Reproductive Pathology Case Studies 2

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Reproductive Pathology Case Studies 2

• Web Path
• http//bb.westernu.edu/web/Pathology/webpath60/web
  path/webpath.htm

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CASE 1

• Note
• Each of the following three kodachromes is from a
  hysterectomy specimen. Below are three factitious
  case histories. Match the slide with the history.
  Obviously, in an actual clinical setting, only an
  endometrial biopsy would be performed.
• History A
• A 28 year-old woman, who was having periods of 4
  to 7 days duration every 28 to 37 days, was being
  evaluated for infertility. Daily morning
  temperature measurements revealed no rise in
  basal body temperature. An endometrial biopsy was
  performed on the 27 day following the onset of
  her last menstrual period.

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Slide 1.1Note the tubular endometrial glands
with intervening dense stroma.
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• History B
• A 32 year-old woman desired sterilization. She
  had complained of irregular periods during the
  last 6 months. During laparoscopic tubal
  ligation, a bulging, 2 cm diameter mass was noted
  on the left ovary. A depression lined by yellow
  tissue was present on the surface of this mass. A
  DC was performed.

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Slide 1.2Note the large, tortuous endometrial
glands containing secretions.
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• History C
• A 52 year-old woman, who had had no periods for
  three years, began to experience intermittent
  vaginal bleeding. On pelvic exam, a small
  endocervical polyp protruded from the external
  os. A DC was performed.

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Slide 1.3Note the scattered small tubular
endometrial glands, some of which are slightly
cystically dilated.
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CASE 2

• History
• A 35 year-old woman complained of irregular
  periods and dysmenorrhea. The uterine corpus was
  thought to be diffusely enlarged on pelvic exam.
  A hysterectomy was performed. The uterus weighed
  300 grams (normal up to 225 grams). and the cut
  surface of the myometrium showed coarse
  trabeculations. The slide is a section of the
  myometrium. Notice the multiple foci of
  endometrial-type glands within the smooth muscle.
  These glands are associated with endometrial-type
  stroma.

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Slide 2.1The enlarged uterus has a spongy,
cystic appearance to the myometrium.
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Slide 2.2At low power, endometrial glands and
stroma are seen scattered in the myometrium.
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Slide 2.3At high power, an endometrial gland
with stroma is seen in the myometrium.
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Case 2 Questions

1. What is the diagnosis?
2. How is this process different from an invasive
   endometrial carcinoma?

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CASE 2 Adenomyosis

1. What is the diagnosis? This is an excellent
   example of what is termed adenomyosis. The
   abnormally-placed endometrial tissue induces
   myometrial smooth muscle hypertrophy, and, hence,
   gross uterine enlargement. The condition is
   associated with irregular periods and
   dysmenorrhea.
2. How is this process different from an invasive
   endometrial carcinoma? In invasive endometrial
   adenocarcinoma, only the neoplastic endometrial
   glands would be present in the myometrium.

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CASE 3

• History
• A 34 year-old woman complained of severe
  dsymenorrhea and irregular bowel movements. She
  had two children during her early twenties, but
  had been unable to conceive since then. At
  laparotomy, multiple "powder-burn" lesions were
  noted on the pelvic peritoneum, uterine serosa,
  left fallopian tube, and left ovary. A 2 cm
  diameter mass was palpable in the wall of the
  sigmoid colon.

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Slide 3.1The surface of the uterus shows a few
focal small darkly discolored lesions.
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Slide 3.2Upon closer inspection, the lesions on
surface of the uterus have the appearance of
small "powder burns".
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Slide 3.3Microscopically, the lesions have
endometrial glands and stroma with hemorrhage.
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Case 3 Questions

1. What is the pathologic process?
2. What three histologic elements can be found in
   this condition?
3. What is the pathogenesis of this condition?

