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Medical Instructor, East Tennessee State University James H. Quillen College of Medicine
Growth in the form of thin cords may potentially mimic metastatic mammary lobular carcinoma but the above findings facilitate the diagnosis acne 6dpo generic decadron 4 mg mastercard. In most such cases there is more extensive intra-abdominal or generalized lymphoma acne young living buy cheap decadron 0.5 mg on line. The rare long-term survival of a patient with ovarian lymphoma after oophorectomy indicates that rarely such tumors are primary in the ovary skin care gift packs decadron 8 mg purchase without a prescription. Ferry for her many helpful comments on this section pertaining to hematolymphoid neoplasms. Lymphomatous ovarian involvement in general may occur at any age, but the peak age is in the fourth and fifth decades. In contrast to adults in whom lymphomas of many types (both follicular and diffuse) are encountered, younger patients almost always have aggressive diffuse lymphomas. The most common presenting manifestations are those related to an ovarian mass; occasional patients have generalized symptoms or abnormal vaginal bleeding. The problems in staging lymphomas involving the ovary have been well summarized by Vang, Medeiros et al. Ovarian lymphomas range from microscopic to large masses with a mean diameter of ~12 cm. In rare cases associated with (and possibly arising from) a teratoma, the latter may be grossly evident. The microscopic appearance resembles that in extraovarian sites, except for a greater frequency of sclerosis (sometimes resulting in a storiform pattern) and for the tumor cells to form islands, cords, and trabeculae, potentially suggesting a carcinoma. The tumor may surround follicles and their derivatives or obliterate all the normal tissue. The tumor cells, particularly in sclerotic tumors, may be elongated or spindled, potentially suggesting a sarcoma. The sectioned surface of the tumor consists of numerous well-circumscribed, white, fleshy nodules. There is a diffuse growth and obvious pleomorphism raising the differential of undifferentiated carcinoma. The neoplastic cells are growing in a striking cord-like pattern, raising various other diagnostic possibilities. Attention to cytologic detail, familiarity with the spectrum of the histologic features of ovarian lymphomas, and differing immunoprofiles facilitate the diagnosis. Lymphoma presenting with ovarian involvement has in the past been associated with a poor prognosis. Less than 10% of patients in one series and <25% in another series who were treated by oophorectomy, radiation, or both, survived >5 years. With recently improved therapy, the prognosis is similar to that for nodal lymphomas of comparable stage and histologic type. Overall the prognosis tends to be better in adults than in children and adolescents. Features associated with a poor prognosis have included a rapid onset of symptoms related to a mass, the presence of systemic symptoms, bilaterality, and an advanced stage. Ovarian myeloid sarcoma (also known as extramedullary myeloid tumor) is a rare mass-forming lesion composed of primitive neoplastic myeloid cells. The microscopic patterns are similar to those of lymphoma, in particular diffuse large B-cell lymphoma, which is the most important tumor in the differential diagnosis. We have also seen a case of bilateral ovarian involvement by erythroid sarcoma in a 30-year-old woman with synchronous bone marrow involvement. The diagnosis was challenging given the rarity of erythroid sarcoma, and its unusual but distinctive immunophenotype.
Nongestational choriocarcinoma skin care therapist buy cheap decadron 0.5 mg line, including those of germ cell origin (Chapter 15) metastatic to the uterus acne medication accutane discount decadron 0.5 mg online, and endometrial adenocarcinomas with trophoblastic differentiation (Chapter 8) skin care 6 months before wedding decadron 0.5 mg buy with visa. Other malignant tumors, both epithelial (such as undifferentiated carcinoma) and mesenchymal (such as epithelioid leiomyosarcoma), that can potentially resemble typical or atypical choriocarcinoma. Death is usually due to hemorrhagic events within the metastases or pulmonary insufficiency (tumor burden or effects of treatment). Choriocarcinomas arising in term placentas may have an uneventful course or be associated with metastatic disease in the mother or infant. A confluent growth of intermediate trophoblast whose cells have typical abundant amphophilic cytoplasm is seen. The confluence of the proliferation in most of the image can lead to a misinterpretation of malignancy. The differential diagnosis with epithelioid trophoblastic tumor is considered under that heading. The interval from the most recent known pregnancy (which rarely has been a hydatidiform mole) may be many years (average 3 years in one series). The most commonly involved sites are the lower uterine segment, the endometrium immediately above this area, or the endocervix. Microscopic examination reveals single or multiple, typically well-circumscribed, paucicellular nodules or plaques, sometimes with lobulated margins, within or on the surface of the endometrium or endocervix, or within the myometrium or endocervical stroma. Intermediate trophoblastic cells are disposed singly or in irregular clusters, cords, or rounded nests within a usually abundant eosinophilic to hyalinized matrix. Focal necrosis may be seen and rarely there is cystic degeneration or calcification. The periphery of the lesions may show pseudopod-like extensions that can suggest infiltration. A band like proliferation of intermediate trophoblast is seen coating the lower uterine segment. The trophoblastic cells contain cytoplasmic vacuoles, eosinophilic hyaline bodies, and have hyperchromatic nuclei that vary considerably in size and shape. Their nuclei are often irregular and lobated (sometimes multiple) and vary from hyperchromatic to pale and vesicular; mitotic figures are typically absent or rare. Differential diagnosis suggesting that high-stage and fatal cases are more