OVARIAN PATHOLOGY

BENIGN CYSTS
Follicular cysts
 2.5 to 10 cm (< 2.5 cm = cystic follicle).
 unilateral with a thin, smooth lining
 inner layer of granulosa cells
 outer layer of theca cells
Corpus luteum cysts
 >3 cm in diameter
 filled hemorrhagic fluid with yellow lining
 undulating wall of luteinized granulosa cells
 intervening theca cells
Surface epithelial inclusion cysts
 < 1 cm in diameter
 single layer of bland flat, cuboidal, or ciliated
columnar cell
 Psammoma bodies may be seen
 Serous epithelial neoplasms arise from
these inclusions.
Endometriosis
 endometrial epithelium or glands
and stroma with associated hemosiderin-laden
macrophages and fibrosis are diagnostic
SURFACE EPITHELIAL TUMORS (SET)
Serous cystadenoma
 MC SET
 reproductive-aged women
 unilocular; smooth-walled cysts
 single layer of columnar and usually ciliated
epithelium (resemblance to fallopian tube).
 cystadenofibromas = cysts surrounded by a
variable amount of fibrotic tissue
 adenofibromas = lesions without a cystic
component
 surface papillomas = small papillary growths
with bland, serous-type epithelium
 CK7, EMA, and WT1 positive
CK20 negative

Serous borderline tumors/atypical proliferative serous

tumors (SBT/APST)
 Perimenopausal
  Predominantly cystic
 Papillary excrescences with hierarchically
branching stromal cores and epithelial
detachment
 Moderate cytologic atypia with stratification and
mildly increased mitosis
 No stromal invasion
 Psammoma bodies are frequently seen
Serous borderline tumor-micropapillary variant /
Non-invasive low-grade serous carcinoma (Non-
invasive LGSC)
 non-hierarchical branching architecture
 micropapillary pattern, long thin filiform
projections (five times as long as they are wide)
 mitotic index is low but typically higher than in
SBT/APST
 requires at least one confluent area of
micropapillarity measuring 5 mm in one
dimension and nuclear atypia greater than that
allowed in an SBT/APST
Serous borderline tumors with microinvasion
 microinvasion has been applied to clusters of cells
in the stroma with abundant eosinophilic
cytoplasm, that measure < 5 mm
in greatest dimension
Low-grade serous (adeno)carcinoma (LGSC)
 commonly presents as bilateral
 multiloculated cysts and polypoid
 necrosis is rare
 calcification is frequent and extensive
 mild to moderate nuclear atypia, and may contain
a single prominent nucleolus
 mitotic activity is low (usually < 12 mitotic
figures per 10 HPF)
High-grade serous (adeno)carcinoma (HGSC)
 commonly presents as bilateral
 multiloculated cysts and solid exophytic growth
 extensive hemorrhage and necrosis
 calcification is frequent and extensive
 nuclei are large, hyperchromatic and
pleomorphic, often with large bizarre
or multinucleated forms
 mitotic activity is high (usually ≥12 mitotic
figures per 10 HPF)
Mucinous cystadenomas
 unilateral, multiloculated, and large (up to 50 cm)
 single layer of tall columnar cells with bland
basal nuclei, most often of intestinal type
 benign mucinous tumor has a dense fibromatous
stroma (mucinous adenofibroma)
Mucinous borderline tumour /
Atypical proliferative mucinous
tumour (MBT/APMT)
 unilateral, multiloculated
  perimenopausal
 thick wall sometimes with papillary excrescences
 stratified, tufted intestinal-type (more common)
or endocervical-type (less common; with
hierarchical branching) epithelial lining with mild
to moderate nuclear atypia
 The mitotic index varies from slight to brisk
 Pseudomyxoma ovarii (acellular pools of mucin
in the stroma) is present in about 20%
MBT/APMT with intraepithelial carcinoma
 has foci of marked nuclear atypia confined to the
epithelium
MBT/APMT with microinvasion
 foci of invasion either as small nests or as
individual eosinophilic cells
 size criterion for each focus has varied from 2 to 5
mm, with no requirement regarding
the number of foci
Mucinous adenocarcinoma
 perimenopausal
 large, typically unilateral, complex, solid and
cystic
 with benign, borderline and frankly
carcinomatous areas
 Two patterns of invasion are recognized. The
expansile pattern (more common) shows
crowded glands, little stroma, and, sometimes a
cribriform architecture.
