PATHOLOGY OF THE FEMALE GENITAL SYSTEM.
THE VULVA
-composed of the labia majora, labia minora and clitoris
Bartholin´s glands- are mucus-secreting and open at the vaginal introitus
Skene´s glands are situated around the urethral opening
Lesions of Bartholin glands
 cyst and abscess
-cyst caused by retention of mucus- clinically swelling, pseudotumorous lesion
-abscess due to bacterial infection-erythematous swelling and pain
treatment: surgical drainage and antibiotics
 carcinoma of Bartholin gland- may take form of squamous cell carcinoma or
adenocarcinoma-very rare
Inflammatory vulval lesion
 Lymphogranuloma venereum- is a venereal disease caused by Chlamydia
trachomatis, mainly affects lymphoid tissue and lymphatic vessels
-first- small ulcer at a site of infectious contact- first clinical manifestation is
swelling of inquinal lymph nodes- with stellate abscess- extensive scarringchronic suppuration and chronic fistulas and strictures of the urethra, vagina,
and the rectum
 Condyloma - vulval condyloma is a venereal disease caused by human papilloma
virus (HPV), usually type 6
-there are two variants of the vulval condyloma- condyloma accuminatum
and condyloma planum
condyloma accuminatum- it is grossly characterized by one or more
elevated papillary soft masses of variable but usually small size, and
microscopically by complicated papillary arrangements of well-differentiated
squamous epithelium supported by delicate well-vascularized stromal stalks
condyloma planum- flat condyloma- is more common
-in both forms- koilocytic metaplasia of the epithelium- cytoplasmic swelling
with pale vacuolated cells with basophilic polymorphic nuclei surrounded by clear
halo (koilocyte)
“Chronic vulval dystrophies”
-is a group of different clinical disorders, common features include
-irregular patchy areas of thickened white skin- leukoplakia -clinical descriptive
term
-clinically- pain, severe pruritus
-mucosal surface may also become red and ulcerated-erythroplakiabiopsy and histological examination is mandatory- possibility of epithelial
dysplasia and carcinoma
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-diseases included in chronic vulval dystrophies are
 keratosis (squamous cell hyperplasia)- the most common histopathologic lesion
clinically called leukoplakia-macro- skin is white, and scaling, often thickened,
but may be thin and easily to be traumatized, micro-thick keratinized
squamous epithelium which is hyperplastic, and acanthotic, chronic
inflammatory infiltrate in dermis, foci of dysplasia
 vulval lichen sclerosus et atrophicus- this is a type of dermatosis that may
occur anywhere on the skin, in the vulva- the lesion is characterized by
yellowish-blue papules or macules, that may later coalesce into thin gray areas
microscopically- there is epithelial thinning and subepithelial fibrosis,
occasionally marked hyperkeratosis, and perivascular T-lymfo reaction- the
cause is unknown, probably immune mediated reaction
 clinical term kraurosis- is used for those lesions- which are associated with
atrophy and shrinkage of the mucosa
- chronic vulval dystrophies are not precancerous lesions, providing there is no
dysplasia- there is no a higher risk for carcinoma
benign tumors of the vulva
 hidradenoma papilliferum - benign tumor arising in the sweat gland- wellcircumscribed nodule- histologically it has papillary glandular pattern, with
stratification and some degree of nuclear polymorphism, but completely
benign
 melanocytic nevi- commonly seen in the vulva, most common are intradermal
benign nevi, malignant melanoma is rare
malignant tumors of the vulva
 Carcinoma in situ- Bowen´s disease- it presents as slightly elevated mass,
plaque-like lesion, microscopically- there is hyper- or parakeratosis,
acanthosis and variable number of bizzare mutinucleated cells, and mitoses
and polymorhism within the entire thickness of the epidermis, basement
membrane is intact
-if left untreated- invasive carcinoma will develop in about 10 % of cases,
treatment depends on general conditions and age of the patients- local or wide
excision is recommended
 bowenoid papulosis (bowenoid dysplasia) - is a disorder characterized by
solitary or multiple papules on the vulva of young patients
clinically -it resembles small condylomas or nevi but microscopically the lesion
shows variable degree of atypia- spontaneous regression is possible, treated by
local excision or conservative therapy- recurrences
 Paget´s disease - the vulva is the most common site for extramammary Paget
disease- it is rare lesion when compared to the breast Paget disease
grossly: elevated scaling erythematous rash in the labia or perianal region
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histologically: the epidermis contains large anaplastic tumor cells that give
positive reaction for mucin
