SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix lymphatics adnexae l...

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SALPINX: SALPINGITIS SALPINX: SALPINGITIS Cause: chlamydia and gonococcus = most Cause: chlamydia and gonococcus = most Route: cervix Route: cervix lymphatics lymphatics adnexae adnexae Complications: Complications: abscess tubes, ovaries, tubo-ovarian, abscess tubes, ovaries, tubo-ovarian, peritonitis, peritonitis, tubal scarring, hydrosalpinx, tubal scarring, hydrosalpinx, adhesions, bowel obstruction, ectopic adhesions, bowel obstruction, ectopic pregnancy, infertility pregnancy, infertility Tuberculosis: usually part of endometritis Tuberculosis: usually part of endometritis

Transcript of SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix lymphatics adnexae l...

Page 1: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

SALPINX: SALPINGITISSALPINX: SALPINGITIS

Cause: chlamydia and gonococcus = mostCause: chlamydia and gonococcus = most

Route: cervix Route: cervix lymphatics lymphatics adnexae adnexae

Complications: Complications:

abscess tubes, ovaries, tubo-ovarian, peritonitis,abscess tubes, ovaries, tubo-ovarian, peritonitis,

tubal scarring, hydrosalpinx, adhesions, bowel tubal scarring, hydrosalpinx, adhesions, bowel

obstruction, ectopic pregnancy, infertilityobstruction, ectopic pregnancy, infertility

Tuberculosis: usually part of endometritisTuberculosis: usually part of endometritis

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Supprative salpingitis with massively swollen fallopian tube

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Purulent exudate flowing from transected fallopian tube

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Wall and lumen of fallopian tube is filled with PMNs

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Bilateral hydrosalpinx dwarfs uterus: hydrosalpinx may be end result of resolution of infection

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Hydrosalpinx

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SALPINX: NEOPLASMSSALPINX: NEOPLASMS

Adenomatoid tumors (mesothelioma) Adenomatoid tumors (mesothelioma) subserosally on tube subserosally on tube Incidental finding Incidental finding Small nodules of benign appearing glands within muscular wallSmall nodules of benign appearing glands within muscular wall

Paratubal cysts & hydatid cysts of Morgagni Paratubal cysts & hydatid cysts of Morgagni common serous common serous filled cysts usually near fimbriafilled cysts usually near fimbria

Adenocarcinoma: Adenocarcinoma: Sx late, so prognosis poor Sx late, so prognosis poor

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Adenomatoid tumor as seen at surgery in wall of fallopian tube

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Adenomatoid tumor of fallopian tube

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PREGNANCY-RELATED LESIONS (1)PREGNANCY-RELATED LESIONS (1)

Ectopic pregnancyEctopic pregnancy

Frequency: 1% of all pregnancies!Frequency: 1% of all pregnancies!

Sites: Sites: tube (85%)tube (85%), ovary (14%), abdomen (1%), ovary (14%), abdomen (1%)

Cause: Cause: PIDPID (50%), endometriosis, leiomyomas, (50%), endometriosis, leiomyomas,

I.U.D., adhesionsI.U.D., adhesions

Course: tube and ovary: Course: tube and ovary: placenta perforates wall placenta perforates wall hemorrhage hemorrhage

bleeding is often life-threateningbleeding is often life-threatening

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PREGNANCY-RELATED LESIONS (2)PREGNANCY-RELATED LESIONS (2)

Dx: clinical suspicion (acute abdomen) Dx: clinical suspicion (acute abdomen) pelvic exam, pregnancy test, ultrasound, pelvic exam, pregnancy test, ultrasound,

laparoscopylaparoscopy D&C = D&C = deciduous stroma but no villideciduous stroma but no villi

Abdominal pregnancy may implant on psoas Abdominal pregnancy may implant on psoas muscle muscle to term to term Fetus may die and calcify Fetus may die and calcify lithopedion lithopedion

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Ectopic pregnancy within fallopian tube

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Ruptured ectopic pregnancy of fallopian tube

Page 14: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Ectopic pregnancy near fimbriated end of tube. A corpus luteum is present within the ovary (arrow)

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Chorionic villi within lumen of fallopian tube Thin arrows point to chorionic villi

