Difference between revisions of "An introduction to gynecologic pathology"

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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.


=Site specific=
=Site specific=
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==Peritoneal inclusion cyst==
==Peritoneal inclusion cyst==
*[[AKA]] ''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>
{{Main|Benign multicystic mesothelioma}}
**Should '''not''' be confused with ''[[malignant 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''.
*[[AKA]] ''inflammatory cyst of the peritoneum''.
*[[AKA]] ''[[mesothelial inclusion cyst]]''. (???)
===General===
*Usu. conservative management.
*Serum CA-125 usu. low.
*May occur in men.<ref name=pmid12239771>{{Cite journal  | last1 = Cavallaro | first1 = A. | last2 = Murazio | first2 = M. | last3 = Modugno | first3 = P. | last4 = Vona | first4 = A. | last5 = Revelli | first5 = L. | last6 = Potenza | first6 = AE. | last7 = Colli | first7 = R. | title = Benign multicystic mesothelioma of the peritoneum: a case report. | journal = Chir Ital | volume = 54 | issue = 4 | pages = 569-72 | month =  | year =  | doi =  | PMID = 12239771 }}</ref>
 
===Microscopic===
Features:<ref name=pmid19386139/><ref name=pmid18349460>{{Cite journal  | last1 = Levy | first1 = AD. | last2 = Arnáiz | first2 = J. | last3 = Shaw | first3 = JC. | last4 = Sobin | first4 = LH. | title = From the archives of the AFIP: primary peritoneal tumors: imaging features with pathologic correlation. | journal = Radiographics | volume = 28 | issue = 2 | pages = 583-607; quiz 621-2 | month =  | year =  | doi = 10.1148/rg.282075175 | PMID = 18349460 | URL = http://radiographics.rsna.org/content/28/2/583.full}}</ref>
*Thin-walled, irregular-shaped, cysts - unicystic or multicystic.
**Mesothelial lining.
**Eosinophilic fluid.
 
Image:
*[http://radiographics.rsna.org/content/28/2/583/F30.expansion.html Multicystic mesothelioma (rsna.org)].


==Endosalpingiosis==
==Endosalpingiosis==
===General===
{{Main|Endosalpingiosis}}
*Benign entity that may lead to a misdiagnosis of adenocarcinoma<ref name=pmid19415948>{{cite journal |author=Lin O |title=Challenges in the interpretation of peritoneal cytologic specimens |journal=Arch. Pathol. Lab. Med. |volume=133 |issue=5 |pages=739–42 |year=2009 |month=May |pmid=19415948 |doi= |url=}}</ref> or serous carcinoma.
*The clinical significance of endosalpingiosis is not definitively settled; opinions differ on whether it is:
*# associated with pelvic pain,<ref name=pmid9350013>{{Cite journal  | last1 = deHoop | first1 = TA. | last2 = Mira | first2 = J. | last3 = Thomas | first3 = MA. | title = Endosalpingiosis and chronic pelvic pain. | journal = J Reprod Med | volume = 42 | issue = 10 | pages = 613-6 | month = Oct | year = 1997 | doi =  | PMID = 9350013 }}</ref> ''or''
*# an incidental finding discovered in the course of investigating something else (pelvic pain, menstrual irregularities, infertility).<ref name=pmid12039470>{{Cite journal  | last1 = Heinig | first1 = J. | last2 = Gottschalk | first2 = I. | last3 = Cirkel | first3 = U. | last4 = Diallo | first4 = R. | title = Endosalpingiosis-an underestimated cause of chronic pelvic pain or an accidental finding? A retrospective study of 16 cases. | journal = Eur J Obstet Gynecol Reprod Biol | volume = 103 | issue = 1 | pages = 75-8 | month = Jun | year = 2002 | doi =  | PMID = 12039470 }}</ref>
 
===Microscopic===
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>
*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>
 
DDx:<ref>{{Cite journal  | last1 = Rosenberg | first1 = P. | last2 = Nappi | first2 = L. | last3 = Santoro | first3 = A. | last4 = Bufo | first4 = P. | last5 = Greco | first5 = P. | title = Pelvic mass-like florid cystic endosalpingiosis of the uterus: a case report and a review of literature. | journal = Arch Gynecol Obstet | volume = 283 | issue = 3 | pages = 519-23 | month = Mar | year = 2011 | doi = 10.1007/s00404-010-1700-1 | PMID = 20931212 }}</ref>
*Serous carcinoma.
*[[Peritoneal inclusion cyst]].
 
