Female Genitourinary Pathology

Question 1

Describe the normal histology of the urothelium.

Answer 1

The urothelium lines the entire conducting passage of the urinary tract. Is stratified with 3 to maximum 7 cell layers and on the luminal surface covered by umbrella cells. This makes it an impermeable barrier with the ability to distend. It rests on a basement membrane and a lamina propria.

Question 2

List some non-neoplastic lesions of the ureter.

Answer 2

Congenital: bifid ureter or diverticuli;
Infection: secondary to vesico-uteric reflux;
Inflammation: ureteritis cystica;
Deposits: calculi, blood clot, fibrosis.

Question 3

List some non-neoplastic lesions of the urinary bladder.

Answer 3

Congential: exstrophy, hypoplasia, diverticuli;
Infection: shistosomiasis;
Inflammation: eosinophilic, drugs - cyclophosphamide, radiation, idiopathic;
Deposits: calculi, amyloid

Question 4

List some non-neoplastic lesions of the urethra.

Answer 4

Congenital: hypospadiasis;
Infection: gonococcal, chlamydia, E. coli.

Question 5

Describe how urothelial neoplasms are classified.

Answer 5

Into either flat or papillary, then each of these into benign or malignant.
Flat, benign: regenerative changes following inflammation.
Flat, malignant: carcinoma in situ; urothelial carcinoma.
Papillary, benign: papilloma, papillary urothelial neoplasm of low malignant potential.
Papillary, malignant: papillary urothelial carcinoma.

Question 6

Describe the presentation, cystoscopy, and histology of urothelial carcinoma in situ.

Answer 6

Urothelial carcinoma in suit:
Presentation: asymptomatic or symptoms of UTI not responding to treatment.
Cytoscopy: flat, red, inflamed looking mucosa.
Histology: features of malignancy, hyperplasia of urothelium beyond 7 cell layers, but without breach in basement membrane.

Question 7

What distinguishes a low grade urothelial carcinoma to a high grade urothelial carcinoma?

Answer 7

A low grade urothelial carcinoma has invaded only to the lamina propria, whereas a high grade urothelial carcinoma has invaded into the muscularis propria.

Question 8

Contrast the treatment of urothelial carcinoma in situ to high grade urothelial carcinoma.

Answer 8

Urothelial carcinoma in situ is treated with transurethral resection and intravesical BCG, whereas a cystectomy is needed to treat high grade urothelial carcinoma.

Question 9

Describe the architecture of a papillary.

Answer 9

A papillary is a finger-like projection with a core of blood vessels and connective tissue surrounded by urothelium.

Question 10

Name and describe some histological features of a benign papillary urothelial neoplasm.

Answer 10

A papilloma. This is lined by essentially normal urothelium, that has normal thickness and organisation with no mitoses.

Question 11

Describe some of the histological features of a papillary neoplasm of unknown malignant potential.

Answer 11

A papillary neoplasm of unknown malignant potential is lined by cytological dysplastic urothelium, with increased thickness beyond 7 cells, mild disarray and occasional mitoses.

Question 12

Name and describe some histological features of a malignant papillary urothelial neoplasm.

Answer 12

A papillary urothelial carcinoma. This is lined by cytologically malignant urothelium, with drastically increased thickness which has a complete loss of organisation and several mitoses. Involves invasion into the submucosa, muscularis propria.

Question 13

How do papillary neoplasms present?

Answer 13

Often patients present with haematuria, as the delicate papillae break due to stresses leading to bleeding from the central core of blood vessels. Any haematuria outside the setting of a UTI is abnormal and needs to be investigated.

Question 14

List some non-neoplastic lesions of the fallopian tubes.

Answer 14

Infection/inflammation: salpingitis: acute, chronic, granulomatous, foreign bod type.
Obstructive cause: ectopic pregnancy, endometriosis, paratubal cyst.

Question 15

List some neoplastic lesions of the fallopian tubes, both benign and malignant.

