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.


=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=
Michael
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