Pathology of Female Genital Tract 2 with Answers 17 05 24 - Tagged.pdf

Female Genital Tract 2: Ovaries with Answers Catherine Chinyama [email protected] 17 May 2024 1 Learning Objectives To revise the changes which occur in the ovary during the menstrual cycle To learn the normal and pathological features of the ovary from images of surgical specimens with clinical...

Female Genital Tract 2: Ovaries with Answers Catherine Chinyama [email protected] 17 May 2024 1 Learning Objectives To revise the changes which occur in the ovary during the menstrual cycle To learn the normal and pathological features of the ovary from images of surgical specimens with clinical correlations To learn the pathology of the most common ovarian tumours As usual this will be an interactive session 2 Functional Microscopic Anatomy A developing ovarian or Graafian follicle The ovum (arrow) is surrounded by pink wall (zona pellucida) and follicular cells What are the changes occurring in the endometrium at this stage? The endometrium will be in the proliferative phase Graafian Follicle Stroma Developing ovum Follicular Cysts Corpus Luteum Corpus Albicantis Anatomy of the Ovary The ovary in slide 4 was removed for treatment of breast cancer and illustrates the different structures: After ovulation, the follicle develops into a corpus luteum ( yellow body) and then into a fibrous corpus albicantis (white body) Name hormones produced by: a) Corpus luteum (Progesterone) b) Corpus albicantis (None) Find out why ovaries are removed in patients with breast cancer. To remove the source of oestrogen which 5 promotes the growth of breast cancer The corpus luteum is yellow because the cells are rich in lipids. On microscopi c examinatio n the cells are pale because the yellow Corpus Luteum Cells What specimens are submitted to the lab from the ovary? Simple ovarian cyst Incidental for treatment of endometrial cancer 7 Hysterectomy for ovarian cancer Ovarian Tumours Arise from the surface epithelial cells or stroma Surface epithelial tumours are usually cystic What is a cyst ? A cyst is closed hollow lesion lined by epithelium Stromal tumours are rare but can be hormonally active: e.g. if they produce oestrogens, the patient may present with post-menopausal bleeding, e.g. granulosa cell tumour Tumours also arise from the fallopian tube fimbria and may be associated with BRCA1 gene mutation 8 Classification of Ovarian Tumours 1. Tissue of origin: epithelial or stromal 2. Macroscopic appearance: cystic or solid 3. Contents of the cyst: serous, mucinous, dermoid 4. Histological appearance: a) Benign b) Borderline c) Malignant Serous cystic tumours secrete watery fluid Mucinous cystic tumours secrete mucin Cysts can be multilocular (multiple cavities) or unilocular 9 Dermoid Cyst/Mature Cystic Teratoma What does teratoma mean? Gk – teratos; meaning monster; the tumours may have eyes and limbs How do teratomas arise embryologically? Derived from the three germ cell layers: - Endoderm - Mesoderm - Ectoderm 10 CASE 1 A 26-year-old woman 16 weeks pregnant Complex ovarian cyst noted at antenatal ultrasound scan She did not have an MRI or CT scan. Why? Because she was pregnant 11 CASE 1 Had left salpingo-oophrectomy Intact cyst = 150 x 110 x 60mm Weight of cyst = 475g Multilocular with ‘dirty’ fluid, greasy material admixed with hair 12 CASE 1: Intact Dermoid Cyst 13 Multilocular = multiple cavities Dermoid cyst Fat Hair admixed sebum CASE 1: Histology of the Dermoid Cyst cyst showed Mature cystic teratoma / dermoid constituents of all three germ cell layers:  endoderm  mesoderm  ectoderm Please match the tissue to a germ cell layer  Skin - ectoderm  Fat - mesoderm  Large bowel mucosa - endoderm  Respiratory mucosa - endoderm  Smooth muscle - mesoderm  Cartilage - mesoderm  Bone - mesoderm 15 CASE 1: Histology of the Dermoid Cyst 16 CASE 1: Histology of the Dermoid Cyst 17 Case 1: Histology of the Dermoid Cyst 18 CASE 1: Histology of the Dermoid Cyst Bone Fat nerve Cartilage 19 CASE 1: Histology of the Dermoid Cyst 20 What do dermoid cysts look like in patients of different racial groups? They contain the same hair colour as the patient because they are genetically the same CHINESE PATIENT AFRICAN PATIENT TORTED DERMOID CYST IN CAUCASIAN PATIENT WITH BLONDE HAIR CAUCASIAN PATIENT WITH DARK HAIR Torsion in Ovarian Cysts 1. What is torsion of an ovarian cyst? The cyst twists on its pedicle and cut off its blood supply 2. What is the complication of torsion? Rupture/perforation with resultant peritonitis CASE 2 A 21-year-old woman presented with abdominal distension with minimal discomfort 1. What single question would you ask her if you were her GP? When was your last menstrual period? 