Answer 15

Benign: adenomatoid tumour.
Malignant: primary carcinoma or secondary metastasis from ovary or other organ.

Question 16

List some of the causes behind chronic salpingitis. What is seen in histology with salpingitis and what are some of the complications of this?

Answer 16

Chonic salpingitis can occur due to:
Infection, such as STI of Neisseria gonorrhoeae, chlamydia, mycoplasma;
post instrumentation or IUD, pregnancy;
Endometriosis;
Congenital abnormality.
Results in adhesion and fusion of fimbria, plicae, tube dilation and pus.
Complications include ectopic pregnancy (requires urgent salpingectomy), abscess formation, and infertility.

Question 17

What histological tissue comprises the endometrium?

Answer 17

Glands and stroma.

Question 18

List some neoplasms of the uterus, both benign and malignant.

Answer 18

Benign: leiomyoma.
Malignant: endometrial carcinoma.

Question 19

Briefly describe histological features of endometrial carcinoma.

Answer 19

Glands are lined with multiple layers of cells and are arranged back to back without intervening normal stroma. Cells show signs of malignancy: large nuclei without nucleoli, altered nuclear to cytoplasmic ratio, pleomorphism.

Question 20

Briefly describe histological features of a leiomyoma.

Answer 20

Smooth muscle proliferation results n homogenous whorled appearance.

Question 21

List some complications of a leiomyoma.

Answer 21

Pain, menorrhagia, infertility, compressive symptoms.

Question 22

Describe the epithelium of the cervix.

Answer 22

The endocervix is lined with simple columnar glandular epithelium, the squamocolumnar junction is a transition zone, and the ectocervix is lined with stratified squamous epithelium.

Question 23

List some non-neoplastic lesions of the cervix.

Answer 23

Infection: trichomonas, candida, HPV;

Question 24

List neoplastic lesions of the cervix, both benign and malignant.

Answer 24

Benign: polyps.
Malignant: squamous cell carcinoma, adenocarcinoma.

Question 25

List some non-neoplastic lesions of the vagina.

Answer 25

Congenital: artresia, septate vagina, Gartner duct cysts.
Infection: candida, HPV.

Question 26

List some neoplastic lesions of the vagina, both benign and malignant.

Answer 26

Benign: squamous papilloma.
Malignant: squamous cell carcinoma, clear cell carcinoma, embyronal rhabdomyosarcoma
BUT VAGINAL NEOPLASM IS RARE!

Question 27

Briefly compare and contrast the epithelium of the vagina to the vulva.

Answer 27

Both are stratified squamous epithelia, however the vulva is keratinised whereas the vagina is not.

Question 28

List some non-neoplastic lesions of the vulva.

Answer 28

Congenital: ectopic mammary tissue.
Inflammation: dermatitis, lichen scelorsus, lichen planus.
Infection: HPV, candida.

Question 29

List some neoplastic lesions of the vulva, both benign and malignant.

Answer 29

Benign: fibroepithelial polyp, nevi, hideradenoma papilliferum.
Malignant: squamous cell carcinoma, melanoma, Paget’s disease.

Question 30

Define leukoplakia and state why it needs to be investigated.

Answer 30

“white patch”, a thickened layer of keratin on the mucosal surface (hyperkeratosis).
Could be non neoplastic inflammation (lichen sclerosus); benign vulval intraepithelial neoplasia; or malignant sign of early squamous cell carcinoma, as all of these macroscopically look like leukoplakia and therefore it needs to be biopsied.
Microscopically in lichen sclerosus there is thickening of the epidermis due to the hyperkeratosis and loss of rete pegs.
Microscopically in vulval intraepithelial neoplasia there is no invasion beyond the BM, but there is elongation of the rete pegs, nuclear atypia, and mitoses.

Question 31

List some of the risk factors for vulval squamous cell carcinoma.

Answer 31

Age over 60 years, HPV infection, immunodeficiency, cigarette smoking.