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Y. Derek, M.B. B.CH., M.B.B.Ch., Ph.D.

Deputy Director, Des Moines University College of Osteopathic Medicine

Differential Diagnosis Ovarian fibromatous tumors can closely resemble easy muscle tumors, and are the main differential diagnostic consideration. Since ovarian fibroma and its cellular variant are rather more frequent than ovarian leiomyoma and cellular leiomyoma. Routine histologic options can be of some help when trying to distinguish leiomyomas from fibromas. Normal and most neoplastic clean muscle cells generally have elongated and blunt-ended (cigar-shaped) nuclei. In addition, those bland ovarian spindle cell tumors with a storifurm somewhat than fascicular growth pattern are more probably to be fibromas rather than leiomyomas. A: this high-magnification view highlights the cigar-shaped nuclei of most of the easy mustle cells. B: In this trichrome-stained section, the fibrillar cytoplasm of the graceful muscle cells has a brick-red appearance. A small amount at bluestained collagenous tissue can also be present in the background. More conclusive proof of clean muscle differentiation in this setting is diffusely posi� tive immunoreactivity for muscle markers such as dcsmin and h-caldcsmon, but one may query the cost-effectiveness of utilizing immunohistochemistry in an effon to distinguish one benign ovarian twnor from one other. A: A band of steroid cells extEnds from just beneath the mucinous epithelial lining of the cyst at right) to the interface between the neoplastic mucinous glands and the nonnal ovarian stroma (as marked by the dotted line). B: the steroid cells inside 1he stroma between the mucinous glands have plentiful eosinophilic cytoplasm and round nuclei. Miscellaneous Tumors of Soft Tissue Type Fibrosarcoma is discussed in tbe section on intercourse cord-stromal tumors, and leiomyosarcoma is briefly talked about within the part on ovarian ldomyoma. A number of different types ofbenign and malig� nant sofi tissue tumors are rardy encountered in the awry and are discussed in additional oomprehensive teXtS ofgynecologic pathology. The tumors more than likely to exhibit this phenomenon are muci� nous cystadenomas (panicularly these from pregnant patients) (F~g. In most instances, the steroid cells are scattered haphazardly all through the neoplasm in small aggregates, but in struma ovarii and another tumors these cells preferentially form discontinuous peripheral bands measuring up to 2 mm in thickness. Moreover, in th03e sufferers with an endoc;rinologic abno1111ility, ddittitive eviclcna: that the hormo11e>-rda~ ~ ale dim;tly amibutahL: to the ovarian tu. Intraoperative Consultation the pathologist is usually known as upon to consider ovarian tumors intraoperatively. Although 60% to 80% of ovarian metastases can be distinguished from primary ovarian tumors by frozen part, in some instances it can solely be instructed as a differential diagnostic consideration:m For mucinous carcinomas, a presumption may be made that unilateral tumors ~13 em are main, whereas those which might be either bilateral (any size) or unilateral and <13 em are metastases, though there are aceptions to these general guidclines. A agency, fibromatous area could represent a benign adenofibromatous part inside a pri� mary malignant tumor. The most malignant component ofan ovarian tumor is likdy to be gentle or fleshy and could also be associated with. The pathologist ought to go through the listing as outlined in (a) through (h) within the "General Considerations" part and make an assessment as to the probable main versus meta� static nature of the tumor. Examples during which the intraopera� tive opinion of the pathologist might he instrumental in serving to to determine an occult main neoplasm embrace suggesting removing of the appendix in instances of mucinous ovarian tumors related to pseudomyxoma peritonei, and recommending close analysis of (a) the abdomen and different less probably major websites when quite a few signet�ring cells are current, (b) the large bowel when the attribute pseudoendometrioid sample of metastatic colon most cancers is encountered, and (c) the small bowel when the ovaries are involved by bilateral carcinoid tumors. A: A peripheral band of steroid cells (arrows) is imerposed between the thyroid follicles (top and ovarian stroma Ibottom). Metastatic adenocarcinoma is well-known for its capacity to masquerade as a primary ovarian tumor, which is related to observations that (a) the first tumor may be a lot smaller than the involved ovaries and may not be dini� cally obvious, as exemplified by some gastric carcinomas with this pattern of spread, (b) the ovarian metastasis could additionally be par� tially or predominandy cystic, even when the first tumor is strong, (c) metastatic mucinous carcinomas can have areas that carefully resemble the glands and cysts of mucinous borderline tumors and even mucinous cystadenomas, and (d) metastatic colorectal adenocarcinoma often has an endometrioid�like look and should sometimes also simulate main muci� nous carcinoma. The following options, notably when seen in combi� nation, favor ovarian involvement by a metastatic somewhat than major tumor: (a) recognized history of an extraovuian malig� nancy with histologic features just like the ovarian tumor (the chance ofsynchronous primary tumors as often happens with endometrial and ovarian endometrioid carcinomas must be excluded), (b) high�stage illness in a tumor whose differ� entia! These sections will Intestinal Carcinoma413-416 Colorectal adenocarcinomas are th. Scattered cysts are current within this predominantly strong neoplasm, which accommodates prominent areas of grayish vellow necrosis. This solid and cystic neoplasm has a glistening, gelatinous sectioned surface as a outcome of the presence of plentiful mucin. Although most sufferers have both a current history of colon most cancers or the 2 sites of involvement arc discovered concurrently, there an: occasional circumstances during which surgical treatment for presumed ovarian cancer prcc. Most sufferers are middle-aged adults who current with abdominal ache and/or signs associated to their colon cancer. The typi� cal colon most cancers that metastasizes to the ovary has (a) a recto� sigmoid location, (b) prolonged through the bowel will, and (c) spread to mesenteric lymph nodes. Histologically, the standard kind of colonic adenocarcinoma produces a pseudocndometrioid look when it metas� tasizes to the ovary. Characteristic options of this sample are glands with garland and cribriform progress patterns, intralu� minal "dirtf necrosis, and segmental glandular destruction. The garland progress sample refers to a back�to�back wreath-like arrangement of rings of malignant glands encircling necrotic debris. This multiloculated neoplasm has a honeycombed sectioned floor that mimics a main mucinous cystadenoma. Classic histologic appearance with garlands of malignant glandular epithelium encircling lumens filled with dirty necrosis. Segmental destruction of glandular epithelium (circle~ is another characteristic function. This kind of necrosis must be distinguished from the buildup ofdegenerated neuttophiJs, histiocytes, and occasional sloughed tumor cells inside inspissated mucus, which has a much less densely eosinophilic background and is commonly seen within the cystically dilated glands of primary mucinous tumors. When the cystic glandular spaces of metastatic colonic adenocarcinoma turn out to be macroscopic and the epithelial lining of the cym becomes extra simplified, the resemblance to major ovarian neoplasia is heightened. A treacherous tumor of this type requires thorough clinicopathologic correlation and adequate sampling with supplemental immunohistochemistry so as to keep away from misinterpretation as a primary ovarian neoplasm. In addition to the pitfalls offered by pseudoendometrioid metastatic colonic adenocarcinoma, malignant epithelium derived from some colonic adenocarcinomas is occasionally overtly mucinous or has hybrid endomettioid-mucinous featwes. Infiltrative glands related to a desmoplastic stromal response, as proven at right and at larger magnification within the inset are commonly present. Cystically dilated glands with intraluminal netrosis and segmental glandular destruction are additionally present within the upper left portion of the principle picture. The ample pale to clear-appearing materials is extracellular mucin, which is associated wi1h strips and clusters of neoplastic mucinous epithelium. The stroma of metastatic colonic adenocarcinoma comp monly incorporates scattered aggregates of steroid cells which may be related to endocrine abnormalities. The immunopro6le of mei:2Static colonic adenocarcinoma is discussed throughout the context of the differential diagnosis. Differential Diagnosis In the commonest situation, the pseudoendometrioid sample of colonic adenocarcinoma metastatic to the ovaries must be distinguished from main endometrioid carcinoma. Features that within the aggregate help to set up the fOrmer diagnosis include (a) a clinical historical past of a previ. Less regularly, colonic adenocarcinoma metastatic to the ovaries has mucinous featun:s and needs to be distinguished from major mucinous carcinomas and hordedine tumors. Most p:uients have complaints associated to the presence of an ovarian mass, although symptoms because of the primary tumor or its other websites of metastatic illness might dom� inate the scientific picture. Stromal luteinization is occasion� ally seen in Krukcnberg tumors, and could also be related to manifestations related to irregular hormone production. The prognosis of this unusual tumor is poor, with most sufferers dying inside 1 to 2 years ofdiagnosis. At least 80% of Krukcnberg tumors as encountered recent from the operating room are bilateral, though sequence primarily based on difficult and unusual session circumstances in which a major tumor is a severe diagnostic consideration understandably repon a lower share of bilaterality. The traditional lack of adhesions or implants on the surface of the tumor favors lym� phatic over transperitoneal unfold as the likely route of mctas� tasis in most cases. Their sectioned floor is often strong, however wries substantially in phrases ofits colour (white. Histologically, the classic Krukenberg tumor is composed of numerous mucin-containing signet�ring cells set within a mobile spindle-cell stroma. The signet�ring part shows solely minimal mitotic activ� ity and its degree of nuclear atypia is often unimpressive. Angiolymphatic invasion is often identified, particularly within the hilar area. As bas been lately emphasised, Krukenberg tumors might stray from their traditional look. A tubular variant of Kruke� nbcrg tumor is recognized, whereby stable tubules or these with small lumens predominate. In different Krukenberg tumors, small microcystic glands lined by flattened tumor cells. The sectioned floor of this bivalved ovarian tumor consists of a number of coalescing nodules, a few of that are separated by edematous and hemorrhagic tissue.

