Pathoma: Female Genital System & Gestational Pathology Flashcards
General
Vulva
- Anatomically includes skin & mucosa of female genitalia external to the hymen
- Labia majora & minora
- Mons pubis
- Vestibule
- Lined by squamous epithelium
Vulva
Cystic dilation of Bartholin gland
Pathophysiology
Bartholin cyst
Vulva
Bartholin glands
Anatomy
- One present on each side of the vaginal canal
- Produce mucus-like fluid that drain via ducts into lower vesibule
Vulva
Unilateral, painful cystic lesion at lower vestibule adjacent to vaginal canal
Clinical Presentation
Bartholin cyst
Vulva
Results from inflammation & obstruction of Bartholin gland
Etiology
Bartholin cyst
Inflammation associated w/ infections, STDs
Vulva
Usually seen in reproductive-aged women
Epidemiology
Bartholin cyst
Infections, STDs more common in this age group
Vulva
- Warty neoplasm of vulvar skin
- Often large
- Rarely progress to carcinoma
Morphology
Condyloma
Vulva
Most common cause of condyloma
Etiology
Low-risk HPV types 6, 11
Condyloma acuminatum
Vulva
2nd most common cause of condyloma
Etiology
Syphilis
Condyloma latum
Vulva
Koilocytes
Histology
Condyloma acuminatum (HPV-associated condyloma)
Koilocyte = HPV hallmark; raisin-like nucleus w/ perinuclear halo
Vulva
Condyloma acuminatum
Microscopic appearance
Vulva
Condyloma acuminatum
Koilocytic change: raisin-like nucleus w/ perinuclear halo
Vulva
- Thinning of epidermis & fibrosis of dermis
- Benign; slightly increased risk of SCC
Pathophysiology
Lichen sclerosis
Vulva
Leukoplakia (white patch) w/ parchment-like vulvar skin
Clinical Presentation
Lichen sclerosis
Parchment-like = paper-thin
Vulva
Most commonly seen in post-menopausal women
Epidemiology
Lichen sclerosis
Post-menopause: atrophy of epithelium & fibrosis of dermis
Vulva
- Hyperplasia of vulvar squamous epithelium
- Benign; no increased risk of SCC
Pathophysiology
Lichen simplex chronicus
Hyperplasia due to chronic irritation & scratching of skin
Vulva
Leukoplakia with thick, leathery vulvar skin
Clinical Presentation
Lichen simplex chronicus
Thick & leathery due to hyperplasia
Vulva
Associated with chronic irritation & scratching
Etiology
Lichen simplex chronicus
Chronic irritation & scratching results in hyperplasia
Vulva
Carcinoma of vulvar squamous epithelium
Histology
Vulvar carcinoma
Vulva
- Presents as leukoplakia
- Biopsy may be required to distinguish from other causes of leukoplakia
Diagnosis
Vulvar carcinoma
Vulva
- Rare; makes up small % of female genital cancers
- May be HPV or non-HPV related
Etiology
Vulvar carcinoma
Vulva
Cause of HPV-related vulvar carcinoma
Etiology
High-risk HPV types 16, 18
Vulva
- Risk factors are related to HPV exposure
- Multiple sexual partner
- Early first age of intercourse
- Exposure generally occurs at reproductive age
- Carcinoma typically seen at age 40-50 yrs
Epidemiology
HPV-related vulvar carcinoma
Vulva
Arises from VIN precursor lesion
Pathophysiology
HPV-related vulvar carcinoma
Vulva
Dysplastic precursor lesion characterized by koilocytic change, disordered cellular maturation, nuclear atypia, and increased mitotic activity
Histology
Vulvar intraepithelial neoplasia (VIN)
Vulva
Most common cause of non-HPV related vulvar carcinoma
Etiology
Long-standing lichen sclerosis
Vulva
Chronic inflammation & irritation eventually lead to carcinoma
Pathophysiology
Non-HPV related vulvar carcinoma
Vulva
Generally seen in elderly women (average age >70 years)
Epidemiology
Non-HPV related vulvar carcinoma
Vulva
- Characterized by malignant epithelial cells in epidermis of vulva
- Represents CIS; usually no underlying carcinoma
Histopathology
Extramammary Paget disease of the vulva
Vulva
Erythematous, pruritic, ulcerated vulvar skin
Clinical Presentation
Extramammary Paget disease of the vulva