Ectopic pregnancy

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Placental insertion into liver

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Ectopic pregnancy associated with IUD use

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PREGNANCY-RELATED LESIONS (3)PREGNANCY-RELATED LESIONS (3)

Toxemia (pre-eclampsia, eclampsia):Toxemia (pre-eclampsia, eclampsia): Pre-eclampsia = hypertension, proteinuria and Pre-eclampsia = hypertension, proteinuria and

edema (~ 6% of pregnancies)edema (~ 6% of pregnancies) eclampsia = convulsions tooeclampsia = convulsions too

Usually last trimesterUsually last trimester Pathology: Pathology:

DICDIC fibrinoid vascular necrosis and thrombosis with fibrinoid vascular necrosis and thrombosis with

multiple small infarcts of liver, brain, kidney and multiple small infarcts of liver, brain, kidney and placentaplacenta

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PREGNANCY-RELATED LESIONS (5)PREGNANCY-RELATED LESIONS (5)

Placenta accreta:Placenta accreta:

Absence of decidua of endometrium so placenta adheres Absence of decidua of endometrium so placenta adheres

directly to myometrium: failure of placental separation directly to myometrium: failure of placental separation

during pregnancyduring pregnancy

Often when placenta implants on scar (C-section)Often when placenta implants on scar (C-section)

60% associated with placenta previa60% associated with placenta previa

Bleeding may be life-threatening Bleeding may be life-threatening hysterectomy hysterectomy

Placenta previa: placenta implants over lower uterine segment Placenta previa: placenta implants over lower uterine segment

or cervix. During labor or cervix. During labor hemorrhage. hemorrhage.

Page 21: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

PREGNANCY-RELATED LESIONS (6)PREGNANCY-RELATED LESIONS (6)

Hydatidiform mole (partial and complete)Hydatidiform mole (partial and complete)

Most present with spontaneous abortion or are Dx’ed at U/SMost present with spontaneous abortion or are Dx’ed at U/S

Complete moleComplete mole

Placental villi massively edematous (hydropic) Placental villi massively edematous (hydropic)

center of villi = hyaline; no embryo; trophoblast center of villi = hyaline; no embryo; trophoblast

proliferative.proliferative.

Mechanism: Mechanism: ovum loses nuclear DNAovum loses nuclear DNA; sperm ; sperm

“fertilizes” with 23X, doubles to 46XX“fertilizes” with 23X, doubles to 46XX

Or two sperm fertilize empty ovum, 46XX or 46XYOr two sperm fertilize empty ovum, 46XX or 46XY

all chromosomes paternal.all chromosomes paternal.

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PREGNANCY-RELATED LESIONS (7)PREGNANCY-RELATED LESIONS (7)

Complete moleComplete mole Rapid uterine enlargement to excessive size; high Rapid uterine enlargement to excessive size; high

urinary gonadotropin; expelled @urinary gonadotropin; expelled @10-18 weeks 10-18 weeks

bleedingbleeding

2% 2% choriocarcinoma choriocarcinoma (mole histology doesn’t (mole histology doesn’t

predict) Malignant tumor of trophoblastic tissue predict) Malignant tumor of trophoblastic tissue

(cytotrophoblasts and synctiotrophoblasts)(cytotrophoblasts and synctiotrophoblasts)

May be Dx at ultrasound May be Dx at ultrasound Rx: suction curettage; Rx: suction curettage; follow urinary gonadotropinsfollow urinary gonadotropins

Page 23: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

PREGNANCY-RELATED LESIONS (8)PREGNANCY-RELATED LESIONS (8)

Partial molePartial mole

About 1/2 villi = normal (with fetal RBC), rest = hydropicAbout 1/2 villi = normal (with fetal RBC), rest = hydropic

Focal trophoblast proliferationFocal trophoblast proliferation

Mechanism:Mechanism: 2 sperm fertilize ovum that retains its 2 sperm fertilize ovum that retains its

nucleus nucleus triploidy (69, XXY or 69,XXX) or rarely triploidy (69, XXY or 69,XXX) or rarely

tetraploid (92, XXXY)tetraploid (92, XXXY)

Embryo formed, dies 4-8 weeks Embryo formed, dies 4-8 weeks fetal parts fetal parts

