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Sex Cord-Stromal and Miscellaneous Tumors of the Ovary

Introduction Histogenesis Stromal and sex cord–stromal tumors of the ovary constitute a diverse collection that is derived from the ovarian cortical stromal and hilar cells ( Fig. 27.1 ). These cells form during embryogenesis as condensations of subcoelomic mesenchyme, in the form of “sex cords,” which ultimately differentiate into the supporting stroma of the cortex and the granulosa-theca cells of the developing follicle in the adult…

Germ Cell Tumors of the Ovary

Germ cell tumors of the ovary are presumed to derive from the pathogenic transformation of ovarian germ cells at different stages of development. The tumors that develop from these transformed germ cells are among the most unique in the human body for the simple reason that they re-create, however imperfectly, aspects of human development ( Fig. 26.1 ). Germ cell neoplasms are divided into three general…

The Pathology of Pelvic-Ovarian Epithelial (Epithelial-Stromal) Tumors

Epithelial Tumors Tumor Origin, Terminology, and Classification This chapter addresses pelvic epithelial malignancies that are commonly held synonymous with “ovarian cancer.” To maintain consistency, the term ovarian will be used as a generic term but this category encompasses tumors that might arise from the fallopian tubes and peritoneal surfaces. This view is manifest in the new International Federation of Gynecology and Obstetrics (FIGO) staging. Epithelial tumors…

Assessing Pelvic Epithelial Cancer Risk and Intercepting Early Malignancy

Introduction This chapter addresses the risk factors for pelvic (ovarian and fallopian tube) epithelial cancer, detection, and the role of the pathologist in risk reduction. The 5-year survival for stages IA and IV ovarian cancer are 88% and 18%, respectively, indicating that early detection may improve survival. However, the opportunity to detect the tumors when they are limited to the ovary or fallopian tube may be…

Disorders of the Peritoneum

Introduction The practice of gynecologic pathology often entails the evaluation of abnormalities in the peritoneal cavity and determination of their relationship to the reproductive tract. This exercise requires that the pathologist distinguish which peritoneal disorders are müllerian derived versus originating from other organs. Diseases affecting the peritoneal cavity and the intra-abdominal organs include entities arising from elements native to the peritoneal cavity (secondary müllerian system, mesenchymal,…

Benign Conditions of the Ovary

Introduction To the obstetrician-gynecologist, the ovarian examination is a fundamental part of the gynecologic evaluation and, depending on the age of the patient and other risk factors, ovarian enlargement triggers a series of investigative procedures. The surgical pathologist examines the ovarian specimen for several reasons, including to confirm or exclude pathology when the clinical impression is an ovarian abnormality or to examine the ovary for completeness…

The Fallopian Tube and Broad Ligament

Introduction The fallopian tube comes to the attention of the surgical pathologist under four general scenarios: The tube has been interrupted for sterilization, and the pathologist must confirm this. The tube has been removed as a component of the hysterectomy and is examined routinely. The tube is removed for specific reasons, usually tubal pregnancy or, rarely, a tubal mass. The tube becomes an important part of…

Uterine Mesenchymal Tumors

Introduction Definition Uterine mesenchymal tumors are neoplasms derived from or differentiating toward mesodermally derived tissues. Differentiation is typically toward normal constituents of the uterine corpus—endometrial stromal and myometrial smooth muscle cells. However, differentiation toward heterologous tissues—that is, mesenchymal tissue not normally present in the uterus (e.g., striated muscle, cartilage, or bone)—also may be seen. Mixed epithelial and mesenchymal uterine tumors are composed of benign or malignant…

Adenocarcinoma, Carcinosarcoma, and Other Epithelial Tumors of the Endometrium

Introduction This chapter addresses endometrial carcinomas, including those with mesenchymal differentiation (carcinosarcomas). Primary endometrial carcinomas constitute a range of morphologies, including carcinomas closely resembling preexisting endometrial epithelium (endometrioid), clear cell carcinomas, uterine serous carcinomas (USCs; also referred to as uterine papillary serous carcinomas), carcinomas sharing one or more of these features, undifferentiated carcinomas, and tumors with mixed epithelial-mesenchymal differentiation (carcinosarcomas). They can also be divided according…

Altered Endometrial Differentiation (Metaplasia)

Introduction Endometrial metaplasia is defined as epithelial differentiation that differs from the conventional morphologic appearance of endometrioid epithelium. Altered differentiation would be a better term in that its use would avoid implying that the distinction between metaplasia and neoplasia can always be made. However, for simplicity, the term metaplasia is used in this chapter. In a sense, metaplastic changes are the so-called pathologist's disease. They are…

