Diseases of female genital systeDiseases of female genital system and the breast m and the breast

Xuemei jiang

Department of PathologyBasic Medical School

Anatomy of female genital system

Ovary (gross)Ovary (gross)

1 上皮

2 不同发育阶段的卵泡 follicle

3 ，间质

Histological Classification and tumor Histological Classification and tumor orignorign

Most tumors arise from the ovarian Most tumors arise from the ovarian stromastroma a and germinal epitheliumnd germinal epithelium. .

The embryonic coelomThe embryonic coelom(( 胚体腔 )from which that epithfrom which that epith

elium develops also gives rise to the Mullerianelium develops also gives rise to the Mullerian(( 苗勒 ( 氏 ) duct from which develop the structures of the genital trduct from which develop the structures of the genital tract, and it is this common origin which explains the gract, and it is this common origin which explains the great variety of epithelial patterns which are met with.eat variety of epithelial patterns which are met with.

epithelial tumors

Sex cord-stromal tumors,SST

Germ cell tumors

Tumors of the ovary

General IntroductionGeneral Introduction

Ovarian tumors are commoOvarian tumors are commonest between nest between 30 and 60 years 30 and 60 years old. old. They are particularly liable They are particularly liable to be or to become malignant.to be or to become malignant. In their early stages, they arIn their early stages, they are e asymptomatic and painless.asymptomatic and painless. They may grow to They may grow to a large sa large size.ize. 1.4%1.4% lifetime risk of ovaria lifetime risk of ovarian cancern cancer

Risk FactorsRisk FactorsFamily historyFamily history– Ovarian cancerOvarian cancer– Breast cancerBreast cancer– Colon cancerColon cancer

Genetic factorsGenetic factorsOlder ageOlder ageCaucasianCaucasianMore More menstrual circlesmenstrual circles during lifetime during lifetime ((OvulationOvulation induction induction))

IncidenceIncidence

Nearly 25% of all ovarian neoplasm are Nearly 25% of all ovarian neoplasm are malignant.malignant.

Approximately 80Approximately 80 ％ ％ of them are primarof them are primary growths of the ovary.y growths of the ovary.

The remainder being secondaryThe remainder being secondary ，， usuausually carcinomata.lly carcinomata.

The most widely accepted theory for tThe most widely accepted theory for the derivation of he derivation of müllerian epithelial tumorsmüllerian epithelial tumors is through is through the transformation of coelomic the transformation of coelomic mesotheliummesothelium. . This view is based on the embryologic patThis view is based on the embryologic pathway by which hway by which the müllerian the müllerian ductsducts are for are formed and evolve into med and evolve into serous (tubal),serous (tubal), endom endometrioid (endometrium),etrioid (endometrium), and and mucinous (cervmucinous (cervix)ix) epithelia epithelia present in the normal female g present in the normal female genital tract (see the section on anatomy). enital tract (see the section on anatomy).

epithelial tumors

Ovary (low power)Ovary (low power) Cortical inclusion cysts of the ovary. These cysts appear to arise from the overlying mesothelium and are presumed to be the site of origin for many ovarian epithelial neoplasms. Another source of ovarian epithelium neoplasia is endometriosis

Primary Epithelial TumorPrimary Epithelial Tumor

Mucinous cystadenoma or cystadencarcinomaMucinous cystadenoma or cystadencarcinoma

(of. Cervical epithelium).(of. Cervical epithelium).

Serous cystadenoma or cystadenocarcinomaSerous cystadenoma or cystadenocarcinoma

(of . Tubal(of . Tubal(( 输卵管的 )epithelium).epithelium).

Endometrioma or Endometrioid carcinomaEndometrioma or Endometrioid carcinoma

(of. Endometrium).(of. Endometrium).

Clear cell carcinoma.Clear cell carcinoma.

Brenner tumour.Brenner tumour.