Patients with anovulatory cycles whose cohort of estrogen-producing follicles undergoes synchronized atresia represent an extra c:umple of estrogen withdrawal bleeding (note that anovulatory cycles can he associated with estrogen-related bleeding of either the breakthrough or withdrawal types). Exposure, adopted by withdrawal, ofan estrogen-primed endometrium to proges� tin ends in progesterone withdrawal bt"ding, which can he seen in sequential hormonal alternative therapy. Notll#on Used to Indica~t Prtgtutncy History: Gravida (G) refers to the number of pregnancies, together with any current preg� nancy. Para (P) refers to the number of previous deliveries of infants that weigh at least 500 g, which is commonly followed by a subscripted collection of 4 numbers that indicates their varied outcomes. A: Several dark blue aggregates of collapsed stroma are admixed with winding strips of disrupted glands. When examined at excessive magnification, the stromal aggre-gates of nonmenstrual endometrial breakdown arc discovered to be composed of cells with hyperchromatic nuclei with scant cytoplasm, molded nuclear contours, and associated karyorrhectic debris. As discussed in the part on small a:U carcinoma, these findings may be misconstrued by the uninitiated as proof of malignancy. Histologically, this interprets into a proliferative or disordered proliferative section sample with patches of stromal breakdown that are characteru. At high magnification, the resemblance of collapsed and condensed endometrial stromal cells to small cell carcinoma in these two totally different examples is hanging. The glands are lined by cel1s whose mitotic price and nuclear traits are indistinguishable from normal proliferative endometrium. In cases with the architectural and nuclear options of disordered proliferation in which the giands-to-stroma ratio exceeds 2 to 1, a diagnosis of easy hyperplasia with out atypia is rendered. By utilizing this strategy, the lower end of the spectrum of what constitutes simple hyperplasia without atypia for some investigators is incorporated into the disordered proliferative class. Sample microscopic and prognosis sections of a pathology report for disordered proliferative endometrium with breakp down are as follows. Microscopic: Sections present numerous fragments of disordered proliferative endometrium, as characterised by haphazardly distributed, cystically dilated endometrial glands with delicate levels of branching and budding. Patchy areas ofstromal breakdown are additionally current, typically in affiliation with ectatic, thin�waUed vessels that contain fibrin thrombi. The variably-shaped glands are haphazardly disttibuted and exhibit mild levels of cystic dilatation. Diagnosis: Uterus, endometrium, curettageDisordered proliferative with patchy stromal breakdown (sec Microscopic). For aample, there may be an admixture of early secre� tory and mid to late secretory patterns. Secretory differentiation is indicated by cytoplasmic vacuolization and the presence of basally oriented nuclei devoid of mitotic activity. The proper side of the picture shows stromal breakdown, as evidenced by condensed aggregates of dark blue stromal cells. Associated stromal breakdown may or will not be readily apparent in all of those abnormal secretory patterns. It is defined because the presence of an admixture of proliferative and secretory patterns in an endometrium obtained at least 5 days following the onset of uterine bleeding. Early secretory sort glands with subnuclsar vacuoles (top are sean adjacsm to mid-secretory-type glands with intraluminal secretions! In the endo� metrium, the binding of tarnoxifen to estrogen rca:ptors mim� ics the effect of estrogen to some degree. As could be anticipated, the endometrium can react to this altered hormonal environ� ment in all kinds of how. This can he confusing for the pathologist, notably within the frequent state of affairs by which the gynecologist has uncared for to provide the history of hormone therapy. Fortunately, the most important histologic patterns induced by these hormones are fairly distinctive, as discussed beneath. The less commonly encountered and less well-documented endometrial patterns of response to progesterone receptor modulators, gonadotropin releasing hormone agonists, and ovulation induction brokers arc past the scope of this overvicw:zero M. Mixed proliferative and secretory glandular components are preserrt on this endometrium from a patient with a persistent corpus luteum cyst. Most oral con� traceptives (birth management pills) arc