Cytology and Surgical Pathology of Gynecologic Neoplasms

Cytology and Surgical Pathology of Gynecologic Neoplasms

Current Clinical Pathology ANTONIO GIORDANO, MD, PHD SERIES EDITOR For further titles published in this series, go to http://www.springer.com/springer/series/7632

Cytology and Surgical Pathology of Gynecologic Neoplasms Edited by David Chhieng, MD, MBA, MSHI Yale University School of Medicine, New Haven, CT, USA Pei Hui, MD, PhD Yale University School of Medicine, New Haven, CT, USA

Editors David Chhieng Department of Pathology Yale University School of Medicine New Haven, CT USA david.chhieng@yale.edu Pei Hui Department of Pathology Yale University School of Medicine New Haven, CT USA pei.hui@yale.edu ISBN 978-1-60761-163-9 e-isbn 978-1-60761-164-6 DOI 10.1007/978-1-60761-164-6 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2010937989 Springer Science+Business Media, LLC 2011 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. If there is cover art, insert cover illustration line. Give the name of the cover designer if requested by publishing. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Preface The neoplasms found in the female genital tract are numerous and diagnostically growing more complex. Understanding gynecological pathology can be overwhelming. As an extension to comprehensive textbooks that are ubiquitous around sign-out microscope, this text has been written to provide a practical reference for practicing pathologists and cytopathologists in a quick and concise fashion. The primary focus of our book is on gynecological tumors, specifically common ones and their benign mimics, and every effort is made to integrate major diagnostic criteria with the ancillary studies. We hope we have made concrete the usually abstract dictum of gynecological pathology on both histological and cytological grounds. Understandably, as one of the highly complex pathology specialties, it is impossible to include every aspect of its ingredients in this compact reference book. Hematoxylin and eosin staining and immunohistochemistry remain the cornerstones of diagnostic gynecological pathology. This manual presents a logical approach to pathological diagnosis based primarily on conventional histology and cytology and assembles the most important diagnostic features of common neoplastic entities of the female genital tract. The most common differential diagnosis is discussed when necessary. Many entities in gynecological pathology may have multiple names and variants, but an attempt has been made to present a concise approach to the diagnostic problem often reflecting opinions of the authors. Throughout the book, the approach is simple and straightforward entity-based discussion of each diagnostic entity followed by cytopathology related to the whole group of disease under each chapter. Because of this practical approach and the concrete and accessible nature of the material, we believe that this text also forms the basis for a bridge course to introduce residents, fellows, and junior practitioners to the specialty practice of gynecological pathology. We wish to express our deepest gratitude to all of our mentors, past and current, who have been the major source of knowledge and courage in our academic careers. Our sincere appreciation goes to many colleagues and trainees in pathology at Yale University and University at Alabama, who have shared or presented many cases that provided the basis for this volume. v

Contents 1 Normal Histology of Female Genital Organs... 1.1 Normal Histology of Vulva... 1.2 Normal Histology of Vagina... 1.3 Normal Histology of Cervix... 1.4 Normal Histology of Uterus... 1.5 Normal Histology of Fallopian Tube... 1.6 Normal Histology of Ovary... 1.7 Normal Cytology of Female Genital Tract Organs... 1.7.1 Squamous Cells... 1.7.2 Parabasal Squamous Cells... 1.7.3 Endocervical Cells... 1.7.4 Squamous Metaplastic Cells... 1.7.5 Endometrial Cells... 1.7.6 Direct Sampling of the Lower Uterine Segment... 1.8 The Bethesda System... 1.8.1 Specimens Adequacy... 1.8.2 Minimum Squamous Cellularity Criteria... 1.8.3 Endocervical/Transformation Zone Component... 1.8.4 Obscuring Factors... 1.8.5 Management of Women with Unsatisfactory Pap Test... Suggested Reading... 1 1 1 1 2 4 4 5 5 6 6 7 7 8 10 11 11 12 12 12 13 2 Lesions of the Vulva and Vagina... 2.1 General Classification of Tumors or Tumor-Like Conditions of Vulva and Vagina... 2.2 Benign, Preneoplastic, and In Situ Neoplastic Squamous Lesions... 2.3 Glandular Lesions... 2.3.1 Benign Glandular Lesions... 2.3.2 Adenocarcinomas... 2.4 Other Epithelial or Epithelioid Lesions... 2.5 Melanocytic Lesions... 2.6 Mesenchymal and Lymphoid Neoplasms... 2.7 Secondary Tumors... 2.8 Cytology of Vulva... 2.8.1 Dysplasia (Vulvar Intraepithelial Neoplasia)... 2.8.2 Squamous Cell Carcinoma... 15 15 15 20 20 20 25 26 26 30 vii

