Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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        Fallopian Tubes and Ovaries
      
      Vaginal diseases:
      1. Colporrhaphy tissue: these mucosal strips are processed to search for occult coincidental disease such as unexpected vascular atherosclerosis (52 y/o with 3+ atherosclerosis [L12-5270]; 87 y/o negative for it [L12-2843]), amyloid, neoplasia, etc. The strips are tissue portions from the reduction of mucosal prolapse, rectocele, and rectocele.
      2. cysts:
        1. Gartner's duct (mesonephric) cyst: endocervical-like mucinous epithelium [L13-7611].
      Tubal diseases:
      1. neoplastic
        • benign:
        • malignant: carcinoma, lymphoma, sarcoma
        • "intense protocol exam gynecologic prophylactic therapy related hysterectomy and BS&O specimens" are part of "oncoprophylactic" surgery in breast cancer cases to (1) remove risk of GYN cancer in genetic positive breast cancers and/or (2) to remove ovaries (oncoendocrinectomy) in genetic negative cases that have hormone-positive breast cancers & move from, say Tamoxifen to Femara [L12-6963; B11-105] (partly a sort of "bilateral ablational endocrinectomy"). As of now, this justifies an 88307 code rather than 88305.

          NOTE: A young Medicaid case where genetic tests not approved & surgery done and very early tubal changes were seen as focal secretory cell atypia clusters with increased N/C ratio and loss of polarity plus some probable overall increased Ki67 proliferation but without clustered positivity and with increased p53 positive secretory cell nuclei but never 12 good positive nuclei in a row (never with those clusters called "p53 signatures"9) [L14-3068]. I checked Ki-67 & p53 on a 35 y/o having hysterectomy & salpingectomies & found a surprising rate of tubal epithelial Ki-67 (sometimes with short zones at 35-50%). And, there was a good amount of p53 marking but never 12 or more in a row (L14-3770). So (as of 2014), I don't have confidence in calling "positives" unless "slam dunk" unequivocally excessive, unequivocal "p53 signatures"!

          In 2017, note was made of a 2013 SGO practice guideline requests complete sectioning & viewing of the fimbriated end to go along with a practice's policy for the rest of the tube (we do a mid-tube & proximal tube cross-section)10. Screening is with H&E & without IHC unless one sees definite cytological atypia, loss of polarity, and suggestion of mitotic activity10. That same article clarifies that there is a spectrum which has an earliest end with "p53 signature" foci and the CIS end being STIC lesions (serous tubal intraepithelial carcinoma) composed of: (1) increased N/C ratios, (2) loss of cell polarity, (3) prominent nucleoli, and (4) absence of ciliated cells10. In the middle of the spectrum are changes variously called: "serous tubal intraepithelial lesion", "tubal intraepithelial lesion in transition", and "serous tubal intraepitheial neoplasia"10.

      2. nonneoplastic:
        • endosalpingiosis cysts.
        • cystic Walthard cell rests.
        • endometriosis (can be cysts and masses).
        • post-fimbriectomy pregnancies & then completion salpingectomies evaluation of lumen patency [L10-8990].
        • did stents or devices cause inflamatory pain [L10-2047]?

      Ovarian diseases:

      1. neoplastic (see JHU website)(screening:see this ARUP file)
        • prophylaxis: "intense-protocol-exam oncologic prophylactic/therapy-related hysterectomy, BS&O specimens" are part of surgery in breast cancer cases to (1) remove risk of GYN cancer in genetic positive breast cancers and/or (2) to remove ovaries in genetic negative cases that have hormone-positive breast cancers & move from, say Tamoxifen to Femara [L12-6963; B11-105].
        • ovarian surface epithelial masses (coelomic, Mullerian origin):[benign or malignant adenofibromatous ovarian lesions...especially the glandular-cystic rather than papillary dominant patterns...have a 14% association with breast cancer, usually already diagnosed, and a significant association with various thyroid disorders5]
          • Benign & borderline epithelial:
            1. serous (tubal-like): adenoma vs. cystadenoma vs cystadenofibroma (see below) vs. adenofibroma; interior cyst fluid can seem mucinous grossly in serous tumors & cells may be ciliated.
              1. ca., low grade8: often from precursor situations & confined to ovary @ DX; often somatic genetic mutations; poor chemo responders.
              2. ca., high grade8: chromosomal instability is hallmark & have DNA copy number changes and p53 expression, grow rapidly & spread early.
            2. mucinous (endocervix-like): adenoma vs. cystadenoma vs cystadenofibroma vs. adenofibroma.
            3. endometrioid (tubular glands resembling proliferative endometrium): usually a cystadenofibroma.
            4. transitional cells (Brenner): fibroepithelial histology & often with a minor component of mucinous glands; solid vs. cystic vs. cystadenofibromatous; most are benign & rare (usually unilateral & at least partly cystic) borderline (mild atypia [like LG-TCC], "proliferative" & worse atypia [like HG-TCC], "low malignant potential")7.
            5. mesothelial (coelomic) inclusion cysts (cortical mullerian inclusion cysts).
          • Malignant (carcinoma): type by Canadian on-line calculator.
            1. serous: solid vs. cystic vs. cystadenofibromatous & be sure to consider primary peritoneal serous carcinoma [L-04-8307].
              1. low grade8: often from precursor situations & confined to ovary @ DX; often somatic genetic mutations; poor chemo responders.
              2. high grade8: chromosomal instability is hallmark & have DNA copy number changes and p53 expression, grow rapidly & spread early.
            2. clear cell:
            3. mucinous: solid vs. cystic vs. cystadenofibromatous & can be associated with (or cause) pseudomyxoma peritonei & if with bilateral ovarian mucinous tumors, look for an extra-ovarian primary6. A benign appendicular mucocoel can rupture and release localized to massive quantities of non-cellular mucous to mimmic pseudomyxoma peritonei.
            4. endometrioid (resembling adenoca. endometrium): solid vs. cystic vs. cystadenofibromatous; clear cell adenocarcinoma is an aggressive variant.
              1. low grade8: often from precursor situations & confined to ovary @ DX; often somatic genetic mutations; poor chemo responders.
              2. high grade8: chromosomal instability is hallmark & have DNA copy number changes and p53 expression, grow rapidly & spread early.
            5. transitional cells (Brenner): solid vs. cystic vs. cystadenofibromatous & only Brenner rarely malignant; metastatic endometrial or other to ovary can sclerose & nest in such a way as to mimic a malignant Brenner [L07-7293]. If no benign Brenner component found, DX as primary TCC of ovary [L11-3500...a massive cystic tumor with only about 50g of malignant tissue].
            6. poorly differentiated: this group is mostly serous cell type but can include anything, including TCC, and can be a wastebasket (as may be true for TCC)1.
            7. mesothelioma:
        • ovarian stromal sex cord masses:
          1. thecoma: usual vs. luteinized thecoma: [LMC-02-40]
          2. fibroma (stroma dominates any epithelial component):
            • solid
              1. ordinary
              2. cellular [LMC-04-4795, mitotic rate was 1 per 10 hpfs ]
            • cystadenofibroma: papillary dominant vs. glandular/cystic dominant [LMC-04-6513; L07-9116; L07-11817; S07-13135; L08-1324]...this latter variant, especially when bilateral and over age 60, is associated with a 20+% risk of breast cancer and an increased risk of thyroid disorders5.
          3. granulosa cell tumor (has more discrete nests of cells than fibroma or sclerosing stromal tumor):
            • adult type
            • juvenile type
          4. Sertoli-Leydig cell tumor
          5. Sertoli cell tumor
          6. SCTAT (sex cord tumor with annular tubules)
          7. Leydig cell tumor
          8. steroid cell tumor
          9. gynandroblastoma
          10. sclerosing stromal tumor
          11. stromal luteoma
        • ovarian oocyte follicular germ cell masses:
          1. benign:
            1. mature teratoma, dermoid, struma ovarii
          2. malignant:
            1. immature teratoma
            2. dysgerminoma (a seminoma counterpart).
            3. yolk sac adenocarcinoma (yolk sac tumor; endodermal sinus tumor). Can see microscopic Schiller-Duval body which resembles a stuctures in the yolk sac of rat placentas...tumor cells rdiating around a small vascular lumen and set apart by peripheral tissue clefts. AFP positive by IHC.
            4. choriocarcinoma.
            5. embryonal carcinoma (looks similar to testicular).
            6. polyembryoma (contains embryoid bodies).
            7. mixed malignant germ cell tumor.
        • malignant, metastatic:
          1. mucinous: stomach, large bowel, breast, and carcinoid-adenocarcinoma [LMC-02-1598]; called Krukenberg tumor if signet ring infiltrate and multinodular enlargement (usually bilateral) are present.
          2. other: (see ref.3  page 1523) for excellent 2 paragraphs
      2. non-neoplastic:
      3. The ovaries of a mature, non-menopausal virginal female each have an average weight of 5.7 grams per ovary and a size averaging 4.7 by 2.4 by 1.0 cm. Following child-bearing but prior to menopause, the ovaries average about 7 grams each. An ovary is an "oophoron". Therefore, terms for ovarian enlargement are oophoromegally, or macro-oophoron, or megalo-oophoron.

