Female Genital Tract

General Pathology FGT & Breast (Dr. Sionzon) 2nd wk ng 4th shift (silent ‘f’)

Normal Female Genital Tract Vulva - lined with keratinized squamous epithelium Vagina non keratinized stratified squamous epithelium Uterus divided into 3 segments 1. cervix 2. lower uterine segment 3. corpus lined by columnar epithelium layers: 1. endometrium: contains basal cells 2. myometrium: smooth muscle 3. serosa: outermost portion * leiomyomas are called based on their location i.e. submucosal, intramural, subserosal Cervix - ectocervix: stratified squamous epithelial lining Squamo-columnar junction : important site for the development of cervical Ca : pre-neoplastic changes usually occur here : aka transformation zone

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Endocervix: mucus epithelium

columnar secreting : varies with age : may extend outside the cervical os : during late adulthood this migrates to the inner part of cervical os

joyce + MR

(kung alam ko lang, sana di na ko nagnotes!)

Infections of the Female Genital Tract - usually affects the lower genital tract but may infect ovaries and peritoneum 1.

HSV

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vulva, vagina, cervix common in teenagers, young women HSV 2 = sexually transmitted HSV 1 = oral ⅓ will have signs and symptoms painful red papule that progress to vesicles  ulcers fever, malaise, tender vaginal nodes pap smear = viral inclusions and multinucleated giant cells

2. Yeast (Candida) -

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10% of women enhanced by DM, OCP, pregnancy leukorrhea, pruritus

3.

Trichomonas flagellated protozoa 15% of referrals to STD clinics purulent vaginal discharge - fever, malaise or systemic manifestations bright red appearance “strawberry cervix”

4.

Mycoplasma - spontaneous abortion and chorioamnionitis - associated with preterm deliveries if mild

5.

Gardnerella part of the flora may have a problem if there is over growth Gr (-) small bacilli

Pelvic Inflammatory Disease etiologic agent has reached upper part of female genital tract - pelvic pain, adnexal tenderness, fever and vaginal discharge - puerperal infection: Staphylococcus, Streptococcus, Clostridia, coliform bacteria Common: Gonococcus, Chlamydia and enteric bacteria o acute salpingitis: lined by columnar epithelium with abundant inflammatory infiltrates o salpingoophoritis: fibrous adhesions of ovary and fallopian tube o tuboovarian abscesses: cavity is filled with purulent material 1 of 5

Patholab – FGT & Breast by Dr. Sionzon

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Premalignant: 1) Vulvar intraepithelial neoplasm - dysplastic or paraneoplastic change of epithelial lining carcinoma in situ - atypia of nuclei, proliferation, ↑ mitoses, ↓ surface differentiation 2) Carcinoma of the vulva - rare, 5% of genital carcinoma 85% = SCCA, 15% = BCCA, adenocarcinoma, melanoma 3) Malignant melanoma - > 5% of vulvar varcinoma, 2% of all melanomas in women 4) Paget’s disease - pruritic, red, crusted, sharply demarcated, map like area, occurring usually in the labia majora tumor cells infiltrate between epithelial cells of epidermis

o

pyosalpynx / hydrosalpynx: presence of serous fluid Complications: peritonitis, intestinal obstruction from adhesions

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Vulva

1. Bartholin’s Cyst - obstruction of Bartholin’s duct, usually by an -

infection may dilate to 3-5 cm in diameter lined by transitional normal duct with metaplasia

epithelium of the some squamous

2.

Vestibular adenitis - inflammation of the serosa of the vulva - vulvadynia: pain in the vulva may require surgical excision

3.

