OB-GYN Pathology for the Clinician

Transcription

1 OB-GYN Pathology for the Clinician

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3 Debra S. Heller OB-GYN Pathology for the Clinician A Practical Review with Clinical Correlations

4 Debra S. Heller Department of Pathology Rutgers-New Jersey Medical School Newark, NJ, USA ISBN DOI / ISBN (ebook) Library of Congress Control Number: Springer Cham Heidelberg New York Dordrecht London Springer International Publishing Switzerland 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer International Publishing AG Switzerland is part of Springer Science+Business Media (

5 Foreword The evolution of training programs in obstetrics and gynecology has led to gains and losses. In former years, the residency in obstetrics and gynecology was usually preceded by a year of internship, either in medicine or in surgery or in a rotating multidisciplinary program. That separate internship has virtually disappeared, and the residency programs now include attention to subjects which were unknown or nascent in former years and are now competing for the time spent in obstetrics and gynecology. In years past, many residency programs in obstetrics and gynecology included a fixed assignment to study gynecologic pathology and the professional organization examinations, the board examinations, included questions on gross pathology and histology. Other subjects have crowded out the pathology study. With the advent and addition of more sophisticated diagnosis and treatment in maternal and fetal medicine as well as reproductive endocrinology, gynecologic neoplastic disease, gynecologic urology, and other subspecialties, formal training in gynecologic pathology has virtually disappeared from obstetrics and gynecology. Without a grounding in gynecologic pathology for the clinician, pathologists may be dictating clinical care as the clinicians react to pathology reports with algorithms of care, unsupported by a more complete knowledge of the relation between the pathology, the disease, the patient, and treatment. There are occasional sophisticated gynecologic pathology diagnoses, where the subject is unknown to the clinician, e.g., the size of a lesion above which endometrial carcinoma can be diagnosed or the rare germ cell tumors. The progress and dependability of sonographic analysis has frequently eliminated endometrial aspiration biopsies, further divorcing the gynecologic clinician from the pathology from which a decision will be made for treatment. To the best of my knowledge, there is no residency program which now gives formal training in cervical cytology and the clinician is completely dependent on the cytologists/pathologists, although management of the clinical situation where there is abnormal cytology is universally taught. A recurrent theme is the change in names of common and/or unusual diseases, e.g., basal cell hyperplasia, dysplasia, condyloma, carcinoma in situ, class 2 cytology, ASCUS, LGSI, LSIL, carcinosarcoma, and MMMT. The change in focus in the training programs has led to diminished attention to pathology in the American Board examinations. The time available for study of gynecologic pathology has been diminished because of the overall pressures on the training programs to comply with work-hour rules, and participate in newer training programs in endoscopy, simulation laboratories, etc. The impact of v

6 vi Foreword these changes weakens what was once one of the greatest strengths of obstetrics and gynecology, the understanding of and familiarity with the nature of the disease processes. For all these reasons, it is appropriate (for the clinicians, investigators, and teachers) to focus attention again on gynecologic pathology and the powerful and important relation between the obstetrician gynecologist and the gynecologic pathologist. This book valiantly helps to rebuild the valuable and important bridge between the clinical arena and the pathological laboratory. New York, NY, USA Robert C. Wallach, M.D., F.A.C.O.G., F.A.C.S.

7 Preface Providers of obstetrical and gynecological care need to understand the pathology of the female genital tract in order to provide optimal patient care. A rotation through the Pathology Department was a prior requirement of an Ob/Gyn residency, but has fallen to the wayside with current time constraints in training. The decreased exposure to pathology may make interpretation of pathology reports more difficult for the clinician at times, as a basic understanding may not have been developed. The pathologist gynecologist interaction requires good communication, with both understanding the other s point of view. This is a very personal text. I was originally a practicing obstetrician gynecologist, who retrained as an anatomic pathologist with subspecialty training in obstetrical and gynecological pathology. During my Ob/Gyn residency, my chairman told us that if we didn t review the pathology with the pathologist after we operated, that we were merely functioning as technicians. When I first switched to pathology, I, like many of my clinical colleagues, viewed the pathology process as similar to an ATM. You enter some information, and the money comes spitting out. I was surprised to learn that this is not the case. Pathology diagnosis is a physician-tophysician consultation. In addition, the pathologic diagnosis is not always black and white, much to my shock at the time. There are nuances, shades of gray, artifacts and insufficient or poorly oriented tissue, and lesions that don t look like the textbook. This is something a clinician who communicates with his/her pathologist understands, and through conversations, both sides continue their education and the best answer is arrived at. This monograph is thus aimed to meet two needs. One is to establish a fundamental knowledge source of Ob/Gyn pathology for the clinician. The other is to enhance communication between the two specialties, in order to accomplish the goal of us all, to provide the best patient care. Newark, NJ, USA Debra S. Heller, M.D. vii