2. What other simple test would you perform in your office after examining her? Pregnancy test 25 CASE 2: MRI of the Ovarian Cyst An ultrasound scan revealed a cyst. The Radiologist recommended MRI The MRI showed a unilocular cyst, 24 x 10.3 x 19.4 cm SEE QUESTIONS NEXT SLIDE 26 CASE 2: MRI of the Ovarian Cyst 1. Do you think the cyst is benign or malignant? Give your reasons Benign, because she would be very ill if this was malignant at that size; cyst also unilocular with no complex structures 2. What is the organ below the cyst ( yellow arrow) The cyst is ‘sitting’ on the bladder 3. What other symptoms did she experience? Increased frequency of urination 27 CASE 2: CT Scan of the Ovarian Cyst What other possible symptoms could she have experienced? 28 Case 2: Other Possible Symptoms Because of the pressure effect of the cyst the patient may have experienced the following symptoms:  Constipation/bloating  Shortness of breath because the diaphragm cannot move down effectively  Gastro-oesophageal reflux/heartburn 29 CASE 2 The gynaecologist drained dark watery fluid from the cyst prior to surgery. Why? 1. To reduce the risk of bursting the cyst during surgery 2. Draining of the fluid also reduced the size of the cyst and therefore required a smaller surgical incision CASE 2: The empty cyst submitted to the lab was thick - walled, unilocular, 17cm in diam; the wall was 2mm thick CASE 2: The histology showed thick fibrous wall The cyst was lined by a single layer of serous epithelium DIAGNOSIS Benign serous cystadenofibroma Another example of a benign ovarian cyst in 19-year old pt 33 Note the mucin in the cavity; histology showed a mucinous cystadenoma 34 Case 3 68-year-old woman presented with abdominal distension Bilateral ovarian cysts were noted on US Had a raised CA125 of 349 U/ml (0-35) What is CA125? Tumour marker for ovarian cancer but can be raised in other conditions CT confirmed bilateral ovarian cysts one complex and the other unilocular 35 CASE 3 The patient had hysterectomy and bilateral salpingo-oophrectomy Left ovary = 90 x 70 x 35mm and was intact; why is this important? Leakage of cystic contents into the abdomen will seed the peritoneal cavity with cancer cells which can lead abdominal recurrence Right ovary = 140 x 80 x 50mm and intact 36 CASE 3: Hysterectomy specimen from the postmenopausal woman with bilateral ovarian cysts 37 CASE 3: Ovarian cysts on cut surface Lt - multilocular; Rt - unilocular + mucoid contents 38 CASE 3: HISTOLOGY      Both cysts were borderline mucinous tumours Borderline because of: Complex architecture with papillary structures Cytological atypia →variation in nuclear size and shape Nuclear stratification (piling up of nuclei) Mitotic activity But no invasion of the wall Borderline tumours have all the cellular features of cancer without invasion of the cyst wall Although no invasion, borderline tumours can present later with metastases 39 CASE 3: Borderline tumour with complex architecture of the cells lining the cyst (blue arrow) but no invasion of the wall (black arrow). 40 CASE 3: The cells from the tumour show mucin secretion (arrow) 41 CASE 4 A 79-year-old woman presented with abdominal discomfort; CA125 = 60 CT Scan showed a complex cyst with solid area suspicious of malignant She did not have an MRI. Why? see next slide Because she has right hip replacement 42 CASE 4: CT Scan of a complex ovarian cyst (arrow) CASE 4 Whilst waiting for surgery she presented with an acute abdomen due to torsion of the ovarian cyst/tumour ( twisted on its pedicle) At surgery the ovarian tumour/cyst was involved in fibrous adhesions with the bowel The ovarian cyst/tumour was haemorrhagic 44 CASE 4: Macroscopic Appearance Ovarian tumour = 160 x 100 x 85mm Weight =702g Multi-locular (multiple cavities) and haemorrhagic, cut surface with solid areas 45 CASE 4: haemorrhagic multilocular cyst with solid areas (arrow) locule 46 CASE 4: Microscopic Appearance On microscopic examination most of the tumour showed haemorrhagic necrosis Only a few viable cells of poorly differentiated serous adenocarcinoma were present The cells were pleomorphic (variation in nuclear size and shape) There were no glands normally present in adenocarcinoma Mitotic figures were also present 47 CASE 4: Microscopic appearance of the poorly differentiated serous adenocarcinoma 48 CASE 5: Post menopausal woman↑↑ Wt Ovarian tumours present with distended abdomen and increase in weight; post- menopausal women attempt to lose weight and will appear thin on presentation 49 CASE 5: Massive ovarian cyst on CT Scan 50 CASE 5: 12 litres of fluid were drained before surgery CASE 5: Collapsed cyst after draining of fluid CASE 5: Benign, borderline or malignant tumour? This was a borderline tumour; multilocular cyst with solid area ; too large to be malignant without 53 Have a break - Have a chocolate ovarian cyst! Uterine Tube 54 Chocolate Cysts Chocolate cysts arise from endometriosis in the ovary i.e. presence of endometrial stroma and glands outside the endometrial cavity When the woman menstruates the endometriosis also menstruates The blood collects in the cyst and is altered to look like chocolate! 55 [email protected] THE END! 56