 The destructive pattern (high risk of metastasis)
shows single glands or individual cells invading
>3 mm in two linear dimensions (>10 mm2 in
area)
 Mitosis is brisk with abnormal MFs
 Pseudomyxoma peritonei in 5%
 Primary tumors exhibit benign, borderline, and
malignant epithelium whereas metastatic tumors
are more uniformly malignant.
Endometriotic cyst (endometrioma)
 cystic forms of endometriosis
 can occasionally undergo malignant
transformation (endometrial ca and clear cell ca)
Endometrioid cystadenoma /
adenofibroma
 cystic lesion lined by benign endometrioid
epithelium with fibrotic stroma instead of the
endometrial stroma
Endometrioid borderline tumor/Atypical proliferative
endometrioid tumor (EBT/APET)
 show cytologic atypia and areas of confluent
epithelial proliferation without stromal support up
to 5 mm in maximal dimension
Endometrioid carcinoma
 cystic or solid
 back-to-back arrangement of villoglandular or
tubular glands with confluent or cribriform pattern
  squamous metaplasia is common
 destructive growth pattern with obvious stromal
invasion in the form of glands, cell clusters or
individual cells, disorderly infiltrating the stroma
Clear cell cystadenoma / adenofibroma
 cystically dilated lined by bland cuboidal to
flattened cells with clear or eosinophilic
cytoplasm
 fibromatous stroma
Clear cell borderline tumor / Atypical proliferative
clear cell tumor (CCBT/APCCT)
 adenofibromatous tumors with atypia of the
glandular epithelium but without stromal invasion
Clear cell carcinoma
 typically unilateral with a mean size of 15 cm
 tubulocystic, papillary and solid patterns
 cells vary from polygonal to cuboidal to flattened
and the cytoplasm ranges from clear
to less commonly eosinophilic.
 Hobnailing (cells with apical hyperchromatic
nuclei)
 mitosis is uncommon
 may arise in the setting of endometriosis
Benign Brenner tumour
 fifth to seventh decades
 nests of bland, transitional-type cells (resembling
urothelial cells) within a fibromatous stroma.
 in some cases, nuclei contain longitudinal
grooves
 mitosis is rare
Borderline Brenner tumor / Atypical proliferative
Brenner tumor
 fifth to seventh decades
 almost always unilateral
 large, cystic tumors with papillary masses
 cytologic features are similar to those in benign
transitional cell tumors, but occasional atypia and
mitotic activity are present.
Malignant Brenner tumor
 irregularly shaped masses of malignant
transitional type cells and rarely of squamous cells
 stratified epithelium exhibiting
hyperchromatic and pleomorphic nuclei
and prominent mitotic activity
 invasion is difficult to identify due to compact
stroma
 there is always an identifiable benign or
borderline component
Transitional cell carcinoma
 purely malignant
 no identifiable benign or borderline component
Seromucinous cystadenoma / adenofibroma
 unilocular cyst with a smooth surface and
inner lining
  lined by a variable admixture of serous and
mucinous cells (endocervical-type)
 endometrioid and less often transitional or
squamous cells may be seen.
