Comprehensive Guide to Female Genital Pathology

Organ Pathology Female Genital System - II Pathology of ovaries, tubes, breast, pregnancy Jaroslava Dušková Inst. Pathol. ,1st Med. Faculty, Charles Univ. Prague http://www1.lf1.cuni.cz/~jdusk/

Diseases of the Fallopian Tubes • inborn – malformations: • aplasia (Müllerian duct disorders) • bilateral incl. uterus & vagina • unilateral incl. kidney • partial atresia • acquired

Diseases of the Fallopian Tubes • inborn • acquired • non neoplastic : atrophy, infection – pyosalpinx, hydrosalpinx, tbc salpingitis, synechiae • salpingitis isthmica nodosa • pseudotumours – cysts, ectopic pregnancy, • neoplastic: adenocarcinoma

Diseases of the Fallopian Tubes & Ovaries • PID – pelvic inflammatory disease (chronic salpingooophoritis) • tubar sterility

Diseases of the Ovaries • inborn • acquired • non-neoplastic • pseudotumours • neoplastic • benign • BORDERLINE • malignant (cont.)

Diseases of the Ovaries • inborn – malformations: • aplasia (incl. kidney, uterus & vagina), • hypoplasia/dysplasia (e.g. in adrenogenital syndrome –pseudohermafroditismus femininus, Turner sy (45X0, or 45X0/46XX) • acquired (cont.)

Diseases of the Ovaries • inborn • acquired • non-neoplastic • atrophy - involution, inflammation – PID, actinomycosis, tbc • pseudotumours • neoplastic • benign • BORDERLINE • malignant (cont.)

Diseases of the Ovaries • inborn • acquired • non-neoplastic • pseudotumours • stromal hyperplasia • CYSTS • neoplastic • benign • BORDERLINE • malignant (cont.)

Ovary - cysts • follicle • luteal • inclusion • endometrial („chocolate“) • POLYCYSTIC OVARIES(Stein- Leventhal syndrome) • obesity • hirsutism • infertility • oligo- or amenorrhea

Diseases of the Ovaries • inborn • acquired • pseudotumours (stromal hyperplasia, dif. dg. CYSTS) • TUMOURS

TUMOURS of the Ovary119 (!) coded nosology units ICD-OClassification groups • Surface epithelial stromal • Sex cord stromal • Germ cell • Mixed germ cell sex cord-stromal • Tumour of the rete ovarii • Miscelaneous, tumour like lesions • Lymphomas & leukemias • Secondary tumours of the ovary • Peritoneal tumours

Ovary malignant neoplasms • Czech Rep. 1323 new cases 2002 • Czech Rep. 25,3/ 100 000 women • Europe 20,6/ 100 000 women • World 15,1/ 100 000 women

TUMOURS of the Ovary Surface epithelial stromal tumours • 30% of fem. gen. neoplasms • middle & old age • risk factors: longer HRT, obesity • protective factors: high parity, oral contraceptives • precursors: inclusion cyts, endometriosis • lack of early warning symptoms • 70% dg. at a late stage – ca peritonitis • mean 5-year survival in Europe 32% (!!!)

TUMOURS of the Ovary Surface epithelial stromal tumours - macroscopy • small to more than 20cm • two thirds bilateral • solid & cystic with intracystic papillae • confluent papillae, softer borderline • necroses & haemorrhage susp. malignancy

serous - endosalpigeoma mucinous – endocervicoma mixed endometrioid (coinciding with endometrial ca) Brenner tumour ------------------------ papillary cystadenoma papillary borderline papillary cystadenocarcinomas TUMOURS of the Ovary Surface epithelial stromal tumours - microscopy

TUMOURS of the Ovary Sex cord stromal tumours • Granulosa-stromal cell tumours • Thecoma-fibroma group • Sertoli- Leydig cell group • Others…..