likely reported. There is usually an endomyometrial polypoid and/or endophytic mass (mean size, 5 cm) unless most of it has been removed by curettage. The tumors vary from circumscribed to ill defined, and usually have a fleshy, yellow or tan sectioned surface, often with focal hemorrhage and necrosis. The distinction between decidual cells and intermediate trophoblast has been considered above (see Normal Intermediate Trophoblast). The lesions were within the anterior uterus at the site of a cesarean section scar and were characterized by a subserosal cyst with a fistulous connection with the endometrial cavity. The tumors typically consist of a relatively monotonous population of polygonal intermediate trophoblastic cells with moderate amounts of amphophilic or eosinophilic cytoplasm, or in occasional tumors, a minor or predominant population of clear cells. Amenorrhea and an enlarged uterus may suggest a normal pregnancy and an episode of abnormal vaginal bleeding in this setting may suggest a missed abortion. There is usually a history of an antecedent normal pregnancy, nonmolar abortion, or hydatidiform mole, with a median interval of 18 months from the gestation. The neoplasm is partially hemorrhagic but also contains a yellow ill-defined component which blends into the adjacent myometrium. Left: Sheets and clusters of tumor cells with typical abundant amphophilic cytoplasm invade myometrial smooth muscle. Right: the tumor cells fill the lumen of a myometrial vessel, the wall of which has been replaced by fibrin. The manner in which the neoplastic cells split the myometrial fibers is characteristic.
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Distinguishing features from nodular lymphoma include an absence of a mass acne 19 year old male decadron 4 mg cheap on line, the presence of follicles with germinal centers acne questionnaire buy decadron 0.5 mg visa, and a mixed inflammatory infiltrate acne treatment generic decadron 8 mg. There is frequently an abnormal gross appearance (occasionally with ulceration), but unlike cervical lymphoma, the cervix is not enlarged. Beneath an intact or eroded epithelium, a typically dense superficial band-like lymphoid infiltrate is composed predominantly of large lymphoid cells (including immunoblasts) with mitotic activity. Immunohistochemical studies indicate an admixture of B and T cells without immunoglobulin light chain restriction. A benign interpretation in such cases is supported by an absence of lymphoma on staging or follow-up. Features of this lesion vs lymphoma include an admixture of different cell types and an absence of the following: a large mass, cervical enlargement, deep invasion, perivascular involvement, and sclerosis. A dense plasma cell infiltrate in the endocervical stroma and within the stroma of endocervical polyps is a common incidental microscopic finding; numerous Russell bodies may be present. As with typical endocervicitis, if a fragment of cervix with plasma cell cervicitis contaminates an endometrial sample, it can be misinterpreted as chronic endometritis if the cervical origin of the tissue is not appreciated. Circumscribed collections of ceroid-rich histiocytes (ceroid granulomas), and rarely lipogranulomas, may occur within the cervical stroma. Xanthogranulomatous cervicitis is characterized by an inflammatory stromal infiltrate of numerous histiocytes with foamy, lipid-rich cytoplasm, and in some cases, ceroid. Other rare histiocytic infiltrates that may involve the cervix are malacoplakia and mucicarminophilic histiocytosis (Chapter 20). The cells were immunoreactive for vimentin but not for epithelial or histiocytic markers. Complete loss of normal epithelium with cautery-destroyed tissue (brown foci) within the superficial stroma (left) that is surrounded by a granulomatous inflammatory reaction (right). Initially the epithelium and superficial stroma are necrotic with a dusky brown hue on routine staining; a Prussian blue stain reveals diffuse iron positivity. The stroma contains thrombosed blood vessels and neutrophils followed by brown pigment-laden macrophages, granulation tissue, and fibrous tissue. The usual presence of infertility may be due to endometrial, tubal, or ovarian involvement. Microscopic examination reveals loss of the surface epithelium and massive deposition of amorphous, eosinophilic, hyaline, or necrotic material, some of which is fibrin. The differential includes the rare cases of amyloidosis of the cervix in which the eosinophilic material has a denser appearance and will have different staining properties (see subsequent Miscellaneous Tumor-like Lesions section). Pyoderma Gangrenosum Two cases of a cervical ulcer related to pyoderma gangrenosum have been described, one in a woman with long-standing cutaneous pyoderma gangrenosum; in the other, the lesion was confined to the cervix. Both arteritides are usually an incidental and isolated microscopic finding without clinical significance. Rare cases, however, are associated with, and may be the first manifestation of, systemic disease. Of their 52 cases, the vasculitis was confined to the cervix (23 cases), endomyometrium (6), ovaries (7), fallopian tubes (3), adnexa (3), and >1 organ (10). Conspicuous amorphous eosinophilic material is seen adjacent to the squamous mucosa. We have seen a case associated with and possibly the cause of florid reactive lymphoid hyperplasia (see corresponding heading). In the former, the ulcer extends deeper than the endocervical glands and is subtended by granulation tissue and an infiltrate of lymphocytes, neutrophils, and histiocytes. Molluscum bodies in a Pap smear have been reported, although a tissue sample was not obtained to prove a cervical origin. The most common bacterial infections are caused by sexually transmitted Neisseria gonorrhoeae and Chlamydia trachomatis. Cultures usually establish the diagnosis; molecular methods can be diagnostic in cases of chlamydial infection. Chlamydia can elicit a diffuse chronic inflammatory infiltrate, sometimes with lymphoid follicles (follicular cervicitis); intracytoplasmic inclusions are seen in some cases.
