Pathology of the Ovaries and Fallopian Tubes - Part 2

Cheryl A. Hanau, M.D.

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Cystadenofibroma
• Uncommon variant – with pronounced proliferation of fibrous stroma underlying
columnar lining epithelium
• Benign tumor – usually small and multilocular
• May have mucinous, serous, endometrioid or transitional epithelial component

Brenner Tumor (Transitional Cell)

• 10% of ovarian epithelial tumors
• Most are benign; usually unilateral
• Usually solid and firm, 1-20 cm in diameter
• Fibrous stroma
Brenner Tumor Brenner Tumor – Transitional Cell
containing scattered
groups of transitional
epithelial cells

Clinical – Ovarian Epithelial Tumors

• Often presents with vague symptoms – GI complaints, urinary symptoms, pelvic
pressure - so it is often found when large
 • Benign tumors are removed – patient recovers
• If malignant
• May see ascites – can contain malignant cell
• Tumor can spread throughout peritoneum – tiny nodules seed the serosal
surface
• May spread to liver, lungs, GI tract, opposite ovary
• Searching for early diagnosis method – serum CA-125 is good marker for known disease
to monitor recurrence/progression, but not for screening

Germ Cell Tumors

• 15-20% of ovarian tumors
• Most are mature teratomas (Dermoid Cysts) – Benign
• Others include:
• Immature teratoma
• Dysgerminoma
• Endodermal Sinus (Yolk Sac) tumor
• Choriocarcinoma
• Embryonal carcinoma
• Mixed germ cell tumor
Teratoma
• Benign Teratoma (Mature)
• Usually cystic, 10-15% are bilateral, filled with sebaceous material, hair shafts,
and other tissue types
• Malignant transformation is rare
• Malignant Teratoma (Immature)
• Usually seen in children and young adults, contain immature embryonic tissues,
mostly solid with focal necrosis and hemorrhage
• Monodermal (specialized)
• Struma ovarii – entirely composed of mature thyroid tissue

Mature Cystic Teratoma Mature Teratoma

Mature Cystic Mature Teratoma

Teratoma (Dermoid (Dermoid Cyst)
Cyst)

Mature Teratoma
 Immature Teratoma Immature Teratoma Struma Ovarii
(Monodermal Teratoma
of Thyroid tissue)

Dysgerminoma
• Ovarian counterpart of seminoma
• Always malignant, usually unilateral
• 2% of ovarian tumors, 50% of malignant ovarian germ cell tumors
• 75% in 2nd and 3rd decades
• Some produce gonadotropins
• Micro – large cells with clear cytoplasm and centrally located nuclei in cords or sheets,
separated by thin, fibrous septa that contains lymphocytes

Dysgerminoma (Ovarian Dysgerminoma

Counterpart of Testicular (Ovarian Counterpart of
Seminoma) Testicular Seminoma)

Endodermal Sinus (Yolk Sac) Tumor

• Malignant and very aggressive
• Seen in children and young women
• See yolk sac differentiation with Schiller-Duval (look like a glomerulus) bodies that
contain intracytoplasmic hyalin droplets
• Droplets contain Alpha-fetoprotein and alpha-1-antitrypsin
Yolk Sac Tumor (Endodermal Yolk Sac Tumor
Sinus Tumor) (Endodermal Sinus
Tumor)
Choriocarcinoma
• Rare tumor
• Histologically identical to choriocarcinoma of placental origin but much more malignant
with early widespread metastases
• Produce chorionic gonadotropin
• Often seen as a component in combination with other germ cell tumor types
Choriocarcinoma Choriocarcinoma

Embryonal Carcinoma Embryonal Carcinoma

• Solid tumor with necrosis and hemorrhage
• Micro shows solid sheets and nests of large, primitive cells
• Can see syncytiotrophoblast-like cells, secrete chorionic
gonadotropin
• Can also see elevated alpha-fetoprotein levels

Sex Cord Stromal Tumors

• 5% of all ovarian tumors
• Include:
• Granulosa Cell Tumor
• Thecoma and Fibroma
• Sertoli-Leydig Cell Tumor (Arrhenoblastoma)
• Leydig Cell Tumor (Hilus Cell Tumor) Granulosa Cell Tumor
• Lipid Cell Tumor

