Gynecologic and Obstetric Pathology: High-Yield Pathology Part 1

345 Pages·203.182 MB·English

by  Crum Ch., Matthew Quick C., Laury A., Peters P., Hirsch M.

Gynecologic and
Obstetric Pathology
H I G H - Y I E L D P A T H O L O G Y
Christopher P. Crum, MD Charles Matthew Quick, MD
Professor of Pathology, Harvard Medical School Assistant Professor of Pathology
Vice Chair and Director, Women’s and Perinatal Director of Gynecologic Pathology
Pathology University of Arkansas for Medical Sciences
Department of Pathology Little Rock, Arkansas
Brigham and Women’s Hospital
Boston, Massachusetts William A. Peters III, MD
Clinical Professor of Obstetrics & Gynecology,
Anna R. Laury, MD University of Washington
Department of Pathology & Laboratory Medicine Swedish Medical Center
Cedars-Sinai Medical Center Seattle, Washington
Los Angeles, California
Michelle S. Hirsch, MD, PhD
Associate Professor of Pathology
Brigham and Women’s Hospital
Department of Pathology
Division of Women’s and Perinatal Pathology
Boston, Massachusetts
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
GYNECOLOGIC AND OBSTETRIC PATHOLOGY: ISBN: 978-1-4377-1422-7
HIGH-YIELD PATHOLOGY
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CONTRIBUTORS
Odise Cenaj, MD, PhD Jelena Mirkovic, MD, PhD
Resident in Pathology Fellow in Women’s and Perinatal Pathology
Department of Pathology Department of Pathology
Brigham and Women’s Hospital Brigham and Women’s Hospital
Boston, Massachusetts Boston, Massachusetts
Brooke E. Howitt, MD Bradley J. Quade, MD, PhD
Instructor in Pathology Associate Professor of Pathology
Department of Pathology Department of Pathology
Brigham and Women’s Hospital Division of Women’s and Perinatal Pathology
Boston, Massachusetts Brigham and Women’s Hospital
Boston, Massachusetts
Emily E.K. Meserve, MD, MPH
Fellow in Women’s and Perinatal Pathology Kathleen Sirois, BA
Department of Pathology Pathology Specialist
Brigham and Women’s Hospital Women’s and Perinatal Pathology
Boston, Massachusetts Brigham and Women’s Hospital
Boston, Massachusetts
iii
PREFACE
just the original pathologist but also the “expert” who is
NAVIGATING THE SEVEN “CS” OF DECISION
being asked to review the case. The value of additional
MAKING IN PATHOLOGY
consultation from the literature cannot be overestimated,
notwithstanding the limitations in illustration. A “perfect
Consultations, whether intradepartmental or extradepart- match” between the slide and an image in the literature
mental, are a vital component of patient care and are designed should be viewed with caution!
to come as close as possible to the theoretical ideal of an 4. Are we about to contradict the diagnosis of the submit-
error-free practice. This book is intended to touch on both ter? Pathologists are by nature independent in their
routine and potentially problematic areas of diagnosis; assessments, a natural and necessary aspect of maintain-
hence, the “pitfalls” designation for many of the chapters ing objectivity. That being said, the submitting patholo-
and the appendix, which summarizes many of the problems gist has often gone to considerable effort to understand
we have encountered in our experience. No summary can and describe the difficulties of a particular case. In a
possibly cover all of the potential traps awaiting the practi- nonreferral routine practice, problematic cases are less
tioner, but the following guidelines (the seven Cs are offered common and thus receive careful scrutiny. The consultant
based on our own experience) are intended to reduce errors is well advised to carefully consider the impressions of
in interpretation. They are as follows: the submitter and be certain when he or she contradicts
their diagnosis. In our experience the submitter is correct
1. When examining a case as consultants, are we paying in the large proportion of cases.
attention to the submitter’s concerns? This is an aspect 5. Are we exercising caution in our interpretation? One of
that can be quite variable and requires careful review of the biggest threats to a correct diagnosis is overconfi-
the submitted records. In particular, the letter from the dence and a “snap diagnosis” because it short-circuits the
person requesting the consultation must be read carefully slower but more orderly process of weighing the differ-
to ascertain not only the history but also the reasons for ential diagnoses, obtaining confirmatory opinions, and
the consultation request. In many cases the reason for the making the soundest judgment possible.
