The Pathology of THE FALLOPIAN TUBE AND OVARY

INFECTIONS OF THE FALLOPIAN TUBE

Infections of fallopian tube Suppurative salpingitis may be caused by any of the pyogenic organisms, and often more than one is involved. The gonococcus still accounts for more than 60% of cases of suppurative salpingitis, with chlamydiae less often a factor. Tuberculous salpingitis is an important cause of infertility in these areas.

SALPINGITIS PELVIC INFLAMMATORY DISEASE The usual infectious agents are the gonococcus and chlamydia. TB is now rare in the developed world, but very common in the poor nations. Actinomycosis usually results from the presence of an intrauterine device, –"sulfur granules" colonies.

Gonococcal and Chlamydial PID A very common sexually transmitted disease During acute phase, there is severe pelvic pain, especially when the cervix is manipulated, with peritoneal signs. Grossly, the tubes are swollen and inflamed. –They may be packed with pus ("pyosalpinx"). The acute phase: neutrophils and marked edema. –complications of the acute phase: sepsis, peritonitis, obstruction.

In chronic infection: a mixture of neutrophils, lymphocytes, and other inflammatory cells. –After everything is over, it is likely to form scar tissue which will probably interfere with fertility. –If the ends of the tubes are plugged by scar tissue, a "hydrosalpinx" results.

pyosalpinx

Other Lesions of the OVIDUCT Cysts –arise from embryonic structures. –Hyatids of Morgagni / paratubal cysts Ectopic pregnancy.

The most common primary lesions of the fallopian tube (excluding endometriosis) are minute, 0.1- to 2-cm translucent cysts filled with clear serous fluid, called paratubal cysts. Larger varieties are found near the fimbriated end of the tube or in the broad ligaments and are referred to as hydatids of Morgagni. These cysts are presumed to arise in remnants of the müllerian duct and are of little significance. Larger varieties are found near the fimbriated end of the tube or in the broad ligaments and are referred to as hydatids of Morgagni. These cysts are presumed to arise in remnants of the müllerian duct and are of little significance.

Tumors Primary adenocarcinoma of the fallopian tubes is rare and is defined as an adenocarcinoma with a dominant tubal mass and luminal and mucosal involvement. These tumors are detected by pelvic exam, abnormal discharge or bleeding, and occasionally, cervical cytology. Approximately one half are stage I at diagnosis, but nearly 40% of these patients will not survive 5 years. Higher stage tumors have a poor prognosis. Recently, occult carcinoma of the fallopian tube has been associated with BRCA mutations, requiring attention to this site as a potential source of tumors in patients with BRCA germ-line mutations.

Ovary Autoimmune oophoritis an important cause of infertility around half of women with unexplained premature ovarian failure have autoantibodies. autoantibodies are found against granulosa/theca cells and/or zona pellucida, and T-killer cells abound around the follicles.

OVARY

Ovarian torsion Usually is caused by an ovarian mass. Present as an acute abdomen. Ultrasound / laparoscope.

CYSTIC FOLLICLES (Follicular and Luteal cysts) Common They are remnants of graafian follicles (unruptured or resealed, luteinized or not) Big ones can cause torsion and/or possess too much luteinized theca cell tissue resulting in hyperestrogenism. Corpus luteum cysts – –They are filled with blood (corpus hemorrhagicum) and fatty debris, – –may undergoe torsion or rupture.

STEIN-LEVENTHAL SYNDROME Polycystic ovarian disease; polycystic ovaries Common, enlarged ovaries with numerous cysts, excess stroma, and thick capsule. –failure of ovulation, –obesity (often), –insulin resistance and failure of release of insulin, –amenorrhea or irregular periods, –hirsutism / excessive androstenedione androstenedione  estrone  hyperestrogenism  risk for endometrial adenocarcinoma.

OVARIAN TUMORS Ovarian cancers are common and deadly. There are three overriding categories of Primary ovarian tumors: –Surface epithelial tumors –Sex cord stromal tumors –Germ cell tumors Secondary ovarian tumors (metastases)

Surface epithelial tumors These are the common ovarian tumors. Derived from the women's müllerian epithelium These usually present as mass lesions. Rare before age 30. Sometimes a benign one will be almost all stroma, and be called an "adenofibroma". The malignant ones tend to metastasize to the peritoneum

Subtypes of Surface epithelial tumors Serous tumors Mucinous tumors Endometrioid tumors Clear cell adenocarcinoma Brenner tumor (transitional cell)

Serous tumors This is the most common ovarian cancer (about 40%). These recapitulate oviduct, with papillary structures and often cilia. Often there are psammoma bodies. Most of these are malignant; a majority of the malignant ones arise bilaterally.

These common cystic neoplasms are lined by tall, columnar, ciliated epithelial cells and are filled with clear serous fluid. Although the term serous appropriately describes the cyst fluid, it has become synonymous with the tubal-like epithelium in these tumors. Benign and borderline tumors are most common between the ages of 20 and 50 years. Cystadenocarcinomas occur later in life on average, although somewhat earlier in familial cases.

Papillary serous cystadenoma

Borderline serous cystadenoma

Papillary serous cystadenocarcinoma

Mucinous tumors Benign mucinous tumors are very common. Most of these are benign, with well- developed columnar cells and abundant mucin. They are always multicystic and can be very large. They are usually unilateral. Mucin in contact with the ovarian stroma can cause it to produce androgens (masculinization).