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9 Contents 1 Getting the Best Answer: Specimen Handling and a Quick Review of the Workings of the Pathology Laboratory The Anatomic Pathology Laboratory The Requisition Sheet Accessioning Gross Examination Processing Embedding Cutting Sections Staining Labeling Recuts and Levels Floaters and Contaminants Rush Specimens Special Studies and Fixation Frozen Sections: Uses and Limitations Special Studies Slide Review Conclusion References Normal Histology of the Female Genital Tract Embryology Histology of the Vulva Labia Majora Histology of the Vagina Histology of the Cervix Exocervix Endocervix Transformation Zone Histology of the Uterus Endometrium Proliferative Endometrium ix

10 x Contents Secretory Endometrium and Endometrial Dating Myometrium Histology of the Fallopian Tubes Histology of the Ovaries Anatomy and Histology of the Placenta References Diseases of the Vulva and Anal Neoplasia Diseases of the Vulva Congenital Anomalies of the Vulva Ambiguous Genitalia Imperforate Hymen Pediatric and Adolescent Lesions of the Vulva Infantile Perianal Pyramidal Protrusion Vulvar Ulcers in Adolescents Vestibular Adenosis Lichen Sclerosus Cysts of the Vulva Epidermal Inclusion Cyst Endometriosis/Endometrioma Mucinous Cyst/Ciliated Cyst of Vestibule Bartholin s Duct Cyst Cyst of Canal of Nuck Skene s Duct Cyst Lymphangioma Circumscriptum Infections and Inflammations of the Vulva Ulcers Condyloma Acuminatum Molluscum Contagiosum Hidradenitis Suppurativa Noninfectious Inflammatory Diseases of the Vulva Lichen Planus Lichen Sclerosus Squamous Cell Hyperplasia Benign Pigmented Lesions of the Vulva Lentigo Nevus Pigmented Seborrheic Keratosis Angiokeratoma Acanthosis Nigricans Post-inflammatory Hyperpigmentation Benign Neoplasms of the Vulva Acrochordon (Fibroepithelial Polyp, Skin Tag) Syringoma Granular Cell Tumor... 56

11 Contents xi Fibroma Leiomyoma Hemangioma Hidradenoma Papilliferum Aggressive Angiomyxoma Other Soft Tissue Benign Lesions Preinvasive Neoplasia of the Vulva Usual Vulvar Intraepithelial Neoplasia Differentiated VIN Paget s Disease of the Vulva Malignant Neoplasms of the Vulva Squamous Cell Carcinoma Superficial Invasion Verrucous Carcinoma Melanoma Basal Cell Carcinoma Leiomyosarcoma HPV-Related Neoplasia of the Anus Anal Pap Smears Anal Carcinoma Anal Paget s Disease Anal Melanoma References Diseases of the Vagina and Urethra Diseases of the Vagina Congenital Anomalies of the Vagina Vaginal Agenesis Vaginal Duplication Longitudinal Vaginal Septum Transverse Vaginal Septum Imperforate Hymen Adenosis Cysts of the Vagina Müllerian Cyst Gartner (Mesonephric, Wolffian) Cyst Mucinous Cyst Epidermal Inclusion Cyst Endometriosis Vaginitis Emphysematosa Infections and Inflammations of the Vagina Vaginitis Condyloma Acuminatum Herpes Simplex... 78