Seromucinous borderline tumor / Atypical
proliferative seromucinous tumor
 typically unilocular, smooth-surfaced and contain
viscid fluid
 friable papillary excrescences
 architectural features similar to SBT/APST
 The epithelium lining the papillae is typically
stratified and is composed mostly of
endocervical-type mucinous or serous epithelium
 nuclei are low-grade; mitotic figures are
infrequent
Seromucinous carcinoma
 Papillary excrescences were present on
the inner lining of the cysts and on the
surface
 epithelial stratification closely resembling serous
tumors
 pattern of invasion is cribriform
 mitotic index tends to be low (< 5 mitotic
figures/10 HPF)
Undifferentiated carcinoma
 solid masses with extensive necrosis
 cells are often monotonous and
non-cohesive
 they are typically round but they may be spindle-
shaped
 mitotic activity is high
SEX CORD STROMAL TUMORS
Adult granulosa cell tumors (AGCTs)
 low-grade malignancy
 commonly in postmenopausal
 The cut surface is soft and yellow-tan with cysts
and hemorrhage
 bland with oval nuclei, longitudinal nuclear
grooves (coffee-bean), and a low mitotic rate
 Diffuse (most common), trabecular, micro and
macrofollicular, and gyriform pattern
 The microfollicular contain characteristic Call-
Exner bodies consisting of a small collection of
eosinophilic material lined by palisaded granulosa
cells
 inhibin, calretinin, FOXL2 positive
Juvenile granulosa cell tumors (JGCTs)
 children and young adults
 solid sheets of cells mixed with small follicle-like
spaces with basophilic or eosinophilic secretions
 no Call-Exner
 no coffee-bean nuclei
 Mitotic figures are typically frequent and striking
nuclear atypia is seen
  inhibin, calretinin, FOXL2 positive
Fibroma
 MC sex cord-stromal tumors
 unilateral, solid, firm, white-gray cut surface
 interlacing bundles and storiform areas
of spindle cells that show no atypia and few
mitoses
 Meig syndrome (fibroma, ascites, and pleural
effusion)
 Gorlin syndrome (basal cell nevus syndrome)
 vimentin positive
 inhibin and calretinin variable

Thecomas
 postmenopausal
 lobulated, yellow-tan cut surface
 round to oval, lipid-laden theca cells in a
fibromatous stroma with little atypia or mitotic
activity
 oil red o positive in RFS
 inhibin positive
Sertoli-Leydig cell tumors (SLCT)
 yellow-orange to red-brown, and frequently have
a nodular appearance with a central scar
 Leydig cells often show lipidization
with foamy rather than eosinophilic cytoplasm
Leydig cell tumors
 benign steroid cell neoplasms
 arise within the ovarian hilus
 cut surface is yellow-brown with areas of
hemorrhage
 large polygonal cells with foamy or granular
eosinophilic cytoplasm and round nuclei
grow in cellular clusters separated by pink
acellular areas
 Reinke's crystals (intracytoplasmic eosinophilic
rod-like structures) must
be identified.
Sertoli cell tumors
 low-grade, nonfunctioning tumors
 yellow-tan, solid, lobulated tumors
 closely packed tubules separated by fibrous
stroma
 tubules are lined by cuboidal to columnar cells
with abundant pale eosinophilic cytoplasm with
little atypia or
mitotic activity
Sex cord tumour with annular tubules (SCAT)
 a component of Peutz-Jeghers syndrome
 well-circumscribed, ring-shaped tubules that
contain central hyalinized material
 tubules are lined by cells with pale cytoplasm
oriented toward the center of the
 tubule (antipodal), with peripheral elongated
nuclei
GERM CELL TUMOR (GCT)
Mature teratomas
 MC ovarian GCT
 usually cystic (mature cystic), less commonly
solid (mature solid) with a single solid nodule
(Rokitansky protuberance)
 may contain fat, teeth, bone, and many other
tissue types
 dermoid cyst is commonly used to when lined by
squamous epithelium with appendages
 can have malignant component (malignant
teratoma) – i.e SCCa, AdenoCa, carcinoid,
sebaceous Ca
Immature teratomas
 unilateral and typically have solid and cystic
components
 they contain immature or primitive tissue (derived
from any or all three germ cell layers)
 MC immature element is neuroectodermal and
consists of rosettes, masses, or tubules of
primitive neural cells
 graded based on the relative amount of immature
tissue (neuroectoderm) present
 Grade 1 = immature neuroectoderm occupies
< 1 LPF
 Grade 2 = immature neuroectoderm occupies
1-3 LPF
 Grade 3 = immature neuroectoderm occupies
≥ 4 LPF
 “Grade 0” = mature peritoneal implants
(so-called peritoneal gliomatosis)
Struma Ovarii
 MC monodermal teratoma
 mature teratoma composed either exclusively or
predominantly (>90 %) of thyroid tissue.
 secondary changes such as hyperplasia, adenoma,
and even carcinoma may be seen
Other Monodermal Teratomas
 Carcinoid – 2nd MC
 Neuroectodermal-type
 Prolactinoma
 Corticotroph cell adenoma
Dysgerminoma
 MC malignant GCT
 pure dysgerminoma or mixed GCT
 large and solid with a smooth external surface and
a lobulated gray-tan cut surface.
 nests and sheets of uniform large polygonal cells
with abundant granular eosinophilic or clear
cytoplasm, large nuclei, and
prominent nucleoli.
