Atlas of Gynecologic Pathology

CONTENTS
1 VULVA ............................................................................................................1
Unremarkable Vulvar Histology ......................................................................3
The Mons Pubis ................................................................................................... 3
Labia Majora ........................................................................................................ 4
Labia Minora ........................................................................................................ 5
Clitoris ................................................................................................................. 5
Vulvar Vestibule ................................................................................................... 5
Urethral Meatus ................................................................................................... 5
Infectious Diseases .........................................................................................6
Fungal Infections ................................................................................................. 6
Viral Infections ..................................................................................................... 6
Bacterial Infections ............................................................................................ 11
Parasitic Infestations .......................................................................................... 14
Noninfectious Inflammatory Lesions ............................................................ 14
Interface ............................................................................................................. 14
Graft- V ersus- Host Disease ................................................................................. 17
Psoriasiform ....................................................................................................... 17
Spongiotic ......................................................................................................... 18
Granulomatous .................................................................................................. 19
Other ................................................................................................................. 19
Nonneoplastic Changes ...............................................................................21
Vulvodynia ......................................................................................................... 21
Endometriosis .................................................................................................... 22
Adenosis ............................................................................................................ 22
Vulvar Cysts ..................................................................................................22
Follicular Cyst/Epithelial Inclusion Cyst ............................................................. 22
Mucinous and Ciliated Vestibular Cysts ............................................................ 23
Bartholin Duct Cyst ............................................................................................ 23
Cysts of the Canal of Nuck ................................................................................ 23
Mammary- like Cysts (Hidrocystoma) ................................................................. 23
Genital Stromal Tumors ................................................................................24
Fibroepithelial Polyp.......................................................................................... 24
Superficial Myofibroblastoma ............................................................................ 24
Cellular Angiofibroma ....................................................................................... 27
Angiomyofibroblastoma .................................................................................... 28
Deep (Aggressive) Angiomyxoma ..................................................................... 29
Squamous Precursor and Malignant Lesions................................................30
Vulvar Intraepithelial Neoplasia ......................................................................... 30
Differentiated Vulvar Intraepithelial Neoplasia .................................................. 34
Differentiated Exophytic Vulvar Intraepithelial Lesion ....................................... 35
Squamous Cell Carcinoma and Variants ............................................................ 36
Basal Cell Carcinoma ......................................................................................... 44
Extramammary Paget Disease ........................................................................... 45
Anogenital Mammary- like Glandular Lesions ...............................................48
Anogenital Mammary-like Glands ..................................................................... 48
Hidradenoma Papilliferum ................................................................................. 48
Fibroadenoma ................................................................................................... 50
Phyllodes Tumor ................................................................................................ 52
Adenocarcinoma of Mammary Type .................................................................. 52Glandular Lesions .........................................................................................52
Bartholin Gland Carcinoma ............................................................................... 52
Neuroendocrine Neoplasia ..........................................................................53
Neuroendocrine Tumors .................................................................................... 53
Neuroendocrine Carcinoma .............................................................................. 53
Pigmented Lesions .......................................................................................55
Vulvar Melanosis ................................................................................................ 55
Common Acquired Nevus ................................................................................. 56
Atypical Genital Nevi ......................................................................................... 56
Malignant Melanoma......................................................................................... 57
Mesenchymal Lesions ...................................................................................59
Leiomyoma ........................................................................................................ 59
Leiomyosarcoma ............................................................................................... 59
Rhabdomyosarcoma .......................................................................................... 59
Alveolar Soft Part Sarcoma ................................................................................ 60
Dermatofibrosarcoma Protuberans ................................................................... 61
Epithelioid Sarcoma .......................................................................................... 62
Skin Adnexal Lesions ....................................................................................63
Sebaceous Gland Hyperplasia .......................................................................... 63
Syringoma ......................................................................................................... 63
Other Tumors ...............................................................................................63