-Paget disease of the vulva differs from breast-majority of cases of
vulval Paget disease are not associated with an invasive underlying carcinoma and
always contain mucin- this contrasts to the breast lesions
-Paget disease of the vulva -represents sweat gland carcinoma arising in
the intraepidermal portion of the gland
prognosis- is good if there is no invasive component
 invasive squamous cell carcinoma- it is the commonest malignant neoplasm of
the vulva- only 5 % of female genital tract cancers, it occurs mostly in women
older than 60 years of age
grossly: early lesion in an indurated plaque, progressing to firm nodule that
ulcerates
histologically: well-differentiated squamous cell carcinoma in most cases- degree
of differentiation does not correlate with prognosis- usually poor- spread to
inguinal and pelvic lymph node is early and rapid- about 60 % of patientsinvolved lymph nodes at the time of diagnosis
treatment: radical vulvectomy, chemotherapy and radiotherapy
 verrucous carcinoma - is a variant of well-differentiated squamous carcinoma,
characterized by polypoid growth pattern with little if any infiltrative
component, tends to remain localized
treatment: wide excision, resistent to radiation- radiation prohibited !! –it has
been reported to induce more aggressive behavior
 malignant melanoma- second most common malignant tumor of the vulvatreatment: radical vulvectomy, prognosis- depends on the stage- lymph node
involvement
 aggressive angiomyxoma - is a soft tissue neoplasm that presents as polypoid
vulvar or perianal mass, grossly: it is ill defined, without capsule, soft in
consistency and gelatinous,
microscopically- composed of myxoid hypocellular stroma with large thick-walled
blood vessels- recurrences are very common, difficult to be removed surgicalno margins
 benign angiomyofibroblastoma- rare well circumscribed mesenchymal
benign tumor, it arises of site specific myoid stroma
 benign fibroepithelial polyp
VAGINA
-the vagina in adults is rarely a site of primary disease
 congenital anomalies- rare- include septate and double vagina and congenital
small lateral cyst from persistent embryonic remnants
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vaginitis- common clinical problem, often transient and not serious- it causes
vaginal discharge
o variety of organisms can be involved, fungi, bacteria, parasites…
o two organisms are common- candida albicans and trichomonas vaginalis
 candida is present in 5% of asymptomatic women,
 trichomonas present in about 10% of asymptomatic women
-active infection represents usually sexually transmitted new strain
 vaginal adenosis - is the occurrence of endocervical type glands in the vaginal
wall
the incidence has been shown high in women whose mothers received
diethylstilbestrol during pregnancy- it is postulated that DES inhibits
transformation of the mullerian epithelium of the embryonic vagina into adult
squamous epithelium
-clinically of little significance- except for its relationship to clear cell
adenocarcinoma of the vagina
 prolaps of tubal epithelium - lesion develops following vaginal hysterectomy, in
the process of healing, fibria of the fallopian tube may become entrapped in
the vaginal apex - proliferation- may mimick carcinoma
benign tumors- are rare, they include squamous papilloma, leiomyoma- the most
common benign tumor of the vagina,
malignant tumors of the vagina- most carcinomas in the vagina represent direct
extension from the uterine cervix, primary carcinoma is much less common
grossly - ulceration or nodule
microscopically: 90% are squamous cell carcinomas of varying degree of
differentiation, rarely- sarcomatoid carcinoma, verrucous carcinoma,
 embryonal rhabdomyosarcoma (sarcoma botryoides)- is the commonest
sarcoma of the vagina- it occurs in the first 5 years of life, grossly: large,
lobulated protruding tumor mass- botryoides- means like a bunch of grapes,
frequently protrudes at the vaginal orifice
microscopically, it is an anaplastic embryonal tumor- behaves as a highly
malignant tumor- early hematogenous meta
 clear cell adenocarcinoma- is rare, accounts for less than 0.5% of cancer in
the female genital tract, occurs in young women- betwen 10 and 35 years of
age, definite association with the motherś exposure to diethylstilbestrol
during pregnancy, in 2/3 of the patients there is a history of prenatal
diethylstilbestrol exposure or related nonsteroid estrogens- steroid
estrogens are not associated with this risk
grossly: polypoid mass, histo: it is composed of clear cells arranged in a
tubuloglandular pattern- hobnail appearance of the tumor cells
 -yolk sac tumor- highly malignant tumor, typically arises in infants under the
age of two years- located in the posterior wall of the vagina

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THE UTERINE CERVIX
Normal anatomy of the uterine cervix.