Regardless of their specific origin(s), Regardless of their specific origin(s), ovovarian epithelial tumorsarian epithelial tumors composed of composed of serouserous, mucinous, and endometrioid cell typess, mucinous, and endometrioid cell types a are emblematic of the plasticity of müllerian re emblematic of the plasticity of müllerian epithelium and range from epithelium and range from clearly benign, tclearly benign, to tumors of borderline malignancy, to malio tumors of borderline malignancy, to malignant tumorsgnant tumors

serous cystadenoma

Serous

mucinous

mucinous cystadenoma

borderline serous cystadenoma

serous cystadenocarcinoma

Borderline mucinous cystadenoma

mucous cystoadenocarcinoma

一、 epithelial tumour

epithelial tumour (types)

content

content

11 、、 Serous Serous epithelial tumour（ 30% of all ovarian tumors ）

1)serous cystadenoma

2) 2) borderline serous cystadenoma

3) 3) serous cystadenocarcinoma (25%)

(75%)

They are the most common They are the most common benigbenign epithelial tumorsn epithelial tumors and form and form 20%20% of all of all ovarian neoplasm. ovarian neoplasm.

In 10% of cases they are In 10% of cases they are bilaterbilateralal. .

It is uncommon to find them large It is uncommon to find them large than than a fetal head.a fetal head.

1)OVARIAN SEROUS CYSTADENOMA

Gross:Benign tumors typically present with a smooth glistening cyst wall with no epithelial thickening

A A unilocular or multilocularunilocular or multilocular cyst cyst lined by epithelium similar to the lined by epithelium similar to the fallopian tubefallopian tube.. These common cystic neoplasms are filled with clear serous fluid

ovarian serous cystadenoma

Unilocular Unilocular cystcystmultilocularmultilocular cyst cyst

Papillary serous cystadenoma

a cyst cavity lined by more thick papillary tumor growths

Benign tumors typically present with with small papillary projecti

ons ，

Histological appearance of serous cystadenoma

LM:

the lining epithelium of cystic neoplasms is composed of short columnar epithelium with abundant cilia in benign tumors

serous Papillary cystadenoma

stromal papilla

LM ： Papillary serous cystadenoma revealing stromal papillae with a columnar epithelium.

2)Borderline serous cystadenoma

Bilateral

Borderline tumors contain an increased number of papillary projections

low potential malignancy

a cyst cavity lined by more delicate papillary tumor growths

borderline Serous cystadenoma

LMLM ：： Tumors of borderline malignancy cTumors of borderline malignancy contain ontain increased complexity of the strincreased complexity of the stromal papillae with stratification of the omal papillae with stratification of the epitheliumepithelium （ （ 2-3layer2-3layer ）） and and nuclear nuclear atypiaatypia

. . but destructive infiltrative growth ibut destructive infiltrative growth into the stroma is not seennto the stroma is not seen

5-year survival rate of about 90%5-year survival rate of about 90% 。。

borderline Serous cystadenoma

Microscopy （ LP)

papillary projections of epithelium extending into the lumen of the tumor.

There is no invasion of the stroma or capsule.

borderline Serous cystadenoma (( 三级乳头三级乳头 ------ 交界性 细胞有异型性交界性 细胞有异型性 ))

increased complexity of the stromal papillae --- papillae of three-stage branch

HM(HP):HM(HP): ( 1)exhibiting increased architect( 1)exhibiting increased architectural complexityural complexity (2) (2) epithelial cell stratification(2-epithelial cell stratification(2-3layers),3layers),papillae of many-stage , (3)Cell andnuclearatypiaatypia ,mitotic figure appear . (4)destructive infiltrative growth destructive infiltrative growth into the stroma is not seeninto the stroma is not seen

borderline Serous cystadenoma

3)Serous cystadenocarcinoma 3)Serous cystadenocarcinoma --common

This is by far the coThis is by far the commonest primary carcimmonest primary carcinoma, accounting for noma, accounting for 660%0% of all cases, of all cases,

and over half the casand over half the cases is es is bilateral.bilateral.

Ascites Ascites is always preis always present.sent.

5-year survival rate 5-year survival rate of about of about 20-30%

Gross appearance of serous cystadenocarcinoma

The cysts are alwayThe cysts are always of s of papillary typepapillary type Larger amounts of soliLarger amounts of solid(d(fragile,easily blood and necrosifragile,easily blood and necrosi

s)s) or papillary tumor mass or papillary tumor mass, , irregularity irregularity in the tumoin the tumor mass, r mass, andand fixation fixation or or nodularitnodularityy of the capsule are all im of the capsule are all important indicators of probportant indicators of probable able malignancymalignancy

Larger amounts oLarger amounts o

f solid or papillary tuf solid or papillary tumor mass mor mass

the epithelium the epithelium burrowingburrowing through the through the capsule produces capsule produces papillary processespapillary processes 乳头突 on the serous on the serous surface.surface.