TUMOURS of the Ovary Sex cord stromal tumours Granulosa-stromal cell tumours • manifesting mostly as a solid or cystic mass or with steroid hormones productionE/A effects • adult • juvenile • bleeding disorders, virilisation, • isosexual precoccious puberty

TUMOURS of the OvaryGerm cell Tumours • dysgerminoma (= seminoma ovarii) • embryonal carcinoma • teratoma (mature, immature) • yolc sac tumour • choriocarcinoma

Embryonal carcinoma • composed of primitive anaplastic-appearing epithelial cells • pure rare, mostly in combined germ cell tumours • peak incidence 30 years • swelling, 2/3 patients with metastases at diagnosis • macro : tan/gray, necroses, hemorrhages • micro: solid, tubular, PLAP, CK +

Mesoblastoma vitellinum- yolc sac tumour –endodermal sinus tumour • 80% of prepubertal germ cell tumours • in postpubertal as admixture • painless mass, serum AFP elevated • macro: gray/tan nonencapsulated • micro: many variants – microcystic, solid,festoon-like, hepatoid, spindle cell… • AFP+, alpha1-Antitrypsin

Choriocarcinoma (non gestational) • rare • admixture in many germ cell tumours • malignant • children & young adults • presents with bleeding and precoccious pseudopuberty • ß-HCG + morphologicall identical with gestational ch.

Teratomas Def.: Tumours (benign, borderline or malignant) composed of two or more different cell lines that are NOT normally present in the place of tumour origin

Teratoma • coetaneous – differentiated -cystic • embryonal – nondifferentiated - solid

TUMOURS of the OvarySecondary tumours of the ovary • metastatic - advanced stage • poor prognosis • Krukenberg tumour – metastatic signet ring cell ca originating mostly in the stomach or colon

Diseases of the Breast • inborn – malformations: • amastia, polymastia (mamma accessoria), aberant mammary tissue, polythelia • acquired

Diseases of the Breast • inborn • acquired • degenerations:amyloid, mastitis: acute puerperal, chronic • Pseudotumours (& precanceroses) : fibrocystic disease, lipophagic granuloma, silicon granuloma, suture granuloma…. • TUMOURS

Fibrocystic Breast Disease Def: dyshormonal changes of the breast tissue with variably increased risk of breast cancer according to the type of epithelial proliferation

Fibrocystic Breast Disease - symptoms • palpable lump • fluctuating cysts • (pain)

Fibrocystic Breast Disease - morphology • fibrosis • cysts • epithelial hyperplasia • ductal, lobular – adenosis :simple, florid, sclerosing, microglandular • usual, atypical • papillary

Tumours of the BreastWHO 200375 ICD-O coded nosology units • epithelial • myoepithelial • mesenchymal • fibroepithelial • tumours of the nipple • malignant lymphoma • metastatic tumours • tumours of the male breast

Tumours of the Breast symptoms • early stage – asymptomatic – mammography – (microcalciffication) • palpable lump • nipple discharge • breast configuration change • ulceration • metastases

Benignepithelial tumours • intraductal papilloma - central - peripheral • tubular adenoma

Breast cancer – high risk • age more than 50 • developed countries USA, Europe • positive family history • atypical hyperplasia • BRCA1 gen (40-50%), BRCA2 gen, + other ca (bowel, ovary, prostate, stomach, pankreas..)

Breast cancer – increased risk • menarche prior 11 & menopause after 55 yrs • nuliparity late first delivery 30-35 let • higher socioeconomic group • obesity • radiation

Breast cancer – increased risk • etanol abuse • oral contraceptives uncertain • HRT following 10-15 yrs administration

Ductal ca in situ DCIS • TDLU, seldom larger ducts • precursor of invasive ca • microcalcification on mammography 85% of cases detected with imaging techniques screening introduction incidence from 2,4/ 100 000 to 15,8/ 100 000

Ductal ca in situ DCIS Histopathology • solid, papillary, cribriform, comedo • cytology (grading) G1-3

Lobular carcinoma in situ LCIS • 85% multicentric, 30% bilateral • precursor of invasive ca Histopathology: • preserved lobular architecture, TDLU involvement, small monomorphous cells, regular nuclei

Breast cancer -prognosis • typing • grading • staging • hormonal receptors (ER & PR- immunohistochemistry) • c-erbB-2 receptoru (immunohistochemistry, FISH) • proliferation activity (immunohistochemistry Ki-67 index) • angioinvasion

Mixed Tumours Def.: Tumours (benign or malignant) composed of two or more different cell lines that are normally present in the place of tumour origin

Fibroadenoma • young age (30yr) • firm circumscribed, painles • mostly up to 30 mm • solitary • stromal & epithelial component

Phyllodestumor • middle age (50yrs) • mostly benign, recurrences • painless, up to 50 mm • more cellular stromal component

Comprehensive Guide to Female Genital Pathology