Pathology of the Ovary & Fallopian Tube

Question 1

Describe the structure of a normal fallopian tube

1. general structure (what is it?) [3]
2. internal structure? [1]
3. what type of epithelium covers the fallopian tube and fimbriae? [1]

Answer 1

1. general structure:
   
   • tubal structure
   • with a muscular wall
   • covered by peritoneum
2. internally, composed of a complex arrangement of plical folds
3. serous epithelium
   
   • cuboidal cells with cilia and secretory cells

Question 2

Describe the histological features of the ovary

1. what does the peripheral cortex contain? [2]
2. when are the corpus lutea and corpus albicans seen? [2]
3. what does the central medulla contain? [3]
4. what does the stroma consist of? [2]
5. what type of cell forms the peritoneal covering of the ovary? [1]

Answer 2

1. peripheral cortex contains numerous follicles containing ova (germ cells)
2. corpus lutea and albicans during menstration but only the corpus albicans remains after menopause
3. central medulla contains:
   
   • stroma
   • blood vessels
   • sometimes Leydig cells
4. stroma consists of:
   
   • spindle shaped cells
   • collagen fibres
5. mesothelial cells

Question 3

Describe the development of the ovary and fallopian tube [7]

Answer 3

1. germ cells (endodermal) originate at the yolk sac
2. by week 5-6, they migrate to the urogenital ridge
3. mesodermal epithelium of this ridge forms structures of the ovary
4. around week 6, invagination and fusion of the coelomic epithelium forms the Mullerian ducts
5. these Mullerian ducts grow downwards into the pelvis and fuse togther and with the urogenital sinus
6. the unfused portions of Mullerian ducts → fallopian tube
7. the fused portion of Mullerian ducts → uterus + vagina

Question 4

What are the 4 types of non-neoplastic ovarian cysts? [4]

Answer 4

1. follicular cysts
2. luteal cysts
3. peritoneal inclusion cysts
   
   • complex cystic adnexal masses consisting of a normal ovary entrapped in multiple fluid-filled adhesions
4. polycystic ovarian syndrome

Question 5

What are the signs and symptoms of polycystic ovarian syndrome? [5]

Answer 5

1. irregular periods (often anovulatory - i.e. uterine bleeding in absence of ovulation)
2. hirsutism (excess coarse pigmented hair)
3. acne
4. weight gain
5. fertility problems

Question 6

How does polycystic ovarian syndrome present histologically? [2]

Answer 6

the ovaries contain a large number of follicular cysts, many of which lack a central oocyte

Question 7

Ovarian Stromal Hyperplasia

1. Who gets it? [1]
2. What is it? [1]
3. Macroscopic features? [1]
4. Microscopic features? [2]
5. If luteinised cells are present, what does this indicate? [2]

Answer 7

1. post-menopausal women
2. uniform enlargement of the ovary
3. ill-defined white/yellow nodules
4. replacement of the cortex and medulla by nodules of ovarian stroma and no luteinised cells
5. if luteinised cells present → stromal hyperthecosis and an increased incidence of hyperandrogenism

Question 8

Pelvic Inflammatory Disease: Salpingitis

1. Definition? [1]
2. Causes? [3]
3. Presenting symptoms [4]
4. Microscopic features [1]
5. Treatment [1]
6. Describe the complications of PID [3]

Answer 8

1. inflammation of the fallopian tube
2. causes:
   
   • chlamydia trachomatis
   • neisseria gonorrhoea
   • TB
3. presenting symptoms:
   
   • abdominal/pelvic pain
   • adnexal tenderness
   • fever
   • vaginal discharge
4. microscopic features:
   
   • aggregates of neutrophils
5. treat with antibiotics
6. complications:
   
   • tubo-ovarian abscess, which leads to fusion of tubal plicae and results in increased risk of infertility and ectopic pregnancy

Question 9

Define tubal gestation and what is caused by? [2]

Answer 9

1. ectopic pregnancy occuring in the fallopian tube
2. occurs due to the inability of the ovary to go right through the fallopian tube to the uterus

Question 10

Endometriosis

1. Definition? [1]
2. Complications? [3]

Answer 10

1. the presence of endometrial constituents (glands and stroma) occurring outwith the endometrial cavity
2. complications:
   
   • formation of blood filled cysts called endometriomas
   • continuous bleeding can result in scarring and adhesion formation in adjacent tissues
   • rarely, tumours can form in endometrial tissue

Question 11

Where can ovarian tumours arise from? [4]

Answer 11

1. surface epithelium
2. germ cells
3. ovarian stroma
4. elsewhere in body (metastases)

Question 12

What are the general signs & symptoms of ovarian neoplasia? [3]

Answer 12

1. abdominal distension
2. urinary symptoms
3. GI symptoms

Question 13

Larger neoplasms can result in adnexal torsion. What is this and how does it present? [2]

Answer 13

1. condition when an ovary twists around its ligaments and leads to the cut off of blood flow to ovary and fallopian tubes
2. presents as several abdominal pain

Question 14

Name the different types of epithelial ovarian tumours [7]

Answer 14

1. benign serous cystadenoma
2. borderline serous cystadenoma
3. low grade serous carcinoma
4. high grade serous carcinoma
5. mucinous Epithelial tumours
6. clear cell carcinoma
7. endometroid carcinoma