Granular Cell Tumor .......................................................................................... 63
Yolk Sac Tumor .................................................................................................. 64
Near Miss ......................................................................................................65
2 VAGINA .......................................................................................................89
Unremarkable Vaginal Histology ..................................................................90
Infectious Disorders ......................................................................................90
Vaginal Cysts ................................................................................................91
Müllerian Cysts .................................................................................................. 91
Gartner (Mesonephric) Cysts ............................................................................. 93
Bartholin Duct Cyst ............................................................................................ 93
Skene Duct Cyst/Skene Gland Cyst .................................................................. 95
Squamous Inclusion Cyst/Epithelial Inclusion Cyst ........................................... 95
Benign Polyps ...............................................................................................96
Tubulosquamous Polyp ..................................................................................... 96
Fibroepithelial Polyp.......................................................................................... 97
Cellular Pseudosarcomatous Fibroepithelial Polyp ........................................... 98
Epithelial Lesions ..........................................................................................99
Human Papillomavirus–Associated Squamous Lesions ..................................... 99
Benign Glandular Lesions ................................................................................ 104
Malignant Glandular Tumors ........................................................................... 108
Mixed Tumor (Spindle Cell Epithelioma) ....................................................110
Mesenchymal Lesions .................................................................................112
Rhabdomyoma ................................................................................................ 112
Leiomyoma ...................................................................................................... 114
Leiomyosarcoma ............................................................................................. 115
Embryonal Rhabdomyosarcoma, Botryoid Type ............................................. 115
Genital Stromal Tumors ..............................................................................118
Malignant Melanoma .................................................................................118
Postoperative Spindle Cell Nodule ............................................................121
Near Miss ....................................................................................................122
3 CERVIX .......................................................................................................131
Unremarkable Cervical Histology ...............................................................133
Squamous Epithelium ...................................................................................... 133
Endocervical Glandular Epithelium ................................................................. 134Transformation Zone........................................................................................ 135
Changes in the Transformation Zone due to Squamous Epithelialization
and Squamous Metaplasia ............................................................................. 135
Cervical Stroma ............................................................................................... 136
Noninfectious Inflammatory Changes ........................................................ 137
Follicular Cervicitis and Russell Body Cervicitis ............................................... 137
Papillary Endocervicitis .................................................................................... 138
Inflammatory Changes Related to Infectious Diseases .............................. 139
Protozoal Causes of Cervicitis ......................................................................... 139
Bacterial Causes of Cervicitis........................................................................... 139
Viral Causes of Cervicitis ................................................................................. 140
Fungal Disease ................................................................................................ 141
Cysts ...........................................................................................................141
Nabothian Cyst ................................................................................................ 141
Polyps and Pseudopolyps ..........................................................................143
Endocervical Polyp .......................................................................................... 143
Fibroepithelial Polyp........................................................................................ 144
Metaplasia ..................................................................................................144
Squamous Metaplasia ..................................................................................... 144
Tubal/Tuboendometrioid Metaplasia .............................................................. 144
Transitional Cell Metaplasia ............................................................................. 145
Endocervical Glandular Hyperplasia ..........................................................146
Microglandular Hyperplasia............................................................................. 146
Tunnel Clusters ................................................................................................ 147
Lobular Endocervical Glandular Hyperplasia .................................................. 148
Diffuse Laminar Endocervical Glandular Hyperplasia ...................................... 149
Melanocytic Lesions ...................................................................................149
Blue Nevus ...................................................................................................... 149
Mucosal Melanosis .......................................................................................... 149
Miscellaneous Benign Lesions ....................................................................150
Endometriosis .................................................................................................. 150
Endocervicosis ................................................................................................. 150
Pr egnancy- Related Changes ......................................................................150
Decidual Reaction or Decidual Pseudopolyp .................................................. 150
Arias- Stella Reaction ........................................................................................ 151
Placental Site Trophoblastic Nodule ............................................................... 153
Reactive and Reparative Lesions ................................................................153
Radiation-Induced Atypia ................................................................................ 153