 the nuclear membrane is characteristically
angulated (“squared off”)
 Tumor cells are separated by a lymphocyte-rich
fibrous stroma
 PLAP, CD117 (c-KIT), SALL4, OCT-4 positive

Yolk sac tumors

 aka endodermal sinus tumors
 elevated AFP
 unilateral and large, soft, well encapsulated with a
smooth external surface and a solid and cystic
yellow to tan cut surface
 The microcystic/reticular pattern is the MC
variant and is composed of small cystic spaces
lined by cuboidal to columnar cells with clear
cytoplasm and large hyperchromatic nuclei
 The endodermal sinus/classic pattern is the 2nd
MC pattern. This pattern features characteristic
Schiller-Duvall bodies (rounded fibrovascular
papillae containing
a single central capillary lined by columnar tumor
cells)
Embryonal carcinoma
 rare, almost exclusively in children and young
women
 elevated ß-hCG levels
 large, solid tumour with soft and fleshy with
variably sized cysts on cut section
 large anaplastic cells with pale eosinophilic
vacuolated cytoplasm that grow in sheets and
nests
 nuclei are hyperchromatic with prominent
nucleoli and atypical MFs
Mixed germ cell tumors
 MC combination is dysgerminoma and yolk sac
tumor
Non-gestational choriocarcinoma
 rare
 markedly elevated ß-hCG
 hemorrhagic, soft, and tan
 composed of cytotrophoblast and
syncytiotrophoblast cells in plexiform pattern
GERM CELL – SEX CORD – STROMAL TUMOR
Gonadoblastoma
 rare
 contains both germ cell and sex cord-stromal
components
 benign unless a malignant GCT component
(dysgerminoma in half of cases)
 solid tan or white and measure up to 2–3 cm with
gritty cut surface is common
 nests of predominantly sex cord-like cells
distributed around hyalinized and calcific acini
separated by fibrous stroma or Leydig cells
FALLOPIAN TUBE PATHOLOGY
 BENIGN CYSTS
Paratubal cysts
 (Mesonephric/Wolffian) lined by simple or
stratified epithelium
 (Paramesonephric/Mullerian) lined by ciliated or
nonciliated columnar epithelium
UTERINE CORPUS PATHOLOGY
 ENDOMETRIUM

NORMAL ENDOMETRIUM
Menstrual phase endometrium
 characterized by glandular and stromal
breakdown
Proliferative phase endometrium
 glands are simple tubular structures with
pseudostratified ciliated epithelium with loose
stroma
 mitosis can be seen
 gland-to-stroma ratio of about 1:1
Ovulation as occurs on day 14 of the cycle.
Early secretory phase endometrium
 DAYS 16-18; 2nd–4th POD
 The initial morphological feature of ovulation are
the subnuclear vacuoles (DAY 16)
 Maximal between DAY 17-18 of the cycle (3rd
and 4th POD)
 It is assumed that ovulation has occurred when
there are subnuclear vacuoles in at least 50% of
the cells in at least 50% of the glands
Mid secretory phase endometrium
 DAYS 19-23; 5th-9th POD
 Cytoplasmic vacuoles become supranuclear
 Luminal secretions
INITIAL - DAY 19
MAXIMAL - DAY 21-22
 Glands are usually angular in shape
 Stromal edema maximal at DAY 22 - best time
for implantation ("day 22, I'm ready for you")
 DAY 23: prominent spiral arterioles (thickened
walls, coiling and endothelial proliferation)
Late secretory phase endometrium
 DAYS 24-28; 10th -14th POD
 Day 24: perivascular predecidualization (stromal
cell hypertrophy with accumulation of
cytoplasmic eosinophilia); serrated / tortuous
glands
 Day 26: confluence of predecidual tissue; stromal
granulocytes (probably lymphocytes) appear
 Day 28: shedding, also called glandular and
stromal breakdown; prominent necrosis and
hemorrhage; predecidual stroma and glandular
exhaustion; nuclear dust at base of glandular
epithelium; condensed stroma with overlying
papillary-syncytial change; intravascular fibrin
thrombi; stromal granulocytes
Atrophy

CHANGES IN PREGNANCY & HORMONE THERAPY
 BENIGN DISEASES
Acute endometritis
 dense neutrophilic infiltration of the stroma
forming microabscesses, and in severe cases, up
to the epithelium of non-menstruating
endometrium
 uncommon and is usually seen only
in postpartum or postabortive endometrium
Chronic endometritis
 presence of plasma cells in the endometrial stroma
 Chlamydia trachomatis, Ureaplasma urealyticum,
CMV, and HSV.