Less Less in serum HCG than complete mole in serum HCG than complete mole

These rarely lead to choriocarcinomaThese rarely lead to choriocarcinoma

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PREGNANCY-RELATED LESIONS (9)PREGNANCY-RELATED LESIONS (9)

Invasive mole: mole that penetrates & may perforate Invasive mole: mole that penetrates & may perforate

uterine walluterine wall

Gross: trophoblastic invasion of myometrium (shallow or Gross: trophoblastic invasion of myometrium (shallow or

perforating)perforating)

Micro: trophoblast invades myometrial veins and spreads Micro: trophoblast invades myometrial veins and spreads

to lungs or brain but does not thrive there, withersto lungs or brain but does not thrive there, withers

Threat: bleeding from ruptured uterus or at distant sitesThreat: bleeding from ruptured uterus or at distant sites

Has persistently elevated HCGHas persistently elevated HCG

Rx: chemotherapy and/or hysterectomyRx: chemotherapy and/or hysterectomy

Page 25: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Hydatidiform mole fills and expands uterus: hydropic villi are evident

Page 26: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Hydatidiform mole: uterus is filled with thin-walled, translucent, polypoid masses consisting of hydropic villi

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Hydropic villi of mole

Page 28: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Markedly swollen (hydropic) villi of mole

Page 29: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Central cavitation (cisterns) of complete mole

Page 30: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

PREGNANCY-RELATED LESIONS (10)PREGNANCY-RELATED LESIONS (10)

ChoriocarcinomaChoriocarcinoma

Malignant transformation of trophoblastic tissue from any form of Malignant transformation of trophoblastic tissue from any form of

pregnancy, 1 in 20-30,000 pregnancies in USpregnancy, 1 in 20-30,000 pregnancies in US

1 in 40 hydatidiform moles1 in 40 hydatidiform moles

Lacking its own vessels, necrosis and hemorrhage commonLacking its own vessels, necrosis and hemorrhage common

Early metastasis—widely hematogenouslyEarly metastasis—widely hematogenously

First symptom usually hemorrhage, but may be metastases First symptom usually hemorrhage, but may be metastases

Markedly elevated serum HCGMarkedly elevated serum HCG

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PREGNANCY-RELATED LESIONS (11)PREGNANCY-RELATED LESIONS (11)

Choriocarcinoma (cont.) Choriocarcinoma (cont.)

Dx: Dx: dimorphic histologydimorphic histology (cytotrophoblasts & (cytotrophoblasts &

syncytiotrophoblasts) without chorionic villisyncytiotrophoblasts) without chorionic villi

Rx: chemo Rx Rx: chemo Rx 70% survival 5 yr even if metastatic 70% survival 5 yr even if metastatic

Placental site trophoblastic tumor = intermediate Placental site trophoblastic tumor = intermediate

trophoblast, lower gonadotropin level trophoblast, lower gonadotropin level

Local invasionLocal invasion

10% metastasize10% metastasize

Page 32: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Hemorrhagic tumor nodules of choriocarcinoma has distorted uterus

Page 33: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Dimorphic histology of choriocarcinoma. Cytotrophoblasts have clear cytoplasm.

Page 34: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Choriocarcinoma: syncytiotrophoblasts (arrows) flanked by cytotrophoblasts and necrotic tissue

Page 35: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Multiple hemorrhagic nodules of metastatic choriocarcinoma in lungs

Page 36: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,
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Germinal epithelium of fetal ovary

Page 38: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Numerous follicles in various stages of development

Page 39: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Maturing follicle with thecal cells (pink arrow) and granulosa cells (blue arrow)

Page 40: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Mature Graafian follicle (arrow depicts oocyte)

Page 41: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Site of rupture of ovum on surface of ovary

Page 42: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Cut surface of corpus luteum

Page 43: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Corpus luteum with luteinized granulosa cells & theca cells (arrow)

Granulosa cells

Page 44: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Atretic follicle – scarring in center where ovum was and stuff around it

Page 45: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: CYSTS, NON-NEOPLASTICOVARY: CYSTS, NON-NEOPLASTIC

