Diagnostic Gynecologic and Obstetric Pathology, Second Edition

1214 Pages·2011·186.95 MB·English

by  Christopher P. Crum

DIAGNOSTIC
GYNECOLOGIC
AND OBSTETRIC
PATHOLOGY

SECOND EDITION
DIAGNOSTIC
GYNECOLOGIC
AND OBSTETRIC
PATHOLOGY
Editors: Associate Editors:
Christopher P. Crum, MD Theonia K. Boyd, MD
Professor of Pathology Associate Professor of Pathology
Harvard Medical School Harvard Medical School
Director, Division of Women’s and Perinatal Pathology Department of Pathology
Department of Pathology Children’s Hospital Boston
Brigham and Women’s Hospital Brigham and Women’s Hospital
Boston, Massachusetts Boston, Massachusetts
Marisa R. Nucci, MD Scott R. Granter, MD
Associate Professor of Pathology Associate Professor of Pathology
Harvard Medical School Harvard Medical School
Division of 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
Hope K. Haefner, MD
Kenneth R. Lee, MD
Professor
Associate Professor of Pathology Department of Obstetrics and Gynecology
Harvard Medical School The University of Michigan Hospitals
Division of Women’s and Perinatal Pathology Ann Arbor, Michigan
Department of Pathology
Brigham and Women’s Hospital William A. Peters III, MD
Boston, Massachusetts Clinical Professor
Department of Obstetrics and Gynecology
University of Washington
Seattle, Washington
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
DIAGNOSTIC GYNECOLOGIC AND OBSTETRIC PATHOLOGY ISBN: 978-1-4377-0764-9
Copyright © 2011 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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Previous edition copyrighted 2006
Library of Congress Cataloging-in-Publication Data
Diagnostic gynecologic and obstetric pathology / editors, Christopher P. Crum, Marisa R. Nucci,
Kenneth R. Lee ; associate editors, Theonia K. Boyd … [et al.].—2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4377-0764-9 (hardcover : alk. paper)
1. Gynecologic pathology. 2. Pregnancy—Complications. 3. Generative organs,
Female—Diseases—Diagnosis. I. Crum, Christopher P. II. Nucci, Marisa R. III. Lee, Kenneth R.,
1941–
[DNLM: 1. Genital Diseases, Female—pathology. 2. Pregnancy Complications—pathology.
WP 140]
  RG77.D53 2011
  618.1′07—dc22
2010044236
Acquisitions Editor: William Schmitt Senior Project Manager: Sharon Corell
Senior Developmental Editor: Kathryn DeFrancesco Project Manager: Joanna Dhanabalan
Publishing Services Manager: Patricia Tannian Design Direction: Steven Stave
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Printed in the United States of America www.elsevier.com | www.bookaid.org | www.sabre.org
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To Tucker
Christopher P. Crum
To my husband, Branch, my two beautiful sons, Julian and Cole,
and my parents, Dr. Maria Bergamo-Nucci and Dr. Cyrus Nucci
Marisa R. Nucci
To Kathleen
Kenneth R. Lee

