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

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

General

  • Benign entity that may lead to a misdiagnosis of adenocarcinoma[3] or serous carcinoma.
  • The clinical significance of endosalpingiosis is not definitively settled; opinions differ on whether it is:
    1. associated with pelvic pain,[4] or
    2. an incidental finding discovered in the course of investigating something else (pelvic pain, menstrual irregularities, infertility).[5]

Microscopic

Features:[6]

  • 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.[7]

DDx:[8]

Notes:

  1. Not associated with hemorrhage.[9]
  2. In a lymph node, endosalpingiosis may be misinterpreted as a metastasis![10]

Images:

Female adnexal tumour of probable Wolffian origin

  • Abbreviated FATWO.
  • AKA Wolffian adnexal tumour.

General

  • Super rare.[11]
  • Adnexal - as the name suggests.
  • Usually benign.
    • May be malignant.[12]

Microscopic

Features:

  • Tubular/glandular spaces.

DDx:

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 ? 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 cells

General

Features:[13]

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

Associated pathology:

Microscopic

Features:[14]

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

Images:

Mesonephric duct remnant

Gartner duct cyst, mesonephric duct cyst and Wolffian duct cyst redirect here.

General

Epidemiology:

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

Notes:

  • This is not a finding that is reported. The importance of this finding is knowing it isn't something neoplastic.
  • Lame way of remember the synonyms Gartner, Mesonephric, and Wolffian: GMW... it is trying to be a BMW but in girls.

Microscopic

Features:[17]

  • Small duct -- typically ~50-100 micrometres in diameter.
    • Duct lined by cuboidal cells with moderate eosinophilic cytoplasm.

DDx:

Images:

IHC

Features:[18]

  • CD10 +ve.
  • CK7 +ve.

Walthard cell rest

General

  • AKA Walthard cell nest.
  • Benign.

Epidemiology

Microscopic

Features:[19]

  • 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:[20]

  • 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. ↑ 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. ↑ Lin O (May 2009). "Challenges in the interpretation of peritoneal cytologic specimens". Arch. Pathol. Lab. Med. 133 (5): 739–42. PMID 19415948.
  4. ↑ deHoop, TA.; Mira, J.; Thomas, MA. (Oct 1997). "Endosalpingiosis and chronic pelvic pain.". J Reprod Med 42 (10): 613-6. PMID 9350013.
  5. ↑ 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.
  6. ↑ URL: http://radiographics.rsna.org/content/29/2/347.full. Accessed on: 27 May 2010.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ URL: http://radiographics.rsna.org/content/29/2/347.full. Accessed on: 27 May 2010.
  10. ↑ 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.
  11. ↑ Tianmin, X.; Weiqim, C.; Mianhua, C.; Xiaocui, L.; Hongwen, G.; Min, Y. (2012). "Tumor of the mesosalpinx: case report of a female adnexal tumor of probable Wolffian origin.". Eur J Gynaecol Oncol 33 (2): 233-5. PMID 22611973.
  12. ↑ Heller, DS.; Kadire, B.; Cracchiolo, B.. "Malignant female adnexal tumor of probable Wolffian origin: a case report.". J Reprod Med 56 (3-4): 175-7. PMID 21542539.
  13. ↑ Sternberg, Stephen S. (1997). Histology for Pathologists (2nd ed.). Lippincott Williams & Wilkins. pp. 953. ISBN 978-0397517183.
  14. ↑ URL: http://path.upmc.edu/cases/case394/dx.html. Accessed on: 16 January 2012.
  15. ↑ URL: http://webpathology.com/image.asp?n=3&Case=540. Accessed on: 22 October 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. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 442. ISBN 978-0781765275.
  19. ↑ 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.
  20. ↑ URL: http://www.med-ed.virginia.edu/courses/path/gyn/ovary2.cfm. Accessed on: 20 May 2010.
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