low�dose combinations of estrogen and progesterone. Progesterone and related artificial hormones, which arc referred to as progestins or progestogens, are used with out estrogens in the empiric administration of dysfunctional uterine bleeding and in the treatment of endome-trial hyperplasia. Qifferentiated endometrial carcinoma in nonsurgical candidates or those who want to protect their fertility. The histology of progestin-treated endometrial lesions inside the spectrum of atypical hyperplasia and well� differentiated carcinoma is discussed in the part on endo� metria! B: Note 1he presence of scattered subnuclear vacuoles within the epithelial cells lining the glands. A: Section through a formalin-fixed uterine wall, demonstrating an irregular endometrial floor as a result of the presence of polypoid projections. In the presence of the appropriate clinical history, which ought to be sought if not provided, a prognosis of "in maintaining with oral contraceptive impact" may be rendered. Progestin Effect In instances in which progestins are given in excessive doses, the endo~ metrium typically responds with a marked decidual response. Grossly, polypoid fulds of endometrial tissue are shaped, which may turn out to be quite prominent. The decidual reaction is indistinguishable from that seen in being pregnant, and the endometrial glands are sparse and atrophic. A: the endometrial cavity of this opened uterus is crammed with hemorrhagic folds of polypoid tissue that might be mistaken for a neoplastic course of. B: Several neutrophils and strands of fibrin are current in this focus of decidualized stroma with impending breakdown. With the more normal substitute remedy that utilizes a combined regimen of low�dose estrogen-progestin preparations, weakly proliferative to atrophic patterns are inclined to be produced, typically with a few cytoplasmic vacuoles within the glandular epithelium. A: In this example of chronic endometritis, a quantity of plasma cells are present within the stroma, certainly one of which is marked by an arrow. B: Granular lymphocytes can typically have eccentric nuclei and simulate plasma cells. Patients with persistent endo� metritis may be both asymptomatic or current with menometrorrhagia, cervical discharge, pelvic ache, and/or infertility. Before embarking upon a dialogue of the histology of persistent endometritis, it is essential to acknowledge tbe regular presence of lymphoid cells throughout the endometrium. Lymphoid aggregates, including an occasional follicle with or with out germinal middle formation, are a normal discovering in tbe endometrium, particularly within the basalis. Although continual endometritis also contains a lymphocytic infiltrate, its principal distinguishing characteristic is the presence of plasma cells (F~g. Predecidualized endometrial stromal cells and granular lymphocytes could have eccentric nuclei and be mistaken for plasma cells, but could be distinguished by their absence of a paranuclear pale zone and their lack of clumped, "clock:f. In addition to alymphoplasmacytic infiltrate, continual endo� metritis can additionally be typically associated with reactive stromal modifications that function elongated, fibroblast�like stromal cells swirling around glands and/or forming pinwheel patterns. This low� magnification clue to the analysis of continual endometritis ought to prompt a careful search for plasma cells, as should circumstances with. In this situation, the endocervical plasma cell in6ltrate may be misinterpreted as evidence of continual endometritis. This error may be prevented by noting the presence of cervical stroma and mucinous endocervical celk which might be typically accompanied by variable degn:es of squamous met2plasia. In my opinion, there has recendy been an extreme quantity of emphasis on the identification of a few plasma cells as a defining feature of persistent endometritis. In reliable cases of persistent endo~ metritis, plasma ceUs are easily recognized in routindy stained sections with out an exhaustive search or the necessity to resort to particular stains, other acute and continual Wl. In assist of Acute Endometritis Acute endometritis usually occurs in postpartum or postabor- tal settings, hardly ever requires submission of tissue for prognosis, and is characterised by microabscess formation, intraepithelial neutrophils, glandular destruction, and intraluminal aggregates of neutrophils. The presence of stromal micmabscesses bdps to distinguish acute endometritis from neutrophilic infiltrates that are unrelated to infection that are discovered within the endometrium in areas of stromal breakdown, simply previous to and through menses, and in association with tissue necrosis. Menstrual endometrium is often the most problem� atic differential diagnostic consideration. Recall that the neu� trophils seen in menstrual endometrium are associated with glands with secretory differentiation and predecidualized stroma. If the patient is a quantity of days removed from supply or an abomon and has a fever, uterine tenderness, purulent vaginal discharge, and leukocytosis, acute endometritis is likely. Granulomatous Endometritis True granulomatous endomettitis is uncommon within the United States.