the uterine cervix is the part of the uterus- it is composed of the exocervix and
endocervical canal
-the cervical mucosa is made up of two distinct types of epitheliasquamous and glandular- they interact at the squamocolumnar junction- located
at the cervix
-exocervix is covered by squamous epithelium
-endocervix is lined by glandular epithelium composed of mucus-secreting
cells and reserve basal and suprabasal cell- involved in the processes of
metaplasia, dysplasia, and carcinoma
-ectropium- age and hormone dependent transformation zone-ectropium
means the presence of columnar glandular mucus secreting epithelium at the
exocervix- commonly covered by squamous epithelium
Inflammatory cervical lesions.
 acute cervicitis- is a common condition characterized by swelling, erythema,
leukocytic infiltration, and focal ulceration of the epithelium
-is usually a sexually transmitted infection- caused by gonococci, Trichomonas
vaginalis, and herpes simplex virus
-clinically- purulent vaginal discharge
 chronic cervicitis - most commonly seen at the endocervical canal- may
associate with squamous metaplasia, stenosis and obstruction of the gland
ducts- resulting in retention cysts- nabothian cyst - develop from blockage of
the endocervical glands secondarily to inflammation- grossly they appear as
cystic spaces filled with mucoid material
histologically- cystically dilated glands
Nonneoplastic cervical proliferations.
 squamous metaplasia- very common finding in the endocervical epitheliumassociated with inflammation
 microglandular hyperplasia- is a unusual proliferation of endocervical glandshas been associated with the use of oral contraceptive agents
grossly- polypoid lesion and microscopically-characterized by an abnormal mass
of proliferating endocervical glands- may mimic adenocarcinoma
 endocervical polyp- very common lesion-grossly- polypoid mass protruding into
the endocervical canal - microscopically- composed of highly vascularized
stroma with hyperplastic glands, covered by columnar or metaplastic squamous
epithelium
-benign
Neoplasms of the cervix.
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 Viral condyloma with dysplasia- is a common lesion of the cervix caused by the
human papilloma virus, the most often detected HPV 16 and HPV 18-high-risk
types
 -intermediate risk types include HPV 31, 33, 35
-grossly- polypoid or flat lesion characterized by koilocytosis (cytoplasmic
vacuolization of the squamous epithelium), and heavy acute inflammatory
reaction
 dysplasia and CIN- cervical intraepithelial neoplasia
-the term dysplasia designates atypical cytologic features and abnormal
maturation of squamous epithelium in the cervix
-cervical dysplasias are graded as mild (CIN I), moderate (CIN II) and severe
(CIN III) - according to degree of abnormalities seen
 carcinoma in situ-CIS of the cervix- is a change in the squamous epithelium
which is characterized by cellular anaplasia, polymorphism and no
differentiation at any level- difficult to distinguish from severe dysplasiathus, CIN III includes both CIS and severe dysplasia
-there is now agreement that majority of invasive carcinomas of the cervix are
preceeded by the sequence metaplasia-dysplasia-CIS
Cause of cervical cancer and precancerous lesions:
HPV is the necessary but not one cause of cervical precancer and cancer
-oncogenic HPV infection is sexually transmitted disease- most often is
self-limiting
-occassionally, oncogenic HPV infection persists- risk of precancer and
cancer
-it is largely unknown, why oncogenic HPV infection persists and
progresses to cancer….several exogenous risk factors may contribute
exogenous co-factors: smoking, prolonged oral contraceptives..