viii Contents 2.8.3 Paget s Disease... 2.8.4 Mimics of Neoplastic Diseases... 2.9 Cytology of Vagina... 2.9.1 Diethylstilbestrol-Related Abnormalities... 2.9.2 Vaginal Intraepithelial Neoplasia... 2.9.3 Squamous Cell Carcinoma... 2.9.4 Embryonal Rhabdomyosarcoma... 2.9.5 Mimics of Neoplastic Diseases... 2.9.6 Role of Vaginal Cytology Screening After Total Hysterectomy... Suggested Reading... 32 32 33 33 33 3 Squamous Lesions of the Cervix... 3.1 General Classification of Tumors of Cervix... 3.2 Squamous Intraepithelial Lesions and Other HPV-Related Lesions... 3.3 Squamous Cell Carcinomas... 3.4 Cytology... 3.4.1 Atypical Squamous Cells... 3.4.2 ASC-US... 3.4.3 ASC-H... 3.4.4 Low-Grade Squamous Intraepithelial Lesion... 3.4.5 High-Grade Squamous Intraepithelial Lesions... 3.4.6 LSIL Cannot Rule Out HSIL... 3.4.7 HSIL with Glandular Involvement... 3.4.8 Squamous Cell Carcinoma... 3.4.9 Mimics of Neoplastic Diseases... 3.5 Clinical Staging and Management... Suggested Reading... 35 35 35 38 40 40 41 41 43 45 46 47 48 49 58 58 4 Glandular Lesions of the Cervix... 4.1 Cervical Polyp and Other Tumor-Like Conditions... 4.2 Glandular Dysplasia/Adenocarcinoma In Situ... 4.3 Invasive Adenocarcinomas... 4.4 Cytology of Cervical Glandular Lesions... 4.4.1 Atypical Glandular Cells, Endocervical Origin... 4.4.2 Endocervical Adenocarcinoma In Situ... 4.4.3 Endocervical Adenocarcinoma... 4.4.4 Mimics of Neoplastic Diseases... 4.4.5 Other Primary Malignant Neoplasms... Suggested Reading... 59 59 62 62 72 72 73 75 75 78 80 5 Human Papillomavirus for Cervical Pathology... 5.1 Classification, Properties, and Viral Genome... 5.2 Natural History of HPV Infection... 5.3 Distribution of HPV in Cervical Lesions... 5.4 Methods of Detection... 5.5 Indications for HPV Testing... 5.6 Applications for HPV Testing in Cytology... 5.6.1 Triage of ASC-US and/or LSIL... 81 81 81 82 82 82 83 83 33 34

Contents 5.6.2 Surveillance After Treatment of CIN... 5.6.3 Primary Screening... 5.6.4 HPV Genotyping... Suggested Reading... ix 83 84 84 85 6 Endometrial Epithelial Neoplasms... 87 6.1 General Classification of Uterine Corpus Neoplasms... 87 6.2 Benign Tumors and Tumor-Like Conditions... 87 6.3 Endometrial Hyperplasia... 89 6.4 Endometrial Carcinomas... 91 6.5 Cytology... 99 6.5.1 Atypical Glandular Cells, Endometrial Origin... 101 6.5.2 Endometrial Adenocarcinoma... 101 6.5.3 Gynecologic Cytology and the Detection of Endometrial Hyperplasia and Malignancy... 101 6.5.4 Hyperchromatic Crowded Groups... 105 Suggested Reading... 105 7 Nonepithelial Tumors of Uterine Corpus... 107 7.1 General Classification of Nonepithelial Tumors of Uterine Corpus... 107 7.2 Endometrial Stromal Tumors... 107 7.3 Mullerian Mixed Epithelial and Stromal Tumors... 111 7.4 Smooth Muscle Tumors... 117 7.5 Other Mesenchymal Tumors... 123 7.6 Cytology... 125 7.6.1 Sarcomas... 128 7.6.2 Melanoma... 128 7.6.3 Lymphoma... 128 7.6.4 Metastatic Tumors... 128 Suggested Reading... 129 8 Gestational Trophoblastic Disease... 1 8.1 General Classification of Gestational Trophoblastic Disease... 1 8.2 Hydatidiform Moles... 1 8.2.1 Complete Hydatidiform Mole... 1 8.2.2 Partial Hydatidiform Mole... 133 8.2.3 Invasive Hydatidiform Mole... 133 8.3 Gestational Choriocarcinoma... 134 8.4 Placental Site Trophoblastic Tumor... 134 8.5 Epithelioid Trophoblastic Tumor... 135 8.6 Exaggerated Placental Site Reaction... 135 8.7 Placental Site Nodule... 137 Suggested Reading... 138 9 Tumors of Fallopian Tube and Broad Ligament... 139 9.1 Benign Tumors and Tumor-Like Conditions... 139 9.2 Malignant Epithelial Tumors... 139 9.3 Cytology... 140 Suggested Reading... 143

x Contents 10 Epithelial Neoplasms of Ovary... 145 10.1 General Classification of Ovarian Neoplasms... 145 10.2 Primary Epithelial Ovarian Neoplasms... 145 10.3 Ovarian Epithelial Tumors of Uncertain Origin... 159 10.4 Secondary Carcinomas Involving Ovary... 162 10.5 Cytology... 168 10.5.1 Exfoliative Cytology in Pap Test... 168 10.5.2 Fine Needle Aspiration Biopsy... 168 10.5.3 Nonneoplastic Cysts... 168 Suggested Reading... 172 11 Nonepithelial Tumor of Ovary... 173 11.1 General Classification of Nonepithelial Ovarian Tumors... 173 11.2 Ovarian Germ Cell Tumors... 173 11.3 Ovarian Sex Cord-Stromal Tumors... 180 11.3.1 Granulosa Cell Tumors... 180 11.3.2 Thecomas and Fibrous Tumors... 181 11.3.3 Sertoli-Stromal Cell Tumors... 184 11.3.4 Steroid Cell Tumors... 185 11.4 Miscellaneous Primary Ovarian Tumors... 189 11.5 Cytology... 189 11.5.1 Mature Cystic Teratomas... 189 11.5.2 Dysgerminoma... 190 11.5.3 Other Germ Cell Tumors... 190 11.5.4 Granulosa Cell Tumors... 191 Suggested Reading... 191 12 Tumors of Peritoneum... 193 12.1 General Classification of Tumors of Peritoneum... 193 12.2 Mesotheliomas... 193 12.3 Other Mesenchymal Tumors... 197 12.4 Cytology... 197 12.4.1 Cytology of Benign and Nonneoplastic Conditions... 197 12.4.2 Psammoma Bodies... 199 12.4.3 Neoplastic Conditions... 201 12.4.4 Ancillary Studies... 205 Suggested Reading... 207 Appendix.... 209 Index... 217