Professional Documents
Culture Documents
2008
Contents: Pathology of
Vulva
Vagina
Cervix
Body of Uterus
Fallopian Tubes
Ovaries
Diseases of Pregnancy
Breast
VULVA
Diseases of vulva:
Vulvitis (more common but not serious).
Non-Neoplastic epithelial disorders.
Carcinomas (uncommon but life threatening).
Painful bartholin cysts (caused by obstruction
of the excretory ducts of the glands).
Imperforate hymen in children.
Impeding secretions and menstrual flow later
in life.
Vulvitis
Most important forms of vulvitis related
to sexually transmitted disease:
HPV: produce condylomata acuminata and
vulvar intraepithelial neoplasia.
Herpes genitalis (HSV1 or 2): causing
vesicular eruption.
Gonococcal suppurative infection
Syphilis: produce primary chancre at site of
inoculation.
Candidal vulvitis.
Vulvitis
Contact dermatitis: the most dommon causes of
vulvar pruritus is a reactive inflammation to an
exogenous stimulus, whether an irritant or an
allergen.
Contact irritant dermatitis: presents as well-
defined erythematous weeping and crusting
papules and plaques. May be a reaction to urine,
sops, detergents, antiseptics, or alcohol.
Contact allergic dermatitis: has similar gross
appearance and may result from allergy to
perfumes and other additives in creams, lotions,
and soaps, chemical treatments on clothing and
other antigens.
Non-Neoplasic epithelial disorders
The epithelium of vulvar mucosa may
undergo atrophic thinning or hyperplastic
thickening
There are two forms of non-neoplastic
epithelial disorders: lichen sclerosus and
lichen simplex chronicus.
Both may coexist in different areas in the
same person, and both may appear
macroscopically as depigmented white
lesions, referred to as leukoplakia.
Non-Neoplastic epithelial disorders
Lichen Sclerosus:
Characterized by atrophic epithelium, usually with dermal
fibrosis.
Pathogenesis is uncertain, autoimmune reaction may
involved
Carries an increased risk of developing squamous cell
carcinoma.
Lichen Simplex Chronicus
End reaction of many inflammatory dermatoses, marked
by epithelial thickening, expansion of stratum
granulosum and surface hyperkeratosis.
Generally, there is no inrecased predisposition to cancer,
but suspiciously, lichen simplex chronicus is often
present at margins of established cancer of the vulva.
Non-Neoplastic epithelial disorders
Lichen Sclerosus
Lichen Planus
Lichen simplex It’s benign dermatoses
chronicus
Tumors
Condylomas and low-grade vulvar
intraepithelial Neoplasian (VIN)
Condylomas fall into two distinctive biologic forms:
- Condylomata lata: (not commonly seen today), are
flat, moist, minimally elevated lesions that occur in
secondary syphilis
- Condylomata accuminata: (more common) may be
papillary and distinctly elevated. They occur
anywhere on the anogenital surface. Significant
characteristic cellular morphology is: perinuclear
cytoplasim vacuolization. Vulvar cndylomas are not
pre-cancerous but coexist with foci of intraepithelial
neoplasia in vulva (VIN grade 1) and cervix.
Condylomas
High-risk HPV types: 16, 18, 45, and 31, account for
the majority of carcinomas, smaller contributions by
HPV33, 35, 39, 45, 52, 56, 58, and 59. The viral DNA
integrates into the host genome and express E6 and
E7 proteins which inactivate tumor suppressor genes
p53 and RB, respectively.
Low-risk HPV types: 6, 11, 42, 44 which produce
condylomas; the viral DNA does not integrate into the
host genome.
The recently introduced HPV vaccine is very effective
in preventing HPV infections and cervical cancers.
Many women harbor these viruses, only few develop
cancer, suggesting other influences like cigarette
smoking and exogenous or endogenous
immunodeficiency.
Invasive carcinoma of the cervix
The most common cervical carcinoma are sqamous
cell carcinoma 75%, adenocarcinoma and
adenosquamous carcinoma 20%, and small cell
neuro-ednocrine carcinoma 5%.
In some individual with aggressive intraepithelial
changes, the time interval may be considerably
shorter, whereas in other women CIN precursors
may persist for life. The only reliable way to
monitor the course of the disease is with careful
follow-up and repeat biopsies.
The relative proportion of adenocarcinoma has
been increasing in recent decades; glandular
lesions are not detected well by Pap smear.
Invasive carcinoma of the cervix
(continued…)
Leiomyoma:
- The most common benign tumor in females and are
found in 30% to 50% of women during reproductive
life. More frequent in blacks than in whites.
- They are often referred to as fibroids because they
are firm.
- Estrogens and oral contraceptives stimulate their
growth; conversely, they shrink postmenopausally.