Question 15

Benign Serous Cystadenoma

1. Histological Features? [2]
2. Treatment? [1]

Answer 15

1. histological features
   
   • the cyst has a thin wall lined by epithelium that is one cell thick with no tufts, papillary areas or solid growth
2. treat by removing the cyst

Question 16

Borderline Serous Cystadenoma

1. Features? [8]
2. What type of cancer is at increased risk from this? [1]

Answer 16

1. features:
   
   • larger than benign serous cystadenoma
   • multiple locules
   • papillary excrescences (solid mass/solid projections)
   • cytological atypia
   • sometimes, there are papillary areas on the ovarian surface
   • usually there is no solid growth, no haemorrhage and no necrosis
2. increased risk of low grade serous carcinoma

Question 17

Low Grade Serous Carcinoma

1. Features? [3]
2. Molecular abnormalities? [2]

Answer 17

1. features:
   
   • slowly progressive with recurrences following excision
   • usually seen in ovaries which also have areas of borderline serous tumour
   • doesn’t respond well to chemotherapy
2. molecular abnormalities
   
   • BRAF or KRAS mutation

Question 18

High Grade Serous Carcinoma

1. Who gets it? [3]
2. Where does it originate from? [1]
3. Signs & symptoms? [4]
4. Microscopic features [1]
5. Molecular abnormalities? [1]

Answer 18

1. peri-menopausal, post-menopausal and younger women with BRCA1/2 mutations
2. originates from a precursor lesion in the fallopian tube called serous tubal intraepithelial carcinoma
3. signs & symptoms:
   
   • pelvic discomfort/pain
   • abdominal fullness
   • GI/urinary issues
4. high grade tumour
5. p53 mutation

Question 19

Mucinous Epithelial Tumours

1. Which is more common, benign or malignant? [1]
2. What can malignant mucinous epithelial tumours be hard to differentiate from? [1]

Answer 19

1. benign
2. can be hard to differentiate from GI tract metastases

Question 20

Clear Cell Carcinoma

1. Features? [3]
2. Microscopy? [3]
3. What differentiates clear cell carcinoma from high grade serous carcinoma? [1]
4. Treatment? [1]

Answer 20

1. features:
   
   • associated with endometriosis (but not always)
   • usually large
   • can be solid or cystic
2. microscopy
   
   • high grade tumour
   • many different growth patterns (tubular/cystic/papillary/solid)
   • don’t always have clear cytoplasm
3. no p53 mutation
4. surgery

Question 21

What condition is endometroid carcinoma associated with? [1]

Answer 21

endometriosis

Question 22

What do germ cell tumours originate from and what can they develop into? [3]

Answer 22

1. originate from germ cells
2. can develop into:
   
   • mature elements
   • immature (embryonal) elements

Question 23

Name the 5 types of germ cell tumours [5]

Answer 23

1. mature teratoma (dermoid cysts)
2. dysgerminoma
3. embryonal carcinoma
4. yolk sac tumour
5. choriocarcinoma

Question 24

Mature Teratoma (Dermoid Cysts)

1. Who gets it? [1]
2. Composition of dermoid cysts [4]
3. Which type of teratomas are malignant and what is the complication of this? [2]

Answer 24

1. usually women of reproductive age (20-50)
2. composition:
   
   • mature tissues derived from 1 or more embryonic germ layers
   • most are cystic, but can have some solid areas
   • contains hair and greasy sebaceous material
   • sometimes has cartilage, bone and teeth
3. immature teratomas are malignant and can recur/metastasise

Question 25

What are the 3 different types of ovarian stromal tumours?

Answer 25

1. sex cord/stromal tumours
2. fibroma
3. adult granulosa cell tumour

Question 26

Sex Cord/Stromal Tumours

1. These tumours develop from…? [3]
2. What are the 2 common types? [2]

Answer 26

1. developed from:
   
   • cells surrounding the germ cell (i.e. granulosa/theca cells)
   • sertoli or leydig cells
   • fibroblast cells within the stroma
2. fibroma (benign) and adult granulosa cell tumour (low grade malignancy)

Question 27

Fibroma

1. Who gets it? [1]
2. Signs & symptoms [2]
3. Macroscopic features [3]
4. Microscopic features [2]
5. What is Meig’s Syndrome? [1]

Answer 27

1. women of all ages
2. non-specific symptoms (e.g. abdominal pain)
3. macroscopically:
   
   • varies in size
   • firm and white with lobulated surface
   • can be bilateral
4. microscopically:
   
   • small bland spindle-shaped cells
   • collagen
5. Meig’s syndrome = ovarian fibroma associated with ascites

Question 28

Adult Granulosa Cell Tumour

1. Features? [3]
2. Appearance [2]
3. Signs & symptoms [3]

Answer 28

1. features:
   
   • oestrogen-secreting tumours
   • occasionally androgen-secreting tumours
   • usually unilateral and confined to ovary
2. appearance:
   
   • variable in size
   • solid/cystic appearance
3. signs & symptoms:
   
   • abnormal vaginal bleeding
     
     • amenorrhoea
     • post-menopausal bleeding (PMB)

Question 29

What is amenorrhoea? [1]

Answer 29

absence or stopping of menstrual periods