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INTRODUCTION

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The role of the pathologist in diagnosing gynecologic disease includes a broad range of conditions from infectious to congenital and from benign to malignant neoplasms in all parts of the female reproductive tract. The following two cases are typical of those seen in the practice of gynecologic pathology.

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CASE 17-1

A 57-year-old woman presents to her gynecologist with the complaint of postmenopausal bleeding. During her workup, a CT scan of her abdomen shows a 12-cm right ovarian mass. Clinical lab values drawn prior to removal of the mass include a markedly elevated inhibin level. Photos of the tumor are shown below (Figure 17-1). What is your diagnosis? What is the significance of her postmenopausal bleeding?

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FIGURE 17-1

Granulosa cell tumor of the ovary. (A) Ovarian gonadal stromal cells resembling the granulosa cell layer of the developing ovarian follicle are shown here forming Call-Exner bodies (microfollicular spaces filled with pale, eosinophilic material). (B) Nuclear grooves ("coffee bean nuclei") are characteristic (high-power view). (C) Immunohistochemical expression of inhibin.

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CASE 17-2

A 30-year-old woman presents to the emergency department with left-lower quadrant abdominal pain. She admits to being sexually active, but has an intrauterine device. A urinary human chorionic gonadotropin (hCG) test is positive, and an ultrasound shows a mass in the left fallopian tube. A section from the intratubal mass is shown (Figure 17-2). What is your diagnosis? What about this patient's history made you suspect this condition? What are the clinical implications?

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FIGURE 17-2

Tubal ectopic pregnancy. (A) Products of conception and blood are noted within this dilated segment of fallopian tube (low-power view). (B) At high power view fetal parts are seen, evidenced by embryonic neural tube and embryonic mesenchyme (lower left); the immature chorionic villi are shown in the top right.

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The diagnosis for Case 17-1 is adult granulosa cell tumor. Figure 17-1 depicts classic histology: neoplastic cells arranged in sheets with characteristic focal gland-like structures arranged around acellular pink material, known as Call-Exner bodies. The positive immunohistochemical staining confirms via immunofixation that this tumor overexpresses inhibin, which corresponds to the elevated blood level. The granulosa cell is a normal component of the ovarian follicle, which supports the follicle. Their classification will be discussed under tumors of the ovary.

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The presentation of this patient with postmenopausal bleeding highlights one of the important clinical implications of this tumor. In addition to producing inhibin, occasionally granulosa cell tumors also produce estrogen. In a postmenopausal woman, unopposed estrogen stimulation can lead to a proliferation of the endometrial lining which can be premalignant or malignant (see section on "Endometrial Hyperplasia"), which can present with abnormal bleeding. Before operating on this patient's ovarian mass, an endometrial biopsy would ...

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