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    Ovary and fallopian tube -benign setting

    Background

    Salpingectomy with or with oophorectomy may be included with total hysterectomy but is also undertaken as an isolated resection for sterilisation or prophylactically in some genetic conditions.1-5

    Fallopian tube segments may be received from tubal ligation sterilisation procedures.1 Commonly an avascular segment in the mid-isthmic portion of the fallopian tube is made into a loop that is tied at the base with a segment of the loop is excised. Ectopic pregnancy in the fallopian tube will also result in salpingectomy.1

    Patients with a family history of breast or ovarian cancer or known BRCA mutations may undergo prophylactic or risk-reducing oophorectomy (and salpingectomy).4,5

    Ovaries may also be received in total hysterectomy specimens with or without abnormalities present.1,4

    Other conditions to affect the fallopian tubes include endometriosis, cysts, hydrosalpinx and pelvic inflammatory diseases.1

    Record the patient identifying information and any clinical information supplied together with the specimen description as designated on the container. See overview page for more detail on identification principles. Note the receipt of fresh tissue, requests for special studies and any introperative consultation performed. However, fresh tissue is not usually submitted.

    • Not performed
    • Performed, describe type and result
      • Frozen section
      • Imprints
      • Other, describe

    See general information for more detail on specimen handling procedures.

    Inspect the specimen and dictate a macroscopic description.


    External Inspection

    Orientate and identify the anatomical features of the specimen.

    Record additional orientation or designation provided by operating clinician:

    • Absent
    • Present
      • Method of designation (e.g. suture, incision)
      • Featured denoted

    Photograph the intact specimen if required.

    Describe the following features of the specimen:

    Procedure

    Record as stated by the clinician.
    • Biopsy/segment
    • Salpingectomy
      • With oophorectomy
      • Without oophorectomy
    • Other reason, describe

    Specimen laterality

    • Left
    • Right
    • Bilateral
    • Unspecified

    Anatomical components included (more than one may apply) and specimen dimensions (mm)

    Describe and measure the anatomical components present.

    • Fallopian tube, in two dimensions, length x diameter.1,3 If abnormal, record in three dimensions.
      • With fimbriae
      • Without fimbriae
    • Ovary, in three dimensions
    • Other, describe and measure according to relevant protocol

    Particular care and documentation is required with specimens from failed sterilisation procedures. They can be difficult to process due to the presence of metal clips and removal of the clips can destroy the evidence of a patent lumen.

    Describe the following for both fallopian tube and ovary if present.

    Specimen integrity

    • Intact
    • Disrupted
    • Fragmented

    Specimen appearance

    • Surface
      • Smooth
      • Roughened
      • Adhesions
      • Cysts

    Evidence of previous tubal surgery (if present)1

    • Clips
    • Number and location

    Dissection

    Clinical history and appearance of the specimen should be considered before dissecting the specimen. Refer to other specimen protocols where applicable.

    Note that where the specimen includes an ovarian cyst, the fallopian tube may be distorted and difficult to recognise as a layer over the surface of the cyst.1

    Transversely section the fallopian tube at 3-4mm intervals. If large, or prophylactic for BRCA mutations, the fimbrial portion (distal 20mm) is sectioned longitudinally. (Protocol for Sectioning and Extensively Examining the FIMbriated End (SEE-FIM) of the Fallopian Tube).6,7

    Carefully dissect the specimen noting the presence of of a gestational sac, or rarely, a fetus. If a fetus is present, measure the length from crown to rump and/or foot length (mm). See products of conception protocol for more detail.

    Serially section the ovary sagitally through its full thickness at 3-4mm intervals.7 Examine the cut surface for abnormalities and heterogeneous areas.

    Post-menopausal ovaries may be bisected longitudinally.1

    Tumour

    If a tumour is suspected, refer to the protocol for ovary and fallopian tube in a malignant setting.


    After opening the specimen may require longer fixation in larger quantity of formalin.