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>
#In a lymph node, endosalpingiosis may be misinterpreted as a [[lymph node metastasis|metastasis]]!<ref name=pmid20631604>{{Cite journal  | last1 = Corben | first1 = AD. | last2 = Nehhozina | first2 = T. | last3 = Garg | first3 = K. | last4 = Vallejo | first4 = CE. | last5 = Brogi | first5 = E. | title = Endosalpingiosis in axillary lymph nodes: a possible pitfall in the staging of patients with breast carcinoma. | journal = Am J Surg Pathol | volume = 34 | issue = 8 | pages = 1211-6 | month = Aug | year = 2010 | doi = 10.1097/PAS.0b013e3181e5e03e | PMID = 20631604 }}</ref>
 
Images:
*[http://commons.wikimedia.org/wiki/File:Endosalpingiosis_-_low_mag.jpg Endosalpingiosis -  low mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Endosalpingiosis_-_high_mag.jpg Endosalpingiosis - high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Endosalpingiosis_-_cropped_2_-_very_high_mag.jpg Endosalpingiosis - very high mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Endosalpingiosis_in_lymph_node_-_intermed_mag.jpg Endosalpingiosis in a LN - intermed. mag. (WC)].
*[http://commons.wikimedia.org/wiki/File:Endosalpingiosis_in_lymph_node_-_very_high_mag.jpg Endosalpingiosis in a LN - very high mag. (WC)].
 
==Wolffian adnexal tumour==
===General===
*Super rare.
*Adnexal - as the name suggests.
*Usu. benign.<ref>URL: [http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970577-0 http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970577-0]. Accessed on: 29 April 2011.</ref>
 
===Microscopic===
Features:
*Tubular/glandular spaces.


DDx:
==Female adnexal tumour of probable Wolffian origin==
*[[Brenner tumour]].
*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)
|-
|-
|}
|}
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=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==
===General===
===General===
Features:<ref name=Ref_H4P2_953>{{Ref H4P2|953}}</ref>
Features:<ref name=Ref_H4P2_953>{{Ref H4P2|953}}</ref>
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**Round nucleus +/- nucleolus.
**Round nucleus +/- nucleolus.


Images:
====Images====
*[http://path.upmc.edu/cases/case394.html Hilus cell hyperplasia (upmc.edu)].
*[http://path.upmc.edu/cases/case394.html Hilus cell hyperplasia (upmc.edu)].


==Mesonephric remnant==
===IHC===
===General===
Features:
Epidemiology:
*Inhibin +ve.
*Embryological remnant - benign.
*Calretinin +ve.
*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>
*PLAP -ve.
 
===Microscopic===
Features:<ref>Sternberg SE. Histology for Pathologists. 2nd Ed. P.893.</ref>
*Cuboidal cells in glands/tubules - may surround cleft.
DDx:
*Adenocarcinoma
**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}}
*Benign.
 
====Epidemiology====
*Thought to be related to [[Brenner tumour]].  
 
===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)].


==Paraurethral cyst==
==Paraurethral cyst==
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==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=
=Other=

Latest revision as of 15:00, 24 July 2017

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 tumours.

Site specific

Vulva

Main article: Vulva

This covers the topic of vulva.

Vagina

Main article: Vagina

This covers the topic of vagina.

Cervix

Main article: Cervix

The most common type of cervical cancer is: squamous cell carcinoma.

Main article: Cervical polyp

Common benign cause of bleeding.

Gynecologic cytology is mostly cervical cytology and cervical cytology is the biggest part of cytology.

Ovary

Main article: Ovary
Main article: Ovarian tumours

The ovary has a wealth of pathology. It has benign tumours and malignant ones. The ovary article covers cysts of the ovary.

