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GYNECOLOGIC PATHOLOGY, SECOND EDITION ISBN: 978-0-323-35909-2
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ISBN: 978-0-323-35909-2
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Preface
All disciplines in the field of surgical pathology are con- standard of care in the future. Prime examples of this are
stantly evolving, and female genital tract pathology is the molecular-based classification of endometrial carci-
no exception. The last decade has brought remarkable noma and the role of molecular testing in the classifica-
progress in terms of our understanding of gynecologic tion of uterine sarcomas.
disease and the role of tissue-based morphologic and This book is the product of the scholarly work of
molecular testing in its diagnosis. This second edition experts in the fields of gynecologic pathology, dermato-
of Gynecologic Pathology, a volume in the Foundations in pathology, and cytopathology. Each author has not only
Diagnostic Pathology series, incorporates these advances extensive knowledge in their areas of practice, but also
using a schematic and simplified layout. In keeping with great passion for education. Their expertise and dedi-
the highly successful format of the series, information cation is reflected in the high quality and educational
is presented in both paragraph and bullet-point forms, value of the chapters. As editors, we were honored and
and complemented by more than 1150 high-quality pho- educated by their contributions, for which we are deeply
tographs. Each topic contains relevant clinical aspects grateful.
including management and prognostic factors. The New to this second edition is the expansion to 21
pathology information is organized in a systematic fash- chapters (from 17 in the first edition), including two
ion: in addition to the key macroscopic and histopatho- new chapters on non-neoplastic lesions of the cervix and
logic features, emphasis is given to the role of ancillary cytology in the practice of gynecologic pathology. We also
testing (histochemistry, immunohistochemistry, and/ cover the role of immunohistochemistry and molecular
or molecular diagnostics). As a major element, the sec- testing throughout the text and in a chapter fully devoted
tion of differential diagnosis discusses pitfalls and dis- to this topic. We hope that the reader, whether a student
tinguishing characteristics helpful in the diagnostic or an experienced pathologist, finds in this reference a
work-up. The information contained in this volume simple yet comprehensive tool to navigate through the
aims to be practical and applicable to most practice set- practice of gynecologic pathology.
tings. We also incorporate emerging evidence and prac-
tice recommendations that, while still in the process of Marisa R. Nucci, MD and
being validated and implemented, are likely to become Carlos Parra-Herran, MD, FASCP
ix
Other books in this series
Busam: Dermatopathology, 2e
978-0-323-26191-3
Folpe and Inwards: Bone and Soft Tissue Pathology
978-0-4430-6688-7
Hsi: Hematopathology, 3e
978-0-323-47913-4
Iacobuzio-Donahue and Montgomery: Gastrointestinal and Liver Pathology, 2e
978-1-437-70925-4
Marchesvsky, Abdul-Karim, and Balzer: Intraoperative Consultation
978-1-4557-4823-5
O’ Malley, Pinder, and Mulligan: Breast Pathology, 2e
978-1-4377-1757-0
Prayson: Neuropathology, 2e
978-1-4377-0949-0
Procop and Pritt: Pathology of Infectious Diseases
978-1-4377-0762-5
Thompson: Head and Neck, 3e
978-0-323-47916-5
Zhou and Magi-Galluzzi: Genitourinary Pathology, 2e
978-0-3231-8827-2
Zander: Pulmonary Pathology, 2e
978-0-323-39308-9
Acknowledgements
The editors thank each of the authors of this second edi- To our mentors, we extend our deepest gratitude for
tion for their invaluable work, patience, and collegiality giving us foundations that allowed us to complete this
throughout the entire process of bringing this book to work. Marisa R. Nucci wants to acknowledge Christo-
completion. We also want to acknowledge the following pher Crum and Christopher Fletcher. Carlos Parra-Her-
authors of the first edition of Gynecologic Pathology: ran wants to acknowledge Drs. Martha Cabarcas, Lilia
Sanchez, Rocio Lopez, C. Felipe Villamil, Monica Gar-
• Timothy R. Quinn
cia-Buitrago, Christopher Crum, Bradley Quade, The-
• Sanjay Logani
onia Boyd, Sharon Nofech-Mozes, and Wedad Hanna
• Maureen L. Harmon
for their mentorship and guidance, and Dr. Marisa R
• Kumarasen Cooper
Nucci for being a role model, colleague, and friend like
• David W. Kindelberger
no other.
• Isabel Alvarado-Cabrero
Lastly, we thank the editorial team at Elsevier, in par-
• Michael T. Deavers
ticular Angie Breckon, Michael Houston and Manchu
• Patricia Baker
Mohan for their continuous support and professionalism.