Non-neoplastic epithelial disorder precursor of carcinoma A. Lichen Sclerosus aka chronic atrophic vulvitis atrophy, fibrosis and scarring 1) atrophy of the epidermis with disappearance of rete pegs 2) hydyropic degeneration of the basal cells 3) replacement of dermis by dense collagenous fibrous tissue 4) monoclonal bandlike lymphocytic infiltrate thinning of epidermis

B. Lichen Simplex Chronicus - hyperkeratosis (proliferation 4.

of keratin) and acanthosis (proliferation of squamous epithelial cells) inflammation of epidermis, thinning of the dermis proliferation of collagenous connective tissue

Neoplasms of the vulva similar to tumors of the skin A. Benign 1) Papillary hydradenoma labia majora or interlabial folds - identical to intraductal papilloma of the breast proliferation of apocrine glands 2) Condyloma acuminata verrucous - koilocytic atypia (anuclear atypia and perinuclear vacuolization) – considered a viral cytopathic effect keratosis, parakeratosis B. Neoplasms

Vagina 1.

Congenital anomalies i.e. absence, fusion - Gartner duct cyst = lesion in gartner duct which is an embryonic remnant in vaginal wall

2.

Malignant and Non-malignant Neoplasm A. VIN atypia, mitoses B. SCC 95% HPV associated - common in the upper, posterior vagina associated with SCCA of cervix - irregular spotting or development of frank vaginal discharge (leukorrhea) C. Adenocarcinoma - usually clear cell type - 0.14% of women whose mothers where exposed to DES (tx for threatened abortion) D. Embryonal Rhabdomyosarcoma - sarcoma botyroides polypoid, rounded, bulky masses grape like clusters malignant tumor arising from skeletal muscle common in children - tumor cells are crowded in a so-called cambium layer - thick rounded cells within a fibromyxomatous stroma Tx: excision with chemotherapy

oops break muna… FYI, from this point forward, me na ang nagtype, imagine… notes ko na me pa magttype, (and formatting + editing) ndi naman me ang trans!  kasi naman, meant for my eyes only ang notes ko! - MR

Patholab – FGT & Breast by Dr. Sionzon

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basal cells: cells with larger nuclei

Cervix 1.

Acute cervicitis characterized by acute inflammatory cells, erosions and reactive cellular changes may have atypia

a.

2.

Chronic cervicitis little clinical significance except if it causes systemic infection inflammation usually mononuclear with lymphocytes and macrophages, plasma cells Causes: o HSV: epithelial ulcers o C. trachomatis: lymphoid germinal centers o T. vaginalis: epithelial spongosis

b.

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c.

Endocervical polyp small and sessile to large lesions spotting, bleeding, which may occur after sexual contact may protrude thru cervical os protrusions are polypoid, columnar endocervical glands with inflammatory infiltrates

CIN I cells with irregular cellular borders koilocytic atypia, perinuclear vacuolization nuclear atypia, increased mitotic activity CIN II enlarged nuclei - irregular borders, dense nuclear chromatin cells are larger atypia occupies 2/3 of epithelial layer CIN III irregular borders very darkly staining marked pleiomorphism dysplastic in all layers may have invasion of mucosa (microinvasive SCCA)

4. Intraepithelial Neoplasia -

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pre-neoplastic changes of the cervix, may progress to cervical cancer risk factors early age at 1st intercourse multiple sexual partners (brim =p) increased parity HPV OCPs and nicotine genital infections Evidences linking HPV to cervical cancer a. HPV DNA is detected in by hybridization technique in 95% of cases b. Specific HPV types are associated with cervical cancer * HPV 6, 11, 42, 44, 53, 54, 62, 66 – low risk group, associated with condylomata * HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 68, 69 – high risk group associated with cervical cancer c. presence of viral oncogenes based on experimental data d. physical state of virus differs in different lesions integrated in host DNA in cancer free (episomal) viral DNA in condylomata e. chromosome abnormalities f. vaccines directed against HPV prevent development of precancerous lesions Grading: CIN I = low grade intraepithelial lesion (LSIL) CIN II = high grade intraepithelial lesion (HSIL) CIN III = carcinoma in situ, carcinoma noted on entire epithelium pap smear: peripheral cells – superficial

