Gynecologic and Obstetric Pathology: High-Yield Pathology. Part 2 PDF
Preview Gynecologic and Obstetric Pathology: High-Yield Pathology. Part 2
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 Copyright © 2016 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/ permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-1-4377-1422-7 Content Strategist: William R. Schmitt Senior Content Development Specialist: Jennifer Ehlers Publishing Services Manager: Catherine Jackson Design Direction: Paula Catalano Printed in China. Last digit is the print number: 9 8 7 6 5 4 3 2 1 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
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