endogenous co-factors: include early age of the first intercourse, early
marriage, multiparity, and low economic level of the family
Diagnosis and treatment of CIN-CIS:
-dysplasia is recognized by the presence of cytological abnormalities in
cervical smears, and confirmed by cervical biopsy - treatment- by conization of
the cervix, cryosurgery, hysterectomy
 microinvasive epidermoid carcinoma - is defined as an invasive carcinoma in
which the depth of stromal invasion is less than 5 mm- microinvasive ca is
rarely associated with metastases, and local surgical excision is curative
 invasive epidermoid carcinoma- is still the most common malignant tumor of
the genital tract in many countries- it is more common in older patients, but
may occur at the age about 40 years
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pathology: grossly- may present as an exophytic, polypoid necrotic mass, or as a
malignant ulceration, or as deeply infiltrative carcinoma
microscopically - three major categories exist
-large cell nonkeratinizing squamous carcinoma- the most common typebest prognosis
-keratinizing squamous carcinoma- with intermediate prognosis
-small cell carcinoma- rare, with poor prognosis
-cervical carcinoma- spreads characteristically by direct extension and
infiltration of the vagina, corpus, parametrium, and lower urinary tract, etc.
-lymph node metastases are also common- the incidence of metastases is
directly related to the stage
-hematogenous metastases- rarer- lungs and bone are the most common sites
-prognosis- is primarily determined by the clinical stage- other prognostic
indicators include - the size of the tumor, depths of invasion, nodal status,
vascular invasion, histological grading- is a lesser prognostic factorcontroversial issue
 verrucous carcinoma- is a highly differentiated variant of squamous
epidermoid carcinoma with polypoid pattern of growth- extremely well
differentiated pattern
-locally invasive, but no metastatic potential- very good prognosis
 endocervical adenocarcinoma- accounts for 10-15 % of cervical cancers, arises
in the endocervical glands
microscopically-the most common pattern is well differentiated adenocarcinoma
with mucus production, often papillary, it may show squamous differentiationadenoacanthoma, adenosquamous carcinoma-overall worse prognosis
prognosis of cervical adenocarcinoma- depends on clinical stage, microscopic
grade, and nodal status
-remarkably well differentiated adenocarcinoma- is called adenoma malignumminimal deviation carcinoma -cytologically very well differentiated- diagnosis is
based on distorsion of the glands
 botryoid rhabdomyosarcoma- rare malignant mesenchymal tumor, presents in
children and young adults as a myxoid polypoid lesion, histologically identical
as in the vagina
 neuroendocrine carcinoma - small number of cervical carcinomas show focal or
diffuse neuroendocrine differentiation- histologically- argyrophilic granules in
the cytoplasm, ultrastructurally- dense core secretory granules,
immunohistochemically- presence of chromogranin, synaptophysin, serotonin,
etc. -prognosis-depends on histologic grade and clinical stage
UTERINE CORPUS
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-the uterus is divided into the body and the cervix
-the body is lined by endometrium- the thickness varies at different ages and
stages of the menstrual cycle
-endometrium is composed of endometrial glands and mesenchymal
stroma- both are very sensitive to female sex hormones
-the normal endometrial cycle- normal endometrium shows cyclic changes
caused by corresponding changes in secretion of ovarian hormone productionhistologic evaluation of the endometrium- in biopsy or curettage specimenevaluation of endometrial cycle
-cycle is divided into preovulatory proliferative phase - results of
estrogenic stimulation- and a postovulatory secretory phase- that is directed by
progesterone secretion (by corpus luteum)- changes in histology
Manifestations of uterine disease.
-abnormal uterine bleeding- represents the commonest clinical
manifestation of uterine disease
menorrhagia-increased amount of regular bleeding or irregular bleedingdysfunctional bleeding
-infertility and spontaneous abortion- congenital anomalies, neoplasms,
endometrial disease- may interfere with implantation
-pain associated with mentruation-dysmenorrhea
Inflammatory lesions.