Syndromes

• You have a hernia that becomes red, purple, dark, or discolored
• Vitamin levels in the blood
• Chills
• Usually appears 3 - 5 days after the first signs of being sick
• Urinalysis
• Acute infection

Metastatic tumors in the ovary: a problem-oriented approach and =iew of the latest literature. From Krukcnberg to right now: the ever p~ent problems posed by metastatic tumors in the ovary. Historical perspective, general rules, mucinous tumors including the Krukcnberg tumor. Accuraq of frozen section in distinguishing primary ovarian neoplasia from tumors metastatic to the awry. Ovarian involvement by metastatic colorcctal adenocarcinoma: still a diagnostic problem. Necrosis in 84 ovarian carcinomas: a morphologic research of main versus metastatic colonic carcinoma with a sdcctive immunohistochemical analpis of cytokcratin subtypes and carcinoembryonic antigen. Cytokeratin immunostaining in differentiating major ovarian carcinoma from metastatic colonic adenocarcinoma. Cytokeratin 7 and cytokeratin 20 cxp~sion in epithelial neoplasms: a surveyof435 instances. Immunohistochemical evidence supporting the appendiceal origin of pscudomyxoma peritonei in ladies. Metastatic intestinal carcinomas simulating main ovarian pricey cell carcinoma and secretory endomctrioid carcinoma: a clinicopathologic and immunohistochemical study of five circumstances. Krukcnbcrg tumors of the awry: a clinicopathologic analpis of one hundred twenty cases with emphasis on their variable pathologic manifestations. Mucinous tumors of the vermiform appendix and awry, and pscudomyxoma peritonei: histogenetic implications of cytokeratin 7 expression. Molecular genetic evidence supporting the donality and appendiceal origin of Pscudomyxoma peritonei in women. A clinicopathologic analpis of 109 instances with emphasis on distinguishing pathologic features, web site of origin, progno1is, and relationship to "pscudomyxoma peritonci". Pscudomyxoma peritonei and 1dected different elements of the unfold of appendiceal neoplasms. The morphologic spectrum of ovarian metastases of appendiceal adenocarcinomas: a clinicopathologic and immunohistochemical analpis of tumors usually misinterpreted as major ovarian tumors or metastatic tumors liom different gastrointestinal sites. Pscudomyxoma peritonei of appendiceal origin: a clinicopathologic analpis of 1 zero 1 sufferers uniformly treated at a single institution, with literature evaluate. Metastases from carcinomas of the pancreas simulating main mucinous tumors of the awry. Intrahepatic cholangiocarcinoma metastatic to the ovary: a report of sixteen instances of an underemphasized kind ofsecondary tumor in the awry that will mimic main neoplasia. Ovarian metastases of pancrcaticobiliary tract adenocarcinomas: analysis of 35 circumstances, with emphasis on the ability of metastases to simulate main ovarian mucinous tumors. Distinction of main ovarian mucinous tumors and mucinous tumors metastatic to the ovary: a practical approach with guidelines for prediction of primary website for metastases of uncertain origin, Pt#hol Cast Rev. Transtubal spread of serous adenocarcinoma of the endometrium: an underrccognized mechanism of metastasis. Endocervical adenocarcinoma in situ with ovarian metastases: a novel variant with potential fur long-term survival. Increased p16 expression in high-grade serous and undifferentiated carcinoma in contrast with other morphologic types of ow. Ovarian involvement by the intra-abdominal desmoplastic small spherical cell tumor with divergent differentiation: a rcpon of three instances. In cytologic preparations, mesothelial cells may be fowtd singly, in dusters, or in sheets. The finest opportunity to see regular mesothelial cells is in unremarkable peritoneal wash specimens, since mesothelial cells at all times show at least some reactive changes in effusions. In peritoneal washings, massive orderly sheets of mesothelial cells are sometimes present. Not all regular mesothelial cells follow their textbook description, with some having eccentric nuclei and others exhibiting nuclear membranes that are indented or folded. In cytologic preparations of benign effusions, the mesothelial cell component is often dominated by individual cells, although groups of cells are also seen. The presence of abundant microvilli on the floor of mesothelial