Follicular:Follicular: cystic dilatation of unruptured graafian follicle cystic dilatation of unruptured graafian follicle Luteal cyst:Luteal cyst: cystic dilatation of corpus luteum cystic dilatation of corpus luteum Polycystic ovaryPolycystic ovary (Stein-Leventhal) syndrome: (Stein-Leventhal) syndrome:

Pathology: multiple follicular cysts and foci of hyperthecosis Pathology: multiple follicular cysts and foci of hyperthecosis with stromal fibrosis with stromal fibrosis

3-6% of reproductive-age women3-6% of reproductive-age women Clinical: persistent anovulation, hirsutism (50%), obesity Clinical: persistent anovulation, hirsutism (50%), obesity

(40%), infertility(40%), infertility Mechanism: Mechanism: excessive LHexcessive LH causes theca lutein causes theca lutein androgen androgen Rx: hormonal (used to be surgical – didn’t help)Rx: hormonal (used to be surgical – didn’t help)

Page 46: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Follicular cyst

Page 47: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Opened follicular cyst

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Wall of luteal cyst with luteinized granulosa cells

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Cut surfaces of polycystic ovary

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Polycystic ovary

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Type % of Malignant Ovarian Tumors % Bilateral

____________________________________________________________________

Serous 40

Benign (60%) 25

Borderline (15%) 30

Malignant (25%) 65

Mucinous 10

Benign (80%) 5

Borderline (10%) 10

Malignant (10%) 20

Endometriod carcinoma 20 40

Undifferentiated carcinoma 10

Clear cell carcinoma 6 40

Granulosa cell tumor 5 5

Teratoma

Benign (96%)

Malignant (4%) 1 rare

Metastatic 5 >50

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OVARY: NEOPLASMS: OVERVIEWOVARY: NEOPLASMS: OVERVIEW

Surface (coelomic) epitheliumSurface (coelomic) epithelium benign cysts, both benign cysts, both

serous and mucinous, serous & mucinous tumors, serous and mucinous, serous & mucinous tumors,

endometrioid, clear-cell, Brenner tumorsendometrioid, clear-cell, Brenner tumors

Germ cellGerm cell dysgerminoma, teratoma, chorioca, dysgerminoma, teratoma, chorioca,

endodermal sinus tumorendodermal sinus tumor

Sex-cord-stromaSex-cord-stroma fibroma, granulosa-theca, Sertoli-fibroma, granulosa-theca, Sertoli-

Leydig cell tumorsLeydig cell tumors

Page 54: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: CYSTIC TUMORS (1)OVARY: CYSTIC TUMORS (1)

Serous cystadenomasSerous cystadenomas (__ca): watery fluid, partly ciliated (__ca): watery fluid, partly ciliated

epithelium (salpinx-type)epithelium (salpinx-type)

Mucinous:Mucinous: slimy content; columnar mucinous (cervical) slimy content; columnar mucinous (cervical)

epitheliumepithelium

Malignancy odds related to: Malignancy odds related to:

gross: gross: solid/cystic ratio, fixation to neighboring solid/cystic ratio, fixation to neighboring

structures – structures – the more solid the more likely to be the more solid the more likely to be

malignantmalignant

micro: micro: amount and extent of lining papillation; amount and extent of lining papillation;

nuclear atypia, invasion of stromanuclear atypia, invasion of stroma

Page 55: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: CYSTIC TUMORS (2)OVARY: CYSTIC TUMORS (2)

Above changes progress: benign Above changes progress: benign borderline borderline malignant. Prognosis inverse (malignant malignant. Prognosis inverse (malignant 70% 70% 5 yr survival, 25% if fixed)5 yr survival, 25% if fixed)

General: mucinous larger, less often malignant General: mucinous larger, less often malignant pseudomyxoma peritoneipseudomyxoma peritonei (tumor produces massive (tumor produces massive mucin with peritoneal implants) mucin with peritoneal implants) may cause fatal may cause fatal obstructionobstruction

Bilaterally Bilaterally toward malignancy toward malignancy

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Benign

Borderline

Malignant

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Serous cystadenoma (3-10 cm is typical)– most common tumor of ovary, smooth cyst with no necrosis and typically no solid areas, smooth lining. Contains watery fluid and explode when cut into.