Uterine tube (Fallopian tube)

Main article: Uterine tube

This was ignored in the past... current thinking is that it may be the real culprit in what is often labeled as "ovarian cancer".[1]

Uterus

Main article: Uterine tumours

The article covers uterine leiomyomas, uterine carcinosarcomas and endometrial stromal tumours.

Endometrium

Main article: Endometrium

Addresses dating of the endometrium.

Main article: Endometrial hyperplasia

Endometrial hyperplasia is considered the precursor of carcinoma.

Main article: Endometrial carcinoma

A look at endometrial carcinoma.

Specific entities

Endometriosis

Main article: Endometriosis

A common non-malignant affliction that causes infertility and morbidity.

Peritoneal inclusion cyst

Main article: Benign multicystic mesothelioma

This is dealt with in the omentum article. It is also known as benign multicystic mesothelioma[2] and inflammatory cyst of the peritoneum.

Endosalpingiosis

Main article: Endosalpingiosis

Female adnexal tumour of probable Wolffian origin

  • Abbreviated FATWO.
  • AKA Wolffian adnexal tumour.
Main article: Female adnexal tumour of probable Wolffian origin

Introduction to gynecologic tumours

Where to start when considering a malignant (epithelial) tumour of the gynecologic tract:

Type Histology Differentiators Associations Typical age Grade IHC Main DDx
Serous cilia, columnar cells
psammoma bodies, papillary arch. 		cilia, psammoma bodies 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
Mucinous mucinous glands, colon-like mucin, lack of necrosis (?) varies (?) often low metastatic tumour (usually GI)

Benign stuff

Where to start when it looks benign:

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
Mesonephric remnant (AKA Wolffian duct) cuboidal, glands/lumen present ovoid, small eosinophilic FATWO, mesonephric adenocarcinoma Develops into vas deferens in males.
MR (WC)
Walthard cell rest cuboidal, nested, solid "coffee bean" shape eosionphilic Brenner tumour nil
WCR (WC)
WCR (WC)

Hilus cells

General

Features:[3]

  • Present in embryo.
  • Absent in childhood.
  • Reappear at puberty.
  • Common in post-menopausal women.

Associated pathology:

Microscopic

Features:[4]

  • Similar to Leydig cells:
    • Typically found in small clusters.
    • Eosinophilic cytoplasm.
    • Round nucleus +/- nucleolus.

Images

IHC

Features:

  • Inhibin +ve.
  • Calretinin +ve.
  • PLAP -ve.

Mesonephric duct remnant

  • AKA Wolffian duct remnant.
  • AKA Gartner duct.[5]
Main article: Mesonephric duct remnant

Walthard cell rest

  • AKA Walthard cell nest.
Main article: Walthard cell rest

Paraurethral cyst

Main article: Paraurethral cyst

Luteinized follicular cyst

Main article: Luteinized follicular cyst

Other

Pregnancy

Main article: Chorionic villi

Chorionic villi are the minimum needed to diagnose pregnancy histologically.

Main article: Gestational trophoblastic disease

When reproduction goes wrong.

Main article: Placenta

A big endocrine organ that gets completely ignored by almost everyone.

See also

References

  1. ↑ Hirst, JE.; Gard, GB.; McIllroy, K.; Nevell, D.; Field, M. (Jul 2009). "High rates of occult fallopian tube cancer diagnosed at prophylactic bilateral salpingo-oophorectomy.". Int J Gynecol Cancer 19 (5): 826-9. doi:10.1111/IGC.0b013e3181a1b5dc. PMID 19574767.
  2. ↑ Vallerie, AM.; Lerner, JP.; Wright, JD.; Baxi, LV. (May 2009). "Peritoneal inclusion cysts: a review.". Obstet Gynecol Surv 64 (5): 321-34. doi:10.1097/OGX.0b013e31819f93d4. PMID 19386139.
  3. ↑ Sternberg, Stephen S. (1997). Histology for Pathologists (2nd ed.). Lippincott Williams & Wilkins. pp. 953. ISBN 978-0397517183.
  4. ↑ URL: http://path.upmc.edu/cases/case394/dx.html. Accessed on: 16 January 2012.
  5. ↑ URL: http://webpathology.com/image.asp?n=3&Case=540. Accessed on: 22 October 2012.
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