- They may be entirely asymptomatic, discovered on
routine pelvic examination. The most frequent
manifestation, when present, is menorrrhagia, with
or without metrorrhagia. They may become palpable
to the woman or may produce a dragging sensation.
- They rarely transform into sarcomas.
Tumors (continued…)
Liomyosarcomas:
- Typically arise de novo from mesenchymal cells of
the myometrium.
- Almost always solitary tumors.
- They are frequently soft, hemorrhagic and necrotic.
- Diagnostic features include tumor necrosis,
cytologic atypia, and mitotic activity.
- They present a wide range of differentiation
- Recurrence after removal is common with these
cancers.
- Many metastasize, typically to the lungs. Yielding a
5-years survival rate of about 40%.
Tumors (continued…)
Clinical course:
Breast cancer is often discovered by the woman or
physician as a discrete, solitary, painless, and
movable mass. At this time, involvement of regional
lymph nodes is already present in about half of
patients.
With mammographic screening, carcinomas are
frequently detected before they become palpable, and
only 15% of these have nodal metastases.
Magnetic resonance imaging is being studied in high-
risk young patients with dense breasts that are
difficult to image by mammography.
Carcinoma (continued…)
Prognosis is influenced by the following variables:
1. The size of the primary carcinoma. Invasive carcinoma
smaller than 1cm have an excellent prognosis in the
absence of lymph node metastases.
2. Lymph node involvement and the number of lymph
nodes involved by metastases. 5-year survival rate is
90% with no axillary node involvement. The survival
rate is decreases with each involved lymph node and is
less than 50% with 16 involved nodes.
3. Distant metastases. Patient who develop hematogenous
spread are rarely curable.
4. The grade of the carcinoma. The most common grading
system for breast cancer evaluates tubule formation,
nuclear grade, and mitotic rate to divide carcinomas in
to three groups. Well-differentiated or poor
differentiated or moderately differentiated.
Carcinoma (continued…)
5. The histologic type of carcinoma. All specialized types of
breast carcinoma (tubular, medullary, cribriform, adenoid
cystic, and mucinous) have a better prognosis than
carcinomas of no special type (ductal carcinoma).
6. The presence or absence of estrogen or progesterone
receptors. The presence of receptors confers a slightly
better prognosis. The reason for determining their
presence is to predict the response to anti-estrogen
therapy.
7. The proliferation rate of the cancer. High proliferative rates
are associated with a poorer prognosis.
8. Aneuploidy. Carcinoma with an abnormal DNA content
have a slightly worse prognosis.
9. Overexpression of HER2/NEU. Ovexpression is associated
with poorer prognosis. However, the importance of
evaluating HER2/NEU is to predict resposne to monoclonal
antibody “Herceptin” to the gene product.
Carcinoma (continued…)
The major prognostic factors are used by the
American Joint Committee on Cancer to devide breast
cancer into clinical stages as follows:
- Stage 0. DCIS or LCIS (5-year survival rate: 92%)
- Stage 1. invasive carcinoma 2cm, without nodal
involvement (5-year survival rate: 87%)
- Stage 2. invasive carcinoma 5cm, with up to 3
involved axillary nodes (5-year survival rate: 75%)
- Stage 3. invasive carcinoma 5cm with four or more
involved axillary nodes. (5-year survival rate: 43%)
- Stage 4. breast cancer with distant metastases (5-
year survival rate: 13%)
Male breast
Only two disorders occur in male breast with sufficient
frequency.
Gynecomastia: male breast are also subject to hormonal
influences, but they are less sensitive than are female breasts.
Gynecomastica may occur in response to estrogen excess. The
most important cause is cirrhosis of the liver, with consequent
inability of the liver to metabolize estrogens. Other causes
include Klinefelter syndrome, estrogen-secreting tumors,
estrogen therapy, digitalis therapy. Physiologic gynecomastia
occurs in puberty and in old age. Morphologic features are
simlar to intraductal hyperplasia.
Carcinoma: frequency ratio to breast cancer in the female of
1:125. It occurs in advanced age. Because of scant amount of
breast substance in males, the tumor rapidly infiltrates the
skin and underlying thoracic wall. Almost half have spread to
regional nodes and more distant sites by the time they are
discovered. They resemble invasive carcinoma in females both
morphologically and biologically.
Review Questions
19. The most likely cause 20.All of the following are
of 1 cm mass in the associated with
upper outer quadrant carinoma of the
of the breast of 65 breast, except:
year old woman. A) High-fat diet
A) Fibrocystic change B) Positive family history
B) Acute mastitis C) Obesity
C) Fibroadenoma D) Early menarche
D) Carcinoma E) multiparity
E) Pagets disease of the
breast
Additional informations
Infectious disorders:
Candidiasis: most common form of vagnitis
Trichomoniasis: second most common type of vaginitis.
