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. 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

General

  • Usu. conservative management.
  • Serum CA-125 usu. low.
  • May occur in men.[3]

Microscopic

Features:[2][4]

  • Thin-walled, irregular-shaped, cysts - unicystic or multicystic.
    • Mesothelial lining.
    • Eosinophilic fluid.

Image:

Endosalpingiosis

General

  • Benign entity that may lead to a misdiagnosis of adenocarcinoma[5] or serous carcinoma.
  • The clinical significance of endosalpingiosis is not definitively settled; opinions differ on whether it is:
    1. associated with pelvic pain,[6] or
    2. an incidental finding discovered in the course of investigating something else (pelvic pain, menstrual irregularities, infertility).[7]

Microscopic

Features:[8]

  • 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.[9]

DDx:[10]

Notes:

  1. Not associated with hemorrhage.[11]
  2. In a lymph node, endosalpingiosis may be misinterpreted as a metastasis![12]

Images:

Wolffian adnexal tumour

General

  • Super rare.
  • Adnexal - as the name suggests.
  • Usu. benign.[13]

Microscopic

Features:

  • Tubular/glandular spaces.

DDx:

Introduction to gynecologic tumours

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

Serous Endometrioid Mucinous
Characteristics cilia, columnar cells
psammoma bodies, papillary arch.		 gland forming, endometrium-like mucinous glands, colon-like
Differentiators cilia, psammoma bodies squamous metaplasia mucin, lack of necrosis
Associations atrophy endometriosis, endometrial hyperplasia (?)
Typical age usually 60s+ 40-60 varies (?)
Grade typically high grade typically low grade often low
IHC p53+ diffuse, WT-1 +ve, D2-40 +ve, CA-125 +ve WT-1 -ve CK7 +ve, CK20 +ve (others CK7 +ve, CK20 -ve)
Main DDx poorly diff. endometrioid serous metastatic tumour (usually GI)

Benign stuff

Where to start when it looks benign:

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 ? Develops into vas deferens in males. mesonephric r., cat (uoguelph.ca)
Walthard cell rest cuboidal, nested, solid "coffee bean" shape eosionphilic Brenner tumour nil Coffee bean n. (WC), WCR (WC)

Hilus cell

General

Features:[14]

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

Associated pathology:

Microscopic

Features:[15]

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

Images:

Mesonephric remnant

General

Epidemiology:

  • Embryological remnant - benign.
  • aka Wolffian duct - precursor of male reproductive tract.[16]

Microscopic

Features:[17]

  • Cuboidal cells in glands/tubules - may surround cleft.

DDx:

  • Adenocarcinoma
    • Mesonephric remnant has no cellular atypia

Image: [1]

Walthard cell rest

General

  • AKA Walthard cell nest.
  • Benign.

Epidemiology

Microscopic

Features:[18]

  • 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:

Paraurethral cyst

Main article: Paraurethral cyst

Luteinized follicular cyst

Features:[19]

  • 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: Luteinized follicular cyst (WC).

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. ↑ 2.0 2.1 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. ↑ Cavallaro, A.; Murazio, M.; Modugno, P.; Vona, A.; Revelli, L.; Potenza, AE.; Colli, R.. "Benign multicystic mesothelioma of the peritoneum: a case report.". Chir Ital 54 (4): 569-72. PMID 12239771.
  4. ↑ Levy, AD.; Arnáiz, J.; Shaw, JC.; Sobin, LH.. "From the archives of the AFIP: primary peritoneal tumors: imaging features with pathologic correlation.". Radiographics 28 (2): 583-607; quiz 621-2. doi:10.1148/rg.282075175. PMID 18349460.
  5. ↑ Lin O (May 2009). "Challenges in the interpretation of peritoneal cytologic specimens". Arch. Pathol. Lab. Med. 133 (5): 739–42. PMID 19415948.
  6. ↑ deHoop, TA.; Mira, J.; Thomas, MA. (Oct 1997). "Endosalpingiosis and chronic pelvic pain.". J Reprod Med 42 (10): 613-6. PMID 9350013.
  7. ↑ Heinig, J.; Gottschalk, I.; Cirkel, U.; Diallo, R. (Jun 2002). "Endosalpingiosis-an underestimated cause of chronic pelvic pain or an accidental finding? A retrospective study of 16 cases.". Eur J Obstet Gynecol Reprod Biol 103 (1): 75-8. PMID 12039470.
  8. ↑ URL: http://radiographics.rsna.org/content/29/2/347.full. Accessed on: 27 May 2010.
  9. ↑ Hallman KB, Nahhas WA, Connelly PJ (September 1991). "Endosalpingiosis as a source of psammoma bodies in a Papanicolaou smear. A case report". J Reprod Med 36 (9): 675–8. PMID 1774734.
  10. ↑ Rosenberg, P.; Nappi, L.; Santoro, A.; Bufo, P.; Greco, P. (Mar 2011). "Pelvic mass-like florid cystic endosalpingiosis of the uterus: a case report and a review of literature.". Arch Gynecol Obstet 283 (3): 519-23. doi:10.1007/s00404-010-1700-1. PMID 20931212.
  11. ↑ URL: http://radiographics.rsna.org/content/29/2/347.full. Accessed on: 27 May 2010.
  12. ↑ Corben, AD.; Nehhozina, T.; Garg, K.; Vallejo, CE.; Brogi, E. (Aug 2010). "Endosalpingiosis in axillary lymph nodes: a possible pitfall in the staging of patients with breast carcinoma.". Am J Surg Pathol 34 (8): 1211-6. doi:10.1097/PAS.0b013e3181e5e03e. PMID 20631604.
  13. ↑ URL: http://www.pathconsultddx.com/pathCon/diagnosis?pii=S1559-8675%2806%2970577-0. Accessed on: 29 April 2011.
  14. ↑ Sternberg, Stephen S. (1997). Histology for Pathologists (2nd ed.). Lippincott Williams & Wilkins. pp. 953. ISBN 978-0397517183.
  15. ↑ URL: http://path.upmc.edu/cases/case394/dx.html. Accessed on: 16 January 2012.
  16. ↑ Hannema SE, Print CG, Charnock-Jones DS, Coleman N, Hughes IA (2006). "Changes in gene expression during Wolffian duct development". Horm. Res. 65 (4): 200–9. doi:10.1159/000092408. PMID 16567946.
  17. ↑ Sternberg SE. Histology for Pathologists. 2nd Ed. P.893.
  18. ↑ Nucci, Marisa R.; Oliva, Esther (2009). Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 332. ISBN 978-0443069208.
  19. ↑ URL: http://www.med-ed.virginia.edu/courses/path/gyn/ovary2.cfm. Accessed on: 20 May 2010.
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