-acute endometritis- is usually seen in association with abortion, the
postpartum state,
-chronic endometritis -characterized by infiltrates of lymphocytes and
plasma cells- may follow the abortion, complicate IUD (intra-uterine device)
-pyometra- refers to an accumulation of pus within the endometrial
cavity- results from combination of infection and obstruction
Non-inflammatory lesions.
 adenomyosis - refers to the presence of endometrial glandsand stroma within
the myometrium- endometriosis interna- adenomyosis is common in older
women (over 40 years of age)- grossly -the uterus may be enlarged,
adenomyosis- may occur intwo forms- as diffuse- or focal, forming nodular
masses- called adenomyoma
 Endometriosis- refers to the presence of endometrial tissue outside the
uterus, may occur in the cervix, vagina, vulva, ovary, large bowel, bladder, etc.
grossly- endometriosis appears as bluish cystic nodules surrounded by fibrosismicroscopically- consists of endometrial glands and stroma, often in fibrotic
interstitium, with deposits of hemosiderin, fresh hemorrhages -changes caused
by cyclic changes of hormones
 endometrial hyperplasia- caused by unopposed estrogen effect, endometrial
hyperplasia can be graded into – mild- simple (glandular cystic) hyperplasia-
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there are increased numbers of cystically dilated glands of varying sizesSwiss cheese appearance, the epithelium is usually stratified and shows
increased mitotic activity, stromal cells are also increased in number
- moderate- complex without atypia (adenomatous)
hyperplasia - shows a more marked increase in the number of glands with
extreme proliferation of epithelial cells which are stratified and a papillary,
mitotic figures are numerous, the stroma is hyperplastic
-severe- complex with atypia (atypical) hyperplasia - is
characterized by cytologic atypia- associated with an increased risk of
development of adenocarcinoma
Neoplasms and pseudotumors of the endometrium.
 endometrial polyps- are common, vary in size and are composed of endometrial
glands, which may show cyclic changes, and of fibrovascular stroma
some polyps show hyperplastic changes- risk of endometrial carcinoma
clinically- endometrial polyps- cause abnormal bleeding
 adenomyomatous polyps- polypoid adenomyoma-are endometrial polyps having
smooth muscle fibers in addition to endometrial glands, stroma and blood
vessels
 atypical polypoid adenomyoma - recently described important variant of
adenomyomatous polyp- these tend to occur in peri and premenopausal womenabout 40 years of age- present with abnormal bleeding-microscopically- glands
within the endometrial stroma and muscles show varying degree of atypiamay mimic invasive endometrial adenocarcinoma
 ENDOMETRIAL CARCINOMA- is the most common malignancy of the female
genital tract, accounting for about 10 % of all cancers of women, and the
incidence is increasing in many countries, it occurs mostly in older women80% are postmenopausal
-risk factors include- obesity, diabetes mellitus, hypertension, infertile patients,
those with abnormal bleeding, failure of ovulation, long-standing unopposed
estrogen effect, and those with atypical endometrial hyperplasia
pathologygrossly- most endometrial carcinomas present as polypoid mass in the
endometrial cavity- the uterus is enlarged- invasion into the myometrium occurs
early
microscopically- there are two major categories of endometrial carcinomacorrelate with histological types as follows:
 -type I - estrogen-related -associated with endometrial hyperplasia
-caused by long-lasting unopposed estrogen effect
-usually low histological grade- low proliferative activity
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-positive estrogen and progesterone receptor status
-minimal myometrial invasion at the time of diagnosis
-better prognosis
-histological types include:
-endometrioid carcinoma- the most common type
is categorized to III grades-most endometrioid ca are grade I- the better
differentiated carcinoma recapitulates microscopic features of hyperplastic
non-neoplastic endometrium, commonly positive estrogen/progesterone receptor
status
behavior: extension to the cervix occurs in about 10%, lymph node metastases
are rare- most often in the pelvic and periaortic lymph nodes
treatment and prognosis: standard treatment is hysterectomy and bilateral
adnexectomy, postoperative radiotherapy only to those patients with poor
prognostic factors, postoperative hormone therapy- has been advocated to
