Difference between revisions of "An introduction to gynecologic pathology"

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An introduction to gynecologic pathology (view source)

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'''Gynecologic pathology''' is a big part of surgical pathology.  Radiologists have a lot of trouble in this area. On CT it is not infrequently hard to pick-out the ovaries... and it is a reason they don't comment on 'em.
'''Gynecologic pathology''', informally '''gyne path''', is a big part of surgical pathology.  Radiologists have a lot of trouble in this area. On CT it is not infrequently hard to pick-out the ovaries... and it is a reason they don't comment on 'em. The [[ovary]] is affected by a huge number of [[ovarian tumours|tumours]].
The ovary is affected by a huge number of tumours.


==Vulva and vagina==
=Site specific=
{{main|Vulva and vagina}}
==Vulva==  
Vulva and vagina are covered together in one article.
{{Main|Vulva}}
This covers the topic of ''vulva''.
 
==Vagina==
{{Main|Vagina}}
This covers the topic of ''vagina''.


==Cervix==
==Cervix==
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Gynecologic cytology is mostly cervical cytology and cervical cytology is the biggest part of [[cytology]].
Gynecologic cytology is mostly cervical cytology and cervical cytology is the biggest part of [[cytology]].
==Endometrium==
{{main|Endometrium}}
Addresses dating of the endometrium.
{{main|Endometrial hyperplasia}}
Endometrial hyperplasia is considered the precursor of carcinoma.
{{main|Endometrial carcinoma}}
A look at endometrial carcinoma.
{{main|Endometriosis}}
A common non-malignant affliction that causes infertility and morbidity.


==Ovary==
==Ovary==
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==Uterus==
==Uterus==
{{main|Uterine tumours}}
{{main|Uterine tumours}}
The article covers ''[[uterine leiomyoma]]s'', ''[[uterine carcinosarcoma]]s'' and endometrial stromal tumours.


==Pregnancy==
==Endometrium==
{{main|Chorionic villi}}
{{main|Endometrium}}
Chorionic villi are the minimum needed to diagnose pregnancy histologically.
Addresses dating of the endometrium.
 
{{main|Endometrial hyperplasia}}
Endometrial hyperplasia is considered the precursor of carcinoma.
 
{{main|Endometrial carcinoma}}
A look at endometrial carcinoma.
 
=Specific entities=
==Endometriosis==
{{main|Endometriosis}}
A common non-malignant affliction that causes infertility and morbidity.
 
==Peritoneal inclusion cyst==
{{Main|Benign multicystic mesothelioma}}
This is dealt with in the ''[[omentum]]'' article.  It is also known as ''benign multicystic mesothelioma''<ref name=pmid19386139>{{Cite journal  | last1 = Vallerie | first1 = AM. | last2 = Lerner | first2 = JP. | last3 = Wright | first3 = JD. | last4 = Baxi | first4 = LV. | title = Peritoneal inclusion cysts: a review. | journal = Obstet Gynecol Surv | volume = 64 | issue = 5 | pages = 321-34 | month = May | year = 2009 | doi = 10.1097/OGX.0b013e31819f93d4 | PMID = 19386139 }}</ref> and  ''inflammatory cyst of the peritoneum''.


{{main|Gestational trophoblastic disease}}
==Endosalpingiosis==
When reproduction goes wrong.
{{Main|Endosalpingiosis}}


{{main|Placenta}}
==Female adnexal tumour of probable Wolffian origin==
A big endocrine organ that gets completely ignored by almost everyone.
*Abbreviated ''FATWO''.
*[[AKA]] ''Wolffian adnexal tumour''.
{{Main|Female adnexal tumour of probable Wolffian origin}}


==Introduction to gynecologic tumours==
=Introduction to gynecologic tumours=
'''Where to start when considering a malignant (epithelial) tumour of the gynecologic tract:'''
Where to start when considering a malignant (epithelial) tumour of the gynecologic tract:
{| class="wikitable"
{| class="wikitable sortable"
| || '''Serous''' || '''Endometrioid'''  || '''Mucinous'''
!Type
|-
!Histology
|Characteristics || cilia, columnar cells<br>psammoma bodies, papillary arch. || gland forming, endometrium-like || mucinous glands, colon-like
!Differentiators
|-
!Associations
|Differentiators || cilia, psammoma bodies || squamous metaplasia || mucin, lack of necrosis
!Typical age
|-
!Grade
|Associations || atrophy || endometriosis, endometrial hyperplasia || (?)
!IHC
|-
!Main DDx
|Typical age || usually 60s+ || 40-60 || varies (?)
|-
|-
| '''Serous'''
|Grade || typically high grade || typically low grade || often low
| cilia, columnar cells<br>[[psammoma bodies]], papillary arch.
|-
| cilia, psammoma bodies
|IHC || p53+ diffuse, WT-1 +ve, D2-40 +ve, CA-125 +ve || WT-1 -ve || CK7 +ve, CK20 +ve (others CK7 +ve, CK20 -ve)
| atrophy
| usually 60s+
| typically high grade
| p53+ diffuse, WT-1 +ve, D2-40 +ve, CA-125 +ve
| poorly diff. endometrioid
|-
| '''Endometrioid''' 
| gland forming, endometrium-like
| squamous metaplasia
| endometriosis, endometrial hyperplasia
| 40-60
| typically low grade
| WT-1 -ve
| serous
|-
|-
|Main DDx || poorly diff. endometrioid  || serous || metastatic tumour (usually GI)
| '''Mucinous'''
| mucinous glands, colon-like
| mucin, lack of [[necrosis]]
| (?)
| varies (?)
| often low
| CK7 +ve, CK20 +ve (others CK7 +ve, CK20 -ve) |
| metastatic tumour (usually GI)
|-
|-
|}
|}