Contributors
Emily J. Amarosa, MD Scott R. Granter, MD
Resident Associate Professor of Pathology
Department of Obstetrics and Gynecology Harvard Medical School
University of Washington Medical Center Department of Pathology
Seattle, Washington Brigham and Women’s Hospital
Boston, Massachusetts
Theonia K. Boyd, MD
Associate Professor of Pathology Hope K. Haefner, MD
Harvard Medical School Professor
Department of Pathology Department of Obstetrics and Gynecology
Children’s Hospital Boston The University of Michigan Hospitals
Brigham and Women’s Hospital Ann Arbor, Michigan
Boston, Massachusetts
Jonathan L. Hecht, MD, PhD
Eleanor Y. Chen, MD, PhD Associate Professor of Pathology
Research Fellow Harvard Medical School
Division of Women’s and Perinatal Pathology Department of Pathology
Department of Pathology Beth Israel Deaconess Medical Center
Brigham and Women’s Hospital Boston, Massachusetts
Boston, Massachusetts
Michelle S. Hirsch, MD, PhD
Edmund S. Cibas, MD Assistant Professor of Pathology
Associate Professor of Pathology Harvard Medical School
Brigham and Women’s Hospital Division of Women’s and Perinatal Pathology
Boston, Massachusetts Department of Pathology
Brigham and Women’s Hospital
Christopher P. Crum, MD Boston, Massachusetts
Professor of Pathology
Harvard Medical School Mark D. Hornstein, MD
Director, Division of Women’s and Perinatal Pathology Associate Professor of Obstetrics,
Department of Pathology Gynecology, and Reproductive Biology
Brigham and Women’s Hospital Harvard Medical School
Boston, Massachusetts Director, Division of Reproductive Endocrinology
Department of Obstetrics and Gynecology
Ronny I. Drapkin, MD Brigham and Women’s Hospital
Assistant Professor of Pathology Boston, Massachusetts
Harvard Medical School
Associate Pathologist Eric Huang, MD, PhD
Department of Pathology Clinical Fellow in Cytology
Brigham and Women’s Hospital Department of Pathology
Principal Investigator, Dana Farber Cancer Institute Brigham and Women’s Hospital
Boston, Massachusetts Boston, Massachusetts
Linda R. Duska, MD Elke A. Jarboe, MD
Associate Professor of Obstetrics and Gynecology Assistant Professor
Department of Obstetrics and Gynecology Department of Pathology
Division of Gynecologic Oncology University of Utah
University of Virginia Health Sciences Center Salt Lake City, Utah
Charlottesville, Virginia
David W. Kindelberger, MD
Ann K. Folkins, MD Instructor in Pathology
Clinical Fellow in Pathology Harvard Medical School
Harvard Medical School Division of 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
vii
Diagnostic Gynecologic and Obstetric Pathology
Jeffrey F. Krane, MD Joel M. Palefsky, MD
Assistant Professor of Pathology Professor, Laboratory Medicine, Medicine and Stomatology
Harvard Medical School University of California at San Francisco
Department of Pathology Director, UCSF General Clinical Research
Brigham and Women’s Hospital University of California at San Francisco
Boston, Massachusetts San Francisco, California
Alvaro C. Laga, MD Mana M. Parast, MD
Research Fellow in Pathlogy Assistant Professor
Harvard Medical School Department of Pathology
Department of Pathology University of California, San Diego
Brigham and Women’s Hospital San Diego, California
Boston, Massachusetts
William A. Peters III, MD
Alexander J.F. Lazar, MD, PhD Clinical Professor
Associate Professor of Pathology and Dermatology Department of Obstetrics and Gynecology
Department of Pathology University of Washington
University of Texas M.D. Anderson Cancer Center Seattle, Washington
Houston, Texas
Alvaro P. Pinto, MD
Kenneth R. Lee, MD Associate Professor of Pathology
Associate Professor of Pathology Universidade Federal do Parana
Harvard Medical School Curitiba, Parana, Brazil
Division of Women’s and Perinatal Pathology Director and Associate Pathologist
Department of Pathology Annalab Cytopathology and Surgical Pathology Laboratory
Brigham and Women’s Hospital Curitiba, Parana, Brazil
Boston, Massachusetts
Bradley J. Quade, MD
Fabiola Medeiros, MD Associate Professor of Pathology
Assistant Professor of Laboratory Medicine and Pathology Harvard Medical School
Department of Pathology Division of Women’s and Perinatal Pathology
Mayo Clinic Department of Pathology
Rochester, Minnesota Brigham and Women’s Hospital
Boston, Massachusetts
Michael G. Muto, MD
Associate Professor of Obstetrics, Gynecology and Peter G. Rose, MD
Reproductive Biology Professor and Director of Gynecologic Oncology
Harvard Medical School Cleveland Clinic Foundation
Division of Obstetrics and Gynecology Cleveland, Ohio
Department of Obstetrics and Gynecology
Brigham and Women’s Hospital Aasia Saleemuddin, MD
Boston, Massachusetts Clinical Fellow in Obstetrics, Gynecology and Reproductive
Biology
George L. Mutter, MD Brigham and Women’s Hospital
Associate Professor of Pathology Boston, Massachusetts
Harvard Medical School
Division of Women’s and Perinatal Pathology Kathleen F. Sirois
Department of Pathology Laboratory Specialist, Placental-Perinatal Service
Brigham and Women’s Hospital Division of Women’s and Perinatal Pathology
Boston, Massachusetts Department of Pathology
Brigham and Women’s Hospital
Alessandra F. Nascimento, MD Boston, Massachusetts
Assistant Professor of Pathology
Harvard Medical School Elizabeth A. Stewart, MD
Associate Pathologist Professor of Obstetrics and Gynecology
Department of Pathology Mayo Clinic
Brigham and Women’s Hospital Rochester, Minnesota
Boston, Massachusetts
Patou Tantbírójn, MD
Marisa R. Nucci, MD Instructor, Division of Gynecologic Pathology
Associate Professor of Pathology Department of Obstetrics and Gynecology
