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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5186_Библиотеки_им_академика_М_И_Перельмана.pdf
Figure 6.85 Metastatic colorectal adenocarcinoma. Top: Metastatic colorectal carcinoma
oftensimulatesaprimaryovariantumor.Notethesmoothexternalcapsule.Bottom:Agarland
glandpatternandthepresenceofextensive“dirtycell”necrosissecondarytothepresenceof
necrotic cellular debris within gland lumens are characteristic of metastatic colorectal
carcinoma.
Figure 6.86 Metastatic gastric signet-ring adenocarcinoma (Krukenberg tumor).
Metastaticsignet-ringcarcinomasareoftenassociatedwithovarianstromalhyperplasia,which
maymimicastromalprocess.
CystsofFollicularOrigin
Cystsoffollicularoriginareclassifiedasfollicularorluteal,dependingonwhetherthecyst
liningiscomposedofnonluteinizedorluteinizedgranulosaandthecacells.Largerthan3cm
bydefinition, most cystsof follicular origindonot exceed 8cm in diameter.Ruptureof a
follicularorcorpuslutealcystmaycauseacuteabdominalpainorhemoperitoneum.
PolycysticOvarianDisease—SclerocysticOvaries
Sclerocysticovariesshowbilateralovarianenlargementwithnumerouscorticalcysts,most
measuringlessthan3cm,underlyingawhitefibrousbandofcorticaltissue.Theetiologyof
thisrelativelycommonconditionisheterogeneous,butinmanycasestheunderlyingdefect
has been attributed to insulin resistance of peripheral tissue, or an abnormality of the
hypothalamic–pituitary–ovarian axis. Patients present with anovulation, menstrual
dysfunction, and hyperandrogenemia (Polycystic Ovarian Syndrome, Stein–Leventhal
syndrome).
MassiveOvarianEdema
Massive ovarian edema occurs predominantly in children, adolescents, and young
women. The etiology is uncertain but is thought to be the result of partial lymphatic or
venousobstructionleadingtoaccumulationofedemafluidandovarianenlargement.Patients
present with abdominal pain, abdominal distention, or menstrual irregularities. Affected
patientsmayshowfeaturesofvirilism,hirsutism,and,rarely,precociouspseudopuberty.The
affected ovary is gelatinous because of fluid accumulation within the interstitium of the
ovary,separatingandsometimesinvolvingpreexistingfollicularstructures(79).
StromalHyperplasia
Stromalhyperplasia is foundpredominantlyin the postmenopausalage group. Theovaries
are enlarged bilaterally by hyperplastic stroma, which may contain luteinized cells. The
condition is benign and generally asymptomatic, often discovered incidentally during
surgeryforothercauses.
StromalHyperthecosis
Stromal hyperthecosis may be seen in association with stromal hyperplasia in
postmenopausal women or reproductive-aged women. Virilization, acne, obesity,
hypertension,andglucoseintolerancemaybeseeninassociationwithstromalhyperthecosis
in premenopausal women. A small percentage of patients have HAIR-AN
(hyperandrogenism,insulinresistance,andacanthosisnigricans)syndrome.Theovaries
arebilaterallyenlargedbyaproliferationofthecacells,similartothoseofthethecainterna.
Endometriosis
Endometriosiscommonly presentsduringthe reproductiveyears and rangesfrom single or
multiplemicroscopicdepositsofectopicendometrialglandsandstromatolargehemorrhagic
cysts (endometriomas) simulating a tumor mass. The larger cysts should be carefully
examinedtoexcludethepresenceofanoccultclearcellorendometrioidcarcinoma.
Figure6.87Polypoidendometriosis.Whenlargeandmultifocal,thesepolypoidmasses of
ectopicendometrialtissuemaysimulateaneoplasm.
PolypoidEndometriosis
Rarely,fociofendometriosismayformlarge,polypoidmassesontheovary,fallopiantube,
bowel, or peritoneum (Fig. 6.87). Most of the reported lesions have followed a benign
clinicalcourse(80),butcompleteexcisionandthoroughmicroscopicexaminationshouldbe
performed to exclude adenosarcoma, stromal sarcoma, or adenocarcinoma arising in the
settingofendometriosis.