Postoperative Spindle Cell Nodule ................................................................. 153
Florid Reactive Lymphoid Hyperplasia ............................................................ 153
Mesenchymal Lesions, Benign and Malignant ...........................................154
Superficial Myofibroblastoma .......................................................................... 154
Leiomyoma ...................................................................................................... 155
Adenomyoma .................................................................................................. 155
Papillary Adenofibroma ................................................................................... 155
Adenosarcoma ................................................................................................ 155
Mesonephric Remnants and Lesions ..........................................................157
Mesonephric Remnants ................................................................................... 157
Mesonephric Hyperplasia ................................................................................ 157
Adenocarcinoma, HPV- independent, Mesonephric Type,
of the Uterine Cervix ....................................................................................... 158
Squamous Precursor and Malignant Lesions..............................................160
Human Papillomavirus ..................................................................................... 160
Low- Grade Squamous Intraepithelial Lesion ................................................... 161
High- Grade Squamous Intraepithelial Lesion .................................................. 164
Superficially Invasive Squamous Cell Carcinoma ............................................ 167
Squamous Cell Carcinoma .............................................................................. 170Glandular Precursor Lesions and Malignant Tumors ..................................177
Adenocarcinoma In Situ .................................................................................. 177
Histologic Variants of Endocervical Adenocarcinoma In Situ .......................... 179
Endocervical Adenocarcinoma, HPV-Associated............................................. 182
Pattern- Based Classification of Endocervical Adenocarcinoma,
HPV-Associated .............................................................................................. 185
Adenocarcinoma of the Cervix, HPV- independent, Gastric Type .................... 193
Adenoid Basal Lesions................................................................................195
Adenoid Basal Hyperplasia ............................................................................. 195
Adenoid Basal Cell Carcinoma ........................................................................ 195
Adenoid Cystic Carcinoma .............................................................................. 197
Miscellaneous Tumors of the Cervix ...........................................................198
Endometrioid Adenocarcinoma of the Cervix ................................................. 198
Clear Cell Carcinoma of the Cervix ................................................................. 200
Adenosquamous Carcinoma ........................................................................... 200
Glassy Cell Carcinoma ..................................................................................... 201
Neuroendocrine Tumors of the Cervix ............................................................ 201
Low- Grade Neuroendocrine Tumors of the Cervix ......................................... 202
High- Grade Neuroendocrine Carcinomas of the Cervix ................................. 202
Near Miss ....................................................................................................204
4 NONNEOPLASTIC AND NEOPLASTIC LESIONS
OF THE ENDOMETRIUM .........................................................................233
The Unremarkable Endometrium ...............................................................235
Premenarchal Endometrium .......................................................................236
Endometrial Changes During Reproductive Years .....................................236
Menstrual Phase .............................................................................................. 236
Proliferative Phase ........................................................................................... 237
Interval Phase .................................................................................................. 237
Secretory Phase ............................................................................................... 240
Postmenopausal Endometrium ..................................................................244
Abnormal Uterine Bleeding .......................................................................244
Disordered Proliferative Endometrium ......................................................247
Nonneoplastic Changes .............................................................................247
Artifacts in Endometrial Biopsies and Curettage Specimens .......................... 247
Epithelial Metaplasias (Epithelial Cell Change) ............................................... 251
Inflammatory Changes ............................................................................... 258
Endometritis .................................................................................................... 258
Hormone- Induced Changes .......................................................................263
Arias-Stella Reaction ........................................................................................ 263
Exogenous Hormone Therapy Effect .............................................................. 264
Benign Polyps .............................................................................................268
Endometrial Polyps.......................................................................................... 268
Endometrial Polyp With Bizarre Stromal Cells ................................................. 271
Tamoxifen- Associated Endometrial Polyp ....................................................... 273
Papillary Proliferations ..................................................................................... 274
Precancerous Lesions .................................................................................276
Endometrial Hyperplasia/Atypical Hyperplasia ............................................... 276
Serous Endometrial Intraepithelial Carcinoma ................................................ 283
Clear Cell Endometrial Intraepithelial Carcinoma ........................................... 287
Endometrial Carcinoma ..............................................................................288
Endometrioid Carcinoma ................................................................................ 289
Serous Carcinoma ............................................................................................ 309
Clear Cell Carcinoma ....................................................................................... 313
Carcinosarcoma ............................................................................................... 319
Undifferentiated Carcinoma ............................................................................ 322
Dedifferentiated Carcinoma ............................................................................ 324Other ..........................................................................................................325
