Transcript The Pathology of OVARY - University of Yeditepe Faculty of

The Pathology of
THE FALLOPIAN
TUBE AND OVARY
INFECTIONS OF
THE FALLOPIAN
TUBE
Infections of fallopian tube
Suppurative salpingitis may be caused
by any of the pyogenic organisms, and
often more than one is involved.
The gonococcus still accounts for more
than 60% of cases of suppurative
salpingitis, with chlamydiae less often a
factor.
Tuberculous salpingitis is an important
cause of infertility in these areas.
SALPINGITIS
PELVIC INFLAMMATORY DISEASE
The usual infectious agents are the
gonococcus and chlamydia.
TB is now rare in the developed world,
but very common in the poor nations.
Actinomycosis usually results from the
presence of an intrauterine device,
– "sulfur granules" colonies.
Gonococcal and Chlamydial PID
A very common sexually transmitted disease
During acute phase, there is severe pelvic
pain, especially when the cervix is
manipulated, with peritoneal signs.
Grossly, the tubes are swollen and inflamed.
– They may be packed with pus
("pyosalpinx").
The acute phase: neutrophils and marked
edema.
– complications of the acute phase: sepsis,
peritonitis, obstruction.
In chronic infection: a mixture of
neutrophils, lymphocytes, and other
inflammatory cells.
– After everything is over, it is likely to form
scar tissue which will probably interfere
with fertility.
– If the ends of the tubes are plugged by
scar tissue, a "hydrosalpinx" results.
pyosalpinx
Other Lesions of the OVIDUCT
Cysts
– arise from embryonic structures.
– Hyatids of Morgagni / paratubal cysts
Ectopic pregnancy.
The most common primary lesions of the
fallopian tube (excluding endometriosis) are
minute, 0.1- to 2-cm translucent cysts filled
with clear serous fluid, called paratubal cysts.
Larger varieties are found near the
fimbriated end of the tube or in the broad
ligaments and are referred to as hydatids of
Morgagni. These cysts are presumed to arise
in remnants of the müllerian duct and are of
little significance.
Tumors
Primary adenocarcinoma of the fallopian tubes is
rare and is defined as an adenocarcinoma with a
dominant tubal mass and luminal and mucosal
involvement.
These tumors are detected by pelvic exam, abnormal
discharge or bleeding, and occasionally, cervical
cytology.
Approximately one half are stage I at diagnosis, but
nearly 40% of these patients will not survive 5 years.
Higher stage tumors have a poor prognosis.
Recently, occult carcinoma of the fallopian tube has
been associated with BRCA mutations, requiring
attention to this site as a potential source of tumors
in patients with BRCA germ-line mutations.
Ovary
Autoimmune oophoritis
an important cause of infertility
around half of women with unexplained
premature ovarian failure have
autoantibodies.
autoantibodies are found against
granulosa/theca cells and/or zona
pellucida, and T-killer cells abound
around the follicles.
OVARY
Ovarian torsion
Usually is caused by an
ovarian mass.
Present as an acute
abdomen.
Ultrasound /
laparoscope.
CYSTIC FOLLICLES
(Follicular and Luteal cysts)
Common
They are remnants of graafian follicles
(unruptured or resealed, luteinized or
not)
Big ones can cause torsion and/or
possess too much luteinized theca cell
tissue resulting in hyperestrogenism.
Corpus luteum cysts
– They are filled with blood (corpus
hemorrhagicum) and fatty debris,
– may undergoe torsion or rupture.
STEIN-LEVENTHAL SYNDROME
Polycystic ovarian disease; polycystic
ovaries
Common,
enlarged ovaries with numerous cysts,
excess stroma, and thick capsule.
– failure of ovulation,
– obesity (often),
– insulin resistance and failure of release of
insulin,
– amenorrhea or irregular periods,
– hirsutism / excessive androstenedione
androstenedione  estrone hyperestrogenism
 risk for endometrial adenocarcinoma.
OVARIAN TUMORS
Ovarian cancers are common and deadly.
There are three overriding categories
of
Primary ovarian tumors:
– Surface epithelial tumors
– Sex cord stromal tumors
– Germ cell tumors
Secondary ovarian tumors (metastases)
Surface epithelial tumors
These are the common ovarian tumors.
Derived from the women's müllerian
epithelium
These usually present as mass lesions.
Rare before age 30.
Sometimes a benign one will be almost
all stroma, and be called an
"adenofibroma".
The malignant ones tend to metastasize
to the peritoneum
Subtypes of Surface epithelial
tumors
Serous tumors
Mucinous tumors
Endometrioid tumors
Clear cell adenocarcinoma
Brenner tumor (transitional cell)
Serous tumors
This is the most common ovarian
cancer (about 40%).
These recapitulate oviduct, with
papillary structures and often cilia.
Often there are psammoma bodies.
Most of these are malignant; a
majority of the malignant ones arise
bilaterally.
These common cystic neoplasms are lined by
tall, columnar, ciliated epithelial cells and
are filled with clear serous fluid.
Although the term serous appropriately
describes the cyst fluid, it has become
synonymous with the tubal-like epithelium in
these tumors.
Benign and borderline tumors are most
common between the ages of 20 and 50
years.
Cystadenocarcinomas occur later in life on
average, although somewhat earlier in
familial cases.
Papillary serous cystadenoma
Borderline serous cystadenoma
Papillary serous
cystadenocarcinoma
Mucinous tumors
Benign mucinous tumors are very common.
Most of these are benign, with welldeveloped columnar cells and abundant
mucin.
They are always multicystic and can be very
large.
They are usually unilateral.
Mucin in contact with the ovarian stroma
can cause it to produce androgens
(masculinization).
They are somewhat less common,
accounting for about 25% of all ovarian
neoplasms
80% are benign or borderline, and about
15% are malignant.
Mucinous cystadenocarcinomas are
relatively uncommon and account for
only 10% of all ovarian cancers
Mucinous cystadenoma
"Pseudomyxoma peritonei“
– if mucin erupts into the peritoneal cavity
and elicits a fibrous response,
– often results from mucinous carcinoma of
the ovary or appendix.
Pseudomyxoma peritonei
Endometrioid tumors
Almost all endometrioid tumors of
the ovary are malignant.
Resemblance to swiss-cheese
endometrial adenocarcinoma.
The risk factors are the same as for
endometrial adenocarcinoma;
– there is often a history of endometriosis
in the ovary as well.
About 50% are bilateral.
Often there is a coexisting
endometrial carcinoma, but this does
not imply that these are metastases.
These neoplasms account for
approximately 20% of all ovarian
cancers,
Most endometrioid tumors are
carcinomas.
Less commonly, benign forms-usually
cystadenofibromas- are encountered.
They are distinguished from serous and
mucinous tumors by the presence of
tubular glands bearing a close
resemblance to benign or malignant
endometrium.
Clear cell adenocarcinoma
This tumor shows lots of big clear
cells in sheets or tubes.
Brenner tumor
These recapitulate the transitional
epithelium of the bladder.
They are almost all benign.
Brenner tumor
Sex cord stromal tumors
Derived from the ovarian stroma or
its counterpart in the male.
If they produce a steroid hormone,
they will be yellow.
They can occur at any age.
They are almost always unilateral.
Subtypes of the Sex cord tumors
Granulosa-Theca tumors
Thecoma-fibromas
Sertoli-Leydig cell tumors
Granulosa-Theca tumors
Contain abundant granulosa-type cells
(cuboidal steroid-producing cells),
– often with some forming Call-Exner
bodies.
There are often theca cells as well,
– these may be spindly, or pink and plump
(luteinized).
Many of these produce estrogen.
– A few produce androgen.
– As steroid-producers, expect yellow
color on gross examination
Any granulosa tumor can metastasize.
Granulosa cell tumor
Thecoma-fibromas
These are a mix of variable
proportions of inactive fibroblasts
and hormonally-active theca cells.
These tumors are solid, hard balls.
Many produce estrogens
– a few produce androgens
Generally benign tumors.
Prone to cause ascites and sometimes
even hydrothorax (Meig's syndrome).
Thecoma-fibroma
Sertoli-Leydig cell tumors
(androblastomas, arrhenoblastomas)
Recapitulate the Leydig cells and/or
seminiferous tubules.
They are unilateral and solid.
Most produce androgens
– a few produce estrogens.
Androgens from these tumors will tend to
defeminize and masculinize (virilize):
–
–
–
–
–
–
enlarge the clitoris,
produce extra body hair,
altered hairline,
acne,
more apocrine sweat,
deep voice.
Look for Reinke crystalloids in the Leydig
cells.
Sertoli cell tumor
Reinke crystalloids

