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

PID – pelvic inflammatory disease

(chronic salpingooophoritis)

tubar sterility

Diseases of the Ovaries inborn

acquired

–atrophy (involution)

–stromal hyperplasia (stromal)

–inflammation (salpingooophoritis, PID, tuboovarian absess. Actinomycosis, tbc.)

(cont.)

Diseases of the Ovaries

inborn – malformations:

– aplasia (incl. kidney, uterus & vagina)

– hypoplasia (e.g. in adrenogenital

syndrome –pseudohermafroditismus

femininus)

acquired (cont.)

Diseases of the Ovaries inborn

acquired– atrophy

– hyperplasia

– inflammation

– pseudotumours

–TUMOURS (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

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 Ovary119 (!) coded nosology units ICD-O Classification 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

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

TUMOURS of the Ovary Surface epithelial stromal tumours - microscopy

serous - endosalpigeoma mucinous – endocervicoma mixed endometrioid (coinciding with endometrial ca) Brenner tumour------------------------ papillary cystadenoma papillary borderleine papillary cystadenocarcinomas

TUMOURS of the Ovary119 (!) coded nosology units ICD-O Classification 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

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 tumoursGranulosa-stromal cell tumours manifesting mostly as a solid or cystic

mass or with steroid hormones production E/A effects

– adult– juvenile

– bleeding disorders, virilisation, – isosexual precoccious puberty

TUMOURS of the Ovary119 (!) coded nosology units ICD-O Classification groups

Surface epithelial stromal Sex cord stromalGerm 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

TUMOURS of the Ovary

Germ 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 Ovary

Secondary 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 Breast WHO 2003

75 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

Benign epithelial tumours

intraductal papilloma - central - peripheral

tubular adenoma

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

Histopathologysolid, 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 – high risk

age more than 50developed countries USA, Europepositive family historyatypical hyperplasiaBRCA1 gen (40-50%), BRCA2 gen,

+ other ca (bowel, ovary, prostate, stomach, pankreas..)

Breast cancer – increased riskmenarche prior 11 & menopause

after 55 yrsnuliparity late first delivery 30-35 lethigher socioeconomic groupobesityradiation

Breast cancer – increased risk

etanol abuse

oral contraceptives uncertain

HRT following 10-15 yrs

administration

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

Phyllodes tumor

middle age (50yrs)mostly benign, recidivespainless, up to 50 mm more cellular stromal component