Robbins: Fallopian Tubes and Ovaries Flashcards
What is adnexa?
Fallopian tubes + ovaries = the parts adjoining an organ
Fallopian tubes are most commonly affected by what?
Infections + inflammatory conditions
Most common etiologies underlying suppurative salpingitis?
- N. gonorrhea = 60% of cases
- C. trachomatis = remainder
- More than one organism can be involved; any pyogenic organism
Tuberculosis salpingitis is an important cause of what in endemic countries; what are the main histo features of this disorder?
- Infertility
- Caseating granulomas + multinucleated giant cells + epitheliod macrophages
What are the most common primary lesions of the fallopian tubes (excluding endometriosis)?
- Paratubal Cysts = small translucent cysts filled w/ clear, serous fluid
- Hydatids of Morgagni = larger cysts found near the fimbriae of the tube or in the broad ligaments formed remnants of müllerian duct.
Which uncommon benign tumor may arise in the fallopian tube?
Adenomatoid tumor (mesotheliomas)
- Sub-serosal/mesosalpinx
Which rare tumor of the fallopian tube may present as dominant tubal mass on pelvic examination or due to abnormal discharge, bleeding, and occasionally abnormal cells on Pap smear?
Primary Adenocarcinoma of the Fallopian Tubes
At diagnosis, what is the prognosis of Primary Adenocarcinoma of the Fallopian Tube?
Treatment?
- 50% = stage I at diagnosis, but 40% of pts die in 5-years
- Chemotherapy used for ovarian cancers bc a subset of serous ovarian cancers arise from epithelium of fallopian tube.
In terms of the fallopian tubes what are the most common disorders you must consider?
- Ectopic pregnancy
- Endometriosis
- Inflammatory disorders –> Salpingitis
What are the most common lesions in the ovary?
Functional or benign cysts/tumors.
- Inflammation (oophoritis) is NOT common, but if occurs => AI component.
How can neoplastic disorders of the ovaries be divided?
- Mullerian epithelium
- Germ cell
- Sex cord-stromal cells
What is the most common cause of an ovarian mass in a reproductive age female?
Cystic follicle –> NL, mulitiple benign cysts with clear/serous fluid in a glistening membrane originating from unrutured graafian follicles or follicles that ruptured and sealed.
34 year old female with pelvic pain, fever, and adnexal mass. Imaging and surgery c/w tubo-ovarian abscess. Most likely organism?
Cystic ovarian follicle
What are the growth characteristics of cystic follicles and how does size dictate their classification?
- Usually multiple < 2cm in diameter.
- If >2cm, called follcle cyst and can cause pelvic pain
How common are luteal cysts (corpora lutea) and what is their gross appearance that distinguishes them from cystic follicles?
- Present in the normal ovaries of reproductive age females
- Lined w/ rim of bright yellow tissue containing luteinized granulosa cells. If it ruptures => peritoneal reaction.
Polycystic ovarian syndrome (PCOS) is a complex endocrine disorder characterized by what findings clinically?
- Hyperandrogenism - hirsutism, acne, deep voice, male pattern baldness
- Menstrual irregularities - amenorrhea
- Chronic anovulation => ↓ fertility
What underlying metabolic disorders are common in women with PCOS?
- Obesity due to altered adipose tissue metabolism
- T2DM due to insulin resistance
- Premature atherosclerosis
Due to increase in free estrone levels (due to aromatization of androgens in fat), women with PCOS are at an increased risk for what?
Endometrial hyperplasia and cancer
What form of estrogen:
- Predominates in reproductive years and is the most potent, made by aromatization of testosterone?
- Least potent and made in placenta, originating in fetal adrenal gland from DHEA.
- Estradiol (E2)
- Estriol (E3)
What is stromal hyperthecosis?
MC?
Bilateral, uniform enlargment of ovary due to hypercellular stroma and leutinzation of stromal cells.
MC = post-menopausal F and overlaps with PCOS in younger F.
What does stromal hyperthecosis look like? What is seen?
Similar presentation to PCOS, except?
- white-tan looking
- Nests of cells with cavuolated cytoplasm
- Viriluzation is more stiking
What is theca-lutein hyperplasia of pregnany>
Looks like?
- Proliferation of concentric theca cells and expansion of perifollicular zone due to increase gonadtropins in PG.
- When follicles regress => nodular appearance
Majority of ovarian tumors are (benign/malignant) and how does age play a role in this?
- 80% are benign, typically occur in younger women (20-45YO)
- Malignant tumors often older women (45-65YO)
what is unique about malignant ovarian tumors by the time they have been diagnosed?
most have spread BEYOND ovaries
What type of tissues can ovarian tumors arise from?
