Pathology of the Adnexa

Dr. Soekimin, SpPA ; dr. Jessy Chrestella, SpPADept. Patologi Anatomi Fakultas Kedokteran Universitas Sumatera UtaraMedan 2010

PATHOLOGY OF FALLOPIAN TUBES

Congenital Anomalies Parametritis/Salphingitis Ectopic pregnancy Hydrosalpinx Endometriosis Para ovarian cyst Carcinoma

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Ectopic Pregnancy:

Tubal – common. implantation allows

early placental development, secretion of hCG, and maintainance of the corpus luteum.

Clinically features of a normal pregnancy and the embryo may also complete the early embryonic stages of development.

Pathology of Ovary

Inflam/Infections - rare Ovarian cysts - common.

Non-Neoplastic▪ Follicular, epithelial, Luteal, etc.▪ Polycystic ovary syndrome▪ Ovarian Hyperstimulation synd.▪ Stromal Hyperplasia*▪ Endometriosis

Neoplasms▪ Benign (Cysts)▪ Malignant (Solid)

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OV. NEOPLASMA Serous cystadenoma Cystoma Papillary cystadenoma serosum Surface papilloma Serous adenofibroma Serous cystadenofibroma Pseudomucinous cystadenoma Teratoma

- dermoid cyst- Solid teratoma.

OV. NEOPLASMA Granulosa cell tumor Theca cell tumor Arrhenoblastoma Adrenal rest tumor Dysgerminoma Brenner tumor Fibroma Meigs syndrome Sarcoma Carcinoma (ad.Carcinoma) Metastase carcinoma.

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Ovary:

Cysts – Common – benign very large. Solid – rare – malignant – high mortality. 5th common cause of female cancer. But carcinomas of the ovaries account for

more deaths than do cancers of all other female malignancies together. (US stat).

Nulliparity & family history (BRCA) - Risk factor.

Polycystic Ovary Synd Amenorrhoea, hyperoestrogenism

and multiple follicular cysts. Stromal hyperplasia &

anovovulation Important cause of infertility, Endometrial

hyperplasia/Carcinoma. Clinical features:

Acne, alopecia, hirsutism, Hypertension, Insulin resistance, Type 2 DM. Obesity – Syndrome X.

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PCOS- Low power view

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Note: capsule thickening, cystic follicles without ova, thecal hyperplasia.

Endometriosis: chocolate cysts Metastases of hyperplastic

endometrium into ovary. Retrograde

menstruation /Metaplasia. Estrogen related. Pouch of Douglas, the

pelvic peritoneum and the ovary - 'chocolate cysts'.

Periodic Pain, pelvic inflammation, infertility.

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Endometriosis:Chocolate Cysts

Endometriosis:

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Chocolate Cysts

Neoplasms of Ovary

Common, produce estrogen. 80% are benign, cystic, young (20-45) 20% are Malignant, solid - older (>40) 6% of all cancers in women. 50% deaths due to late detection. The rule:

Cystic tumors are commonly benign

Solid tumors are commonly malignant.16

Risk Factors

Less clear than other Null parity Gonadal Dysgenesis Family History Ovarian cancer genes

BRCA1 (17q12) & BRCA2(13q12)

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Classification of Ovarian Tumours

Epithelial tumors Coelomic mesothelium

Serous (tubal) Mucinous (Cx) Endometrioid (End) Transitional (UT)

90% of malignant tumors of ovary Morphologically

Cystic – Cystadenomas - Benign Solid/cystic – Cystadenoma - Borderline. Solid –Cystadenocarcinoma – Malignant.

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Serous Tumors

Frequently bilateral (30-66%). 75% benign/bord., 25% malignant. One or few cysts, papillary/solid. Tall columnar ciliated epithelium. Papillary, solid, hemorrhage, necrosis or

adhesions – malignancy. Extension to peritoneum – bad prog.

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Mucinous Tumors

Less common 25%, very large. Rarely malignant - 15%. Multiloculated, many small cysts. Rarely bilateral – 5-20%. Tall columnar, apical mucin. Pseudomyxoma peritonei.

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Serous Cystadenoma

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Serous Cystadenoma

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Serous Cystadenoma

Borderline / Intermediate grade: note larger papillary growth.

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Serous Cystadenoma

multiloculated, 24cm cystic ovary with attached fallopian tube and uterus. – benign serous cystadenoma.

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Mucinous Cystadenoma

Note: papillary growths on inner surface

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Mucinous Cystadenoma

Note: Multi-loculated cystic tumor with some cysts showing hemorrhage.

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Serous - Cystadenoma - Mucinous

Cuboidal simple – Columnar Mucous

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Serous Cystadeno-carcinoma

High grade: note large papillary growth extending and covering the cyst.

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Serous Cystadenoma Borderline

High grade: note large papillary growth extending and covering the cyst.

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Papillary cystadenoma (bor)

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Papillary serous cystadenoma (solid/cystic)

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Serous Cystadeno-carcinoma

High grade: note large papillary growth extending and covering the cyst.

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Papillary cystadenoma (bor)

Infiltration

Papillary projections

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Serous cystadeno Ca – bilateral

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Serous cystadeno Ca.

Solid tumor with atypical cells forming sheets and gland like structures without stroma. (back to back arrangement of

glands)

Germ cell Tumors:

Teratoma – Benign cystic (dermoid cyst) Solid immature Monodermal – struma ovarii, carcinoid

DysgerminomaYolksac tumorMixed germ cell tumor

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Dermoid Cyst:

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Dermoid Cyst:

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Cystic Teratoma

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Dermoid Cyst:

Granulation

tissue lin

ing

Skin lin

ing

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Dermoid Cyst:

Cartilage

Resp. Epith

Sweat Gl.

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Dermoid Cyst:

Sebaceous Gl.Thyroid

MucosaSq. Epithel

M.A.L.T.Cyst Lumen

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Dermoid Cyst:

Black arrow: Stratified squamous Keratinizing epithelium. Blue arrow: Abundant sebaceous glands.

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Immature/Malignant teratoma:

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Immature/Malignant teratoma:

Any type of carcinoma, sarcoma or germ cell malignancy.

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Staging of Ovarian Ca:

Complications of Dermoid cyst Torsion - infarction, perforation,

hemoperitoneum, and autoamputation

Bacterial infection of the cyst Perforation - sudden acute

abdomen, Slow granulomatous peritonitis

Hemolytic anemia – clears after removal.

<5% malignancy – Sq. carcinoma. 48

Other Tumors of Ovary:

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Endometrioid Ca:

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Granulosa Cell Tumor:

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Ovary: Dysgerminoma

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Ovary: Dysgerminoma

• Teenage / young, 2% of ovarian neoplasms.• 1/2 of malignant germ cell neoplasms• Gonadal dysgenesis – risk factor.

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Ovary: Dysgerminoma

Note the pale brown appearance of the parenchyma, along with some central collagenous scar. The gross and microscopic appearance of an ovarian dysgerminoma is essentially same as a seminoma of the testis in a male.

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Granulosa Cell Tumor:

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Granulosa Cell Tumor:

Steroid cell tumour of the ovary. A well-circumscribed benign ovarian stromal tumour that caused virilisation in the patient

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Krukenberg Tumor

Metastases of adenocarcinoma to ovary.

Summary

Thank you