Mesonephric-Like Adenocarcinoma ................................................................ 325
Mucinous Carcinoma, Gastric (Gastrointestinal) Type ..................................... 325
Squamous Cell Carcinoma .............................................................................. 327
Neuroendocrine Neoplasms ........................................................................... 327
Neuroepithelial Tumors ................................................................................... 330
Near Miss ....................................................................................................330
5 MESENCHYMAL AND MISCELLANEOUS TUMORS
OF THE UTERUS .......................................................................................355
The Unremarkable Mesenchymal Tissue of the Uterus ..............................356
Endometrial Stroma ......................................................................................... 356
Myometrial Smooth Muscle ............................................................................. 358
Smooth Muscle Tumors ..............................................................................358
Leiomyoma ...................................................................................................... 358
Fumarate Hydratase–Deficient Leiomyoma .................................................... 363
Smooth Muscle Tumor of Uncertain Malignant Potential ................................ 365
Leiomyosarcoma ............................................................................................. 365
Perivascular Epithelioid Cell Tumor ................................................................. 371
Endometrial Stromal Tumors ......................................................................374
Endometrial Stromal Nodule ........................................................................... 374
Low- Grade Endometrial Stromal Sarcoma ...................................................... 378
High- Grade Endometrial Stromal Sarcoma ..................................................... 378
YWHAE-NUTM2A/B High- Grade Endometrial Stromal Sarcoma .................... 379
ZC3H7B- BCOR High- Grade Endometrial Stromal Sarcoma ............................ 379
Undifferentiated Uterine Sarcoma ................................................................... 380
Uterine Tumor Resembling Ovarian Sex Cord Tumor ................................380
Mixed Epithelial- Mesenchymal Tumors ......................................................384
Atypical Polypoid Adenomyoma ..................................................................... 384
Adenofibroma ................................................................................................. 386
Adenosarcoma ................................................................................................ 387
Other Mesenchymal Tumors ......................................................................391
Inflammatory Myofibroblastic Tumor ............................................................... 391
Miscellaneous Tumors ................................................................................392
Near Miss ....................................................................................................392
6 FALLOPIAN TUBE ..........................................................................................403
The Unremarkable Fallopian Tube .............................................................404
Fallopian Tube Grossing Protocols .............................................................405
Inflammatory Processes .............................................................................. 406
Bacterial Infections .......................................................................................... 406
Tuberculosis ..................................................................................................... 408
Pseudocarcinomatous Hyperplasia ................................................................. 409
Xanthogranulomatous/Pseudoxanthomatous Salpingitis ................................ 410
Benign Nonneoplastic Processes ...............................................................410
Decidual Reaction ........................................................................................... 410
Walthard Cell Nests ......................................................................................... 411
Metaplastic Changes ....................................................................................... 411
Metaplastic Papillary Tumor ............................................................................ 413
Salpingitis Isthmica Nodosa ............................................................................ 413
Mesothelial Tumors ....................................................................................414
Adenomatoid Tumor ....................................................................................... 414
Benign Cysts ...............................................................................................415
Paratubal Cysts ................................................................................................ 415
Benign Epithelial Lesions ............................................................................416
Papillary Tubal Hyperplasia ............................................................................. 416
Benign Epithelial Tumors ............................................................................417Hereditary Breast and Ovarian Cancer Syndrome .....................................418
Epithelial Precursor Lesions ........................................................................418
p53 Signature .................................................................................................. 419
Serous Tubal Intraepithelial Lesion .................................................................. 420
Serous Tubal Intraepithelial Carcinoma ........................................................... 420
Secretory Cell Outgrowths .............................................................................. 424
Epithelial Borderline Tumors ......................................................................424
Atypical Proliferative (Borderline) Serous Tumor ............................................. 424
Malignant Epithelial Tumors .......................................................................424
High-Grade Serous Carcinoma ........................................................................ 424
Endometrioid Carcinoma ................................................................................ 426
Paratubal Tumors ........................................................................................426
Female Adnexal Tumor of Probable Wolffian Origin ....................................... 426
Near Miss ....................................................................................................428
7 BENIGN OVARY ........................................................................................437
Embryology ................................................................................................438
The Unremarkable Ovary ...........................................................................438
Ovarian Surface ............................................................................................... 438
Ovarian Stroma ................................................................................................ 439
Hilus ................................................................................................................. 440
Rete Ovarii ....................................................................................................... 440