12 xii Contents 4.5 Benign Lesions of the Vagina Postsurgical Lesions Ulcers Fistulas Benign Neoplasms of the Vagina Fibroepithelial Polyp Leiomyoma Preinvasive Neoplasia of the Vagina Vaginal Intraepithelial Neoplasia Malignant Neoplasms of the Vagina Squamous Cell Carcinoma Metastatic Carcinoma Clear Cell Adenocarcinoma Sarcoma Botryoides Melanoma Endodermal Sinus Tumor (Yolk Sac Tumor) Lesions of the Urethra Urethral Prolapse Urethral Diverticulum Urethral Caruncle Urethral Carcinoma References Diseases of the Cervix Lesims of the Cervix Congenital Anomalies of the Cervix The Transformation Zone Infections and Inflammations of the Cervix Benign Lesions of the Cervix Nabothian Cysts Endocervical Polyps Microglandular Hyperplasia Endometriosis Leiomyoma Mesonephric Remnants Preinvasive Neoplasia of the Cervix Cervical Squamous Intraepithelial Neoplasia Adenocarcinoma-In-Situ Malignant Neoplasms of the Cervix Squamous Cell Carcinoma Superficial Invasion (SISSCA) Unusual Squamous Cell Carcinoma Variants (Papillary Squamotransitional Carcinoma, Verrucous Carcinoma) Adenocarcinoma Adenoma Malignum

13 Contents xiii Other Variants of Adenocarcinoma Metastatic Carcinoma References Diseases of the Endometrium Lesions of the Endometrium Infections and Inflammations of the Endometrium Acute Endometritis Chronic Endometritis Exogenous Hormones Oral Contraceptives and Progestins Hormone Replacement Therapy Ovulation Induction GnRH agonists Tamoxifen Benign Lesions of the Endometrium Organic (Structural) Lesions Dysfunctional Uterine Bleeding Endometrial Hyperplasia Treated Hyperplasia Endometrial Metaplasias Malignant Lesions of Endometrium Endometrial Adenocarcinoma Malignant Mixed Mesodermal (Müllerian) Tumor (MMMT) (Carcinosarcoma) Adenosarcoma References Diseases of the Myometrium Lesims of the Myometrium Congenital Anomalies of the Uterus Benign Lesions of the Myometrium Adenomyosis Leiomyoma Symplastic Leiomyoma Extrauterine Leiomyomas Stromal Nodule Malignant Neoplasms of the Myometrium Leiomyosarcoma Endometrial Stromal Sarcoma References Diseases of the Fallopian Tube Diseases of the Fallopian Tubes Congenital Anomalies of the Fallopian Tubes

14 xiv Contents 8.3 Infectious and Inflammatory Lesions of Fallopian Tubes Acute Salpingitis Chronic Salpingitis TB Salpingitis Salpingitis Isthmica Nodosa Benign Lesions of the Fallopian Tubes Fallopian Tube Prolapse Tubal Ectopic Pregnancy Paratubal Cyst Endometriosis Adenomatoid Tumor Adrenal Rest Malignant Neoplasms of the Fallopian Tube Serous Tubal Intraepithelial Carcinoma Primary Fallopian Tube Carcinoma References Diseases of the Ovary Diseases of the Ovaries Non-neoplastic Masses Follicle Cyst Corpus Luteum Cyst Polycystic Ovary Cortical Stromal Hyperplasia and Stromal Hyperthecosis Theca Lutein Cysts Endometrioma Ovarian Pregnancy Epithelial Neoplasms Serous Cystadenoma Serous Tumor of Low Malignant Potential ( Borderline ) Papillary Serous Cystadenocarcinoma Mucinous Neoplasms Mucinous Cystadenoma Mucinous Tumor of Low Malignant Potential ( Borderline ) Mucinous Cystadenocarcinoma Pseudomyxoma Peritonei Endometrioid Adenocarcinoma Clear Cell Adenocarcinoma Brenner Tumor Undifferentiated Carcinomas Small Cell Carcinoma, Hypercalcemic Type Malignant Mixed Mesodermal (Müllerian) Tumor (Carcinosarcoma)