        • atrophy
        • enlargement:
        • due to increased weight (stromal hyperplasia) or size (polycystic) or a combination of both L12-14648].
        • due to compensatory hypertrophy due to absence of the other [L00-5149].
        • endosalpingiosis cysts
        • cystic Walthard cell rests
        • endometriosis (can be cysts and masses.
        • siderotic corpora may reflect systemic iron overload, easily screened for with a serum iron profile (iron & TIBC with % saturation)[L11-718].
        • PCOS: we fairly commonly see ovaries with multiple 5-8 mm cortical cysts
        • endosalpingiosis: multiple vessicle-like, small cysts scattered over the tubo-ovarian serosal-cortical surface.
        • mesothelial inclusion cysts.
        • ovarian hyperthecosis (medullary stromal hyperplasia)...maybe with obesity, hypertension, and some hirsuitism [LMC-03-4444].
        • variably luteinized multicystic folliculo-stromal " hyperreactio luteinalis".
    • Associated peri-ovarian tissues:

        1. neoplastic: various soft tissue or mesothelial lesions.
          • mesothelial adenomatoid tumor
          • various benign or malignant soft tissue or lymphoid proliferations.
        2. non-neoplastic:
          • endosalpingiosis, see above
          • ectopic adrenal tissue [LMC-04-1488]
          • peritoneal inclusion cyst [L07-10163].
    • References:

      1. expert consultant's reports & commentary.
      2. Ovarian Tumors...., Robert H. Young guest editor, Seminars in Diagnostic Pathology 18(3):151-235, 8/2001.
      3. Ackerman's Surgical Pathology, vol. II, 8th Ed. 1996.
      4. Charles Zaloudek, Ovarian Pathology: Germ Cell Tumors, Sex-cord Stromal Tumors, and Non-neoplastic Lesions, MUSC McKee-PT Seminar, 7 April 2005.
      5. Silva EG, et. al. [@ M. D. Anderson & SUNY Stony Brook], "The Association of Benign and Malignant Ovarian Adenofibromas with Breast Cancer and Thyroid Disorders", International J. Surg. Path 10(1):33-39, 2002.
      6. Kumar V, et. al., Robbins & Cotran Pathologic Basis of Disease, 7th Ed. 2005, 1525 pages.
      7. Fletcher CDM, Diagnostic Histopathology of Tumors, 3rd. Ed. 2007
      8. Konstantinopoulos PA, et. al., "CLINICAL CROSSROADS: Management of Ovarian Cancer", JAMA 307(13):1420-1429, 4 April 2012.
      9. Crum CP, "Intercepting pelvic cancer in the distal fallopian tube: Theories and realities", Molecular Oncology 3(2):165-170, April 2009.
      10. Okoye E, CAP Today, Q&A, about Bilateral Salpingectomy Processing,page 59-60, March 2017.

      (posted 2003; lastest adjustment 9 April 2017)

 
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