ceUs typically ends in expensive spaces or "windows" between cells that happen in groups of two or extra. Reactive mesothelial ceUs have a wider range of dimensions and shapes than their regular counterparts, sometimes have dense cytoplasm, can exhibit minor chromatin abnormalities, could have nucleoli which would possibly be extra distinguished than traditional, could additionally be mitotically active, and may comprise degenerative vacuoles. In addition to intercellular home windows, the presence of dense cytoplasm and cell teams with knobby, scalloped peripheral borders are probably the most useful options that assist in the recognition of mesothelial differentiation. A: the conventional meso1helial cells that line the peritoneum and different kinds of serosal membranes pleura and pericardium)typically have a flattened look. Differential Diagnosis Distinc:t:ion of mesothelial cells from histiocytes could additionally be troublesome. Histiocytes can be mitotically lively; actually, most cells in mitoses in benign effUsions are of histiocytic ori~ gin. Histiocytes are often described as having nuclei which might be the form of beans or kidneys, however that is normally true of solely a minority of any given population, and their nuclei could additionally be in a central quite than eccentric position. Although not often nec:es� sary, mesothelial cells and histiocytes can be distinguished by immunohistochemistry, with mesothelial cells being immuna. A skinny, cream~ colon:d, fibrinopurulent exudate types and is found adben:nt to the peritoneal surf. Partially folded-over shsst of regular mesothelial calls from a Papanicolaou-stained cytologic preparation of a peritoneal wash. This nonspeci�ic inflammatory response was initially n:ported as nodular mesothelial hyperplasia, which serves as a testa� ment to the degree to which histiocytes can simulate mesoth~ lial cclls. Note how the vacuoles appear to originate within pairs or small teams of mesothelial cells within the area usually occupied by intercellular windows. When the vacuoles are absolutely developed, the cells that include them can resemble these derived from metastatic signet-ring carcinoma. Once pathologists are conscious of the existence of this phenomenon, the correct diagnosis can normally be made on the basis of routinely stained sections; when indicated, similar to when a lesion of this *The n:port that c;oadusivdy demonstntcd the domiaa. Several of 1he cells contain engulfed particulate matter and/or hemosiderin, ami some degenerative vacuoles are present. A: A perforated appendix (arrowJ has resulted in acute peritonitis, which seems grossly as a thin, light grey to pale yellow exudate covering parts of the peritoneal surface. Patients U8Ually have ascites and abdominal pain/distension, often in conjunction with small bowel obstruction. Grossly, areas of omentwu that are concerned by sclerosing peritonitis are indurated, thickened, and nodular. Histologically, the lobular architecture of the omentwu is accentuated due to a combination of enlargement, fibrosis, and i. The bands of fibrosis comprise prolifetating fibroblasts and myofibroblasts, collections of continual inflammatory ceUs, and linear anangements of reactive mesothelial cells. There is often a recognizable linear band of reactive mesothelial cells that corresponds to the extent of the native peritoneal floor (bracket51. B: this highmagnification view of one of the nodules demonstrates the presence of sheets of histiocytes, which can be troublesome to distinguish from mesothelial cells in routinelv-stained sections. This mass-forming lesion typically presents in middle-aged or aged men or women, and can cause bowel obstruction by binding down and kinking loops of gut. The mass is most ofien solitary, averages 10 em in diameter, and is 6rm with a grayish ~Uow discoloration. In some circumstances, the presence of a quantity of nodules could simulate peritoneal carcinomatosis. Tuberculosis is the most typical cause of infectious granulomatous peritonitis, but fungal and parasitic infections can also produce this response. Fibrosis and continual irritation of the omental septa have resulted in accentuation of the lobular architecture. The mass inside the mesentery of the small bowel is discolored and lobulated because of a combination of fats necrosis and fibrosis.

