PATHOLOGY LABORATORY

Female Reproductive Lab II

Case 1: slide 107

Clinical history: A 20 year old woman saw her gynecologist for symptoms of pelvic pressure and pain. Pelvic examination revealed a large left adnexal mass. The adnexal mass was resected. Examine slide 107.

  1. What is the organ and your diagnosis?    The organ is the ovary although slides may have little residual ovarian tissue. The diagnosis is mature or benign cystic teratoma (dermoid cyst).

 

  1. Is the neoplasm a common epithelial tumor, a germ cell tumor, or a sex-cord tumor?    Teratomas, as well as dysgerminomas, yolk sac tumors, embryonal carcinomas, choriocarcinomas, and mixed germ cell tumors, are all germ cell tumors.

 

  1. Name examples of each of the above types of neoplasms.   Common epithelial tumors: includes benign, malignant and borderline serous, mucinous, endometrioid (mainly malignant), Brenner tumors, and clear cell tumors (mainly malignant). Germ cell tumors: include the tumors listed in 2. Sex cord stromal tumors: granulosa cell tumor, thecoma-fibroma group of tumors, sertoli-stromal tumors (androblastomas), Steroid (lipid-lipoid) cell tumors: stromal luteoma, Leydig cell tumor and steroid cell tumor. Germ Cell Sex Cord Stromal tumors: Gonadoblastoma

 

  1. What histologic feature is required to diagnose a teratoma?   A teratoma is composed of tissue from at least two and usually all three embryonic layers (germ layers).

 

  1. What major features separate a mature teratoma from an immature teratoma?   An immature teratoma, like a mature teratoma, is composed of elements derived from the three germ layers. However, it contains immature or embryonal tissues. (Mature teratoma is usually, but not always cystic and an immature teratoma is usually solid grossly.)

 

  1. What are monodermal teratomas?   Monodermal teratomas are teratomas which have a large component of a single endodermal or ectodermal tissue type or is composed exclusively of such tissue such as struma ovarii (thyroid tissue is the predominant or sole component) and carcinoid.

 

  1. How does the prognosis vary with different types of teratomas?    Mature teratomas are benign except for the 1-2% that harbor an adult type cancer. Immature teratomas prognosis varies with the grade of tumor. Well differentiated tumors have a good prognosis and high grades have a poor prognosis. Overall 64% 5 year survival.

 

Case 2:  Slide 108

 

Clinical history:  A 45 year old woman saw her gynecologist for a feeling of fullness in the left lower quadrant.  On pelvic exam a left adnexal mass was palpated and the mass was resected.  The mass was cystic and contained clear watery fluid.  Examine slide 108.

 

1.                  What category of the World Health Organization does this neoplasm fit into?  Serous tumors (benign, borderline, and malignant) are common epithelial tumors. 

 

Is this category of neoplasm common?  What are these types of neoplasms derived from?   This category represents about 65% of all primary ovarian neoplasms.   Common epithelial neoplasms are derived from the surface ovarian epithelium which comes from the coelomic epithelium or mesothelium.

 

Are malignant forms of this category of neoplasm common?    Malignant common epithelial neoplasms (such as serous, mucinous, endometrioid, and clear cell carcinomas and malignant Brenner tumors) represent almost 90% of ovarian carcinomas.

 

2.   This slide contains a serous neoplasm which is a very common type of common epithelial neoplasm. 

 

Serous tumors constitute 50% of all ovarian tumors and 70% of them are benign, 10% borderline, and 25% are malignant. 

 

Mucinous tumors constitute 20% of all ovarian tumors and 85% are benign, 6% borderline, and 9% malignant.  Most endometrioid tumors are malignant (benign and borderline tumors are rare) and is the second most common ovarian cancer.

 

1.                  The diagnosis is benign serous cystadenoma of the ovary.

 

1.                  Epithelium of the neoplasm resembles the epithelium of the fallopian tube.

 

1.                  Benign serous cystadenomas are unilocular or multilocular, thin walled cysts containing watery (serous) fluid.                 

 

 

Case 3:  Slide 111

 

1.                  Diagnosis is serous cystadenocarcinoma of the ovary.  Serous cystadenocarcinomas exhibit obvious stromal invasion and one or more of the following features:  fine papillae, irregular often slit-like glandular lumens, small tight nests of tumor cells, solid sheets of tumor and psammoma bodies.