Germ cell tumors
These usually present as a mass, or as
metastases if malignant.
They usually occur in children and young
women.
The most common is the benign, common
dermoid tumor ("cystic teratoma") of
young women.
The other common ones are all
malignant.
Histogenesis and interrelationships of
tumors of germ cell origin
Subtypes of Germ cell tumors
Mature (benign) teratoma
Specialized teratoma (monodermal
teratoma)
Immature teratoma
Dysgerminoma
Endodermal sinus tumor ("yolk sac
tumor“
Embryonal cell carcinoma
Choriocarcinoma
Mature (benign) teratomas
The most common benign teratoma of
the ovary is the dermoid cyst ("cystic
teratoma"),
filled with hair, sebum and keratin.
About 15% are bilateral.
All have the 46XX karyotype.
Rarely a squamous cell carcinoma will
arise in one of these, but otherwise
they are thoroughly benign.
Specialized teratoma
(monodermal teratoma)
Sometimes a single tissue predominates.
– carcinoids (producing the carcinoid
syndrome)
– thyroid (struma ovarii, rarely with
hyperthyroidism).
Immature teratomas
These are tumors of girls and young
women, and are all malignant.
Composed of cells that resemble
embryonic tissue.
– Amount of neuroepithelial tissue
determines the grade and prognosis.
Immature teratoma of the ovary
illustrating primitive neuroepithelium
Dysgerminoma
Counterpart to a man's seminoma of the
testis,
composed of large, glycogen-rich,
polyhedral "fried egg" cells.
They are rare over age 30.
Like seminomas, some produce human
chorionic gonadotrophin (hCG; a
placental hormone).
Lymphocytes accompany
Dysgerminoma showing polyhedral tumor cells
with round nuclei and adjacent inflammation
Endodermal sinus tumor
("yolk sac tumor")
Aggressive tumor of children or young
adults, which recapitulate the yolk sac.
Like the yolk sac, they are loaded with
alpha-1 antitrypsin and alpha fetoprotein.
Identification of Schiller-Duval bodies :
– recapitulate the duct of the yolk sac.
Schiller-Duval bodies

Schiller-Duval body in yolk sac
carcinoma
Embryonal cell carcinoma
Can arise in the ovary as in a man's
testis.
Choriocarcinoma
can be primary in the ovary.
Metastases to the ovary
Common:
– breast
– stomach.
"Krukenberg tumors" with massive bilateral
enlargement of the ovaries which prove at
surgery to be stuffed with signet ring cells.
Ovarian neoplasms
THANK YOU