Pathology Of The Ovary And Fallopian Tubes

Question 1

What gynaecological organs are covered in peritoneum?

Answer 1

All except the cervix

Question 2

Describe the normal anatomy of the Fallopian tube

Answer 2

• muscular wall with fimbrial end
• internally the tube is arranged in plical folds covered in serous epithelium (cuboidal cells with cilia and secretory cells with a clear vacuole around the nucleus)

Question 3

Describe the anatomy of the normal ovary

Answer 3

• cortex contains follicles (ova)
• medulla contains stroma, blood vessels and sometimes Leydig cells
• appearance is dependent on age, menopausal status and pregnancy
• during menstruation the corpora lutea (yellow body with haemorrhagic centre) and corpora albicantes can be seen
• the corpora albicantes (white dots in cortex) remains post-menopausal
• the stroma is compact containing spindle shaped cells with not much cytoplasm and nuclei that stains blue

Question 4

Describe the development of the ovary and Fallopian tube

Answer 4

• germ cells originate from yolk sac (week 5-6) of gestation and migrate to urogenital ridge
• mesodermal epithelium forms this ridge which forms the epithelium and stroma of the ovary - the germ cells embed themselves
• invagination and fusion of the coelomic epithelium forms 2 Müllerian ducts which grow downward into pelvis and fuse forming the urogenital sinus
• unfused portions form the Fallopian tube and fused parts become the uterus and vagina

Question 5

What are the types of non-neoplastic ovarian cysts?

Answer 5

• follicular cysts and luteal cysts (part of normal menstrual cycle)
• inclusion cysts (infoldings of surface peritoneum that become trapped in stroma)
• PCOS (large follicular cysts with no egg)

Question 6

Describe ovarian stromal hyperplasia

Answer 6

• uniform enlargement of ovary with no lutenised cells usually
• if lutenising cells can result in stromal hyperthecosis (higher incidence of hyperandrogenism)
• ill-defined white/yellow macroscopic nodules
• microscopy shows replacement of cortex and medulla by nodules of ovarian stroma

Question 7

Describe PID

Answer 7

• salpingitis: inflammation of the Fallopian tube (can cause an abscess resulting in fusion with the ovary = tubo-ovarian abscess)
• underlying cause is usually STI (chlamydia or gonorrhoea) causing cervical inflammation
• presents with abdominal/pelvic pain, adnexal tenderness, fever and vaginal discharge (requires antibiotics)
• microscopic aggregates of neutrophils and inflammatory cells
• consequences: turbo-ovarian abscess, fusion and fibrosis of plical folds of the Fallopian tube (increased risk of infertility and ectopic pregnancy)

Question 8

Describe endometriosis

Answer 8

• presence of endometrial constituents occurring out-with the endometrial cavity
• can cause blood filled cysts (endometriomas) = chocolate cysts
• endometrium will bleed causing scarring and adhesion to adjacent tissues
• rarely tumours can form

Question 9

Describe the different origins that ovarian neoplasia can arise from and the symptoms

Answer 9

• surface epithelia
• germ cells
• ovarian stroma
• secondary from elsewhere in the body (most commonly the stomach)
  Symptoms: abdominal distension, urinary symptoms, GI symptoms

Question 10

List the surface epithelium tumours

Answer 10

• benign serous cyst adenoma
• borderline serous cyst adenoma
• low grade serous carcinoma
• high grade serous carcinoma
• clear cell carcinoma
• endometriod carcinoma
• mucinous adenocarcinoma

Question 11

Describe benign serous cyst adenomas

Answer 11

• thin walled
• lined by epithelium 1 cell thick that resembles the epithelia of the Fallopian tube
• no tufts, papillary areas or solid growth, no atypia
• removal is only required treatment
• no risk of recurrence or malignant transformation

Question 12

Describe borderline serous cyst adenomas

Answer 12

• some cytological atypia with more complex growth pattern (difficult to predict)
• evidence of invasion absent
• can only involve ovary or have implants elsewhere in system
• monitoring required for recurrence/development into low grade carcinoma

Question 13

Describe low grade serous carcinoma

Answer 13

• slow and progressive
• can recur after excision and don’t respond well to chemo
• usually in ovaries with areas of borderline serous tumour
• associated with BRAF/KAS mutations
• not associated with BRCA/p53 mutations

Question 14

Describe clear cell carcinomas

Answer 14

• associated with endometriosis but can occur without
• surgery is main treatment (but resistant to platinum based chemo)
• usually large, solid/cystic
• many different growth patterns and don’t always have a clear cytoplasm
• no p53 mutation
• histology shows hobnailing and eosinophil globules

Question 15

Describe endometriod carcinomas

Answer 15

• associated with endometriosis
• resembles endometriod carcinomas of the endometrium

Question 16

What is important to note about mucinous adenocarcinomas

Answer 16

They are rare and have usually differentiated from another primary metastases

Question 17

Describe germ cell tumours

Answer 17

• Eg. Teratoma (mature germ cell tumour)
• consists of mature tissue derived from 1+ embryonic germ cell layers
• most cystic but can have solid areas depending on tissue development
• contain hairy and greasy sebaceous material, sometimes cartilage, bone, teeth
• microscopically different tissues identified
• immature elements are malignant and can recur/metastasise

Question 18

Describe features of stromal tumours

Answer 18

• cells surrounding germ cells
• sertoli/leydig cells
• fibroblasts cells from within stroma
• can be benign/malignant
• common eg. Fibroma (benign) or granulosa cell tumour (low grade malignancy)

Question 19

Describe Fibromas

Answer 19

• present with non-specific symptoms or incidental findings
• minority have Meig’s syndrome where the tumour is associated with ascites
• vary in size, white and firm lobuled surface
• microscopy shows small bland spindle shaped cells and collagen

Question 20

Describe adult granulosa cell tumours

Answer 20

• secretes oestrogen (stimulates symptoms - earlier presentation)
• presents with abnormal vaginal bleeding, menorrhoea/amenorrhoea
• occasionally androgen secreting
• usually confined to ovary and does not recur/metastasise
• variable size, solid/cystic