• Russell Vang
• Brigitte M. Ronnett
Marisa R. Nucci, MD and
A special note of gratitude goes to Dr. Esther Oliva, Carlos Parra-Herran, MD, FASCP
co-editor and author of the first edition, for her previous
contributions which certainly added to the success of
the first iteration of this book.
x
To my family—my loving husband Branch, my two beautiful sons
Julian and Cole, and our rambunctious but adorable cattle dog Rusty.
Marisa R. Nucci, MD
To my mom for her endless love, sacrifice, and insuperable example;
to my dad, my brothers, and their families for being a continuous source of
support and inspiration; and to Chris for being the best part of my day
and the brightest part of my future, today and always.
Carlos Parra-Herran, MD, FASCP
List of Contributors
Bojana Djordjevic, MD Teri A. Longacre, MD
Staff Pathologist Professor of Pathology
Anatomic Pathology Department of Pathology
Sunnybrook Health Sciences Centre Stanford University School of Medicine
Associate Professor Stanford, California, United States
Laboratory Medicine and Pathobiology
University of Toronto Xavier Matias-Guiu, MD, PhD
Toronto, Ontario, Canada Professor of Pathology
Hospital Universitari Arnau de Vilanova
Oluwole Fadare, MD (IRBLLEIDA), University of Lleida
Professor of Pathology and Chief of Anatomic Hospital Universitari de Bellvitge (IDIBELL),
Pathology University of Barcelona, Barcelona, Spain
University of California San Diego
La Jolla, California, United States Anais Malpica, MD
Professor
C. Blake Gilks, MD Departments of Pathology and Gynecologic Oncology
Professor University of Texas MD Anderson Cancer Center
Pathology and Laboratory Medicine Houston, Texas, United States
Vancouver General Hospital and University of British
Columbia Jelena Mirkovic, MD, PhD
Vancouver, British Columbia, Canada Staff Pathologist
Anatomic Pathology
Beth Harrison, MD Sunnybrook Health Sciences Centre
Associate Pathologist Assistant Professor
Department of Pathology Laboratory Medicine and Pathobiology
Brigham and Women’s Hospital University of Toronto
Instructor Toronto, Ontario, Canada
Department of Pathology
Harvard Medical School W. Glenn McCluggage, FRCPath
Boston, Massachusetts, United States Professor of Gynecological Pathology
Department of Pathology
Lynn N. Hoang, MD, FRCP(C) Royal Group of Hospitals Trust
Gynecologic Subspecialist Pathologist Belfast, Northern Ireland, United Kingdom
Anatomical Pathology
Vancouver General Hospital Marisa R. Nucci, MD
Vancouver, British Columbia, Canada Professor of Pathology
Harvard Medical School
Mary Kinloch, MD, FRCP(C) Director
Gynecologic Pathologist Division of Women’s and Perinatal Pathology
Pathology and Laboratory Medicine Department of Pathology
Division of Anatomical Pathology Brigham and Women’s Hospital
University of Saskatchewan Boston, Massachusetts, United States
Saskatoon, Saskatchewan, Canada
vii
viii LIST OF CONTRIBUTORS
Kay J. Park, MD Christopher R. Shea, MD
Associate Attending Pathologist Eugene J. Van Scott Professor
Department of Pathology Chief, Section of Dermatology
Memorial Sloan Kettering Cancer Center University of Chicago
New York, United States Chicago, Illinois, United States
Carlos Parra-Herran, MD, FASCP Ie-Ming Shih, MD, PhD
Associate Professor Richard W. TeLinde Distinguished Professor
Department of Laboratory Medicine and Pathobiology Gynecology and Obstetrics
University of Toronto Johns Hopkins University
Pathologist Director of Breast and Ovarian Cancer Program
Department of Laboratory Medicine Sidney Kimmel Comprehensive Cancer Center
Sunnybrook Health Sciences Centre Johns Hopkins Medical Institutions
Toronto, Ontario, Canada Baltimore, Maryland, United States
Victor G. Prieto, MD, PhD Robert A. Soslow, MD
Professor and Chair Attending Pathologist
Ferenc and Phyllis Gyorkey Chair for Research and Memorial Sloan Kettering Cancer Center
Education in Pathology Professor of Pathology and Laboratory Medicine
Department of Pathology Weill Cornell Medical College
University of Texas MD Anderson Cancer Center New York, United States
Houston, Texas, United States
David C. Wilbur, MD
C. Matthew Quick, MD Professor of Pathology
Associate Professor of Pathology Department of Pathology
Department of P athology Massachusetts General Hospital
University of Arkansas for Medical Sciences Harvard Medical School
Little Rock, Arkansas, United States Boston, Massachusetts, United States
Gynecologic
Pathology
Second edITIon
A Volume in the Series Foundations in diagnostic Pathology
Editors
Marisa R. Nucci, MD
Professor of Pathology
Harvard Medical School
Director
Division of Women’s and Perinatal Pathology
Department of Pathology
Brigham and Women’s Hospital
Boston, Massachusetts, United States
Carlos Parra-Herran, MD, FASCP
Associate Professor
Department of Laboratory Medicine and Pathobiology
University of Toronto
Pathologist
Department of Laboratory Medicine
Sunnybrook Health Sciences Centre
Toronto, Ontario, Canada
Series Editor
John R. Goldblum, MD, FCAP, FASCP, FACG
Chairman, Department of Anatomic Pathology
The Cleveland Clinic Foundation
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Cleveland, Ohio, United States
Philadelphia, Pennsylvania, United States
1
Inflammatory Diseases of the Vulva
n Lynn N. Hoang and Mary Kinloch
morphologic findings which allows the observer to place a
n INTRODUCTION
biopsy within a specific group of cutaneous diseases. This
rational framework was also adopted by the 2006 Inter-
Almost any inflammatory dermatological condition national Society for the Study of Vulvovaginal Disease
occurring on nongenital skin can afflict the vulva. His- (ISSVD) classification of vulvar dermatoses (Table 1.1).