The look of the lengthy, slender micropapillae emanating from thick and fibrotic stromal cores has been likened to the snaky-haired head of Medusa from Greek mythology. The neoplastic cells are monomorphic and exhibit gentle to reasonable nuclear atypia with small nucleoli. Exophytic serous borderline tumor (left) related to an autoimplam that resembles a peritoneal implam of the noninvasive d&Smoplastic type (right). The focus of microinvasion, which is outlined in black, is situated throughout the connective tissue core of the papillary tumor and is composed of an admixture of single cells. The presence ofmicroinvasion has historically been thought to not adversdy impact the prognosis,25. In addition to the invasive macropapillae surrounded by cleft-like areas, a spotlight of typical microinvasion is current in the upper proper portion of the picture. As mentioned beneath, noninvasive implants an: further categorized as being ofepithelial or desmoplastic typc. In contrast, noninvasive implants of desmoplastic sort are often recognized as small plaques or nodules on the floor of the peritoneum, and within the omentum might appear as a tracery of white 6brous tissue representing expanded septa between fat lobules. Most invasive implants an: found within the omentum and are often grossly apparent as small stellate masses akin to small breast carcinomas. Histologically, noninvasive implants of epithelial type an: composed of weD-delimited aggregates of tufted papillary pro� jeaions that an: normally discovered within mesothelial-lined invagi� nations or between lobules ofomental fats. The cells lining the invaginations have been proven to be immunoreac� tive for calretinin, which helps their mesothelial nature. The papillary epithelial cells exhibit gentle nuclear atypia, are mitotically inactive, and arc typically associated with psammomatous calcifications. A: the sectioned surface of the omentum reveals a fantastic tracery of white fibrous tissue. B: the preexisting septa between omental fats lobules are expanded by noninvasive desmoplastic implants which are associated with numerous psammoma our bodies and two lymphoid aggregates. Two glands lined by epithelial cells with mild to average nuclear atypia are present inside a unfastened. They typically resemble metastatic low-grade serous carcinoma, usually with a greater quantity of neoplastic epithelium and a greater diploma of nuclear atypia than that seen in noninvasive implants, a cribriform glandular part, and a desmoplastic stroma. Occasionally, peritoneal implants are composed of obviously malignant cells with out definitive stromal invasion, as can happen in frank serous carcinoma; such lesions are absolutely malignant and may he considered metastatic carcinoma. A: this stellate mass is beyond what could probably be defined by tangential sectioning or septal enlargement by anoninvasive course of. B: In this example, 1he diploma of nuclear atypia is similar to 1hat seen in most noninvasive implants. B: this diploma of nuclear atypia, wi1h chromatin clearing and prominent nucleoli, is commonly seen in invasive implants and exceeds that often seen in noninvasive implants. In this situation, dasp sifying the implant as indc:tenninat:c for invasion is appmpri:ttc. This discovering tends to occur in patients with advancedpstage illness, and is commonly related to psammomatous calcifications. Implants of serous borderline tumor composed of small nests of low-grade neoplastic epithelium surrounded by clefts. Some investigators classify lesions with epithelial nests surrounded by clefts as invasive implants solely on the premise of this discovering, however this could be a minority viewpoint lsee text). Rolx:rt Stclly at Harvard and was the lead writer on the article that d~ the c:laaic standards for invasive implants. The lesion is composed of aggregates of small papillary clusters and particular person tumor cells with intermingled psammoma bodies. The edge of certainly one of these aggregates might symbolize a focus of preexisting endosalpingiosis (arrowt. In addition to the cribriforming glandular aggregates of serous borderline tumor, a portion of a cystically dilated focus of endosalpingiosis is present on the backside. These eosinophilic cells resemble these seen in foci of microinvasion, from which they could be derived in some circumstances. When pure, this sample may require immunohistochemistry to distinguish it from intranodat hyperplastic mesothelial cells; on this situation, caf. This pattern features nested