Typically asymptomatic so picked up incidentally on pelvic exam or vague minor discomfort

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Serous cystadenoma

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Opened serous cystadenoma with a smooth lining and very thin walled

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Serous epithelium of cystadenoma with some papillations (papillary serous cystadenoma)

Page 62: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Ciliated epithelium of a serous cystadenoma

Page 63: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Numerous psammona bodies in paillary serous tumor – not clinically significant, found in both benign and malignant papillary tumors

Page 64: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Benign serous tumors may become large (20cm)

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52 lb benign serous cystadenoma

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Papillary excrescences from lining of serous tumor (papillary serous cystadenoma) – always section any one that looks papillary to check

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Borderline papillary serous cystadenocarcinoma with epithelial atypia

Page 68: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Borderline tumor: no stromal invasion is present

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Multiloculated and solid papillary serous cystadenocarcinoma

Page 70: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Solid areas in papillary serous cystadenocarcinoma

Page 71: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Papillary serous cystadenocarcinoma: tumor has breached surface of ovary

Page 72: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Mostly solid papillary serous cystadenocarcinoma

Page 73: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Papillary serous cystadenocarcinoma

Page 74: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Stratified, atypical nuclei in papillary serous cystadenocarcinoma: stromal invasion is present

Page 75: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Mucin producing lining cells in benign mucinous cystadenoma

Page 76: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Borderline mucinous tumor

Page 77: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Mucin production and stromal implants in pseudomyxoma peritonei

Page 78: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Nuclear atypia & mitotic figures in mucinous cystadenocarcinoma

Page 79: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: ENDOMETRIOID CARCINOMAOVARY: ENDOMETRIOID CARCINOMA

Gross: mixed solid/cystic structureGross: mixed solid/cystic structure

Histo: endometrium-like malignant glandsHisto: endometrium-like malignant glands

25% = concurrent but independent endometrial 25% = concurrent but independent endometrial

ca in uterusca in uterus

Minority = benign cystadenofibromaMinority = benign cystadenofibroma

Variant: clear cell carcinomaVariant: clear cell carcinoma

Page 80: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Endometrioid ovarian Ca

Page 81: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Endometrioid cancer of ovary

Page 82: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Benign cystadenofibroma of ovary

Page 83: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Cystadenofibroma: benign dilated glands within fibrous stroma

Page 84: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Clear cell adenocarcinoma of ovary

Page 85: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: BRENNER TUMOROVARY: BRENNER TUMOR

Gross: Gross:

solid or cysticsolid or cystic

usually more solidusually more solid

Micro: Micro:

fibrous stroma; fibrous stroma; transitionaltransitional (urothelial) epithelium (urothelial) epithelium

microcystic to macrocytic (adenofibroma)microcystic to macrocytic (adenofibroma)

Majority = benignMajority = benign

Page 86: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Mostly solid Brenner tumor

Page 87: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Solid and cystic Brenner tumor

Page 88: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Brenner tumor with transitional epithelium with microcysts & fibrous stroma

Page 89: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Glandular spaces or microcysts in benign Brenner tumor

Page 90: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,
Page 91: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: GERM CELL TUMORS (1)OVARY: GERM CELL TUMORS (1)

TeratomaTeratoma:: Mature: Mature:

““Dermoid cystDermoid cyst”: predominantly skin, hair ”: predominantly skin, hair and teethand teeth

Most benignMost benign 10% bilateral10% bilateral Young adult. 46XXYoung adult. 46XX

Dominant subtypes: Dominant subtypes: thyroid (struma ovarii) thyroid (struma ovarii) hyperthyroidism hyperthyroidism

Carcinoid Carcinoid carcinoid syndrome carcinoid syndrome Malignancy rareMalignancy rare

Page 92: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: GERM CELL TUMORS (2)OVARY: GERM CELL TUMORS (2)

Teratoma (cont.):Teratoma (cont.):

Immature (malignant teratoma): Immature (malignant teratoma): adolescent and young adultadolescent and young adult

solidsolid

Malignant histologyMalignant histology

early capsule penetration early capsule penetration seeding abdomen seeding abdomen

more more embryonic tissueembryonic tissue

prognosis stage + grade-dependentprognosis stage + grade-dependent

Page 93: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Dermoid cyst filled with hair and keratin