consultation may not be clearly stated but implied in the 6. Is a creative diagnosis being considered, that is, one that
preliminary diagnosis. It is imperative that the concerns is not in the books? Most of the diagnoses rendered pertain
of the submitter be ascertained. to common questions as discussed earlier. When a con-
2. Is the suspected entity cryptic as in rare or unusual? In sultant encounters something that is particularly unusual,
most cases the entity under review or the question being there may be the temptation to apply a diagnosis that is
asked is a common one. Is this an endometrial intraepi- nonstandard. The risk is that the consultant is missing an
thelial neoplasia/atypical hyperplasia or a benign pro- unusual presentation of something more common. Cre-
liferation? Is it differentiated VIN or lichen simplex ative diagnoses should always be made with care, espe-
chronicus; atypical leiomyoma or STUMP? Such cases cially if the diagnosis implies a specific line of therapy.
usually do not have a hidden pitfall. For others, the process 7. Have we reviewed the mundane but critical clerical com-
or the question is not readily apparent, that is, the features ponent? Always verify that the slides sent belong to the
on the slide do not conjure up an instant differential. patient whom they should represent. Similarly, always
3. Are we getting consultation from other colleagues or make sure that the abnormality belongs to the patient by
experts, including nongynecologic pathologists? Every excluding laboratory contaminants (floaters).
pathologist knows that discussion with other pathologists
is particularly helpful with unusual, or rarely encoun- Much of the above information is intuitive to most patholo-
tered, problematic lesions. When obtaining consultation, gists, but it is intended to reinforce the great value of taking
the pathologist must consider three things. First, they an organized approach to pathologic diagnosis, whether one
obviously must make sure that the pathologists are expe- is the initial reviewer or consultant. This book will address
rienced; second, they must make sure that the patholo- as many of the potential problems as possible. There will
gists are fully attentive to the case; and third they must certainly be more, and we welcome input from the readers
make certain that the opinion of their consultant(s) is as we hope to include them in a subsequent edition.
reasonable. Ultimately, the pathologist seeking consulta-
tion must formulate the diagnosis, and this goes for not Christopher P. Crum, MD
v
CONTENTS
C. Vulvar Adnexal Lesions
SECTION I. LOWER ANOGENITAL TRACT
Bartholin’s Duct Cyst, 57
A. Inflammatory Disorders
Mucous Cyst of the Vagina, 59
Eczematous Dermatitis, 3
Ectopic Breast Tissue, 61
Lichen Simplex Chronicus and Prurigo Nodularis, 5
Fibroadenoma, 63
Psoriasis, 7
Hidradenoma PITFALL, 65
Seborrheic Dermatitis, 9
Syringoma, 68
Lichen Sclerosus Including Early Lichen Sclerosus, 11
Hyperplasia of Bartholin’s Gland, 70
Lichen Planus, 14
Bartholin’s Adenoma, 72
Zoon’s Vulvitis, 16
Adenoid Cystic Carcinoma, 74
Bullous Pemphigoid, 18
Bartholin’s Gland Carcinoma, 76
Pemphigus Vulgaris, 20
Hailey-Hailey Disease, 22 D. Vulvar Epithelial Neoplasia
Darier’s Disease, 24 Condyloma, 79
Epidermolytic Hyperkeratosis, 26 Verruciform Xanthoma, 82
Hidradenitis Suppurativa, 28 Warty Dyskeratoma, 84
Crohn’s Disease of the Vulva, 30 Fibroepithelial Stromal Polyp, 86
Vulvodynia, 32 Seborrheic Keratosis, 88
