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INTRODUCTION

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.

The diagnosis for Case 18-1 is adult granulosa cell tumor. Figure 18-1 depicts classic histology: neoplastic cells arranged in sheets with characteristic focal follicle-like structures arranged around acellular pink material, known as Call-Exner bodies. The tumor cells show characteristic “coffee bean” nuclear grooves. The positive immunohistochemical staining confirms that this tumor overexpresses inhibin, which corresponds to the elevated blood level. The nonneoplastic granulosa cell is a normal component of the ovarian follicle, which supports the oocyte. The classification of granulosa cell tumors will be discussed under tumors of the ovary.

CASE 18-1

A 57-year-old woman presents to her gynecologist with the complaint of postmenopausal bleeding. During her workup, a CT scan of her pelvis 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 histology are shown further in text (Figure 18-1). What is your diagnosis? What is the significance of her postmenopausal bleeding?

FIGURE 18-1

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.

The presentation of this patient with postmenopausal bleeding highlights one of the important clinical implications of adult granulosa cell tumor. In addition to producing inhibin (see Chapter 17), occasionally granulosa cell tumors also produce estrogen. In a postmenopausal woman, unopposed estrogen stimulation can lead to proliferation of the endometrial lining which can be premalignant or malignant (see section on “Endometrial Hyperplasia”), and can present with abnormal uterine bleeding (AUB). Before operating on this patient’s ovarian mass, an endometrial biopsy would be obtained to rule out a concurrent malignancy of the endometrium.

Figure 18-2 (see Case 18-2) shows an ectopic pregnancy, with placental tissue composed of immature chorionic villi, syncytiotrophoblast, and the neural tube of the fetus. This condition arises when a fetus implants at any location other than the endometrial cavity, with the fallopian tube being the most common site. The highest incidence of ectopic pregnancy is found in women who have a history of pelvic inflammatory disease (PID), although women with an intrauterine device also have an increased risk.

CASE 18-2

A 30-year-old woman presents to the emergency department with left-lower quadrant abdominal pain. She is sexually active, and has an intrauterine device. A urinary human chorionic gonadotropin (hCG) ...

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