- 1. Epithelial tissue from fallopian tubes/endomerial
- 2. Pluripotent germ cells that migrated from yolk sac => ovary.
- 3. Stromal cells (sex-cords)
Sx of ovarian tumors
- Abdominal pain / distention
- Urinary/ GI tract symptoms due to compression or invasion
- Vaginal bleeding
Most primary ovarian neoplasms arise from?
What are the types?
- Mullerian epithelium
- 1. Serous
- 2. Mucinous
- 3. Endometroid
How are epithelial tumors of the ovary classified?
- 1. Benign
- Cystic (cystadenomas), cystic and fibrous (cystadenfibromas) and fibrous (adenofibromas)
- 2. Borderline
- 3. Malignant (cystadenocarcinomas)
How can we classify ovarian carcinomas?
Type I: Low-grade that arise from with borderline tumors or endometriosis
- Low-grade serous/endometroid/mucinous
Type II: High-grade serous carinomas that arise from serous intraepithelial carcinoma (percursor lesion)
What is the most common malignant ovarian tymor (40% of all cancers of ovary)?
Malignant Serous Carcinoma of the ovary
- Serious tumors of the ovary have what kind of epithelium?
- All serous tumors have _________
- Are most benign/malignant?
Tubal-like epithelium, all have psammoma bodies (concentric calficification)
70% = benign or borderline
What are the risk factors associated with malignant serous carcinomas of the ovary?
- Nulliparity (low parity) = never given birth
- Family hx
- Heritable mutations: BRCA1 and BRCA2
The distinction between low-grade (well-differentiated) and high-grade (moderate to poor differentiated) serous ovarian carcinoma is based on what and correlates with?
Degree of nuclear atypia; correlates with patient survival
How do the genetic mutations observed in low- vs. high-grade serous ovarian carcinomas differ?
- Low-grade = arise from serous borderline tumors and have mutations in KRAS, BRAF, or ERBB2; with wild-type TP53
- High-grade = high frequency of TP53 mutations and lack mutations in either KRAS or BRAF.
ALL ovarian and endometrial serous tumors have what characteristic morphologic finding?
Psammoma bodies (concentric calcificaitons)
What are the morphological features of benign serous ovarian tumors both grossly and microscopically?
Bilateral?
- Smooth, glistening cyst wall w/ NO epithelial thickening or have small papillary projections
- Lined by columnar epithelium + abundant cilia
- 20% = bilateral
Morphology of borderline serous tumor
- Increase in papillary projections, often involving surface of voary
- Mild nuclear atypia
- No stromal invasion
What gross morphological features of malignant serous ovarian carcinomas?
- Solid or papillary tumor mass with watery fluid
- Irregular
- Fixation or nodularity of the capsule
- Which cystic lesions of the ovary may be the origin of a vast majority of serous ovarian carcinomas?
- Which precursor lesion associated with sporadic high-grade serous ovarian cancer has been described as originating in the fallopian tube?
- Cortical inclusion cysts
- Serous tubal intraepithelial carcinoma (STIC)
What epithelial proliferation pattern is thought to be the precursor to low-grade serous carcinomas?
Growth in a delicate, papillary pattern known as “micropapillary carcinoma”
Serous tubal intraepithelial carcinomas consist of cells morphologically identical to high-grade serous ovarian carcinomas, but are distinguished how?
LACK of invasion of stroma
Both low- and high-grade serous ovarian tumors have a propensity to spread where; assoc. w/ what common presenting sign?
- Spread to peritoneal surface and omentum
- BL = extend to peritoneum and remain fixed or spread => intestinal obstruction
- Low grade = same but survival is better
- High-grade = highly metastic throughout abdomen and cause ascites
What determines staging of serous carcinoma?
Spread outside ovaries
What is the 5-year survival rate for borderline and malignant serous ovarian carcinomas confined to the ovaries; what is prognosis for same tumor involving the peritoneum?
- Confined to ovary = 100% (borderline) and 70% (malignant)
- Peritoneum = 90% (borderline) and 25 %(malignant)
What is the prognosis of serous ovarian carcinomas dependent on?
Pathologic classification of the tumor and growth pattern on the peritoneum
Describe a serous cystadenoma.
MC in who?
-
Serous Cystadenoma = benign
- Cysts filled with water fluid lined of single cells, often bilateral.
- W 30-40
Type 1: low grade serous cystadenocarcinoma arises from _________
Type 2: high grade serous cystadenocarcinoma arises from _________
- borderline tumors
- in-situ lesions in fallopian tubes or serious inclusion cysts
M
