Pathology Update 2008
Gynecologic Pathology
MUCINOUS TUMORS OF THE OVARY:
Criteria and Considerations
Session 2 - Friday, Nov. 21,2008
By: Terence Colgan, MD, FRCPC
Head, Gynaecological Pathology & Cytology
Pathology & Lab Medicine, MSH
Professor, Laboratory Medicine & Pathobiology
University of Toronto
THE CHALLENGE : Identifying morphologic
entities along a spectrum
• Evidence based ? None available using strength
of recommendation (A → E)
and quality of evidence (1 → 3)
• Consensus statements : NIH and WHO
• The published literature
• The “strong man” (or woman)
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Pathogenesis of Mucinous LMP (Intestinal)
Stepwise Progression
Inclusion cyst
or
(germ cell?)
Mucinous
Cystadenoma
Mucinous
LMP
Mucinous
AdenoCa
Mucinous LMP with
Intraepithelial
carcinoma
Increasing prevalence of KRAS mutations at codons 12 & 13
Diagnostic Criteria for Mucinous
Cystadenoma
A cystic epithelial tumor lined by bland
mucinous epithelium of endocervical type
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Mucinous cystadenoma
Mucinous cystadenoma
3
Mucinous cystadenoma
Mucinous cystadenoma
4
Heterogenesity in mucinous tumor (LMP)
Mucinous cystadenoma “reactive changes”
5
Diagnostic Criteria for Mucinous
LMP’s
(Intestinal)
• Evidence of proliferative activity
(mitotic activity, pleomorphism, and
stratification),
AND
• Absence of stromal invasion
Mucinous LMP
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Natural History of Mucinous LMP’s (Intestinal)
• Stage 1 Mucinous LMP’s , 100% survival
• Stage 2,3 Mucinous LMP’s, reported
survival - 50%
- exclude pseudomyxoma peritonei
(appendiceal) cases
- exclude metastatic adenoca mimics
from upper GI and cervix
• Advanced Stage Mucinous LMP’s may not exist
Mucinous LMP, intestinal type, necrosis
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Mucinous LMP, intestinal type, necrosis
The challenge of the mucinous cystadenoma
with a “borderline component”
NIH 2004 Consensus
•
•
•
•
•
ignore it?
call it borderline?
call it “cystadenoma with borderline”?
call it “cystadenoma” with a note
use a threshold of the proportion of
“borderline” - 10% ?
* Remember 100% of Stage 1 borderline tumours
behave in a benign fashion!
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Diagnostic Criteria for Mucinous LMP Tumour
with Intraepithelial Carcinoma
•
Mucinous LMP tumour of intestinal type
Plus
•
Severe cytologic atypia
Note: Stratification + complexity alone are not
sufficient
865Mc
Intraepithelial carcinoma mucinous tumor (LMP)
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Intraepithelial carcinoma
in mucinous LMP
Diagnostic Criteria for Mucinous LMP Tumour
with Microinvasion
• mucinous tumour of LMP
Plus
• focus (or foci) of stromal invasion ≤ 5 mm in
greater linear measurement *
* alternative dimensions:
≤ 3 mm or ≤ 10 mm2
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Microinvasion in mucinous LMP, e.g. 1
Microinvasion in mucinous LMP, e.g.2
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Diagnostic Criteria for Mucinous
LMP Tumour, Mullerian type
(a.k.a.- “endocervical type”)
(a.k.a. – “seromucinous)
• presence of mucinous epithelium of
endocervical type
• absence of enteric type epithelium
• intracystic papillary architecture of
eosinophilic, stratified epithelium
• may/may not have serous type epithelium
Mucinous LMP, Mullerian type
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Mucinous LMP, Mullerian type
Mucinous LMP, Mullerian type
13
Mucinous LMP, Mullerian type
Mucinous LMP, Mullerian type
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Diagnostic Criteria for Ovarian Mucinous
Adenocarcinoma
• An epithelial tumour with intracytoplasmic
mucin that shows destructive stromal
invasion ( > 5 mm)*
OR
Confluent, glandular expansile pattern of
growth of > 5 mm in linear dimension
• Absence of another acceptable primary origin
(beware of the deceptive situation in
unilaterality and no known primary)
* Less common, but poorer prognosis
“Borderline-like focus” in
primary mucinous adenoCa
15
Primary mucinous adenoCa
(expansile criterion e.g. 1)
Primary mucinous adenoCa
(expansile criterion e.g. 1)
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Primary mucinous adenoCa
(expansile criterion, e.g.2)
Differential Diagnosis of
Mucinous Ovarian Adenocarcinoma
• Metastases from cervix, gall bladder, pancreas,
appendix, colon, stomach ( CK7 + 20 of little value )
• Endometrioid carcinomas with mucinous
differentiation (ovary + endometrium )
• Sertoli-Leytig cell tumour, heterologous type
• Mucinous (goblet cell) carcinoid tumour (primary and
secondary)
• Signet-ring adenocarcinoma (think metastatic)
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Metastatic mucinous
AdenoCa to ovary
Mucinous adenoCa to ovary –
Criteria: sites of disease, bilaterality,
Nodularity, LVI
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Mucinous Ovarian Tumours in Association
with Pseudomyxoma Peritonei
• primary is almost invariably the appendix (or GIT)
• always recommend appendectomy and
examination of pancreatobiliary
• ovarian tumours should be labelled as
‘secondary’ or ‘metastatic’
• avoid use of terms “borderline”, “LMP”, and
“cystadenoma”
• exception: ovarian tumour with pseudomyxoma
peritonei – mucinous tumour arising in a
dermoid cyst
Appendix –Mucinous Neoplasia
19
Mucinous tumor with teratoma
Mucinous tumor with teratoma
20
Mucinous tumor with teratoma
Mucinous tumor with teratoma
21
Mucinous tumor with teratoma
Mucinous tumor with teratoma
22
Assessment of Pseudomyxoma Peritonei
• Are epithelial cells present or not?
• Are any cells benign appearing (adenomucinosis),
malignant (carcinomatosis), or borderline
(indeterminate)?
• Presence/absence of mucin dissection and
fibrous reaction
Pseudomyxoma peritonei
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Pseudomyxoma peritonei
Thank you !
*** L U N C H ***
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