Page 94: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Opened dermoid cyst with keratin and hair

Page 95: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Teeth (arrows), skin and hair in dermoid cyst

Page 96: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Cartilage, glands and keratin cyst in benign teratoma

Page 97: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Teratoma with squamous epithelium, mucin producing glands and cartilage (arrow)

Page 98: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

CNS tissue with neurons (arrow) in mature teratoma

Page 99: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Mature thyroid tissue in monodermal teratoma: struma ovarii

Page 100: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Thyroid follicles in struma ovarii

Page 101: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Mostly solid malignant teratoma

Page 102: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Malignant Transformation: Squamous cell carcinoma in malignant teratoma: arrows point to keratin pearls

Page 103: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: DYSGERMINOMAOVARY: DYSGERMINOMA

Gross: solid, fleshyGross: solid, fleshy Histo: Histo:

identical to testicular seminomaidentical to testicular seminoma solid sheets similar cellssolid sheets similar cells stromal lymphocytesstromal lymphocytes

Behavior: Behavior: no endocrine functionno endocrine function unilateralunilateral radiosensitiveradiosensitive 80% 5 yr survival80% 5 yr survival

Page 104: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Dysgerminoma – white, fleshy

Page 105: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Sheets of polyhedral cells separated by scant fibrous septa (arrow) in dysgerminoma

Page 106: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: ENDODERMAL SINUS (YOLK SAC) OVARY: ENDODERMAL SINUS (YOLK SAC) TUMORTUMOR

Gross: solid, unilateral; necrosis; children or young Gross: solid, unilateral; necrosis; children or young

adults, 2nd most common germ cell tumoradults, 2nd most common germ cell tumor

Histo: resembles glomeruloid structure of rat yolk Histo: resembles glomeruloid structure of rat yolk

sac (Schiller-Duval body)sac (Schiller-Duval body)

Behavior: Behavior:

Makes alpha fetoprotein and alpha antitrypsin Makes alpha fetoprotein and alpha antitrypsin

(hyaline droplets – can be indentified by stains)(hyaline droplets – can be indentified by stains)

Respond well to chemoRx (much better than Respond well to chemoRx (much better than

vaginal yolk sac tumors do)vaginal yolk sac tumors do)

Page 107: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Prominent hemorrhage in endodermal sinus (yolk sac) tumor – necrosis and hemorrhage are very common b/c modeling itself after yolk sac which is very blood vessel rich

Page 108: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Schiller-Duval body in endodermal sinus tumor

Page 109: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: CHORIOCARCINOMAOVARY: CHORIOCARCINOMA

Gross: usually part of other germ cell tumors. Gross: usually part of other germ cell tumors.

Bloody, solid, unilateral.Bloody, solid, unilateral.

Histo: like placental tumors (cytotrophoblasts and Histo: like placental tumors (cytotrophoblasts and

syncytial trophoblasts)syncytial trophoblasts)

Behavior: aggressive 4+. Usually metastatic when Behavior: aggressive 4+. Usually metastatic when

found. Ovarian found. Ovarian choriocarcinoma does not choriocarcinoma does not

respond to chemoRx.respond to chemoRx.

Function Function chorionic gonadotropins. In children chorionic gonadotropins. In children

precocious pubertyprecocious puberty

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OVARY: SEX-CORD-STROMAL TUMORS (1)OVARY: SEX-CORD-STROMAL TUMORS (1)

Granulosa-theca cell tumor: Granulosa-theca cell tumor: Derived from Derived from ovarian stromaovarian stroma Predominantly granulosa cells, minority Predominantly granulosa cells, minority

theca cellstheca cells Most postmenopausal, unilateral, solid to Most postmenopausal, unilateral, solid to

partly cystic partly cystic Histo: cords or sheets cells (occ. “follicle” = Histo: cords or sheets cells (occ. “follicle” =

Call-Exner body); by IHC + for inhibinCall-Exner body); by IHC + for inhibin

Page 112: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Granulosa-Theca Cell TumorsGranulosa-Theca Cell Tumors

some clumps theca cells, some some clumps theca cells, some luteinizedluteinized

Behavior: subset Behavior: subset estrogen estrogen adults adults cystic endometrial hyperplasia or cystic endometrial hyperplasia or endometrial ca or cystic breast. Few endometrial ca or cystic breast. Few androgen androgen