 Actinomyces israelii or Neisseria gonorrheae
(mixed acute and chronic)
 Mycobacterium tuberculosis, fungal, sarcoidosis,
and ablation therapy (granulomatous)
Tubal (ciliated cell) metaplasia
 MC metaplasia
 foci of normal tubal epithelium within the
endometrial glands
Squamous metaplasia
 caused by chronic irritation and
often takes the form of squamous morules
Eosinophilic metaplasia
 glandular epithelium with abundant eosinophilic
cytoplasm and a central round to oval nucleus
 often associated with a neutrophilic infiltrate,
the formation of small epithelial papilla, and mild
nuclear atypia
Mucinous metaplasia
 consists of columnar epithelium with basally
located oval nuclei and abundant apical mucin
Osseous metaplasia
 Osseous tissue in the endometrial stroma
 associated with a previous
history of abortion or instrumentation
Endometrial polyps
 3 “major” criteria
 Varisized glands
 Fibrotic stroma
 Sclerosed or thick-walled vessels
 Other criteria
 Gross polypoid appearance
 Epithelial lining on 3 sides
Adenomyomatous polyps
 polyps with stromal smooth muscle often near
blood vessels
Atypical polypoid adenomyoma
 most commonly
located in the lower uterine segment
 crowded irregular endometrial glands with a
complex architecture and mild to moderate
cytologic atypia in stroma that is predominantly
composed of smooth muscle
  A characteristic histological feature that is present
in most, but not all, cases is abundant squamous
morule
formation
Disordered proliferative endometrium
 mixture of cystically dilated, budding, and tubular
glands in a proliferative setting, with
only focal glandular crowding. It occurs during
anovulatory cycles.
Endometrial stromal breakdown
 troma takes on a blurry blue look as it condenses
into
small dense aggregates (“blue balls”)
 associated surface epithelium shows eosinophilic
metaplasia, becoming almost oncocytic in
appearance
EPITHELIAL TUMORS (BENIGN)
Endometrial hyperplasia without atypia
 Benign endometrial hyperplasia
 Simple and complex hyperplasia without atypia
 ≥ 5 mm thick
 Glands
vary in size and shape and may be separated by
varying amounts of stroma including back-to-back
crowding
 The epithelium is
of stratified columnar type, with frequent
mitotic figures.
EPITHELIAL TUMORS (PRECURSOR)
Atypical hyperplasia /
Endometrioid intraepithelial
neoplasia
 Simple and complex hyperplasia with atypia
 crowded aggregates of cytologically altered
tubular or
branching glands
 distinction between endometrial
hyperplasia without atypia and AH/ EIN
is based on nuclear atypia which may
include enlargement, pleomorphism,
rounding, loss of polarity and nucleoli
EPITHELIAL TUMORS (MALIGNANT)
Endometrioid carcinoma (Type I)
 raised to exophytic, pink tan, hemorrhagic mass
 irregular, confluent, complex glandular or
villoglandular structures lined by pleomorphic
stratified columnar cells with pleomorphic nuclei
 invasion is recognized by the presence of an
irregular endometrial-myometrial border or by an
associated desmoplastic and inflammatory stromal
response
 Endometrioid carcinoma with squamous
differentiation defined as the
presence of sheets of squamous cells usually non
keratinizing
  Endometrioid carcinoma with secretory
differentiation glands composed of cells with
supra or subnuclear
vacuoles resembling secretory endometrium
 Grade 1 = 5% or less of solid growth
 Grade 2 = 6 and 50% solid growth
 Grade 3 = ≥ 50 % solid growth
Mucinous carcinoma (Type I)
 > 50% of the neoplasm is composed of
mucinous cells
 similar to mucinous carcinoma of the
endocervix
 The panel of estrogen receptor (ER), vimentin,
CEA, and
p16 can usually reliably distinguish between
primary endometrial and
endocervical adenocarcinoma, since ER and
vimentin will be positive in
endometrial and negative in endocervical
adenocarcinoma, while CEA
will only be positive in endocervical
adenocarcinomas. Endocervical carcinomas are
typically diffusely positive for p16 whereas
endometrial carcinomas show only patchy
positivity.