those patients with positive hormone-receptor status
-mucinous carcinoma -uncommon type of endometrial carcinoma,
similar to mucinous adenocarcinoma of the uterine cervix, tend to be low grade
and minimally ivnasive, the patients usually present in early stage, excellent
prognosis
-villoglandular carcinoma- is a very well differentiated variant of
endometrioid carcinoma with papillary growth pattern, behaves as low-grade ca excellent prognosis, important to distinguish from papillary serous ca
 type II-non-estrogen related- not associated with endometrial hyperplasia
and estrogen effect, negative estrogen and progesterone receptor status,
poor prognosis, deep myometrial invasion, high grade, high proliferative
activity,
-histological patterns include:
-serous papillary carcinoma- accounts for about 10 % of
endometrial carcinomas, postmenopausal patients- older than the patients
with endometrioid ca, high propensity for myometrial and lymphatic
invasion, common finding of widespread disease at the time of diagnosis
with neoplastic involvement of the ovaries and fallopian tubes, serous
carcinoma often metastasizes- liver, skin, brain
prognosis is poor, tumor is highly aggressive
-clear cell carcinoma -in the past it was called „mesonephroid„ because of its resemblance to renal cell carcinoma, in older women, lack of
association with estrogen therapy
histologically- composed of solid, papillary and tubular cystic structures- large
atypical cell with clear cytoplasm- presence of glycogen- marked nuclear atypia,
high level of mitotic activity,
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clinical behavior- tends to be high grade, deeply invasive, presents at advanced
stage, poor prognosis
-anaplastic and undifferentiated carcinoma - tumors fail to show
evidence of either squamous or glandular differentiation,
 endometrial stromal tumors- composed of endometrial stromal cells, occur in
middle-aged women,
-are categorized to low-grade and high grade stromal sarcoma- based on mitotic
rate and cellular polymorphism
-low-grade stromal sarcoma- infiltrates the myometrium, has a
tendedncy to grow via lymphatic vessels, slow clinical progression, relatively
favorable prognosis
-high-grade stromal sarcoma- high propensity for blood and
lymphatic vessels, rapid growth, poor prognosis, invasive growth and tendency to
recur,
 malignant mixed mullerian tumor (MMMT)- rare, high grade malignant
uterine tumor, occurs in postmenopausal women, clinically present with
bleeding and enlargment of the uterus
grossly- soft, polypoid tumor rapidly growing, sometimes protruding from the
cervix
histologically- is composed of malignant epithelial component (carcinomatous)
and malignant mesenchymal component (sarcomatous)- mesenchymal elements
are often poorly differentiate, most commonly leiomyosarcomatous and
chondrosarcomatous differentiation, extensive necrosis and hemorhages
prognosis-poor, highly malignant tumor
-NEOPLASMS OF THE MYOMETRIUM- very common
 leiomyoma- is a benign tumor of uterine smooth muscle, most common
between 20 and 45 years of age, tend to regress after menopause,
-they produce clinical symptoms because of their size and location
-submucosal leiomyomas- often result in uterine abnormal bleeding, they may
become ulcerated, may interfere with pregnancy
 leiomyosarcoma- is a very rare neoplasm, more common in older women
accounting for 3 % of uterine malignant tumors, it arises from smooth muscle
of the myometrium, histologically- marked atypias, cytologic pleomorphism,
high mitotic rate,
prognosis- poor, 5-year survival rate about 40%
THE FALLOPIAN TUBE.
Inflammatory lesions.
 acute salpingitis- is most commonly the result of gonococcal infection,
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- is characterized by hyperemia and edema of the tube, external surface is
covered by purulent exudate, lumen contain pus
suppuration often occurs- producing abscess formation
clinically- fever and abdominal pain,
 chronic salpingitis- follows recurrent attacks of acute inflammation- complete
luminal obstruction may occur resulting in dilatation of the part of the tube-if filled with serous fluid- hydrosalpinx , if filled with pus- pyosalpinx
 salpingitis isthmica nodosa- is usually bilateral tubal lesion that presents
grossly as a well-circumscribed nodular enlargement of the isthmic portionpathogenesis is unknown- classically regarded as a result of chronic
inflammation
histologically- dilated gland-like structures surrounded by hypertrophic muscle
OVARY.
Nonneoplastic cysts.