Pseudobowenoid Papulosis PITFALL, 90
B. Vulvar Infections
Flat Condyloma (VIN1), 92
Vulvovaginal Candidiasis, 34
Classic (Usual) Vulvar Intraepithelial Neoplasia, 94
Bacterial Vaginosis, 36
Classic Vulvar Intraepithelial Neoplasia with Lichen
Molluscum Contagiosum, 38
Simplex Chronicus PITFALL, 98
Acute Herpes Simplex Virus Infection, 40
Classic Vulvar Intraepithelial Neoplasia (Bowenoid
Chronic Erosive Herpes Simplex PITFALL, 42 Dysplasia), 100
Syphilis PITFALL, 44 Pagetoid Vulvar Intraepithelial Neoplasia PITFALL, 102
Chancroid, 46 Vulvar Intraepithelial Neoplasia with Columnar
Differentiation PITFALL, 104
Granuloma Inguinale, 48
Epidermodysplasia Verruciformis–Like Atypia
Schistosomiasis, 50
PITFALL, 106
Bacillary Angiomatosis, 52
Polynucleated Atypia of the Vulva, 108
Necrotizing Fasciitis, 54
Differentiated Vulvar Intraepithelial Neoplasia, 110
Varicella Zoster, 55
vii
viii CONTENTS
Verruciform Lichen Simplex Chronicus, 114 Rhabdomyoma, 181
Vulvar Acanthosis with Altered Differentiation (Atypical Angiokeratoma, 183
Verruciform Hyperplasia), 116
Granular Cell Tumor, 185
Early Invasive Squamous Cell Carcinoma, 118
Prepubertal Vulvar Fibroma, 187
Vulvar Squamous Carcinoma: Basaloid and Warty
Patterns, 122 G. Anus
Vulvar Squamous Carcinoma: Keratinizing Pattern, 124 Anal Condyloma, 190
Verrucous Squamous Cell Carcinoma, 128 Anal Intraepithelial Neoplasia II and III, 193
High-Grade Squamous Intraepithelial Lesion (Vulvar Anal Carcinoma, 195
Intraepithelial Neoplasia III) with Confluent Papillary
Anal Paget’s Disease, 197
Growth, 131
Giant Condyloma of the External Genitalia H. Vagina
PITFALL, 134
Prolapsed Fallopian Tube, 200
Pseudoepitheliomatous Hyperplasia PITFALL, 137
Granulation Tissue, 202
Keratoacanthoma PITFALL, 139
Vaginal Adenosis, 204
Basal Cell Carcinoma, 141
Polypoid Endometriosis, 206
Adenosquamous Carcinoma, 144
Vaginal Papillomatosis (Residual Hymenal Ring)
Paget’s Disease of the Vulva, 146 PITFALL, 208
Merkel Cell Carcinoma, 149 Low-Grade Vaginal Intraepithelial Lesion (Vaginal
Intraepithelial Neoplasia I and Condyloma), 210
Cloacogenic Neoplasia, 151
High-Grade Vaginal Intraepithelial Lesion (Vaginal
Metastatic Carcinoma of the Vulva, 153
Intraepithelial Neoplasia II-III), 212
E. Pigmented Lesions High-Grade Vaginal Intraepithelial Neoplasia III, 215
Lentigo, 155 Radiation-Induced Atrophy, 217
Genital-Type Nevus, 157 Papillary Squamous Carcinoma, 219
Dysplastic Nevus, 159 Clear-Cell Adenocarcinoma, 221
Melanoma, 161 Metastatic Adenocarcinoma, 223
Melanoma PITFALL, 226
F. Soft Tissue Vulvar Neoplasia
Spindle Cell Epithelioma PITFALL, 228
Angiomyofibroblastoma, 163
Embryonal Rhabdomyosarcoma, 230
Aggressive Angiomyxoma PITFALL, 165
Superficial Angiomyxoma, 166
SECTION II. CERVIX
Cellular Angiofibroma, 168
A. Squamous Lesions
Dermatofibroma (Fibrous Histiocytoma), 170
Exophytic Low-Grade Squamous Intraepithelial
Dermatofibrosarcoma Protuberans, 172
Lesion, 235
Low-Grade Fibromyxoid Sarcoma, 174
Low-Grade Squamous Intraepithelial Lesion
Lipoma, 176 (Flat Condyloma/Cervical Intraepithelial
Neoplasia I), 237
Liposarcoma, 177
High-Grade Squamous Intraepithelial Lesion (Cervical
Synovial Sarcoma of the Vulva PITFALL, 179
Intraepithelial Neoplasia II and III), 240
CONTENTS ix
Low-Grade Squamous Intraepithelial Lesion (Giant Adenoid Basal Carcinoma, 308
Condyloma) PITFALL, 243
Mesonephric Remnants, 310
Low-Grade Squamous Intraepithelial Lesion (Immature
Mesonephric Carcinoma, 312
Condyloma), 245
Prostatic Metaplasia of the Cervix, 315