On gross examination acne vitamin deficiency purchase decadron 1 mg on line, the tumors acne causes purchase 0.5 mg decadron visa, which may reach 40 cm in maximal dimension acne xenia gel cheap decadron 8 mg mastercard, have smooth or bosselated Pathologic features (figs. The aggregates vary from tiny clusters (or even single cells) to rounded or irregularly shaped islands. Tumor cells with eosinophilic cytoplasmic inclusions and an eccentric nucleus, resulting in a rhabdoid appearance, are also frequently present. Irregular nests and cords of neoplastic cells are separated by a desmoplastic stroma. Cords of cells may raise the differential diagnosis of metastatic breast carcinoma. High-power view showing small cells with malignant nuclear feature and mitotic figures. Follicle-like spaces, a rare feature of this tumor, may be diagnostically confusing. Desmin and vimentin immunoreactivity (particularly intense in the rhabdoid cells) is typically paranuclear and globular. The stromal cells are typically immunoreactive for vimentin and muscle specific actin. Cell junctions have varied from scant and primitive to more prominent ones including intermediate, desmosomal, and tight types. Paranuclear intermediate cytoplasmic filaments and basal lamina surrounding tumor nests are often prominent. The typical age of the patient, confinement to the abdomen, and the typical microscopic and immunohistochemical features facilitate distinction from other malignant small cell tumors. A diagnosis of sarcoma was usually considered in the above study, but the follow-up was uneventful, suggesting a hamartomatous origin. Typically there is a well-circumscribed hypocellular proliferation of bland spindle cells separated by dense collagen, foci of calcification, and a variable lymphoplasmacytic infiltrate. The lesions usually occur in patients <20 years of age who present with a mass, fever, growth failure or weight loss, hypochromic anemia, thrombocytosis, and polyclonal hypergammaglobulinemia. Microscopic examination reveals myofibroblastic spindle cells, mature plasma cells, and small lymphocytes. All of the patients have had an uneventful postoperative course with disappearance of the clinical manifestations. There is a loose arrangement of tumor cells that vary from epithelioid to spindled with scattered inflammatory cells and a myxoid matrix. Rare malignant vascular tumors, including epithelioid hemangioendothelioma and epithelioid angiosarcoma, may have a peritoneal origin. In addition to ependymomas of the broad ligament (Chapter 11) and ovary (Chapter 15), rare ependymomas presenting with both ovarian and peritoneal involvement (Liang et al. Immunoreactivity for sex cord markers and exclusion of other neoplasms facilitated the diagnosis. Peritoneal involvement by metastatic tumor usually reflects spread from a primary tumor arising within the abdomen or pelvis, most commonly the ovary. Peritoneal serous tumors (Chapter 19) in which the ovaries are normal or only minimally involved may arise from tubal or endometrial serous carcinomas, which may be microscopic. Other tumors that may spread to the peritoneum with some frequency include carcinomas of the breast and gastrointestinal tract (colon, stomach, pancreas), some of which may have an exclusive or prominent component of signet-ring cells. The glands of mucinous adenocarcinomas may be focally lined by deceptively benign-appearing epithelium Peritoneal involvement by low-grade mucinous tumors (sometimes in the form of pseudomyxoma peritonei, see next heading) is mostly of nonovarian origin. The tumor cells, which are barely visible at this magnification, are widely scattered through a reactive fibrous stroma.