Serous carcinoma (Type II)
 complex papillary architecture
 papilla is lined by
epithelial cells with large atypical nuclei,
prominent nucleoli, and brisk mitotic activity
 Deep myometrial
and lymphovascular invasion are often present
 p16 and PTEN stains are sensitive and specific
for high-grade serous adenocarcinoma
Clear cell adenocarcinoma (Type II)
 papillary, solid,
and tubular structures, often admixed
 characteristic feature is the presence of hyalinized
stromal cores
 pleomorphic cells with hobnail nuclei (nuclei that
jut into the gland lumen), abundant clear or
eosinophilic cytoplasm, and distinct cell borders
Carcinosarcoma (malignant mixed mullerian tumor or
MMMT)
 presence of both malignant epithelial and
mesenchymal (sarcomatous)
elements.
 MYOMETRIUM

MESENCHYMAL TUMORS
Leiomyoma
 white-tan cut surface and are sharply demarcated
(pseudo-encapsulated) from the adjacent
myometrium
 interlacing fascicles of closely packed cells with
uniform elongated nuclei and eosinophilic
cytoplasm
Cellular leiomyomas
 increased cellularity with sheets of
spindle cells
 no pleomorphism,
increased mitotic activity, and necrosis
Epithelioid leiomyomas
 predominantly epithelioid cells with
eosinophilic to clear cytoplasm
 no pleomorphism,
increased mitotic activity, and necrosis
Symplastic (atypical / bizarre) leiomyoma
 scattered enlarged, markedly atypical cells,
often with multiple nuclei
 mitotic count is still < 10 / 10 HPF
Mitotically active leiomyoma
 > 10 / 10 HPF
 lacks cytological atypia and tumor cell necrosis
Lipoleiomyoma (lipomatous variant)
 classic leiomyoma which contains islands of
mature adipocytes
 other heterologous elements may also be seen
Myxoid leiomyoma
 hypocellular with cells widely separated
by myxoid acid-mucin stroma
Benign metastasizing leiomyoma
 classic leiomyoma but
it is found in the lungs of women with a
history of typical uterine leiomyomas
Intravascular leiomyomatosis
 classic leiomyomas that grow into the lumen of
the uterine or pelvic veins.
 free floating within the lumen or adherent to the
vessel wall.
 diagnosis of IVL is reserved for cases where
worm-like growths of smooth muscle are
observed, grossly.
Diffuse leiomyomatosis
 Innumerable hypercellular tumour nodules that
merge
Metastasizing leiomyoma
 typical leiomyoma but
it is found in the lungs of women
 prior history of hysteroscopy with dilatation and
curettage,
 or other procedures such as myomectomy or
hysterectomy.
Smooth muscle tumour of
uncertain malignant potential (STUMP)
 neoplasm that fall between leiomyoma and
leiomyosarcoma
 banal leiomyoma with tumor cell necrosis; (2)
necrosis of uncertain type with ≥10 mitoses/
10 HPFs; (3) marked diffuse atypia and borderline
mitotic counts; (4) tumors with cytologic atypia
where it is difficult to be sure about mitotic
counts; and (5) tumors with early necrosis that is
difficult to classify
Leiomyosarcoma
 cut surface is typically
soft, bulging, fleshy, necrotic and haemorrhagic
with irregular margins
Spindle cell leiomyosarcomas
 Cells with eosinophilic fibrillary cytoplasm and
elongated blunt-ended nuclei
 Diffuse moderate to severe cytologic atypia
 ≥ 10 mitoses/10 HPFs
 CTCN – coagulative tumor cellular necrosis
defined as abrupt transition form viable cells
without a transition zone of hyalinization or
granulation
Epithelioid leiomyosarcomas
 ≥ 50% of the cells with an “epithelial-like”
appearance
 Cells with eosinophilic granular or clear
cytoplasm and round or angular nucleus
 ≥ 5 mitoses/10 HPFs, diffuse moderate to severe
cytologic atypia, or tumor cell necrosis
Myxoid leiomyosarcomas
 Typically hypocellular with abundant
extracellular myxoid matrix
 Cells with stellate, spindle, or abundant cytoplasm
with marked degree of cytologic atypia
 Diagnosis based on finding moderate to severe
cytologic atypia or tumor cell necrosis, and in
their absence finding ≥ 2 mitoses / 10 HPFs
Endometrial stromal nodule
 grossly tan to yellow, well-circumscribed lesions
with a smooth border
 composed of cells that resemble proliferative-
phase endometrial stroma
 uniform small cells with scant cytoplasm, round