-follicular cyst- extremely common finding- develop from the atretic or
developing graafian follicles
-they contain serous fluid, lined by flattened layers of granulosa cells, no clinical
significance
-inclusion cysts- common in older women, small, multiple and have no
clinical significance, close to surface epithelium, psammoma bodies are seen in
the stroma or in their lumen
-polycystic ovaries- characterized by bilateral enlargemnet of the ovaries,
multiple follicular cysts and abnormal corpora lutea- resulting from failure of
ovulation, by hyperplastic ovarian stroma and thickening of the capsule
clinically- anemorhea, infertility, virilism (Stein-Leventhal syndrome), excess
androgen secretion, normal or higher levels of estrogen-resulting in endometrial
hyperplasia and abnormal bleeding
cause- abnormal secretion of pituitary gonadotrophins
-endometrioid cyst- ovarian endometriosis- the ovary is the commonest
site for extrauterine endometriosis- multiple hemorhagic cysts- characterized
microscopically by a lining of endometrial epithelium and stroma
pain is most common symptom- ectopic endometrium is a subject to most of the
influences that affect intrauterine endometrium
NEOPLASMS OF THE OVARY.
- are relatively common, 80% are benign
classification- is primarily morphologic but related to histogenesis- it is based
on the premise that the ovary consists of four types of tissues- that give rise
to a variety of neoplasms
-surface epithelium
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-germ cells
-sex cord
-specialized ovarian stroma
I.surface epithelial ovarian tumors- are classified according to the following
parameters-cell type-which include serous, mucinous, endometrioid, etc
-growth pattern- cystic or surface
- degree of fibrous stroma
-expected clinical behavior- benign, borderline or malignant
 1.serous tumors- account for about one fourth of all ovarian tumors, most
occur in adults- benign tend to occur in younger, malignant in older than 50,
are the most common ovarian neoplasms
serous tumors are characterized in their better differentiated forms by cell
type similar to that of phallopian tube
-benign serous tumors-include a spectrum of overlapping entities, such as
serous papillary cystadenoma, serous cystadenoma, serous adenofibroma and
serous cystadenofibroma
grossly- unilocular or multilocular cyst is the most common presentation- in
better differentiated tumors- contain clear fluid, papillary structures are often
present, often bilateral
more malignant tumors- tend to be solid and invasive- with areas of necrosis and
hemorhages
histologically- cuboidal or columnar epithelium similar to normal tubal epitheliumlines the cysts, morphologic spectrum exists-benign serous cystadenoma- cysts and papillae are lined by a single layer
of cells without atypia, without invasion
-serous papillary tumor of borderline malignancy- marked proliferation,
some cellular polymorphism, and more complex papillae but stromal ivasion is
absent
-malignant serous cystadenocarcinoma (serous papillary carcinoma of
ovary)- characterized by nuclear atypia, high mitotic activity, stratification of
the neoplastic epithelium, branching papillae and glandular complexity, and
stroma invasion, high-grade serous cystadenocarcinomas- highly aggressive,
infiltrating and metastasizing early in the clinical course, spread locally to the
peritoneum, lymph node metastasis occur early, distant meta- lung, liver being
the major sites
 2. mucinous tumors - account for 20% of ovarian neoplasms, they occur most
often in the age from 15 to 50, most are benign, mucinous cystadenocarcinoma
accounts for 5% of ovarian cancers, are less frequently bilateral than serous
-benign mucinous cystadenoma/cystadenofibroma- tends to be larger than
serous, cysts are filled with thick mucus the cysts are lined by uniform tall
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mucin-secreting cells that resemble endocervical epithelium. Surgical removal is
curative
-borderline mucinous tumor- presence of complex papillary projections,
mild to moderate cytological atypia, absence of stromal invasion
-grow slowly, and may spread to the peritoneum- Prognosis is not good when
there is peritoneal disease
-mucinous cystadenocarcinoma- presence of solid areas and evidence of
invasion, histologically- cytologic atypia, marked proliferation, mitoses, invasive
growth
-tumor infiltrates locally and metastasize to the peritoneal cavity, lymph nodes
and distant organs, prognosis is poor.