Granulosa Cell Tumor

• Epidemiology
• 5% before puberty; 40% after menopause
• 10% bilateral
• Gross: Smooth surface, lobulated, gray-yellow color Granulosa Cell Tumor
(Call-Exner Bodies)
• Micro: Microfollicular with Call-Exner bodies – see coffee-bean
nuclei
• 75% associated with hyperestrinism – can cause endometrial
hyperplasia/carcinoma in adults or precocious puberty in
children
• See elevated tissue and serum inhibin
• Risk of recurrence or spread is 5-25%, usually indolent
Theca and Fibroma
• 65% in post menopausal women
• Nearly all are benign
• Round, firm, solid
• Micro: fascicles of spindle cells, can sometimes see fat in thecomas
• May see hyperestrinism in thecomas
• Can see ascites and right sided hydrothorax (Meigs’ Syndrome) with fibroma
• Also can be associated with Basal Cell Nevus syndrome
Thecoma/Fibroma

Virilizing Tumors
• Sertoli-Leydig Cell Tumor (Adroblastoma/Arrhenoblastoma)
• Rare tumor, average age is 25, resembles immature testis with Sertoli and Leydig
cells
• About 15% are malignant Sertoli Leydig Cell Tumor
• Leydig Cell Tumor (Hilus Cell
Tumor)
• Can see cells containing
Reinke crystals
• Benign

More Virilizing Tumors Virilizing Tumors

• Lipid Cell Tumor
• Rare, yellow or brown, 25% malignant
• Gynandroblastoma – mix of Granulosa and Sertoli-Leydig
cell tumor
• Patients have abnormal sexual development and
gonads of indeterminant nature
• 50% have a coexistent dysgerminoma
• Sex-cord tumor with Annular Tubules
• About 1/3 of cases are associated with Peutz-Jegher

Metastatic Tumors
• 7% of ovarian tumors are metastatic, 50% of these are
bilateral
• Most often originate from stomach, large bowel, appendix, breast, uterus and lungs
 • Krukenberg tumor – Usually bilateral and solid, diffuse infiltration by signet ring cells,
most often from stomach
Krukenberg Tumor

Fallopian Tubes

Fallopian Tube Pathology

Acute Salpingitis
• Usually caused by bacteria from uterine cavity
• Number one organism is Gonococcus but can also involve
E. coli, bacteroides, streptococcus, chlamydia
• Gonococci penetrate into subepithelial connective
tissue, cause acute inflammation with:
• Pus accumulation in tube lumen with
distension
• Pus drains out of fimbriated end, into
pelvis
• Fibrinous exudate on serosa
• Nongonococcal bacteria can get to tubes via uterine lymphatics

PID Tubo-ovarian Abscess (TOA) Acute Salpingitis

Chronic Salpingitis
• Residual inflammation and alteration in tubes after an acute episode or repeated
episodes of acute inflammation
• Gross:
 • Adherence of mucosal plicae and/or closure of fimbriated end, fibrous adhesions
between tubes, adjacent peritoneum and ovary
• Can result in pyosalpinx and/or hydrosalpinx

Chronic Salpingitis
• Micro: Lymphocytic and plasmocytic infiltration
• Granulomatous Salpingitis –subtype of chronic
• l% of patients with infertility problem have tuberculosis of oviducts.
• 10% of women patients dying of tuberculosis have tuberculous
salpingitis.
• Source is from primary tuberculosis somewhere else in the body.
• Blood born mycobacterium tuberculosis preferentially involves fallopian
tubes than other female genitalia.
• Lesion starts from the mucosa and may extend into the muscular layer.
Chronic Salpingitis Chronic Salpingitis Chronic Salpingitis Hydrosalpinx

Fallopian Tube - Other Lesions

• Paratubal cyst – very common and benign
• Salpingitis Isthmica Nodosa - diverticular lesion of tubal epithelium in isthmus
• Endosalpinigitis – presence of tubal epithelium in sites other than fallopian tube
• Tumors
• Benign – Adenomatoid tumor (mesothelioma); small nodule, counterpart can be
seen in testis or epididymis
Salpingitis Isthmica Nodosa
• Malignant – Adenocarcinoma, very rare Carcinoma
– Half are stage I at diagnosis but 40% of
Paratubal Cyst
patients die within 5 years