Follicles .......................................................................................................441
Folliculogenesis ............................................................................................... 441
Cystic Follicles and Follicle Cysts .................................................................... 442
Corpus Luteum ................................................................................................ 443
Corpus Luteum Cyst ........................................................................................ 444
Atretic Follicles ................................................................................................ 445
Ovarian Surface Epithelium ........................................................................445
Epithelial Inclusion Glands and Cysts .............................................................. 445
Reactive Mesothelial Proliferation ................................................................... 447
Walthard Cell Nest .......................................................................................... 447
Polycystic Ovary .........................................................................................447
Stromal Endometriosis ...............................................................................449
Decidual Reaction ......................................................................................450
Cortical Granuloma ....................................................................................451
Surface Stromal Proliferation ......................................................................451
Stromal Hyperplasia and Stromal Hyperthecosis .......................................452
Cortical Fibrosis ..........................................................................................454
Ovarian Torsion, Massive Edema, and Fibromatosis ..................................454
Hilus ............................................................................................................456
Rete Cyst and Cystadenomas.......................................................................... 456
Hilus Cells and Hilus Cell Hyperplasia ............................................................. 457
Pr egnancy- Related Findings .......................................................................457
Pregnancy Luteoma ......................................................................................... 457
Hyperreactio Luteinalis (Multiple Luteinized Follicle Cysts) ............................. 459
Large Solitary Luteinized Follicle Cyst of Pregnancy and Puerperium ............ 459
Granulosa Cell Proliferations of Pregnancy ..................................................... 460
Near Miss ....................................................................................................462
8 OVARIAN EPITHELIAL TUMORS ..............................................................469
Serous Tumors ............................................................................................470
Benign Serous Tumors ..................................................................................... 470
Atypical Proliferative (Borderline) Serous Tumor ............................................. 472
Peritoneal Lesions Including Endosalpingiosis,
Noninvasive Peritoneal Implants, and Invasive Peritoneal Implants
(Low- Grade Serous Carcinoma) ...................................................................... 477Lymph Nodes .................................................................................................. 480
Malignant Serous Tumors ................................................................................ 481
Mucinous Tumors .......................................................................................494
Benign Mucinous Tumors ................................................................................ 495
Atypical Proliferative (Borderline) Mucinous Tumor ......................................... 497
Mucinous Tumors With Mural Nodules ........................................................... 500
Atypical Proliferative (Borderline) Seromucinous
(Endocervical- Like or Müllerian) Tumors ......................................................... 500
Malignant Mucinous Tumors ........................................................................... 503
Endometrioid Tumors .................................................................................511
Benign Endometrioid Tumors .......................................................................... 511
Atypical Proliferative (Borderline) Endometrioid Tumor .................................. 513
Endometrioid Carcinoma ................................................................................ 514
Clear Cell Tumors .......................................................................................524
Clear Cell Adenofibroma ................................................................................. 524
Atypical Proliferative (Borderline) Clear Cell Tumor ........................................ 524
Clear Cell Carcinoma ....................................................................................... 525
Brenner (Transitional Cell) Tumors ..............................................................532
Benign Brenner Tumor..................................................................................... 532
Atypical Proliferative (Borderline) Brenner (Transitional Cell) Tumor ............... 534
Malignant Brenner Tumors (Malignant Transitional Cell Tumors) .................... 535
Squamous Tumors ......................................................................................537
Benign Squamous Tumors (Epidermoid Cyst) ................................................. 537
Squamous Cell Carcinoma .............................................................................. 537
Carcinosarcoma ..........................................................................................538
Undifferentiated Carcinoma and Dedifferentiated Carcinoma ..................539
Mesonephric- Like Adenocar cinoma ...........................................................539
Near Miss ....................................................................................................540
9 OVARIAN GERM CELL TUMORS ..............................................................555
Primitive Germ Cell Tumors........................................................................556
Dysgerminoma ................................................................................................ 556
Yolk Sac Tumor ................................................................................................ 559
Embryonal Carcinoma ..................................................................................... 569
Polyembryoma................................................................................................. 572
Nongestational Choriocarcinoma .................................................................... 573
Teratoma .....................................................................................................574
Mature Cystic Teratoma ................................................................................... 575
Mature Solid Teratoma .................................................................................... 578
Gliomatosis Peritonei ...................................................................................... 578
Immature Teratoma ......................................................................................... 578
Chemotherapeutic Retroconversion and the Growing
Teratoma Syndrome........................................................................................ 582