Garnerella vaginitis: “clue cell” are characteristic cells
Toxic shock syndrome: associated with use of tampons.
Gonorrhea: frequent cause of pelvic inflammatory disease.
Chlamydial infection: clymedial cervicitis –
lymphogranuloma venereum.
Herpes simplex virus infection: produce small viscels and
shallow ulcers.
Shyphilis: 1st stage: chancre, 2nd stage: condyloma lata.
Chancroid: soft and painful ulcerated lesion. Caused by
haemophilus dureyi
Granduloma inguinale: characterized by donovan bodies.
Cased by calmmatobacterium granulomatis.
Review Test
21. All of the following 22.HPV infection is not
condition correctly associated with:
matched with the
appropriate association, A Vulvar intra epithelial
except: neoplasia (VIN)
A) Endometriosis: severe B Vaginal intra epithelial
menstrual pain neoplasia (VAIN)
B) Endometrial hyperplasia: C Cervical intra epithelial
excess estrogen
stimulation neoplasia (CIN)
C) Leiomyoma: D Endocervical glandular
postmenopausal decrease dysplasia
in size E Paget's disease of the
D) Endometrial carcinoma: vulva
multiparity
E) Ectopic pregnancy:
hematosalpinx
Review Test
23. Fishy odor, "clue cells”, 24. Which of the following
caused by (from neoplasms of the vagina
additional information) has been associated with
A. Trichomonas in utero exposure to
B. Gardnerella diethylstilbestrol?
C. Candida A. Vaginal intraepithelial
neoplasia (VAIN)
D. Herpes
B. Squamous cell carcinoma
E. Gonorrhea
C. Embryonal
rhabdomyosarcoma
D. Clear cell
adenocarcinoma
E. Leiomyoma
Review Test
25.The most common site 26. A 21 year old woman is at
of an ectopic week 25 of her first
pregnancy. Her gynecologist
pregnancy: tells you she has
A. ovary pre_eclampsia. You would
expect to find which
B. peritoneal cavity constellation of findings on
C. endocervical canal your evaluation:
A Hypertension; otherwise
D. endometrial cavity normal
E. fallopian tube B Hypertension and
proteinuria; otherwise normal
C Glucose intolerance;
otherwise normal
D Glucose intolerance, and
hypertension; otherwise
normal
E Hypertension, proteinuria and
peripheral edema
Review Test
27. A 32-year-old woman 28. A 27 year old woman
with a history of had a palpable right
hyperthyroidism was ovary which an x-ray
found to have a left was found to contain a
adnexal tumor well
composed entirely of the developed molar tooth.
tissue as depicted The most likely diagnosis
microscopically. The would be:
best diagnosis is: A. Dysgeminoma
A. Krukenberg tumor B. Yolk sac tumor
B. Struma ovarii C. Sertoli-Leydig cell tumor
C. Immature teratoma D. Mature cystic teratoma
D. Ovarian carcinoid E. Denturoma
E. Strumal carcinoid
Review Test
29.Elevated beta - HCG 30.A 21 year old woman
A. Choriocarcinoma was diagnosed as
B. Fibroma having pre-eclampsia.
Which of the following
C. Granulosa cell tumor would not be
D. Endodermal sinus consistent with that
tumor diagnosis?
E. Immature teratoma A. Hypertension
B. Convulsions
C. Proteinuria
D. Edema
Review Test
31. The most common 32. A 26-year old female in
primary sites for the the third trimester of her
oringin of Paget’s first pregnancy develops
persistent headaches and
disease are the nipple swelling of her legs and
and the face. Her blood pressure is
A. Anal canal 170/105 mmHg and
urnialysis reveals slight
B. Liver proteinuria. What is the
C. Nasopharynx diagnosis
D. Penis A. Eclampsia
E. Vulva B. Gestational trophoblastic
disease
C. Nehritic syndrom
D. Nehprotic syndrom
E. preeclampsia
Review Test
33.The most important
factor related to the
prognosis of breast
cancer is
A. the presence of
activated oncogenes
B. The histologic type and
grade
C. The size of the tumor
D. The status of axillary
lymph nodes
E. The presence of
estrogen receptors.
Answers
1-E. 11-A. 21-D. 31-E.
2-A. 12-D. 22-E. 32-A.
3-E. 13-B. 23-B. 33-E.
4-C. 14-B. 24-D.
5-C. 15-B. 25-E.
6-B. 16-B. 26-E.
7-D. 17-B. 27-B.
8-C. 18-C. 28-D.
9-E. 19-D. 29-A.
10-B. 20-E. 30-B.
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