Few Few malignant but histology can’t malignant but histology can’t predict which onespredict which ones

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Granulosa cell tumor

Page 114: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Foci of hemorrhage in granulosa cell tumor

Page 115: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Granulosa cell tumor with Call-Exner bodies (arrow)

Page 116: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Oil red O fat stain of luteinized theca cells in granulosa cell tumor

Page 117: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Granulosa cell tumor: coffee bean nuclei with grooves & Call-Exner bodies

Page 118: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: SEX-CORD-STROMAL TUMOR (2)OVARY: SEX-CORD-STROMAL TUMOR (2)

Thecoma-fibroma:Thecoma-fibroma:

Gross: solid, fibrous (white), unilateral, more thecoma (yellow)Gross: solid, fibrous (white), unilateral, more thecoma (yellow)

Micro: fibrous; fat stains + for theca cellsMicro: fibrous; fat stains + for theca cells

Behavior: benign; some Behavior: benign; some fibromas fibromas estrogen; also estrogen; also effusion effusion

(Meig’s syndrome = hydrothorax, ascites & ovarian tumor)(Meig’s syndrome = hydrothorax, ascites & ovarian tumor)

May be part of basal cell nevus syndrome: multiple basal cell May be part of basal cell nevus syndrome: multiple basal cell

carcinomas with abnormalities of ovaries, eyes, bone and CNScarcinomas with abnormalities of ovaries, eyes, bone and CNS

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Fibroma-Thecoma

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Fibroma-Thecoma

Page 121: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Yellow-white cut surface of fibroma-thecoma

Page 122: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Fibroblasts intermixed with lipid laden thecal cells

Page 123: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Oil red O stain demonstrates thecoma elements

Page 124: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: SEX-CORD-STROMAL TUMORS (3)OVARY: SEX-CORD-STROMAL TUMORS (3)

Sertoli-Leydig cell tumors (androblastoma)Sertoli-Leydig cell tumors (androblastoma) Gross: young adult, unilateral, solidGross: young adult, unilateral, solid Micro: Micro:

Sertoli or Leydig cells in cords in fibrous stromaSertoli or Leydig cells in cords in fibrous stroma Some Some tubules (like testis) tubules (like testis) Some heterologous elementsSome heterologous elements Reinke crystalloidsReinke crystalloids

Behavior: most benign; few = aggressiveBehavior: most benign; few = aggressive Function: 1/2 Function: 1/2 androgens androgens masculinization masculinization

Hilus cell tumor (Leydig cells only):Hilus cell tumor (Leydig cells only): lipid-filled cells with Reinke lipid-filled cells with Reinke crystalloids (usually incidental finding), may cause hirsutism, crystalloids (usually incidental finding), may cause hirsutism, masculinizationmasculinization

Page 125: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Well circumscibed Sertoli-Leydig cell tumor

Page 126: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Tubules composed of Sertoli cells

Page 127: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Prominent Leydig cells in Sertoli-Leydig Cell Tumor

Page 128: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Sertoli-Leydig Cell tumor with Reinke crystalloids

Page 129: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

Solid, yellow Hilus Cell Tumor (pure Leydig Cell)

Page 130: SALPINX: SALPINGITIS l Cause: chlamydia and gonococcus = most l Route: cervix  lymphatics  adnexae l Complications: u abscess tubes, ovaries, tubo-ovarian,

OVARY: METASTATIC LESIONSOVARY: METASTATIC LESIONS

Uterus and tube Uterus and tube ovarian metastases (most common mets to ovarian metastases (most common mets to ovary)ovary)

Gastric mucinous ca Gastric mucinous ca both ovaries = Krukenberg tumor both ovaries = Krukenberg tumor (signet-ring ca) (simulates ovarian primary ca)(signet-ring ca) (simulates ovarian primary ca) Breast, pancreas and gallbladder and especially colon Breast, pancreas and gallbladder and especially colon Pseudomyxoma peritonei from appendix may present with Pseudomyxoma peritonei from appendix may present with

ovarian metsovarian mets

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Bilateral metastases to ovaries

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Metastaic adenocarcinoma to ovary with signet cells

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