Can also occur in nipple
Vulva
Must be distinguished from melanoma, which can occasionally occur in the vulva
* Paget cells: PAS-pos, keratin-pos, S100-neg
* Melanoma: PAS-neg, keratin-neg, S100-pos
Diagnosis
Extramammary Paget disease of the vulva
* Keratin-pos = epithelial cell –> carcinoma
* PAS-pos = epithelial cell –> carcinoma
* S100- = not melanoma
Keratin: intermediate filament in epithelial cells; PAS stains for mucus
Vulva
Extramammary Paget disease of the vulva
Microscopic Appearance
General
Vagina
- Fibromuscular canal leading to cervix
- Mucosa is lined by non-keratinizing squamous epithelium
Vagina
Focal persistence of columnar epithelium in upper vagina
Pathophysiology
Vaginal adenosis
* During development, stratified squamous epithelium from lower 1/3 of vagina (derived from urogenital sinus) should grow upward to replace the columar epithelium lining the upper 2/3 of the vagina (derived from Mullerian duct)
Vagina
Increased incidence in females exposed to diethylstilbestrol (DES) in utero
Etiology
Vaginal adenosis
DES: used to prevent pregnancy-related complications; can cross placenta
Vagina
Vaginal adenosis
Microscopic Appearance
Vagina
Malignant proliferation of glands with clear cytoplasm
Pathophysiology
Clear cell adenocarcinoma
Vagina
Rare, but severe complication of DES-associated vaginal adenosis
Etiology
Clear cell adenocarcinoma
Vagina
Malignant mesenchymal proliferation of immature skeletal muscle
Pathophysiology
Embryonal rhabdomyosarcoma
Vagina
Bleeding & a grape-like mass protruding from vagina / penis of a child (usually <5 yrs of age)
Clinical Presentation
Embryonal rhabdomyosarcoma
Also called sarcoma botryoides = “grape-like mass”
Vagina
Characteristic cell: rhabdomyoblast
* Cytoplasmic cross-striations
* Positive IHC staining for desmin & myogenin
Histology
Embryonal rhabdomyosarcoma
Cross-strations resemble skeletal muscle
Vagina
Embryonal rhabdomyosarcoma: grape-like masses
Gross Appearance
Vagina
Carcinoma of vaginal squamous epithelium
Histology
Vaginal carcinoma
Vagina
Usually related to high-risk HPV (16, 18)
Etiology
Vaginal carcinoma
Vagina
- Arises from VAIN precursor lesion
- Spread to regional lymph nodes:
- Cancer from lower 1/3 –> inguinal lymph nodes
- Cancer from upper 2/3 –> iliac lymph nodes
Pathophysiology
Vaginal carcinoma
General
Cervix
- Anatomically comprises “neck” of uterus
- Divided into ectocervix & endocervix
- Ectocervix: visible on vaginal exam; stratified squamous epithelium, non-keratinizing
- Endocervix: lined by single layer of columnar epithelial cells
- Transformation zone = junction between ectocervix & endocervix; lined by immature squamous epithelial cells
- Susceptible to infections (i.e., HPV)
Cervix
Cervical transformation zone, normal
Clearly demarcated stratified squamous epithelium & columnar epithelium
Cervix
HPV infection
Pathophysiology
- Sexually transmitted DNA virus that infects lower genital tract (especially transformation zone)
- Infection is usually cleared by acute inflammation
- Approx. 90% of HPV infections are cleared
- Persistent infection increases risk of CIN
- Risk of CIN depends on HPV genotype:
- Low-risk HPV: types 6, 11
- High-risk HPV: types 16, 18
- High-risk HPV types produce E6 & E7 proteins
- E6 –> increases destruction of p53
- E7 –> increases destruction of Rb
- Loss of TSGs increases risk for CIN
Cervix
- Characterized by koilocytic change, disordered cellular maturation, nuclear atypia, and increased mitotic activity within the cervical epithelium
- Grading is based on the extent of epithelial involvement by immature dysplastic cells
Histology
Cervical intraepithelial neoplasia (CIN)
Cervix
Dysplasia involving < 1/3 of the thickness of epithelium
Histology
CIN 1
Cervix
Dysplasia involving < 2/3 of the thickness of epithelium