Mixed-Pattern Squamous Intraepithelial Lesion
(Low- and High-Grade Squamous Intraepithelial Endocervical Glandular Hyperplasia, 317
Lesions), 247
Metastatic Serous Carcinoma to the Cervix, 319
Atrophy Including Squamous Intraepithelial Lesion in
Metastatic Endometrioid Carcinoma to the
Atrophy, 249
Cervix, 321
Minor p16-Positive Metaplastic Atypias, 252
Atypical Endocervical Polyp, 324
Squamous Intraepithelial Lesion, Not Amenable to Brooke E. Howitt
Precise Grading (QSIL), 255
Adenomyoma of the Cervix, 326
Superficially Invasive Squamous Cell
Microglandular Hyperplasia of the Cervix, 328
Carcinoma, 259
Adenosarcoma of the Cervix, 331
Conventional Squamous Cell Carcinoma, 262
Brooke E. Howitt
Pseudocrypt Involvement by Squamous Cell
Carcinoma, 266 C. Miscellaneous Lesions
Lymphoepithelial-Like Squamous Carcinoma, 268
Cervical Schwannoma, 333
Glial Polyp of the Cervix, 335
B. Glandular Lesions
Superficial (Early) Adenocarcinoma In Situ, 270
SECTION III. UTERUS
Conventional Adenocarcinoma In Situ, 273
A. Benign Endometrium
Stratified Adenocarcinoma In Situ, 276
Dysfunctional Uterine Bleeding (Early or Mid-Cycle
Intestinal Variant of Adenocarcinoma In Situ, 278
Breakdown), 339
Brooke E. Howitt
Breakdown Mimicking Neoplasia, 341
Cervical Endometriosis, 280
Anovulatory Endometrium with Persistent
Pregnancy-Related Changes in the Cervix, 282
Follicle, 343
Reactive Atypias in the Endocervix, 284
Benign Endometrial Hyperplasia, 345
Radiation Atypias, 286
Telescoping Artifacts Mimicking Neoplasia, 347
Villoglandular Adenocarcinoma of the Cervix, 288
Mixed-Pattern Endometrium, 349
Superficially Invasive Endocervical Adenocarcinoma, 290
Adenomyomatous Polyp, 351
Extensive Adenocarcinoma In Situ vs Invasion, 292
Chronic Endometritis, 353
Infiltrative Endocervical Adenocarcinoma, 295
Pseudoactinomycotic Radiate Granules, 355
Clear-Cell Carcinoma of the Cervix, 298
Pyometra, 357
Atypical Lobular Endocervical Glandular
Tubercular Endometritis, 359
Hyperplasia and Invasive (Minimal Deviation)
Adenocarcinoma of the Cervix with Gastric Submucosal Leiomyoma, 361
Differentiation, 300
Exfoliation Artifact, 364
“Serous” Carcinoma of the Cervix, 302
Perforation, 366
Signet-Ring Cell Carcinoma of the Cervix, 305
Ablation Artifact, 368
x CONTENTS
B. Endometrial Glandular Neoplasia and Adenocarcinoma with Spindle Cell Features, 445
Its Mimics
Wilms’ Tumor of the Endometrium, 447
Endometrial Intraepithelial Neoplasia (Atypical
Hyperplasia), 370 C. Mesenchymal Lesions of the Uterus
Atypical Polypoid Adenomyoma, 374 Endometrial Stromal Nodule, 449
Endometrial Involvement by Endocervical Glandular Stromomyoma, 451
Neoplasia, 376
Endometrial Stromatosis, 453
Degenerative Repair, 378
Low-Grade Endometrial Stromal Sarcoma, 455
Proliferative Repair, 380
Uterine Tumor Resembling Sex Cord Stromal Tumor, 459
Mucinous Metaplasia of the Endometrium, 382
High-Grade Endometrial Stromal Sarcoma, 461
Squamous and Morular Metaplasia, 384
Undifferentiated Uterine Sarcoma, 464
Ichthyosis Uteri, 387
Adenosarcoma of the Endometrium, 466
Squamous Carcinoma of the Endometrium, 389 Brooke E. Howitt
Tubal and Eosinophilic (Oxyphilic) Metaplasia, 391 Atypical Endometrial Polyp, 469
Microglandular Endometrial Adenocarcinoma in Brooke E. Howitt
Curettings, 393 Adenomatoid Tumor, 472
Endometrioid Adenocarcinoma, 396 Lipoleiomyoma, 475
Lower Uterine Segment Adenocarcinoma, 400 Cellular Leiomyoma, 477
Lynch Syndrome Screening, 403 Hydropic Leiomyoma, 479
Brooke E. Howitt
Mitotically Active Leiomyoma, 481
