal walls
❖umbilicus
– Pain and infertility
– Retrograde menstruation

Question 12

Fallopian Tube Pathology

Answer 12

Salphingitis

Ectopic Pregnancy

Question 13

Salphingitis

Answer 13

Acute: usually a sexually transmitted
ascending infection, can also become more
chronic - chlamydia

May lead to tubo-ovarian complex and pelvic
peritonitis (PID)

Long term complications: Subfertility due to
decreased tubal patency and increased
incidence of ectopic pregnancy.

Tuberculosis: form of isolated organ
tuberculosis.

–

Question 14

Ectopic Pregancy

Answer 14

Occurrence of a pregnancy outside the
uterine cavity.

Most common site is the fallopian tube.

Most common underlying cause is
salpingitis

As pregnancy develop, the fallopian tube
becomes distended and eventually ruptures
with massive hemorrhage.

Question 15

Classification of Ovarian Tumours

Answer 15

Can be classified as Non-neoplastic and Neoplastic

Question 16

Non-neoplastic Ovarian Tumours

Answer 16

Epithelial inclusion cyst

Follicular cysts

Luetinised follicles

Corpus luteum

Endometriosis

Polycystic Ovarian Syndrome-PCOS

Question 17

Neoplastic Ovarian Tumours

Answer 17

Primary ovarian neoplasms vs metastatic

lesions

Question 18

Polycystic Ovarian Syndrome(5)

Answer 18

A non-neoplastic ovarian tumour

Hyperoestrogenism, amenorrhae, mullitple
follicular cysts in the ovary.

Corpora albicans virtually absent.

Defective insulin metabolism and obesity

Infertility, acne, endometrial hyperplasia
and even endometrial carcinoma

Question 19

Classification of Ovarian Tumours

Answer 19

S M E G

1. Sex-cord stromal tumours
2. Metastases-esp in Breast and Stomach carcinoma
3. Epithelial tumours
4. Germ cell tumours

Question 20

Epithelial Tumours

Answer 20

Subtyped according to lining epithelium and can be categorised as:

Benign: cystadenoma

Borderline: cystadenocarcinoma with low malignant
potential

Malignant: cystadenocarcinoma

Question 21

Pathology of Ovarian Epithelial Tumours

Answer 21

These tumours are derived from the surface epithelium(Modified mesothelium)

Three different types of epithelial differentiation can be found:

1. Mucinous-Looks like endocervical epithelium
2. Serous-Looks like tubal epithelium
3. Endometrioid-Looks like endometrial epithelium

Tumours are usually cystic and multilocular.

Lining of the cysts in the benign tumours is usually smooth while malignant tumours are usually lined by a visible papillary structures

Both benign and malignant tumours are usually unilateral but may be bilateral and varying in size from small to 30 cm in diameter.

Question 22

Benign cystadenoma

Answer 22

Epithelium lining cysts shows no atypia and is
single layered

Common

Can be serous or mucinous

Question 23

Borderline Cystadenocarcinoma of low malignant potential

Answer 23

More epithelial tufting and mild pleomorphism and
mitotic activity.

Looks like a cystadenoma

Prognosis fairly good, can spread to
peritoneum.

Common

Can be serous or mucinous

Question 24

Malignant Cystadenocarcinoma

Answer 24

Usually papillary(Serous, Mucinous or Endometriod)

Severe epithelial proliferation, mitotic activity,
pleomorphism and stromal invasion.

Spread mainly direct through capsule of the ovary to the peritoneum with resultant severe ascites.

Fairly common

Poor prognosis

Question 25

Mucinous Tumour

Answer 25

Mucinous tumour can be associated with pseudomyxoma peritonei = ‘jelly belly’ Must exclude a primary appendiceal neoplasm even in the presence of a mucinous ovarian tumour as it can represent a metastatic lesion Prognosis of ovarian cancer is relatively poor due to advanced stage at time of presentation.

Question 26

Serous Tumour

Answer 26

Lined by serous epithelium

Question 27

Germ Cell Tumours

Answer 27

Dysgerminoma Teratoma-Adult(Common)/Immature/Special Choriocarcinoma

Question 28

Germ Cell Tumours Pathology

Answer 28

Pure or mixed germ cell tumours Types include any of the following in isolation or varying amounts in combination: -Teratomas – mature, immature or special types -Dysgerminoma (similar to seminoma in males) -Extra-embryonic germ cell tumours: choriocarcinoma, yolk sac tumour or embryonal carcinoma Highly malignant tumours that can by mixed or pure Differentiation of germ cells along extra embryonic lines to form neoplastic versions of trophoblastic tissue Yolk sac tumour – kids usually pure, in adults often mixed Embryonal carcinoma Choriocarcinoma Can be mixed with each other or with a teratoma or a disgerminoma