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CASE 3 Endometriosis

1. What is the pathologic process? The slides show
   an area of colonic endometriosis.
2. What three histologic elements can be found in
   this condition? The three elements of
   endometriosis are endometrial-type glands,
   endometrial type stroma, and hemosiderin (or
   hemorrhage). At least two of the three elements
   should be present to make the diagnosis.
3. What is the pathogenesis of this condition? The
   condition is thought to arise from either
   regurgitation of endometrial tissue into the
   peritoneal cavity via the fallopian tube during
   menses, metaplasia of the peritoneal mesothelium,
   or hematogenous dissemination of endometrial
   tissue. Endometriosis tissue may bleed at the
   time of menses, in contrast to adenomyosis
   tissue, which usually does not cycle. There is a
   strong association with infertility.

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CASE 4

• History
• A right adnexal mass was discovered in a 23
  year-old woman, who was being evaluated for
  infertility. On abdominal x-ray, calcification
  was noted in the region of the right ovary. A CT
  scan revealed bilateral ovarian masses that were
  both cystic and solid. At laparotomy, the right
  ovary was found to be enlarged, measuring 7 cm in
  greatest dimension. Its external surface was
  smooth.

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Slide 4.1Bilateral cystic masses are seen
involving the ovaries, and they have dark hair
extending from cut surfaces.
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Slide 4.2At low magnification, the wall of one
of the cystic masses shows well-differentiated
tissues.
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Slide 4.3At medium power, the wall of one of the
cystic masses shows vascular and neural tissues
that are well-differentiated.
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Slide 4.3At medium power, the wall of one of the
cystic masses shows skin and sebaceous glands.
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Case 4 Questions

1. What is the diagnosis and prognosis?
2. What sorts of things can you find in this lesion?

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CASE 4 Mature cystic teratoma of ovary

1. What is the diagnosis and prognosis? This is a
   mature cystic teratoma (dermoid cyst). You can
   probably find the following tissues epidermis,
   sebaceous glands, hair follicles, apocrine
   glands, fat, ovarian stroma, and ganglion cells.
   There is no evidence of embryonic-type tissue
   (malignant immature teratoma), nor is there
   evidence of malignant transformation of the
   mature tissues, so the prognosis is excellent.
2. What sorts of things can you find in this lesion?
   Tissues representing any of the three germ layers
   can be seen. In general, ectodermal components
   (skin with hair) predominate. Sometimes you can
   even see a tooth. An unusual component in rare
   cases is a significant amount of thyroid, which
   can function and lead to the condition known as
   struma ovarii.

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CASE 5 (TEST)

• History
• A 28 year-old white male noted mild, bilateral
  breast enlargement associated with slight breast
  tenderness. After two months, he began to
  experience a dull ache and a sensation of
  heaviness in the right testicle. The right testis
  was noted to be enlarged. An orchidectomy was
  performed.

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Slide 5.1The cut surface of the testicular mass
is shown here.
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Slide 5.2The microscopic appearance of one area
of the testicular mass is shown here.
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Slide 5.3The microscopic appearance of another
area of the testicular mass is shown here at
medium magnification.
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Slide 5.4The microscopic appearance of an area
of the testicular mass is shown here at high
magnification.
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Case 5 Questions

1. What is the diagnosis?
2. What is the most probable reason for the
   gynecomastia and breast tenderness?

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CASE 5 Testicular neoplasm with seminoma and
embryonal cell carcinoma

• What is the diagnosis? This is a malignant
  testicular germ cell neoplasm, which has both
  seminomatous and embryonal cell carcinoma
  components. The seminomatous component is present
  adjacent to the tunica albuginea and is composed
  of a relatively uniform population of
  undifferentiating, primordial-type germ cells
  with clear to frothy-appearing cytoplasm and
  nuclei containing prominent eosinophilic
  nucleoli. Bands of fibrous tissue and clusters of
  lymphocytes are interspersed among the tumor
  cells.
• The predominant tumor component is embryonal
  cell carcinoma, composed of sheets and cords of
  anaplastic-appearing cells with vesicular nuclei
  that contain prominent eosinophilic nucleoli.
  Mitotic figures are easily found. As is
  characteristic of embryonal cell carcinoma, much
  of the tumor is necrotic and hemorrhagic.
• What is the most probable reason for the
  gynecomastia and breast tenderness? In addition
  to producing alpha fetoprotein, nonseminomatous
  germ cell tumors may, at times, produce human
  placental lactogen, chorionic gonadotropin, or
  estrogen. Gynecomastia may be associated with the
  secretion of these hormones.