    Internal Inspection

    Describe the internal or cut surface appearance including the following items:

    Fallopian tube

    • Normal
    • Abnormal

    Fallopian tube abnormalities

    For each abnromality describe:

    • Nature and size in max dimension (mm)
    • Tubal cyst, size in max. dimension (mm)
    • Tubal swelling
    • Perforation/rupture
      • No
      • Yes
    • Contents
      • Fluid
      • Cloudy
      • Clear
      • Blood/clot

    Lumen of fallopian tube

    • Absent
    • Present

    Ovary

    • Normal
    • Physiological
      • Follicle cyst(s)
      • Corpus luteum
    • Abnormal
      • Cyst
        • Unilocular without suspicious papillary or solid areas (if these are present, use template for malignant setting)
        • Multilocular
        • Fluid
        • Serous
        • Mucinous
        • Keratinous debris and hair
        • Old blood and blood clot

    Note photographs taken, diagrams recorded and markings used for identification.


    Processing

    Dissect the specimen further and submit sections for processing according to the illustrations provided.

    Ovary

    Submit one1 or two representative sections3,4 that demonstrate cortex, medulla and hilum1. Where the ovary is >25mm in maximum dimension, more sections may be required to achieve adequate sampling.1

    Submit one longitudinal/half for processing1

    Submit all tissue for processing:

    • All sagittal sections of ovary
    • Longitudinal sections of fimbrial end of fallopian tube at 2-3mm intervals (Refer to Sectioning and Extensively Examining the FIMbriated End (SEE-FIM) of the Fallopian Tube and illustrations provided).4,6,7
    • Transverse sections of remaining tube at 2-3mm intervals.3,4
    • Submit each section consecutively into cassettes for processing.

    Submit representative sections focussing on solid areas and including blocks from solid areas and the cyst wall.1

    Submit representative sections from cyst wall, soft, solid and papillary areas. A section taken in continuity with the fallopian tube (if submitted) is valuable to examine the intervening tissues for endometriosis.4

    Simple thin-walled cysts may be best processed by submitting a piece of the wall in a “Swiss roll” block. 1 Communicate instructions for cyst wall to be embedded on edge to ensure sections demonstrate the epithelial lining, wall and stromal surface.1

    Submit entire cyst if small. Submit one block per 10mm of maximum diameter of larger cysts.4

    Fallopian tube

    For specimens with no abnormalities in the fallopian tube(s), submit one transverse section from the mid portion and one longitudinal section from the fimbrial end of each.

    Prophylactic surgery may be undertaken where there is a family history of ovarian, fallopian tube or breast cancer or BRCA1/BRCA2 mutations, usually with oophorectomy (above).5,6

    Submit all tissue for processing:

    • Longitudinal sections of fimbrial (distal 20mm) end at 2-3mm intervals1
    • Transverse sections of remaining tube1
    • Submit each section in sequential order

    Submit representative sections of:

    • Dilated portion or implantation site on surface of the tube, submit all transverse sections, including products of conception (POC) found such as villi or fetal tissue
    • Sections from any separate blood clot (which may represent POC)
    • Sections demonstrating relationship with adjacent wall1
    • Non-dilated portion of fallopian tube (usually isthmic/proximal end), submit one or more blocks1

    Submit representative sections of:

    • Abnormal (dilated) area, submit all transverse sections1
    • Sample adhesions to other structures including ovary
    • Normal fallopian tube (usually at the isthmic end), submit one1 or more sections including fimbria if present
    • Submit one transverse section demonstrating lumen, muscularis mucosa and serosa to confirm interruption to the tube.1
    • If small (<5mm), submit whole and paint the cut-end surface with ink to assist orientation during embedding. All tissues are submitted for processing.1
    • Communicate instructions for tube to be embedded “on-end”

    Submit all sections of the tube to demonstrate any possible recanalization. Longitudinal sections may be required if the tube is grossly distorted.1

    Submit representative sections of all tubal or paratubal cysts; one block per 10mm of maximum dimension, sampling any solid or papillary areas. Small cysts may be submitted whole for processing.

    Record details of each cassette.

    An illustrated block key similar to those provided below may be useful.