Harvard Medical School Faculty of Medicine, Chulalongkorn University
Division of Women’s and Perinatal Pathology King Chulalongkorn Memorial Hospital
Department of Pathology Bangkok, Thailand
Brigham and Women’s Hospital
viii Boston, Massachusetts
Preface
Any comprehensive textbook on obstetric and gyneco- but of repeated self-assessment. A critical eye, both for
logic pathology should fulfil at least three goals; First, authoritative opinions and newly touted biomarker
provide general or introductory information to the stains, is always in order, with the welfare of the patient
medical student or clinical resident with limited experi- placed in the center.
ence in pathology. Second, school the pathology resident This book is written and edited by members of the
or practicing pathologist in the pathologic diagnosis of Women’s and Perinatal Pathology Division at Brigham
common disorders. Third, assist in managing both diag- and Women’s Hospital with their colleagues and leading
nostically difficult and rare cases. The degree to which a authorities in clinical obstetrics and gynecology. Its goal
single book accomplishes these tasks depends on both its is to provide a comprehensive review of gynecologic and
mission and the expectations of the reader. gestational pathology. To assist readers from different
Both academic and practice-based pathologists face backgrounds, the approach to most of the topics is prac-
increasing demands. In this pressurized setting, the ideal tice-oriented, each beginning with a discussion of the
book would deliver a formula to solve the complex patient at risk and ending with management.
pro blems that characterize modern day practice. Changes from the prior edition include the expansion
Unfortunately, simplicity is a thing of the past. The of the discussion on ovarian carcinogenesis, including the
influx of emerging knowledge has taken diagnostic increasingly recognized role of the fallopian tube. The
pathology from a purely descriptive field of “diagnosis different aspects of this story, be it the routine examina-
by decree” to one in which visually based assumptions tion of the presumably non-neoplastic tube (Chapter 21),
by both general pathologists and subspecialists are con- the role of the tube in carcinogenesis (Chapter 24),
stantly challenged by emerging data. We still have the the systematic examination of the tube following risk-
“Aunt Minnies,” those rare but familiar pathologic dis- reducing surgery (Chapter 25), and the incidental discov-
orders that can be recognized instantly in a hematoxylin ery of early tubal cancer in advanced malignancies
and eosin–stained section, but we also encounter condi- (Chapter 27), are each addressed.
tions that vex us daily and for which an objective marker The pathologist makes one of his or her most impor-
is essential for proper management. In this setting of tant contributions to the management of ovarian neopla-
inquiry the task can become complex, and the obvious sia in the frozen-section room. Thus Chapter 26 is written
question faced by any author is always whether to avoid specifically for the challenges faced there. Sex cord–
controversy in order to avoid confusing the reader. For stromal tumors include the rarest and most confusing
example, under ideal conditions, an inquiring patholo- entities and thus are organized in decision-tree algo-
gist who orders a p16 immunohistochemical stain to rithms in Chapter 30. Gestational disorders have been
confirm the diagnosis in a problematic cervical biopsy expanded to address trophoblastic disease in a separate
might be able to save the patient an unnecessary cone chapter (Chapter 33), fetal death (Chapter 35), and a
biopsy. Unfortunately, the stain might produce a false systematic approach to constellations, or groups of related
positive, or a well-intentioned pathologist might interpret abnormalities seen in association with toxemia of preg-
a positive stain as tantamount to a high-grade precancer. nancy, fetal vascular thrombosis, and infection, among
In navigating both the nuances of staining and its clinical other conditions (Chapter 36). Nearly 800 images have
significance, the pathologist might veer in the wrong been replaced or added, and a series of bullet points has
direction when a simple estimate based on the hema- been inserted at the end of each chapter to stress some of
toxylin and eosin–stained section would have done less the more important practice issues.
harm. Similarly the wary pathologist who performs a p53 Throughout the book, the reader is introduced to con-
immunostain on an unusual-appearing gland in an endo- siderable pathologic detail, on the premise that every-
metrial curetting from a postmenopausal woman might one—medical student, clinical resident, pathologist in
ultimately diagnose a potentially lethal serous carcinoma, training and practicing pathologist—must be fully aware
or he or she might over-classify a benign condition. Such of the degrees of certainty and pitfalls of pathologic
perils await the pathologist who earnestly takes new diagnosis if they are going to care for women with
knowledge and applies it to patient care. The pathologist reproductive tract diseases. Diagnostic pathology can be
learns to address these challenges in daily practice by simplified only by confronting its myriad complexities,
constantly sorting through many diagnostic options, thus using a wide range of tools. Some answers are simple,
gaining experience that is not the product of assumptions but most belie a complexity that will become evident,
ix