Question 29

Dysgerminoma

Answer 29

Rare: Young females and it is usually unilateral Ovarian equivalent of a testicular seminoma Looks macroscopically and histologically the same Spread mainly lymphatic Firm, fleshy tumour on sectioning Consists of uniform germ cells with lymphocytes Radio-sensitive-Good prognosis

Question 30

Adult Teratoma

Answer 30

Most common germ cell tumour and most common ovarian neoplasm. 20-50 years 20% bilateral/80% Unilateral

Question 31

Pathology of an Adult Teratoma

Answer 31

Cystic-may be massive(20cm in diameter) Usually unilocular and lined by skin-squamous epithelium with cutaneous adnexae) Localized areas of thickening present in which a variety of tissue can be found(Fat, cartilage, glial tissue, salivary glands, bronchial epithelium, bone and even perfectly formed teeth) Behaviour: Benign but occasionally a carcinoma may develop in the teratome

Question 32

Immature Teratoma

Answer 32

Rare. 10-30 years. Usually solid. Consists of a mixture of tissue, some of which have an embryonic appearance. Potentially malignant and prognosis depends on amount of embryonic tissue Gliomatosis peritonei: glial tissue in the peritoneum associated with an immature teratoma

Question 33

Special Teratomas

Answer 33

Special teratoma types Occasionaly teratomas develop in a single direction (monodermal teratoma). Most common example: struma ovarii (thyroid tissue) or epidermal inclusion cysts that consists only of squamous epithelial. Rarely malignant transformation can take place to for example a squamous carcinoma

Question 34

Sex Cord Stromal Tumours

Answer 34

They are fairly uncommon, the most important being the granulosa cell tumour. Theca cell tumours, Sertoli cell tumours and Leydig cell tumours are rare.

Question 35

Granulosa Cell Tumour

Answer 35

Common, all age groups. Tumours are often endocrinologically active and produce Estrogen which may cause precocious puberty in young girls or endometrial hyperplasia/carcinoma. Usually small and solid. Small uniform cells with nuclear grooves arranged in trabeculae, groups or solid sheets. May mimic follicles (Call-Exner bodies). Potentially malignant with an unpredictable outcome. The overall 5 year survival rate is about 85%

Question 36

Metastatic Tumours

Answer 36

Tumour mets to the ovary can be genital or extragenital eg endometroid adenocarcinoma metastatic to the ovary versus a primary endometrial type adenocarcinoma of the ovary Most common extra genital tumours: large intestine, stomach and breast Krukenberg tumour: bilateral ovarian neoplasms composed of malignant mucin containing signet ring cells usually of gastric origin

Question 37

Trophoblastic Disease

Answer 37

These are complications of pregnancy. – Hydatiform mole: complete and partial – Choriocarcinoma

Question 38

Hydatiform Mole: Complete

Answer 38

Occurs in 1:1500 pregnancies in RSA. More common in Asia. Present with large for date uterus or haemorrhage. Follow up with BHCG. – Macro: Placenta resembles a bunch of grapes, all the chorionic villi are swollen and oedematous. No foetus develops. – Micro: chorionic villi show hydropic change and swelling covered by trophoblast proliferation. No stromal vessels. – Chromosomal pattern: 46XX, purely paternal – fertilisation of an empty ovum. – Complications: Infiltration of uterine wall with perforation Development of gestational choriocarcinoma.

Question 39

Hydatiform Mole: Partial

Answer 39

``` A foetus may be present. – Some of the villi are normal but others show hydropic change and trophoblastic proliferation. – Chromosomes: triploid: usually one set maternal and two sets paternal chromosomes. – Little if any chance of developing choriocarcinoma. ```

Question 40

CHORIOCARCINOMA

Answer 40

``` – Rare malignant tumour of trophoblast. – Develops weeks to years after a pregnancy: - 50% follow a complete mole - 25% follow abortion - 25% follow a normal term pregnancy – Trophoblasts secrete HCG and serum levels are very high. ```

Question 41

Pathology of CHORICO

Answer 41

Friable haemorrhagic mass is found in the endometrial cavity Infiltration of the myometrium is usually present. Micro: Necrosis and haemorrhage Malignant cytotrophoblasts and syncytiotrophoblast No Chorionic villi

Question 42

Spread and Pathology

Answer 42

Haematogenous spread early: vagina, vulva, lungs, liver, brain, intestinal walls. – Without treatment rapidly fatal. – Treated with cytostatics – prognosis excellent. – Non gestational choriocarcinomas: testis and ovary