LuteinizedOvarianConditions
PregnancyLuteoma
Pregnancyluteoma is a benign condition that occurs in the second half of pregnancy
andregressesafterdelivery.Oneorbothovariesareenlargedbysingleormultiplenodules
of steroid cells with abundant, eosinophilic cytoplasm. Necrosis and degenerative changes
maybepresent.Mostarediscoveredduringcesareansection.
LargeSolitaryLuteinizedCystofPregnancyandthePuerperium
Largesolitaryluteinizedfollicularcystofpregnancyandthepuerperiumisarare,unilateral,
thin-walled cyst lined by largecells with abundant cytoplasm with focal pleomorphic and
hyperchromaticnuclei.Theseatypicalcellsarethoughttobedegenerative.Adistincttheca
layerisabsent.
HyperreactioLuteinalis
Hyperreactioluteinalisischaracterizedbybilateralovarianenlargementsecondaryto
thedevelopment ofmultipleluteinized cysts.This conditionisrare innormalpregnancy
butmay occur in 10–40%ofwomen with gestationaltrophoblasticdisease, and inwomen
undergoingovulationinduction(especiallythosewithpreexistingpolycysticovaries).
FallopianTube
The traditional, admittedly arbitrary, criteria to distinguish serous carcinoma of the ovary
from serous carcinoma of the peritoneum are based on the presence of at least 5 mm of
ovarian parenchymal involvement or, in the case of low-stage disease, by the exclusive
presenceofovarian(surfaceorparenchymal)involvement.Primaryserouscarcinomaofthe
fallopiantube,previouslyconsideredveryrare,isbasedontheexclusionofprimaryovarian
anduterinedisease.Thehistoricalbasisforthisdistinctionrestslargelyonthehypothesis
thatmostserouscarcinomas arise either fromthesurfaceepitheliumofthe ovary or
frominclusionglandswithintheovarianparenchyma.
This hypothesis has been challenged by the revival of the alternative theory that serous
carcinomaarisesfromtheepitheliumofthefimbriaofthefallopiantube.Thedetection
oftubal intraepithelial carcinoma(Fig. 6.88) inwomenundergoing risk-reducing salpingooophorectomy,orinwomenwithanovarianorperitonealserouscarcinomachallengedthis
claim and generated renewed interest in the tubal fimbria as a candidate source of serous
carcinoma. Whether all such examples reflect primary tubal epithelium as the source of
carcinomaorsecondaryinvolvementbycarcinomaarisingelsewhereisunanswered,except
inthosecases inwhichthe fallopiantubeis theonlysiteofinvolvement.Ap53signature
hasbeenidentifiedinthefimbriatedtubal epitheliumthat mayrepresentaprecursor
lesionof tubalintraepithelialcarcinoma(Fig.6.89), but this requires further study (81).
Metastasesnotuncommonlyinvolvethefallopiantubemucosaandserosa.
Figure 6.88 Serous tubal intraepithelial carcinoma. Tubal mucosa is focally replaced by
stratified cells with markedly pleomorphic nuclei. The lesion is confined to the mucosa and
typically occurs in the fimbria and distal fallopian tube in women with BRCA germ-line
mutations.
Thefallopiantubesfromallrisk-reducingsalpingo-oophorectomyspecimensshouldbe
seriallysectioned and completelyexaminedmicroscopicallyinorder toexcludeoccult
tubalintraepithelialcarcinoma(82).
PrimaryTubalCarcinoma
Serous carcinoma is the most common histologic subtype of carcinoma to occur in the
fallopian tube (Fig. 6.90), but endometrioid neoplasms (adenofibroma, borderline, and
carcinoma)mayoccur. The distinction among the three types of endometrioid and serous
tumorsisbasedonthesamecriteriathatareusedelsewhereinthefemalegenitaltract.
AdenomatoidTumor
Adenomatoidtumorsarecommon,benignmesothelialneoplasmsthatariseinthesubserosa
oftheparatubalregion,buttheymaybeseenintheuterusand, rarely, inthe ovary.When
occurringinthefallopiantube,theyaresmall,firm,tanwhitenodules,oftenmeasuringless
than1 cmin diameter. Theuterine tumorsare usuallylarger andarise inthe myometrium.
Thepresenceoftubularandsignet-ring–likecellsmaysimulateametastaticcarcinoma(Fig.
6.91).