    Block allocation keys

    Cassette id Site No. of pieces
    A-B Ovary, representative sections  
    Cassette id Site No. of pieces
    A Ovary, one longitudinal/half section  
    Cassette id Site No. of pieces
    A-D Ovary and fallopian tube, all sections  
    Cassette id Site No. of pieces
    A-D Ovary, representative sections including umbo and cyst wall  
    Cassette id Site No. of pieces
    A-D Ovary, representative sections including soft, solid and papillary areas and a section in continuity with fallopian tube if present  
    Cassette id Site No. of pieces
    A-B Ovary, representative sections including cyst wall  
    Cassette id Site No. of pieces
    A-D Ovary, representative sections including one block per 10mm diameter of cyst  
    Cassette id
    Site
    No. of pieces
    A
    Fallopian tube, fimbrial end, one longitudinal section
     
    B
    Fallopian tube, mid-portion, one transverse section
     
    Cassette id
    Site
    No. of pieces
    A
    Fallopian tube, fimbrial end, longitudinal sections
     
    B
    Fallopian tube, transverse sections
     
     
    All tissue submitted
     
    Cassette id
    Site
    No. of pieces
    A-C
    Fallopian tube, dilated portion, transverse sections, demonstrating possible implantation site, POC and relationship with adjacent wall
     
    D-E
    Fallopian tube, normal
     
    Cassette id
    Site
    No. of pieces
    A-C
    Fallopian tube, dilated portion, transverse sections
     
    D
    Adhesions to ovary/other structure
     
    E
    Fallopian tube, normal and fimbrial end
     
    Cassette id
    Site
    No. of pieces
    A
    Fallopian tube, one transverse section
     
    Cassette id
    Site
    No. of pieces
    A-C
    Fallopian tube, transverse sections, all tissue submitted
     
    Cassette id
    Site
    No. of pieces
    A-C
    Fallopian tube cysts, representative sections of each
     
    D
    Fallopian tube cyst, solid/papillary areas
     
    E-F
    Fallopian tube, normal
     
     

    Acknowledgements

    Drs Kerryn Ireland-Jenkin and Marsali Newman for their contribution in reviewing and editing this protocol.


    References

    1. Brown L, Andrew A, Hirschowitz L and Millan D. Tissue pathways for gynaecological pathology, The Royal College of Pathologists, London, 2008.
    2. Lester SC. Manual of Surgical Pathology, Saunders Elsevier, Philadelphia, 2010.
    3. Heatley MK. Dissection and reporting of the organs of the female genital tract. J Clin Pathol. 2008;61(3):241-57.
    4. Leunen K, Legius E, Moerman P, Amant F, Neven P and Vergote I. Prophylactic salpingo-oophorectomy in 51 women with familial breast-ovarian cancer: importance of fallopian tube dysplasia. Int J Gynecol Cancer 2006;16(1):183-188.
    5. Gwin K, Wilcox R and Montag A. Insights into selected genetic diseases affecting the female reproductive tract and their implication for pathologic evaluation of gynecologic specimens. Arch Pathol Lab Med 2009;133(7):1041-1052.
    6. Clarke BA, Crum CP, Nucci MR, Oiva E, Cooper K, For the Members of the Cancer Committee. Protocol for the Examination of Specimens From Patients With Carcinoma of the Fallopian Tube, College of American Pathologists, 2013.
    7. Lee Y, Medeiros F, Kindelberger D, Callahan MJ, Muto M, Crum CP. Advances in the recognition of tubal intraepithelial carcinoma: applications to cancer screening and the pathogenesis of ovarian cancer. Adv Anat Pathol. 2006;13(1):1-7.

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      Ovary 5

      Simple ovarian cyst (collapsed) with a smooth external surface

      Ovary 6

      Simple ovarian cyst opened

      Ovary 2

      Ovary with attached adnexa, transverse sections

      Fallopian tube 1

      Fallopian tube intact

      Fallopian tube 2

      Fallopian tube demonstrating dissection for SEE-FIM

      Fallopian tube 3

      Fallopian tube, sections for processing using SEE-FIM protocol

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      25-Mar-2019
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