to oval nuclei and inconspicuous nucleoli and
minimal mitosis
 stain strongly and are diffusely positive with
CD10
Endometrial stromal sarcomas
 tan to yellow cut surface
with an infiltrative border into the surrounding
 myometrium, often with foci
of hemorrhage and necrosis
 cells same morphology with ESN but with higher
rate of mitosis, greater
nuclear pleomorphism, prominent stromal
vascularity, and areas of collagenized stroma
 Extensive lymphatic invasion is the hallmark of
the tumor
Mixed epithelial and mesenchymal tumours
Adenomyoma
 A benign tumour composed of a variable number
of endometrial glands and
endometrial-type stroma surrounded by
smooth muscle
Atypical polypoid adenomyoma
 polypoid lesion composed of glands
showing cytologic atypia and usually architectural
complexity set in a fibromuscular stroma
 often centered in the lower uterine segment
 There is often prominent squamous metaplasia
(morules)
Adenofibroma
 postmenopausal
 layer of epithelium with bland nuclear cytology
that overlies a cellular fibrous
stroma composed of fibroblasts and endometrial
stromal cells
Adenosarcoma
 postmenopausal
 arises most commonly from the endometrium
 benign or atypical glandular elements in a
malignant stroma that shows increased cellularity,
pleomorphism, and a mitotic rate of >2 mitotic
figures per 10 HPF
 It may show heterologous elements
 the stromal component is low-grade malignant.
 When ≥ 25% of the tumour contains a high-grade
sarcomatous component it is classified as an
“adenosarcoma with sarcomatous overgrowth.”
Carcinosarcoma
 biphasic tumour composed of highgrade
carcinomatous and sarcomatous elements
 The epithelium is most often of
endometrioid or serous and the mesenchyme is a
high-grade, non-specific
sarcoma
 GESTATIONAL TROPHOBLASTIC DISEAESE

Complete molar pregnancies

 diploid but may be either heterozygous (15% of
cases due to fertilization of an empty ovum by two
sperm) or homozygous (85% of cases due to
fertilization of an empty ovum by a single sperm
with subsequent duplication).
 larger uterus than expected for gestational age
 snow storm pattern without fetal parts
 serum hCG is usually elevated for gestational age
 markedly hydropic villi with central cistern
surrounded by trophoblastic proliferation
 atypia and mitosis maybe seen
 p57(KIP2) loss of expression
Early Complete Hydatidiform Mole
 Bulbous “club-shaped” terminal villi
 Hypercellular myxoid villous stroma with
karyorrhexis
 Labyrinthine network of villous stromal
canaliculi
 Focal hyperplasia of cytotrophoblast and
syncytiotrophoblast
Partial hydatidiform mole
 fertilization of a normal ovum by two sperm,
and so have a triploid karyotype
 normal, elevated, or even low serum hCG
 fetal parts are sometimes present
 demonstrate two intermixed villous populations,
consisting of enlarged hydropic villi and normal-
sized but fibrotic ones
 central cistern formation, scalloped (‘moth-
eaten’) villous contours, and round to oval
trophoblastic pseudo-inclusions are characteristic
 p57(KIP2) intact of expression
Invasive mole
 aka Chorioadenoma destruens (not
recommended)
  A hydatidiform mole, complete or partial, that
invades the myometrium and/or uterine
vasculature
 Persistent elevation of serum hCG after primary
evacuation
Choriocarcinoma
 malignant, trophoblastic tumour consisting of a
trimorphic proliferation of
intermediate trophoblastic cells
syncytiotrophoblast
cytotrophoblast
 absence of chorionic villi
 prominent foci of hemorrhage and necrosis
 All tumour cells express cytokeratin AE1/
AE3 and a high Ki-67 labelling index
(> 90%) is typically observed.
Placental site trophoblastic tumor
 neoplastic implantation site-type
intermediate trophoblast
 characteristic features include abundant
eosinophilic fibrinoid deposition and
dissection of individual smooth muscle cells
by the neoplastic cells
Epithelioid trophoblastic tumor
 very rare form of trophoblastic disease
 neoplastic chorionic-type intermediate
trophoblast
 composed of a uniform population of atypical
mononucleate cells arranged in sheets and
nests associated with eosinophilic material
and surrounded by necrotic debris