Myoinvasion in Endometrial Adenocarcinoma, 406
Atypical Leiomyoma (Leiomyoma with Bizarre
Intraperitoneal Keratin Granuloma, 410 Nuclei), 483
Endometrial Histiocytes and Foamy Stromal Leiomyomatosis, 485
Macrophages, 412
Intravenous Leiomyoma, 487
Serous Cancer Precursors, 414
Bradley J. Quade
Serous Endometrial Intraepithelial Carcinoma, 417 Intravenous Leiomyomatosis, 489
Ischemic Atypias of the Endometrium, 419 Bradley J. Quade
Reactive Atypia in the Endometrium, 421 Morcellation-Related Dissemination of Smooth Muscle
Neoplasia, 491
Uterine Serous Carcinoma, 423
Bradley J. Quade
Mixed-Pattern Adenocarcinoma, 426
Disseminated Peritoneal Leiomyomatosis, 493
p53-Positive Endometrioid Adenocarcinoma, 428
Bradley J. Quade
Neuroendocrine Differentiation in Endometrial Pathology Following Uterine Artery Embolization, 495
Carcinoma, 430
Bradley J. Quade
Undifferentiated Carcinoma of the
Hereditary Leiomyomatosis and Renal Cell Carcinoma
Endometrium, 432
Syndrome PITFALL, 497
Clear-Cell Carcinoma, 434
Leiomyosarcoma, 499
Endometrioid or Clear-Cell Carcinoma? 437
Myxoid Leiomyosarcoma, 501
Carcinosarcoma, 440
Epithelioid Leiomyosarcoma, 503
CONTENTS xi
PEComa, 505 Cortical Stromal Hyperplasia and Hyperthecosis, 569
Reproductive Tract Lymphoma, 507 Endometrioma with Mucinous Metaplasia, 571
Emily E.K. Meserve Endometrioma with Atypia, 573
Decidualized Endometrioma PITFALL, 575
SECTION IV. FALLOPIAN TUBE
Serous Cystadenomas and Cystadenofibromas, 577
A. Benign, Inflammatory/Reactive
Cortical Inclusion Cysts, 580
Adrenal Rest, 511
Endosalpingiosis, 582
Pseudoxanthomatous Salpingiosis, 513
Malakoplakia, 584
Xanthogranulomatous Salpingitis, 515
B. Epithelial Neoplasia
Follicular Salpingitis, 517
High-Grade Serous Carcinoma, Classic Type, 586
Salpingitis Isthmica Nodosum, 519
Brooke E. Howitt
Granulomatous Salpingitis, 520
High-Grade Serous Carcinoma with “SET” Patterns, 588
Torsion of the Tube and Ovary, 522
Brooke E. Howitt
Tubal Arias-Stella Effect PITFALL, 524
Low-Grade Endometrioid Adenocarcinoma with
Squamotransitional or Spindle Features, 590
B. Neoplastic and Preneoplastic
Carcinosarcoma, 592
Adenofibroma, 527
Adenosarcoma of the Ovary, 594
Benign Epithelial Hyperplasia (Secretory Cell
Serous Borderline Tumor (SBT), 597
Outgrowths), 529
Serous Borderline Tumor with Complex
p53 Signatures, 532
Architecture, 600
Low-Grade Serous Tubal Intraepithelial Neoplasia
Low-Grade Invasive Serous Carcinoma of
(Serous Tubal Intraepithelial Lesion), 535
the Ovary, 602
Papillary Hyperplasia, 539
Invasive Implants of Low-Grade Serous
High-Grade Serous Tubal Intraepithelial Neoplasia
Tumor, 605
(Serous Tubal Intraepithelial Carcinoma), 541
Mucinous Carcinoma, 607
The Risk Reducing Salpingo-Oophorectomy, 545
Mucinous Tumors with Mural Nodules, 610
Salpingoliths, 547
Mucinous Borderline Tumor, 613
Adenocarcinoma of the Fallopian Tube, 549
Mucinous Borderline Tumor with Intraepithelial
Endosalpingeal Implants from Remote Tumors, 552
Carcinoma, 615
Female Adnexal Tumor of Wolffian Origin, 554
Low-Grade Endometrioid Adenocarcinoma, 617
Endometrioid Adenofibroma, 620
SECTION V. OVARY
Proliferative (Borderline) Endometrioid
A. Benign Adenofibroma, 622
Tangentially Sectioned Ovarian Follicle PITFALL, 559 Müllerian Mucinous and Seromucinous Tumors of the
Ovary, 625
The Ovary in Pregnancy, 561
Benign Brenner Tumor, 629
Solitary Luteinized Follicle Cyst, 564
Malignant Brenner Tumor, 631
Polycystic Ovarian Syndrome, 566
Clear-Cell Carcinoma, 633
Emily E.K. Meserve