Preinvasive Endometrial Neoplasia

Introduction The pathways to endometrial cancer are multiple but can be condensed into two major carcinogenic sequences, each with their pathologic correlates. The most established pathway is the one leading to endometrioid carcinoma. This route has a well-defined precursor lesion (endometrioid intraepithelial neoplasia [EIN]) that can be detected and treated in advance of malignancy. A second pathway leads to serous carcinoma, and a component of the…

Evaluation of the Cyclic Endometrium and Benign Endometrial Disorders

Introduction Pathologists routinely evaluate endometrial biopsies, which account for at least 20% of gynecologic specimens requiring pathology consultation. The majority of endometrial biopsies are performed for abnormal uterine bleeding (AUB) and questions that are posed in each situation requiring biopsy and the clinical information required vary for each individual case ( Table 16.1 ). For adolescent women, AUB will most likely be transient but can at…

Neuroendocrine Carcinoma, Mixed Epithelial/Mesenchymal and Mesenchymal Tumors, and Miscellaneous Lesions of the Cervix

Neuroendocrine Carcinoma Historical and Clinical Background Primary neuroendocrine neoplasms in the cervix have been described in various terms in the literature, such as carcinoid tumor, endocrine carcinoma, small cell undifferentiated carcinoma, oat cell carcinoma, and large cell carcinoma. In 1997, a workgroup led by the College of American Pathologists and the National Cancer Institute proposed a standardized four-category classification based on histology : small cell neuroendocrine…

Columnar Cell Neoplasia of the Cervix

Overview The Precursor-Cancer Connection The concept of adenocarcinoma in situ (AIS) was first proposed in 1953 by Friedell and McKay on the basis of two cases of cervical adenocarcinoma that also appeared to contain a noninvasive precursor lesion. However, in the ensuing decades, despite remarkable progress in the understanding of the development of cervical squamous carcinoma, AIS remained obscure. It was not until the 1980s that…

Cervical Squamous Neoplasia

Introduction Definition Cervical squamous neoplasia is defined as all squamous cell alterations that occur in or near the cervical transformation zone and are causally related to human papillomavirus (HPV) infections. The terms cervical intraepithelial neoplasia (CIN), dysplasia, and squamous intraepithelial lesion (SIL) apply to this group of lesions as well. In this chapter, the terms CIN1, flat condyloma, and exophytic condyloma are used interchangeably with low-grade…

Epithelial and Mixed Epithelial-Stromal Neoplasms of the Vagina

Introduction This chapter focuses principally on epithelial neoplasms of the vagina (soft tissue tumors are discussed in detail in Chapter 9 ). The most common lesions in the epithelial group are squamous, ranging from mild dysplasia to invasive squamous carcinomas. There is ongoing surveillance of women with in utero exposure to diethylstilbestrol (DES) for glandular lesions, ranging from adenosis to clear cell carcinoma. The most important…

Benign Conditions of the Vagina

Introduction Both the anatomy and histology of the vagina vary throughout life. Traditionally, the vagina is divided into thirds—upper, middle, and lower—using pelvic, fascial, and muscular planes. The mucous membrane of the vagina is covered by a stratified, squamous, nonkeratinizing epithelium. In normal reproductive age women with cyclic menses, the superficial epithelium is glycogenated, with maximum amounts of glycogen appearing during ovulation ( Fig. 11.1 ).…

Diseases of the Anus

Introduction Embryology A portion of the distal hindgut forms an expansion called the cloaca, which is a common chamber for the developing intestinal, urinary, and reproductive tracts. The division of the cloaca into separate conduits for these three functioning systems begins in the fifth week of embryogenesis. The urorectal septum, a coronal ridge of mesenchyme, extends caudally to join the urogenital membrane, thereby creating two separate…

Soft Tissue Lesions of the Vulva and Vagina

Introduction Soft tissue lesions of the vulvovaginal region can be separated into two general categories: those that are prevalent in this anatomic location and those that occur more commonly at other sites. The former group is discussed below, “Vulvovaginal Stromal Tumors and Tumor-Like Lesions”; the latter group comprises the remainder of entities discussed in the chapter. Vulvovaginal Stromal Tumors and Tumor-Like Lesions This group of lesions…

Melanocytic Lesions of the Vulva

Introduction Pigmented lesions of the vulva are a concern to patients, their health care providers, and pathologists who interpret the histopathology. Gynecologists are particularly wary of pigmented lesions of the vulva—the prognosis for vulvar melanoma is poor because of the tendency for increased tumor thickness at the time of presentation. For this reason, gynecologists tend to be liberal about performing biopsies on clinically pigmented lesions. Familiarity…