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Reproductive Pathology Case Studies 2

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Each of the following three kodachromes is from a hysterectomy ... A sonogram showed no fetus, only lots of echos. A quantitative beta-HCG was extremely high. ... – PowerPoint PPT presentation

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Title: Reproductive Pathology Case Studies 2


1
Reproductive Pathology Case Studies 2
  • Web Path
  • http//bb.westernu.edu/web/Pathology/webpath60/web
    path/webpath.htm

2
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.

3
Slide 1.1Note the tubular endometrial glands
with intervening dense stroma.
4
  • 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.

5
Slide 1.2Note the large, tortuous endometrial
glands containing secretions.
6
  • 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.

7
Slide 1.3Note the scattered small tubular
endometrial glands, some of which are slightly
cystically dilated.
8
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.

9
Slide 2.1The enlarged uterus has a spongy,
cystic appearance to the myometrium.
10
Slide 2.2At low power, endometrial glands and
stroma are seen scattered in the myometrium.
11
Slide 2.3At high power, an endometrial gland
with stroma is seen in the myometrium.
12
Case 2 Questions
  1. What is the diagnosis?
  2. How is this process different from an invasive
    endometrial carcinoma?

13
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.

14
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.

15
Slide 3.1The surface of the uterus shows a few
focal small darkly discolored lesions.
16
Slide 3.2Upon closer inspection, the lesions on
surface of the uterus have the appearance of
small "powder burns".
17
Slide 3.3Microscopically, the lesions have
endometrial glands and stroma with hemorrhage.
18
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?

19
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.

20
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.

21
Slide 4.1Bilateral cystic masses are seen
involving the ovaries, and they have dark hair
extending from cut surfaces.
22
Slide 4.2At low magnification, the wall of one
of the cystic masses shows well-differentiated
tissues.
23
Slide 4.3At medium power, the wall of one of the
cystic masses shows vascular and neural tissues
that are well-differentiated.
24
Slide 4.3At medium power, the wall of one of the
cystic masses shows skin and sebaceous glands.
25
Case 4 Questions
  1. What is the diagnosis and prognosis?
  2. What sorts of things can you find in this lesion?

26
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.

27
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.

28
Slide 5.1The cut surface of the testicular mass
is shown here.
29
Slide 5.2The microscopic appearance of one area
of the testicular mass is shown here.
30
Slide 5.3The microscopic appearance of another
area of the testicular mass is shown here at
medium magnification.
31
Slide 5.4The microscopic appearance of an area
of the testicular mass is shown here at high
magnification.
32
Case 5 Questions
  1. What is the diagnosis?
  2. What is the most probable reason for the
    gynecomastia and breast tenderness?

33
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.

34
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.

35
Slide 6.1The uterus removed at surgery has been
opened to reveal a mass lesion.
36
Slide 6.2The microscopic appearance of the mass
lesion is seen at low power.
37
Slide 6.3The microscopic appearance of the mass
lesion is seen at medium power.
38
Slide 6.4The microscopic appearance of the mass
lesion is seen at high power.
39
Case 6 Questions
  1. What is the diagnosis?
  2. What determines the prognosis?
  3. What are risk factors for this disease?

40
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.

41
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.

42
Slide 7.1The gross appearance of material
obtained via D C from the uterus is seen here.
43
Slide 7.2The microscopic appearance of material
obtained via D C from the uterus is seen here.
44
Case 7 Questions
  1. What is the diagnosis?
  2. How does this lesion arise?
  3. What will you do to follow the patient?

45
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).
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