==Benign stuff==
=Benign stuff=
'''Where to start when it looks benign:'''
'''Where to start when it looks benign:'''
{| class="wikitable"
{| class="wikitable sortable"
| || '''Morphology''' || '''Nucleus''' || '''Cytoplasm''' || '''Tumour''' || '''Other''' || '''Image'''
! '''Entity'''
! '''Morphology'''  
! '''Nucleus'''  
! '''Cytoplasm'''
! '''Tumour'''  
! '''Other'''  
! '''Image'''
|-
|-
|Hilus cells || well-defined cell borders, solid || eccentric, mild pleomorphism || eosinophilic || Hilus cell tumour || absent in childhood || Need one
|[[Hilus cells]]
| well-defined cell borders, solid
| eccentric, mild pleomorphism  
| eosinophilic  
| [[Hilus cell tumour]]
| absent in childhood  
| Need one
|-
|-
|Mesonephric remnant (aka Wolffian duct) || cuboidal, glands/lumen present || ovoid, small || eosinophilic || ? || Develops into vas deferens in males. || [http://www.uoguelph.ca/~rfoster/repropath/surgicalpath/female/cat/F%20fel%20anomaly%20mesonephric%20remnants%20YB108065%2011wl.jpg mesonephric r., cat (uoguelph.ca)]
|[[Mesonephric remnant]] ([[AKA]] Wolffian duct)
| cuboidal, glands/lumen present  
| ovoid, small  
| eosinophilic
| [[FATWO]], [[mesonephric adenocarcinoma]]
| Develops into vas deferens in males.  
| [[Image:Mesonephric duct remnant -- intermed mag.jpg|100px|thumb|center|MR (WC)]]
|-
|-
|Walthard cell rest || cuboidal, nested, solid || "coffee bean" shape || eosionphilic || Brenner tumour || nil || [http://commons.wikimedia.org/wiki/File:Walthard_cell_rest_-_very_high_mag.jpg Coffee bean n. (WC)], [http://commons.wikimedia.org/wiki/File:Walthard_cell_rest_-_very_low_mag.jpg WCR (WC)]
|[[Walthard cell rest]]
| cuboidal, nested, solid  
| "coffee bean" shape  
| eosionphilic  
| [[Brenner tumour]]
| nil  
|[[Image:Walthard_cell_rest_-_very_high_mag.jpg|thumb|center|100px|WCR (WC)]][[Image:Walthard_cell_rest_-_very_low_mag.jpg|thumb|center|100px|WCR (WC)]]
|}
|}


==Hilus cell==
==Hilus cells==
Ref: Sternberg H4P.<ref>Sternberg SE. Histology for Pathologists. 2nd Ed. P.953.</ref>
===General===
 
Features:<ref name=Ref_H4P2_953>{{Ref H4P2|953}}</ref>
===Epidemiology===
*Present in embryo.
*Present in embryo.
*Absent in childhood.
*Absent in childhood.
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*Common in post-menopausal women.
*Common in post-menopausal women.


===Micro.===
Associated pathology:
*Well-defined cell borders/spaced.
*[[Hilus cell tumour]].
*Eosinophilic cytoplasm.
*Prominent nucleus.
*In small clumps.
**Similar to Leydig cells.


===Pathology===
===Microscopic===
*[[Hilus cell tumour]].
Features:<ref>URL: [http://path.upmc.edu/cases/case394/dx.html http://path.upmc.edu/cases/case394/dx.html]. Accessed on: 16 January 2012.</ref>
*Similar to Leydig cells:
**Typically found in small clusters.
**Eosinophilic cytoplasm.
**Round nucleus +/- nucleolus.