They are somewhat less common, accounting for about 25% of all ovarian neoplasms 80% are benign or borderline, and about 15% are malignant. Mucinous cystadenocarcinomas are relatively uncommon and account for only 10% of all ovarian cancers

Mucinous cystadenoma

"Pseudomyxoma peritonei“ –if mucin erupts into the peritoneal cavity and elicits a fibrous response, –often results from mucinous carcinoma of the ovary or appendix.

Pseudomyxoma peritonei

Endometrioid tumors Almost all endometrioid tumors of the ovary are malignant. Resemblance to swiss-cheese endometrial adenocarcinoma. The risk factors are the same as for endometrial adenocarcinoma; –there is often a history of endometriosis in the ovary as well. About 50% are bilateral. Often there is a coexisting endometrial carcinoma, but this does not imply that these are metastases.

These neoplasms account for approximately 20% of all ovarian cancers, Most endometrioid tumors are carcinomas. Most endometrioid tumors are carcinomas. Less commonly, benign forms-usually cystadenofibromas- are encountered. Less commonly, benign forms-usually cystadenofibromas- are encountered. They are distinguished from serous and mucinous tumors by the presence of tubular glands bearing a close resemblance to benign or malignant endometrium.

Clear cell adenocarcinoma This tumor shows lots of big clear cells in sheets or tubes.

Brenner tumor These recapitulate the transitional epithelium of the bladder. They are almost all benign.

Brenner tumor

Sex cord stromal tumors Derived from the ovarian stroma or its counterpart in the male. If they produce a steroid hormone, they will be yellow. They can occur at any age. They are almost always unilateral.

Subtypes of the Sex cord tumors Granulosa-Theca tumors Thecoma-fibromas Sertoli-Leydig cell tumors

Granulosa-Theca tumors Contain abundant granulosa-type cells (cuboidal steroid-producing cells), –often with some forming Call-Exner bodies. There are often theca cells as well, –these may be spindly, or pink and plump (luteinized). Many of these produce estrogen. –A few produce androgen. –As steroid-producers, expect yellow color on gross examination Any granulosa tumor can metastasize.

Granulosa cell tumor

Thecoma-fibromas These are a mix of variable proportions of inactive fibroblasts and hormonally-active theca cells. These tumors are solid, hard balls. Many produce estrogens –a few produce androgens Generally benign tumors. Prone to cause ascites and sometimes even hydrothorax (Meig's syndrome).

Thecoma-fibroma

Sertoli-Leydig cell tumors (androblastomas, arrhenoblastomas) Recapitulate the Leydig cells and/or seminiferous tubules. They are unilateral and solid. Most produce androgens –a few produce estrogens. Androgens from these tumors will tend to defeminize and masculinize (virilize): –enlarge the clitoris, –produce extra body hair, –altered hairline, –acne, –more apocrine sweat, –deep voice. Look for Reinke crystalloids in the Leydig cells.

Sertoli cell tumor

Reinke crystalloids 

Germ cell tumors These usually present as a mass, or as metastases if malignant. They usually occur in children and young women. The most common is the benign, common dermoid tumor ("cystic teratoma") of young women. The other common ones are all malignant.

Histogenesis and interrelationships of tumors of germ cell origin

Subtypes of Germ cell tumors Mature (benign) teratoma Specialized teratoma (monodermal teratoma) Immature teratoma Dysgerminoma Endodermal sinus tumor ("yolk sac tumor“ Embryonal cell carcinoma Choriocarcinoma

Mature (benign) teratomas The most common benign teratoma of the ovary is the dermoid cyst ("cystic teratoma"), filled with hair, sebum and keratin. About 15% are bilateral. All have the 46XX karyotype. Rarely a squamous cell carcinoma will arise in one of these, but otherwise they are thoroughly benign.

Specialized teratoma (monodermal teratoma) Sometimes a single tissue predominates. –carcinoids (producing the carcinoid syndrome) –thyroid (struma ovarii, rarely with hyperthyroidism).

Immature teratomas These are tumors of girls and young women, and are all malignant. Composed of cells that resemble embryonic tissue. – –Amount of neuroepithelial tissue determines the grade and prognosis.

Immature teratoma of the ovary illustrating primitive neuroepithelium

Dysgerminoma Counterpart to a man's seminoma of the testis, composed of large, glycogen-rich, polyhedral "fried egg" cells. They are rare over age 30. Like seminomas, some produce human chorionic gonadotrophin (hCG; a placental hormone). Lymphocytes accompany

Dysgerminoma showing polyhedral tumor cells with round nuclei and adjacent inflammation

("yolk sac tumor") Endodermal sinus tumor ("yolk sac tumor") Aggressive tumor of children or young adults, which recapitulate the yolk sac. Like the yolk sac, they are loaded with alpha-1 antitrypsin and alpha - fetoprotein. Identification of Schiller-Duval bodies : –recapitulate the duct of the yolk sac.

Schiller-Duval bodies 

Schiller-Duval body in yolk sac carcinoma

Embryonal cell carcinoma Can arise in the ovary as in a man's testis. Choriocarcinoma can be primary in the ovary.

Metastases to the ovary Common: –breast –stomach. "Krukenberg tumors" with massive bilateral enlargement of the ovaries which prove at surgery to be stuffed with signet ring cells.

Ovarian neoplasms

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