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CASE 6

• History
• A 73 year-old female, who had experienced her
  last menstrual period approximately nineteen
  years previously, developed intermittent vaginal
  bleeding. On pelvic examination, the cervix
  appeared normal however, the uterine corpus was
  diffusely enlarged.

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Slide 6.1The uterus removed at surgery has been
opened to reveal a mass lesion.
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Slide 6.2The microscopic appearance of the mass
lesion is seen at low power.
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Slide 6.3The microscopic appearance of the mass
lesion is seen at medium power.
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Slide 6.4The microscopic appearance of the mass
lesion is seen at high power.
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Case 6 Questions

1. What is the diagnosis?
2. What determines the prognosis?
3. What are risk factors for this disease?

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CASE 6 Endometrial adenocarcinoma

1. What is the diagnosis? There is a
   moderately-well-differentiated endometrial
   adenocarcinoma that is invading into the inner
   third of the myometrium. The tumor shows a
   polypoid growth pattern into the endometrial
   cavity. Compare the histologic features of the
   adenocarcinoma with those of the proliferative
   endometrium (Slide 1.1).
2. The neoplastic endometrial epithelial cells are
   forming glandular structures, and in some areas
   there is a cribiform pattern, i.e. bridges of
   neoplastic cells growing across gland lumens.
   Cellular bridging ("cribiforming") is a feature
   commonly seen in adenocarcinioma. The
   neoplastic-cell nuclei are atypical in that they
   exhibit chromatin clearing, nuclear membrane
   irregularity, and, often, prominent nucleoli.Many
   of the malignant epithelial cells have lost their
   normal polarity with respect to the glandular
   basement membrane. Necrotic cell debris is
   present in the lumens of many glands. The
   endometrial stroma surrounding the neoplastic
   glands has the fibrotic (desmoplastic) appearance
   commonly seem when malignant epithelium invades
   stroma. Endometrial stromal invasion is to be
   distinguished from myometrial invasion. Focally,
   the neoplastic glands show areas of squamous
   differentiation this does not affect the
   prognosis.
3. What determines the prognosis? As with malignant
   neoplasms in general, the prognosis is determined
   by the stage and the grade. The stage is the
   extent of spread. In general, endometrial
   adenocarcinomas that are confined to the
   myometrial wall (Stage I) have a much better
   prognosis (90 5 year survival). The grade is
   based upon the degree of histologic
   differentiation, in this case on a scale of 1 to
   3.
4. What are risk factors for this disease? Female
   sex, you say? Good, now several more are
   obesity, infertility, hypertension. Unopposed
   estrogen effect leading to adenomatous
   hyperplasia and possible subsequent carcinoma can
   occur either with exogenous estrogen
   administration or from estrogen- producing
   ovarian neoplasms.

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CASE 7

• History
• This 20 year old Taiwanese woman was in the
  second trimester of pregnancy. She was having
  severe hyperemesis. Her physician found that on
  physical exam, she seemed to be large for dates,
  and no fetal heart tones were audible. A sonogram
  showed no fetus, only lots of echos. A
  quantitative beta-HCG was extremely high. A DC
  was done.

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Slide 7.1The gross appearance of material
obtained via D C from the uterus is seen here.
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Slide 7.2The microscopic appearance of material
obtained via D C from the uterus is seen here.
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Case 7 Questions

1. What is the diagnosis?
2. How does this lesion arise?
3. What will you do to follow the patient?

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CASE 7 Hydatidiform mole

1. What is the diagnosis? Hydatidiform mole.
2. How does this lesion arise? Molar pregnancies
   arise when a fertilized egg loses the maternal
   component of chromosomes and the chromosomes are
   derived from a single sperm or from fertilization
   by two sperms.
3. What will you do to follow the patient? Use
   beta-HCG levels. The levels should continue to
   decrease, as happens in a little over 80 of
   cases. Continued increased levels suggest the
   possibility of invasive mole (16) or
   choriocarcinoma (2.5).