GestationalTrophoblasticDisease
Gestationaltrophoblasticdiseasearisesasaresultofabnormalplacentaldevelopment,witha
resultant proliferation of syncytiotrophoblastic, cytotrophoblastic, or intermediate
trophoblastictissue(83).
HydatidiformMole
Hydatidiform mole is the most common form of gestational trophoblastic disease and is
dividedintocompleteorpartialmoles.Thecompletemoleisdiploid(46XXor46XY)and
derivedentirelyfrompaternalchromosomesbecauseoffertilizationofanemptyovumbya
singlespermatozoon,whereasapartialmoleistriploid(69XXX,69XXY,or69XYY)and
derivedfromfertilizationofanormaleggbytwospermatozoa.
CompleteHydatidiformMole
Complete moles exhibit uniformly enlarged, hydropic villi, with variable degrees of
circumferential trophoblastic proliferation. The well-developed, second trimester
completemolesarevisualizedastransparent,grapelikevesiclesonmacroscopicexamination,
but complete moles in early trimester abortuses may be difficult to detect, even on
microscopicexamination.Becausecompletemolesarepaternallyderived,proteinsencoded
by paternally imprinted genes are not expressed in the villous stromal tissue or
cytotrophoblastofcompletemoles.Oneoftheseproteins,p57,maybeusedtoestablishthe
diagnosisofcompletemolesindiagnosticallymoredifficultcases(Fig.6.92).
Figure6.89Fallopiantubewith“p53signature.” Histologicallynormal tubal mucosa (left)
mayexhibitnuclearover-expressionof p53(topright),butlowKi-67proliferationrate(bottom
right). Although it has been proposed that this lesion may be a precursor to serous tubal
carcinoma, it is not known to be associated with an adverse prognosis in the absence of
morphologiccarcinoma.
Figure6.90Invasiveserouscarcinoma,fallopiantube. Superficial invasion intothe tubal
stromaisseeninthisearlyinvasiveseroustubalcarcinoma.
Figure 6.91 Adenomatoid tumor, fallopian tube. Signet-ring appearance may simulate
metastaticcarcinoma.
Complete moles may progress to invasive mole or choriocarcinoma. Progression is
associatedwithprogressivelyrisingserumbeta-humanchorionicgonadotropinlevels.
PartialHydatidiformMole
Partial moles exhibit a dimorphic population of small and larger villi, with lesser
degreesof trophoblasticproliferation.Mostareassociatedwithafetus. Progressionof
partialmoletoinvasivemoleorchoriocarcinomaisrareornonexistent.
InvasiveMole
Invasivemoleisdiagnosedonthebasisofinvasionintomyometriumoritsbloodvessels
(Fig.6.93).Commonsitesofextrauterinespreadincludethevagina,vulva,andlungs.
Choriocarcinoma
Choriocarcinoma is a highly malignant tumor composed of syncytiotrophoblastic,
intermediate trophoblastic and cytotrophoblastic cells arranged in a bilaminar
configuration (Fig. 6.94). Chorionic villi are almost always absent. Hemorrhage and
necrosis are common. Patients often present with profuse vaginal bleeding. Distant lung,
brain,orlivermetastasesmaybepresent.
PlacentalSiteTrophoblasticTumor
Thisveryuncommonformofgestationaltrophoblasticdiseaseiscomposedofintermediate
trophoblasticcells(Fig.6.95).Thetumormay forma discretemass orirregularly infiltrate
themyometrium,causinguterineenlargement.Althoughmostplacentalsitetrophoblastic
tumors follow a benign clinical course, the behavioris unpredictable, and occasional
tumorsspreadthroughouttheuterusandmetastasizetodistantsites.
Anepithelioidvariant,composedofsmaller,moreepithelioidcellsresemblingsquamouscell
carcinoma,appearstobemoreaggressive(83).
ExaggeratedPlacentalSite
Exaggerated placental site is a benign condition marked by an exuberance of
intermediate trophoblastic cells that may simulate placental site trophoblastictumor.
The lesion is no differentfromtheusual implantationsite, but the individual intermediate
trophoblasticcells are largerandmore numerous; nuclear hyperchromasiamaybe present.
Unlikeplacentalsitetrophoblastictumor,chorionicvilliandsyncytiotrophoblasticgiantcells
aretypicallypresent,mitoticfiguresarerareorabsent,andthereisnonecrosis.