Mixed Germ Cell Tumors ...........................................................................582
Monodermal Teratomas and Somatic- Type Tumors Arising
From a Teratoma ........................................................................................583
Struma Ovarii ................................................................................................... 583
Thyroid- Type Tumors Arising in Struma Ovarii ................................................ 585
Carcinoid Tumor .............................................................................................. 585
Insular Carcinoid .............................................................................................. 588
Trabecular Carcinoid ........................................................................................ 588
Strumal Carcinoid ............................................................................................ 589
Mucinous Carcinoid ......................................................................................... 591
Mucinous Tumors Arising in Mature Teratomas............................................... 591
Sebaceous Tumors .......................................................................................... 593
Neuroepithelial Tumors ................................................................................... 594
Malignant Transformation of a Mature Teratoma ............................................ 596Tumors Composed of Germ Cells and Sex Cord- Stromal Derivatives .......598
Gonadoblastoma ............................................................................................. 598
Miscellaneous .............................................................................................600
Small Cell Carcinoma of the Ovary, Hypercalcemic Type ................................ 600
Paraganglioma................................................................................................. 602
Near Miss ....................................................................................................602
10 OVARIAN SEX CORD- STROMAL TUMORS ..............................................617
Stromal Tumors ...........................................................................................618
Fibroma ........................................................................................................... 618
Thecoma .......................................................................................................... 622
Luteinized Thecoma (Thecomatosis) Associated With Sclerosing Peritonitis .. 623
Sclerosing Stromal Tumor ................................................................................ 628
Signet- Ring Stromal Tumor.............................................................................. 629
Microcystic Stromal Tumor .............................................................................. 630
Fibrosarcoma ................................................................................................... 633
Sex Cord Tumors ........................................................................................634
Granulosa Cell Tumor ...................................................................................... 634
Adult Granulosa Cell Tumor ............................................................................ 634
Juvenile Granulosa Cell Tumor ........................................................................ 641
Sertoli Cell Tumor ............................................................................................ 643
Sex Cord Tumor With Annular Tubules ........................................................... 645
Mixed Sex Cord- Stromal Tumors ...............................................................646
Sertoli-Leydig Cell Tumors .............................................................................. 646
Sex Cord- Stromal Tumors, Not Otherwise Specified ...................................... 653
Steroid Cell Tumors ....................................................................................654
Stromal Luteoma ............................................................................................. 654
Leydig Cell Tumor ........................................................................................... 655
Steroid Cell Tumor, NOS ................................................................................. 658
Other ..........................................................................................................658
Gynandroblastoma .......................................................................................... 658
Near Miss ....................................................................................................660
11 GESTATIONAL TISSUE AND GESTATIONAL TROPHOBLASTIC
DISEASE AND NEOPLASMS ....................................................................671
The Unremarkable Gestational Endometrium, Arias-Stella Reaction,
Decidua, and Chorionic Villi ......................................................................672
Gestational Endometrium ............................................................................... 672
Arias- Stella Reaction ........................................................................................ 672
Decidua ........................................................................................................... 673
Chorionic Villi .................................................................................................. 674
Nonneoplastic Lesions ...............................................................................676
The Exaggerated Placental Site ...................................................................... 676
Placental Site Nodule and Plaque ................................................................... 677
Molar Pregnancies ......................................................................................678
Patient Demographics ..................................................................................... 678
Cytogenetics ................................................................................................... 678
Complete Hydatidiform Mole ......................................................................... 678
Partial Hydatidiform Mole ............................................................................... 683
Persistent or Invasive Hydatidiform Mole ........................................................ 685
Abnormal (Nonmolar) Villous Lesions ............................................................. 686
Ancillary Techniques for Differentiating Hydatidiform Moles and Nonmolar
Gestations ....................................................................................................... 686Gestational Trophoblastic Neoplasms........................................................690
Choriocarcinoma ............................................................................................. 691
Placental Site Trophoblastic Tumor ................................................................. 693
Epithelioid Trophoblastic Tumor...................................................................... 697
Near Miss ....................................................................................................701
APPENDIX A: ATLAS OF GYNECOLOGIC PATHOLOGY
STUDY QUESTIONS .................................................................................707
APPENDIX B: ATLAS OF GYNECOLOGIC PATHOLOGY
STUDY QUESTIONS: ANSWERS ..............................................................725
INDEX ...............................................................................................................747