aggregates of tumor cells with eosinophilic cytoplasm. Most such tumors contain both ovaries, and the vast majority of sufferers have cnraovarian disease at the time of presentation. There is powerful proof for a dualistic pathway of ovarian serous carcinogenesis, which helps a division of serous car� cinomas into two rather than three grades. As discussed under, high� grade serous carcinomas are thought to arise through an indcpen� dent pathway and exhibit a different mutational pattern. Low-grade serous carcinoma has a median measurement of 8 em and commonly has a grossly recognizable noninvasive papillary component. Low-grade serous carcinoma infiltrates the ovarian stroma at proper, and is seen arising adjoining to the micropapillary variant of serous border1ine tumor. It should be famous that the distinguished nested and miaopapillary architectural patterns which are typical oflaw-grade serous carcinoma can be seen in the high-grade �0nu,sixty six which is distinguished primarily by its nuclear features. A: Nests and micropapillary groups of neoplastic epithelial cells that are typically surrounded by clear areas infiltrate the ovarian stoma. The sectioned surface demonstrates an admixture of stable tumor, geographic areas of necrosis. The precise origin of many ovarian high-grade serous carcinomas might be intraepithe� lial carcinoma of the distal fallopian tube, though de novo growth via transformation of ovarian epithelial inclusion cysts (which can also finally be of tubal origin) is one other possibility. Grossly, high-grade serous carcinomas average about eight em in diameter and are predominandy solid tumors with. Histologically, high-grade serous carcinoma normally exhibits no less than focal areas of destructive stromal invasion and archi� tectwally frequendy consists ofsheets of tumor cells with some differentiation into slit-like glandular areas admixed with vari� ably distinguished papillae, stable nests, and tubules. In this context, massive alternative of the ovarian stroma by a neoplastic epithelial proliferation of this type is considered adequate proof of suomal invasion. In an intraoperative setting, each areas ought to be sampled for frozen section evaluation. Mitotic exercise is brisk, and atypical division 6gun:s are usu� ally readily identified. As indicated above, some serous carcinomas lack traditional damaging stromal invasion, however can be confidently diagnosed as totally malignant by advantage of confluent carcinomatous elements. This low-magnification view of the tumor within the preceding figure reveals the nodule of grade three serous carcinoma (left adjoining to the serous adenofibroma right). Nate the presence of slit-like spaces, which is characteristic of tumors with serous differentiation. The concern of tips on how to handle a serous tumor with borderline-like architecture and high-grade nuclear features is addressed in the above dialogue. The presence of patches ofsquamous c:lifferentiation, tubular rather than slitlike glands, and related endometriosis additionally favor finish. In addition, highgrade serous carcinoma also virtually at all times exhibits a a lot larger mitotic price than pricey cell carcinoma. The distinction between higb�stage ovarian serous carcinoma and first peritoneal serous carcinoma with ovarian involvement is mentioned in Chapter 8. High-grade serous carcinoma with out identifiable stromal invasion (serous borderline tumor with intraepithelial carcinoma). B: this high-magnification view demonstrates the presence of quite a few high-grade nuclei with macronucleoli. This function, coupled with the ability of the ovaries involved by metastatic mucinous tumors to simulate primary ovarian neoplasia, makes enough sam� pling especially essential on this group of tumors and creates distinctive challenges in the setting of an intraoperative consultation. As is true for ovarian carcinoma normally, intraabdominal unfold is usually manifested as nodules studding the peri� toncal surface, replac:emcnt of parts of the omentum, and involvement of regional lymph nodes. When visceral organs are concerned, it virtually at all times represents progress of metastatic carcinoma that began on the serosal surface. That said, paren� cbymal metastases to the liver and spleen do occur on uncommon events. Mucinous Tumors Mucinous ovarian tumors kind cysts, glands, or papillae whose epithelial lining incorporates a significant number of cells with plentiful intracytoplasmic mucin exhibiting endocervical� like or gastrointestinal options.