 3. endometrioid carcinoma -accounts for about 15-20% of malignant ovarian
tumors
-they are defined by microscopic resemblance to endometrial carcinoma
-origin in endometriosis can be demonstrated in some cases
-up to 45 % of patients has endometriosis in the same ovary or elsewhere in the
pelvis
grossly- solid and cystic masses, frequently with hemorhages and necrosis,
histologically- similar to endometrioid ca of the uterine body, in half of casessquamous metaplasia
-some patients have simultaneous endometrioid carcinoma of the ovary and
endometrium
-endometrioid borderline tumor-low malignant potential, rare tumor,
characterized by atypical epithelial proliferation, and lack of stromal invasion
 4. clear cell adenocarcinoma- originally called „mesonephric„ because of
presumed origin from mesonephric rests, clear cell carcinoma accounts for 5%
of malignant tumors of the ovary
histologically- characterized by large cell with water-clear cytoplasm- solid,
glandular and papillary patterns
-high association with endometriosis
-prognosis depends on the stage, overall survival and prognosis-poor
 5. Brenner tumor- constitutes about 1% of all ovarian tumors, the tumor
grows slowly, grossly- the tumor is firm, white or yellow
histologically- consists of cellular fibroblastic stroma and epithelial islands
composed of uniform benign looking cells that resemble transitional epithelium
prognosis:spectrum of biological behavior, in most cases is benign, sometimes
clinical behavior similar to borderline tumors
 II. germ cell neoplasms.
-constitute about 20% of all ovarian tumors, most of them are seen in children
and young adults, about 95 % of them are benign cystic teratoma- common
neoplasm, grossly appears as a cyst containing thick sebaceous material and hair
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(dermoid cyst), the wall of the cyst is composed of mature cartilage, smooth
muscle, adipose and fibrous tissues, glands, glial elements, respiratory and GIT
components, etc.
 immature teratoma- very rare, malignant variant of teratoma, mainly in young
adults
-grossly- solid, with minimal cystic change, histologically- composed of immature
elements derived from all three germ layers
 dysgerminoma- less than 1% of all ovarian tumors, most patients are young, it
is the ovarian counterpart of seminoma of the testis, grossly- solid,
histologically- nests of germ cells separated by fibrous septa infiltrated by
lymphocytes, malignant, but is usually cured by simple resection, good
prognosis
 yolk sac tumor- rare, highly malignant rapidly growing- poor prognosis
composed of a lacelike arrangement resembling immature glomeruli (SchillerDuval bodies), identical histologically with yolk sac tumor of the testis
 embryonal carcinoma-young women, rare histology as in testicular EC
 III. sex-cord- stromal tumors.
-composed of variable mixture of granulosa cells, theca cell and stromal
fibroblasts,
 granulosa cell tumor- derived from follicular epithelium of the primordial
follicle, may occur at any age, most frequently in postmenopausal women
grossly- solid, yellow fleshy masses, histologically- composed of mixture of
granulosa and theca cells - secret estrogens- result in hyperplasia of the
endometrium
biologic behavior- cannot be predicted - about 25 % is locally aggressive, distant
meta occur in about 15% of cases
 fibroma- benign neoplasm that arises from the ovarian mesenchymal stroma
 Sertoli-Leydig cell tumor- rare, they occur at all ages, most commonly in the
10-30 age group, grossly- solid, cystic, hemorhagic, histologically- composed
of large cell with abundant eosinophilic cytoplasm, tumors produce androgenscause virilization, rarely-produce estrogens, most are benign
 IV.germ cell-sex cord stromal tumors
These tumors are composed of a mixture of germ cells and sex-cord stromal
elements, they have mainly benign behavior, except of the cases with malignant
germ cell component
 gonadoblastoma- very rare, composed of a mixture of stromal cells (SertoliLeydig) and germ cells (dysgerminoma), biologic behavior depends on the
amount of germ cell component- the more there is, the more malignant the
tumor is
metastatic neoplasm-
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-the ovary is a common site for metastasis- particularly of ca of breast,
stomach, large intestine, endometrium,etc
-occur approximately in 30% of women dying of cancer- lymphatic and
hematogenous meta
prognosis is poor- ovarian metastases represent a late disseminated stage of
disease
-Krukenberg tumor- consists of bilateral involvement of the ovaries
by desmoplastic signet -ring carcinoma of gastric or intestinal origin
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