Gross appearance of serous cystadenocarcinoma

Gross appearance of serous cystadenocarcinoma

Cystadenocarcinoma growth on the ovarian surface （ left ） Extension of the groExtension of the growth to wth to the pelvis and athe pelvis and adjacent organs fixes thdjacent organs fixes the tumor.e tumor.

frozen pelvis

HM ： Papillary serous cystadenocarcinoma of the ovary with invasion of underlying stroma

According to the differentiation of papillae or gland ： well \moderated\poorly differentiated adenocarcinoma

Serous cystadenocarcinoma

the malignant papillae penetrate into the cystic wall. Ovarian papillary serous cystadenocarcinomas may contain small concretions called psammomma bodies, as purplish rounded and laminated objects. They are essentially just a form of dystrophic calcification in neoplasms.

Concentric calcifications

(psammoma bodies)

Serous cystadenocarcinoma at low pSerous cystadenocarcinoma at low powerower

The individual tumor cells in the carcinomatous esions display the usual features of all malignant more complex gland and papillae more complex growth with infiltration

solidpapillae

gland

Serous cystadenocarcinoma at high power

HM:The individual tumor cells in the carcinomatous lesions display the usual features of all malignant neoplasia with the more extreme degrees of atypia, the cells may become undifferentiated

More than 3 layers

prognosisprognosis

Consequently, careful pathologic classificatiConsequently, careful pathologic classification of the tumor, even if it has extended to the peon of the tumor, even if it has extended to the peritoneum, is ritoneum, is relevant to both prognosis and selecrelevant to both prognosis and selection of therapy tion of therapy

The 5-year survival rate for borderline and The 5-year survival rate for borderline and malignant tumors malignant tumors confined within the ovarian maconfined within the ovarian massss is, respectively, is, respectively, 100% and 70%,100% and 70%,

whereas the 5-year survival rate for the whereas the 5-year survival rate for the samsame tumors involving the peritoneume tumors involving the peritoneum is about is about 90% 90% and 25%,and 25%, respectively. respectively.

Because of their protracted courseBecause of their protracted course(( 迁延疗程 ),, borderline tumors may recur after many years, aborderline tumors may recur after many years, and 5-year survival is not synonymous with curend 5-year survival is not synonymous with cure

22 、 、 mucinous epithelial tumour ((about 25% of all ovarian neoplasms ) )

1 ） mucinous cystadenoma

2 ） borderline mucinous cystadenoma

3 ） mucous cystoadenocarcinoma (about15-20%)

These tumors closely resemble their serous counterparts.

They are somewhat less commonThey are somewhat less common

80%

1)OVARIAN MUCINOUS CYSTADENOMA

It is usuallyIt is usually large large and may r and may reach each immense proportions,immense proportions, occ occupying the whole peritoneal caviupying the whole peritoneal cavity and compressing other organty and compressing other organs. s.

some have been recorded wisome have been recorded with weights of more than 25 kgth weights of more than 25 kg

..

They are They are less frequently bilatless frequently bilateraleral It may occur at It may occur at any ageany age

Benign Benign ovarian Mucinous cystadenomaMucinous cystadenomaGrossGross ：：

the cut surface of the cyst is multilocular

more cysts of variable size

the surface of the cthe surface of the cyst is yst is completely smcompletely smoothooth but may be but may be sligslightly nodular due to phtly nodular due to projecting loculirojecting loculi

multilocularmultilocular cyst cyst

cysts filled with sticky, gelatinous fluid rich in glycoproteins

ovarian Mucinous cystadenomaMucinous cystadenoma

HM:HM: A A unilocular or multilunilocular or multilocularocular cyst of ovary lined by cyst of ovary lined by tall columnar epithelium resetall columnar epithelium resembling that of the mbling that of the cervix or lcervix or large intestine arge intestine Cell without atypiaCell without atypia

Mucinous cystadenoma

HM ： multilocularmultilocular cyst lined by tall columnar epithelium cyst lined by tall columnar epithelium with apical mucin and the absence of cilia,, nuclear located basilar part ， Cell without atypiaCell without atypia