topathologic diagnosis in the vulva, however, is often The pattern of inflammation refers to the distribution of
complicated by its unique anatomy (where there is in- the inflammatory infiltrate within the dermis and subcutis
creased occlusion, friction, and moisture, causing a va- (Box 1.1). Once the major tissue reaction pattern and pat-
riety of secondary changes), delayed seeking of medical tern of inflammation are identified, the pathologist can gen-
attention due to patient embarrassment, and the use erate a working differential diagnosis (Table 1.1). In 2011,
of self-treatment regimens which may not be readi- the ISSVD published a separate clinically oriented frame-
ly divulged to the treating clinician. Moreover, vulvar work to classify vulvar dermatoses, allowing the clinician
dermatoses exhibit varying histologic features depend- to generate a differential diagnosis based on macroscopic
ing on the course of the disease and when the biopsy features (Table 1.2). This 2011 ISSVD framework serves
was taken. A patient may have endured multiple trials as an adjunct tool to aid in diagnosis and was meant to
of recalcitrant treatments before a biopsy is eventually supplement, not supplant, the 2006 classification scheme.
obtained. In the setting of vulvar inflammatory derma- The above approach can be applied to the most com-
toses, it must be emphasized that clinical information is mon inflammatory disorders of the vulva, which should
of utmost importance to arrive at an accurate diagnosis. allow the pathologist to categorize lesions and generate
The initial histologic approach to any inflammatory a rational differential diagnosis. This, in turn, will allow
disorder of the skin or mucosa requires knowledge of the the clinician to develop a meaningful treatment plan.
precise anatomic location and an appreciation of the alter-
ations in the regional mucocutaneous anatomy. The mons
pubis and labia majora closely resemble skin from other
n SPONGIOTIC (ECZEMATOUS) REACTION
anatomic regions of the body and are composed of a slightly
PATTERN
rugose, keratinizing, stratified epithelium containing all
of the cutaneous adnexal structures and a richly vascular
dermis. Areas of compact stratum corneum, in addition The terms “eczema” and “eczematous dermatidities” are
to the conventional basket-weave stratum corneum, are a clinical terms used to describe a variety of lesions that
normal finding in the mons pubis/labia majora. The labia share similar clinical and histologic features (spongiotic
minora, in contrast, have a stratified, glycogen-rich squa- dermatitis), but often are etiologically unrelated. Eczem-
mous epithelium. Adnexal structures are absent. On each atous dermatitis can be due to intrinsic factors (atopic
side, the mucocutaneous junction between the labium dermatitis and seborrheic dermatitis) or be triggered by
majus and labium minus (also known as Hart’s line) may extrinsic agents (irritant contact dermatitis [ICD]).
exhibit a focal zone of parakeratosis and should not be All eczematous dermatidities demonstrate epider-
mistaken for a pathologic abnormality. The subjacent der- mal spongiosis during their evolution, clinically seen as
mis is highly vascular and contains erectile tissue. crusted patches and plaques, papules and vesicles, and,
The next step in evaluating an inflammatory process at the far end of the spectrum, frank bullous lesions and,
is the identification at low power of the major tissue reac- rarely, ulceration. The histologic changes of spongiotic
tion pattern, followed by the pattern of inflammation. dermatitis typically affect the epidermis and sometimes
Detailed descriptions of this approach, championed ini- upper dermis, while the lower dermis, follicular infundib-
tially in the teachings of Wallace Clark, have been fur- ula, and acrosyringia are spared. The cardinal histologic
ther popularized and refined by Ackerman, Weedon, and feature of the spongiotic (eczematous) epidermal reaction
LeBoit. The tissue reaction pattern is a distinctive group of pattern is spongiosis, seen histologically as an increase in
1