15 Contents xv 9.4 Germ Cell Tumors Benign Cystic Teratoma Malignant Germ Cell Tumors Immature Teratoma Dysgerminoma Yolk Sac Tumor Other Germ Cell Tumors Sex Cord-Stromal Tumors Granulosa Cell Tumor Fibrothecoma Sertoli Leydig Cell Tumor Steroid Cell Tumor Metastatic Tumors Krukenberg Tumor Miscellaneous Tumors Sex Cord Tumor with Annular Tubules Gonadoblastoma Gynandroblastoma References Diseases of the Broad Ligaments and Peritoneum Lesions of the Broad Ligament Female Tumor of Probably Wolffian Origin (FATWO) Rare Broad Ligament Neoplasms and Broad Ligament Neoplasms More Often Occurring in Other Pelvic Locations Lesions of the Peritoneum Benign Lesions of the Peritoneum Endometriosis Endosalpingiosis Paraovarian/Paratubal Cyst Ectopic Decidua (Decidualization, Deciduosis) Ectopic Pregnancy Mesothelial Hyperplasia Benign Multicystic Mesothelioma Diffuse Peritoneal Leiomyomatosis (Leiomyomatosis Peritonealis Disseminata) Malignant Neoplasms of the Peritoneum Primary Peritoneal Serous Carcinoma Malignant Mesothelioma Pseudomyxoma Peritoneii References

16 xvi Contents 11 Pathology of the Female Genital Tract Related to Pregnancy Lesims of the Female Genital Tract Related to Pregnancy Vulvo-Vaginal Lesions Associated with Pregnancy Cellular Pseudosarcomatous Fibroepithelial Stromal Polyp of the Vulva and Vagina Uterine Lesions Associated with Pregnancy Arias-Stella Reaction Spontaneous Abortion (Implantation Site) Pregnancy-Related Changes in Leiomyomata Uterine Lesions Seen in Postpartum Hysterectomies Placenta Acreta/Increta/Percreta Couvelaire Uterus Subinvolution Retained Placenta Puerperal Endomyometritis Pseudoneoplastic Ovarian Lesions Associated with Ovulation Induction or Pregnancy Luteoma of Pregnancy Hyperreactio Luteinalis Large Solitary Luteinized Follicle Cyst of Pregnancy and Puerperium References Pathology of the Placenta Abnormalities and the Approach to Examination of the Placenta Gross Placental Abnormalities Abnormalities of Placental Shape Abnormalities of the Membranes Abnormalities of the Cord Abnormalities of the Parenchyma Lesions Associated with Ischemia Abruption Decidual Vasculopathy/Atherosis Chorangiosis Villous Malperfusion Infarction Myonecrosis Increased Syncytial Knots Increased Nucleated Red Blood Cells in Fetal Vessels Infectious Lesions Acute Chorioamnionitis and the Fetal Inflammatory Response Villitis

17 Contents xvii 12.5 Lesions of Possible Immune Origin Miscellaneous Parenchymal Lesions Twins References Gestational Trophoblastic Neoplasia Gestational Trophoblastic Neoplasia Hydatidiform Mole Complete Hydatidiform Mole Partial Hydatidiform Mole Distinguishing Complete Mole, Partial Mole, and Hydropic Abortion Invasive Mole Gestational Choriocarcinoma Tumors of Intermediate Trophoblast Exaggerated Placental Site Placental Site Trophoblastic Tumor Placental Site Nodule and Plaque Epithelioid Trophoblastic Tumor References Gynecologic Cytology The Pap Smear The Bethesda System Preparation of Cytology Slides Normal Pap Smear Findings Normal Squamous Epithelium Normal Endocervical Cells Endometrial Cells Atrophy Infectious and Other Non-neoplastic Findings Candida Bacterial Vaginosis Trichomonas Herpes Actinomyces Other Findings Atypical Squamous Cells of Uncertain Significance Atypical Squamous Cells of Uncertain Significance, Cannot Exclude High-Grade Squamous Intraepithelial Lesion Atypical Glandular Cells Intraepithelial Neoplasia Low-Grade Squamous Intraepithelial Lesion High-Grade Squamous Intraepithelial Lesion Adenocarcinoma-In-Situ Invasive Carcinoma Squamous Cell Carcinoma

18 xviii Contents Adenocarcinoma Peritoneal Washings Fine Needle Aspiration References Index