Mucinous cystadenoma

Borderline Mucinous cystadenoma

1 ）上皮≤ 3 层，轻度异型，核大，有少量核分裂像， 2 ）增生上皮向腔内突出形成乳头分支短而粗。 3 ）没有间质的浸润

The feature of borderline mucinous cystadenoma is the same with borderline serous cystadenoma 。 Only different with the content in the cyst （（ 11 ） ） increased complexitincreased complexity of the stromal papillae with y of the stromal papillae with stratification of the epitheliumstratification of the epithelium （ （ 2-3 layer2-3 layer ） ） （（ 22 ）） nuclear atypianuclear atypia . . （（ 33 ）） but destructive infilbut destructive infiltrative growth into the stroma trative growth into the stroma is not seenis not seen

5-year survival rate of about5-year survival rate of about 40-50% The feature of mucinous cystadenocarcinoma is

the same with borderline serous cystadenocarcinoma ， Mainly different with the content in the cyst

。

Mucinous cystadenocarcinoma （ 10

% ）

Mucinous cystadenocarcinoma

halfbig ， Cystadenocarcinomas contain more solid growth Larger amounts of solidLarger amounts of solid((fragile,easily blood and necfragile,easily blood and necrosis)rosis) or papillary tumor ma or papillary tumor massss

solid tumor masssolid tumor mass

papillary tumor masspapillary tumor mass

cyst

papillary tumor masspapillary tumor mass

HM: conspicuous epithelial cell atypia and stratification （ More than 3 layers ） gland architecture ---well differentated less stroma

Without Concentric calcifications (psammoma bodies)

Mucinous cystadenocarcinoma

Teratoma ( 良 / 恶性畸胎瘤 )

Desgeminoma ( 无性细胞瘤 )

endodermal sinus tumor ( 内胚窦瘤 )

embryonal carcinoma ( 胚胎性癌 )

Ovarian Germ cell tumors

yolk sac tumor （卵黄囊瘤）

teratoma

arise from germ cell ,havethe potentiality of forming body cell differentiation,most . tumors contain at least bis-blastodermblastoderm or tris- blastoderm blastoderm tissue 。 mature tissue of tris- blastodermblastoderm : ectoderm: skin ;hair ;sebum; tooth;brain endoderm: respiratory tract; digestive tract ; thyroid gland mesoderm:connective tissue; cartilage( 软骨 ); bone; blood vessel

Type according todifferentiation Type according todifferentiation

mature teratoma:Cystic teratoma or dermoid:Cystic teratoma or dermoid

benign benign (common)(common)

immature teratoma:Solid teratoma:Solid teratoma

malignant

1 、 mature teratoma

: cystic nature of a mature teratoma of ovary. The most common tissue element of these teratomas is skin, so large amounts of hair and sebum are produced,

gross ：

HMmature tissue ectoderm: skin ;hair ;sebum; tooth;brain endoderm: respiratory tract; digestive tract ; thyroid gland mesoderm: connective tissue; blood vessel

cartilage( 软骨 ); bone;

a form of ovarian germ cell tumor.

These tumors are often called "dermoid cysts" because they are mostly cystic.

mature cystic teratomas of the ovary

mature teratoma

1. 成熟性畸胎瘤：良性

TEETH

皮脂腺

角化的鳞状上皮

Histologically, a variety of mature tissue elements may be found.

squamous epithelium

Sebaceousgland

hairs

Colonic gland

cartilaginous tissue

（ ectoderm）

（ entoderm）

（ mesoderm）mature teratoma

sebaceous gland     

skin

mature teratoma--- Dermoid cysts

thyroid tissue

struma ovarii ： Microscopically, this teratoma has cartilage, adipose tissue, and intestinal glands at the right, while at the left is a lot of thyroid tissue. This condition can be termed struma ovarii. Rarely, a struma ovarii can even be a cause for hyperthyroidism.( 以甲状腺组织为主的单胚层畸胎瘤 )

struma ovarii

cartilage, tissue

adipose tissue

intestinal glands

thyroid tissue

2 、 immature teratoma

tumors are mostly solid with partOf cyst

gross ： malignant, primitive neural tube

immature teratoma

primitive neural tube

Like chrysanthemum-shape

TeratomaTeratoma

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