==Mesonephric remnant==
====Images====
===Epidemiology===
*[http://path.upmc.edu/cases/case394.html Hilus cell hyperplasia (upmc.edu)].
*Embryological remnant - benign.
*aka Wolffian duct - precursor of male reproductive tract.<ref>{{cite journal |author=Hannema SE, Print CG, Charnock-Jones DS, Coleman N, Hughes IA |title=Changes in gene expression during Wolffian duct development |journal=Horm. Res. |volume=65 |issue=4 |pages=200–9 |year=2006 |pmid=16567946 |doi=10.1159/000092408 |url=}}</ref>


===Micro===
===IHC===
*Cuboidal cells in glands/tubules - may surround cleft.<ref>Sternberg SE. Histology for Pathologists. 2nd Ed. P.893.</ref>
Features:
*Inhibin +ve.
DDx:
*Calretinin +ve.
*Adenocarcinoma
*PLAP -ve.
**Mesonephric remnant has no cellular atypia


Image: [http://www.uoguelph.ca/~rfoster/repropath/surgicalpath/female/cat/F%20fel%20anomaly%20mesonephric%20remnants%20YB108065%2011wl.jpg]
==Mesonephric duct remnant==
*[[AKA]] ''Wolffian duct remnant''.
*[[AKA]] ''Gartner duct''.<ref>URL: [http://webpathology.com/image.asp?n=3&Case=540 http://webpathology.com/image.asp?n=3&Case=540]. Accessed on: 22 October 2012.</ref>
{{Main|Mesonephric duct remnant}}


==Walthard cell rest==
==Walthard cell rest==
===General===
*[[AKA]] ''Walthard cell nest''.
*[[AKA]] ''Walthard cell '''n'''est''.
{{Main|Walthard cell rest}}
===Microscopic===
Features:<ref name=Ref_GP332>{{Ref_GP|332}}</ref>
*Collection of eosinophilic (i.e. pink) cuboidal cells; usually solid, may be cystic.
*Elliptical nucleus with single groove along major axis; "coffee bean" nucleus -- '''key feature'''.
 
Location:
*Usually in soft tissue of the uterine tube.
 
 
Images:
*[http://commons.wikimedia.org/wiki/File:Walthard_cell_rest_-_very_high_mag.jpg Coffee bean nucleus (WC)].
*[http://commons.wikimedia.org/wiki/File:Walthard_cell_rest_-_very_low_mag.jpg WCR (WC)].
===Epidemiology===
*Thought to be related to [[Brenner tumour]]. (???)


Ref: <ref>URL: [http://pathologyoutlines.com/fallopiantubes.html#walthard http://pathologyoutlines.com/fallopiantubes.html#walthard].</ref>
==Paraurethral cyst==
{{Main|Paraurethral cyst}}


==Luteinized follicular cyst==
==Luteinized follicular cyst==
Features:<ref>URL: [http://www.med-ed.virginia.edu/courses/path/gyn/ovary2.cfm http://www.med-ed.virginia.edu/courses/path/gyn/ovary2.cfm]. Accessed on: 20 May 2010.</ref>
{{Main|Luteinized follicular cyst}}
*Stratified cuboidal/columnar epithelium-like cells with:
**Small nuclei and small nucleoli.
**Cytoplasm may be eosinophilic.
**Sit on spindled cells (theca interna) that is luteinized.


Image: [http://commons.wikimedia.org/wiki/File:Luteinized_follicular_cyst.jpg Luteinized follicular cyst (WC)].
=Other=
==Pregnancy==
{{main|Chorionic villi}}
Chorionic villi are the minimum needed to diagnose pregnancy histologically.


==Endosalpingiosis==
{{main|Gestational trophoblastic disease}}
===General===
When reproduction goes wrong.
*Benign entity that may lead to a misdiagnosis of serous carcinoma.


===Microscopic===
{{main|Placenta}}
Features:<ref>URL: [http://radiographics.rsna.org/content/29/2/347.full http://radiographics.rsna.org/content/29/2/347.full]. Accessed on: 27 May 2010.</ref>
A big endocrine organ that gets completely ignored by almost everyone.
*Cystic lesions with:
**Ciliated (tubal type) epithelium, without endometrial stroma.
***Endosalpingiosis is surrounded by fibrous stroma; tubal type epithelial surrounded by ovarian stroma is a variant of endometriosis.
*Associated with psammoma bodies.<ref name=pmid1774734>{{cite journal |author=Hallman KB, Nahhas WA, Connelly PJ |title=Endosalpingiosis as a source of psammoma bodies in a Papanicolaou smear. A case report |journal=J Reprod Med |volume=36 |issue=9 |pages=675–8 |year=1991 |month=September |pmid=1774734 |doi= |url=}}</ref>
 
Notes:
*Not associated with hemorrhage.<ref>URL: [http://radiographics.rsna.org/content/29/2/347.full http://radiographics.rsna.org/content/29/2/347.full]. Accessed on: 27 May 2010.</ref>


==See also==
=See also=
*[[Testicular tumours]].
*[[Testicular tumours]].
*[[Gastrointestinal pathology]].
*[[Gastrointestinal pathology]].
*[[Omentum]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}


[[Category:Gynecologic pathology]]
[[Category:Gynecologic pathology]]
Michael
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