 

1.                  Grossly may be cystic and papillary, entirely solid and firm or both cystic and solid.  Usually contain friable, necrotic and hemorrhagic areas.  Bilateral in 2/3 of cases.

 

1.                  FIFO staging of ovarian carcinoma:

 

            Stage I:  Limited to ovaries.

            Stage II: One or both ovaries and pelvic extension.

Stage III: One or both ovaries and intraperitoneal mets outside pelvis (includes superficial liver mets) or positive retroperitoneal or inguinal lymph nodes.

Stage IV: One or both ovaries and distant mets (ex.  lung, parenchyma of liver).

           

This case represents a stage III from the information known since there is involvement of the omentum.

 

 

Case 4:  Slide 112

 

1.                  Diagnosis is borderline serous tumor.

 

1.                  Borderline serous tumors have moderate to marked epithelial proliferation shown by nuclear stratification which differentiates it from the benign serous cystadenomas.  The lack of destructive stromal invasion differentiates it from serous cystasdenomas.  Peritoneal serous proliferations can be present in 20-55% of the cases.

 

1.                  5 year survivals:

 

            Borderline tumor, stage I:          90%, stage II 80%

            Serous carcinoma, stage I:        66%, stage II 15%

 

1.                  Mucinous neoplasms are composed of mucin secreting epithelium resembling endocervix, or intestinal epithelium.

 

 

Case 5:  Slide 38

 

1.                  Diagnosis is infiltrating ductal carcinoma.

 

1.                  Invasive because tumor cells are not confined within the ductal basement membrane and there is a desmoplastic (scirrhous) stromal response.

 

1.                  Ductal (adeno)carcinomas constitute 85% of breast cancers and the majority are scirrhous.

 

1.                  Geographic:

            USA > far east.

            Jews > non-Jews.

Familial:  increases with number of close relatives with breast cancer and with the age the cancer occurred in the relatives.

            Nulliparous > multiparous.

Mother’s age at 1st child > 30 year (breast feeding early thought to be protective).

Estrogen excess states:  obesity, estrogen producing tumors of ovary, exogenous estrogens (not balanced contraceptive pills)

            Hyperplasia and atypical hyperplasia.

            Cancer of contralateral breast or cancer of the endometrium.

            ?  increased alcohol consumption.

 

1.                  Stage III includes breast cancer of any size with possible skin involvement, pectoral and chest wall fixation and/or nodal involvement including axillary nodes, fixed but without disseminated metastases.

 

1.                  Scirrhous:         Firm, white, gritty, poorly delineated.

                                    Forms cords and tubules infiltrating dense stroma.

            Medullary:        Soft, fleshy, yellow, well demarcated, “pushing borders”.

Large tumor cells admixed with lymphocytes with minimal intervening stroma.

            Paget’s:            Involves nipple, eczematoid, crusty nodule +/- ulceration. 

Characterized by Paget cells in epidermis (large cells surrounded by clear zone in the epidermis and stain positively for mucin).

A form of ductal carcinoma that arises from main lactiferous ducts and extends to involve skin of nipple and areola.

 

 

Case 6:  Slide 113

 

1.                  Diagnosis is fibroadenoma.

 

1.                  Well defined nodule composed of fibrous tissue and ducts.

 

1.                  Yes, second most common benign pathologic condition.  Yes it is neoplastic.  It is benign.

 

1.                  Cystosarcoma phyllodes or phyllodes tumors are related to fibroadenomas, but are large, bulky tumors in which the stroma differs by being more cellular.  The glandular spaces are “leaf-like” and the stromal cells are more plump and larger than regular fibroblasts.  Malignancy is present when there are increased mitoses and anaplasia.

 

 

Case 7:  Slide 114

 

1.                  The diagnosis is fibrocystic changes (fibrocystic disease).

 

1.                  It is not a neoplasm.

 

1.                  Proliferative changes which may be found include epithelial hyperplasia and papillomatosis.  Thought to increase risk for carcinoma. 

 

Non-Proliferative changes include fibrosis, cyst formation, apocrine metaplasia, and sclerosing adenosis.  Entirely benign and have no premalignant potential.

 

Changes present in slide 114 include fibrosis, cyst formation, apocrine metaplasia, and epithelial hyperplasia.

 

1.                  Proliferative changes of epithelial hyperplasia and papillomatosis increase the risk for the development of carcinoma (x2).  Atypical hyperplasia further increases the risk (x5).