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Invasive cervical cancer usually occurs during late adulthood patterns: fungating, ulcerating or infiltrative spreads by; o direct spread (to peritoneum, urinary bladder, ureter, rectum) o lymphatics (to inguinal or iliac nodes) o hematogenous spread histologic patterns: o large keratinizing cells (well differentiated) o non keratinizing cells (moderately differentiated) o small cell squamous (poorly differentiated) o small cell undifferentiated (neuroendocrine or oat cell carcinoma) stain via Chromogranin (visualize neuroendocrince cells) associated with HPV 18 Staging Stage 0: CIN III Stage 1: confined to cervix Stage 1a: preclinical disease diagnosed by microscopy

Stage 1a1: stromal invasion Stage 2: extends beyond cervix but not onto pelvic wall Stage 3: extended into pelvic wall Stage 4: extended beyond true pelvis Uterus – Endometrium

Patholab – FGT & Breast by Dr. Sionzon

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1.

Dysfunctional uterine bleeding most common cause: anovulation with estrogenic stimulation excessive prolonged estrogen stimulation with decreased progesterone lack of ovulation probably due to the following causes: o endocrine disorders o ovarian lesions o metabolic disturbances associated with anovulatory endometrium with stromal breakdown

2.

Endometritis not common usually only in patients with a. chronic PID (i.e. gonococcus) b. postabortal/postpartal endometrial cavities usually related to retained gestational tissue c. intrauterine contraceptive devices d. tuberculosis

3.

Endometriosis presence of endometrial glands or stroma in abnormal locations outside the uterus most common locations: ovaries, lower part of genital tract - important cause of dysmenorrhea, pelvic pain, infertility and other problems - responds to hormonal changes in the menstrual cycle may form hemorrhagic cyst (chocolate cyst) in ovaries presence of RBCs and lining of endometrium in abnormal locations

4.

Adenomyosis presence of endometrial tissue in uterine wall (myometrium)

composed of islands of stroma and glands in muscle layer causes severe bleeding (menorrhagia), dysmenorrhea, dyspneuria, and pelvic pain

5.

Endometrial Polyps may protrude into uterine cavity may be single or multiple sessile masses responsive to estrogen may be functional or hyperplastic

6.

Endometrial hyperplasia pre cancerous lesion increase number of glands compared to stroma cystic dilatation - lined by pseudostratified hyperplastic epithelium with atypia or presence of stratification of epithelium and mitoses inactivation of PTEN tumor suppressor gene Patterns: a. Simple hyperplasia without atypia glands are compressed and laid back to back b. Simple hyperplasia with atypia c. Complex hyperplasia with atypia leads to adenocarcinoma

7.

Carcinoma of the endometrium most common invasive cancer of the genital tract - peak incidence in the 55 to 65 year old women associated with obesity, DM, hypertension, infertility 85% are adenocarcinoma may protrude or occupy entire endometrial surface Grading 1: well differentiated adenoCa, with glandular pattern 2: easily recognizable glandular patterns; with well-formed glands mixed with solid sheets of malignant cells 3: solid sheets of malignant cells with barely recognizable glands with high degree of atypia and mitoses, cribriform pattern

8.

Other Tumors a. Carcinosarcomas mesenchymal tumor mixed tumor with malignant mesodermal components differentiating into muscle, cartilage, osteiod b. Adenocarcinoma large, broad based polypoid masses endometrial glands are benign but stroma is malignant c.

Stromal tumors either (1) benign stromal tumor or (2) endometrial stromal sarcoma (invades muscle tissue)

Patholab – FGT & Breast by Dr. Sionzon

Uterus - Myometrium 1.

Leiomyoma occurs in 75% of women in the reproductive age well circumscribed tumors; discreet, round, firm, gray white tumors common cause of bleeding produces whorled pattern of smooth muscle bundles described based on location as: submucosal, intramural, subserosal

2.

Leiomyosarcoma uncommon, bulky fleshy masses on inspection not well differentiated invades uterine wall high degree of atypia, mitotic index and zonal necrosis >10 mitoses per HPO field peak incidence 40 to 60 years old metastasize to different organs i.e. lungs, brains and bones

End of transcription Tip lang, yung lecture nya as in librong libro. Kasi yung ppt nya, as in outline lang talaga. Gamitin ang book, huwag lang gawing paper weight at pang straighten ng gusot na trans (me yun) Yun lang.

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