Histology
CIN 2
Cervix
Dysplasia involving almost entire thickness of epithelium
Histology
CIN 3
Cervix
Dysplasia involving entire thickess of epithelium
Histology
Cervical carcinoma in situ (CIS)
Cervix
CIN 3 / CIS
Dysplasia of almost entire thickness / Dysplasia of entire thickness
Cervix
Progression of CIN
Natural History & Complications
Classic stepwise progression through CIN 1, CIN 2, CIN 3 and CIS to become invasive SCC
* CIN progression to carcinoma takes 10-20 yrs
* Progression not inevitable –> CIN 1 often regresses
* Higher grade of dysplasia:
* More likely to progress to carcinoma
* Less likely to regress to normal
Cervix
Invasive carcinoma of cervical epithelium
Histology
Cervical carcinoma
Invasive = penetrates basement membrane; distinguishes from CIS
Cervix
Most commonly seen in middle-aged women (average age = 40-50 yrs)
Epidemiology
Cervical carcinoma
HPV infection occurs earlier (age 20-25 years)
Cervix
- Vaginal bleeding, esp. postcoital
- Cervical discharge
Clinical Presentation
Cervical carcinoma
Cervix
Key risk factor: high-risk HPV infection
Epidemiology
Cervical carcinoma
Cervix
Secondary risk factors: smoking, immunodeficiency (cervical carcinoma = AIDS-defining illness)
Epidemiology
Cervical carcinoma
Immunodeficiency –> impaired clearance of HPV infection
Cervix
Common subtypes of cervical carcinoma
Epidemiology
- SCC = 80% of cases
- Adenocarcinoma = 15% of cases
Both subtypes are related to HPV infection
Cervix
Consequences of cervical carcinoma
Natural History & Complications
- Tumors tend to grow locally & do not metastasize until very late in diease course
- Cervical cancers tend to produce local symptoms
- Advanced tumors often invade through anterior uterine wall into bladder, resulting in obstruction of ureters
- Hydronephrosis with postrenal failure is a common cause of death in advanced cervical carcinoma
Cervix
Cervical carcinoma screening
Prevention
- Goal is to identify CIN before progression to carcinoma
- Begins at age 21; performed every 3 yrs
- Gold standard = Pap smear
- Most successful cancer screening test ever
Cervix
Pap smear
Prevention
- Cells are scraped from transformation zone & analyzed under microscope
- Dysplastic cells are classified as low grade (CIN 1) or high grade (CIN 2/3)
- High grade dysplasia is characterized by:
- Hyperchromatic (dark) nuclei
- High N:C ratios
- High grade dysplasia is characterized by:
- Abnormal Pap smear is followed by confirmatory colposcopy & biopsy
- Limitations:
- Inadequate sampling of transformation zone (false negative screening)
- Limited efficacy in screening for adenocarcinoma
Colposcopy = visualization of cervix w/ magnifying glass
Cervix
High-grade dysplasia, Pap smear
Hyperchromatic nuclei & high N:C ratios
Cervix
HPV vaccine
Prevention
Immunization is effective in preventing HPV infection
* Quadrivalent vaccine covers HPV 6, 11, 16, 18
* Abs against HPV 6, 11 prevent condylomas
* Abs against HPV 16, 18 prevent CIN & carcinoma
* Pap smears still necessary due to limited number of HPV types covered by vaccine
General
Endometrium & Myometrium
- Endometrium = mucosal lining of uterine cavity
- Myometrium = smooth muscle wall underlying endometrium
- Endometrium is hormonally sensitive
- Proliferative phase: endometrial growth driven by estrogen
- Secretory phase: endometrial preparation for implantation driven by progesterone
- Menstrual phase: shedding occurs with loss of progesterone support
Endometrium
Secondary amenorrhea (absence of menstruation) due to loss of basalis (regenerative layer of endometrium) & scarring
Pathophysiology
Asherman syndrome
Loss of basalis impairs regeneration & shedding of endometrium
Endometrium
Result of overaggressive dilation and curettage (D&C)
Etiology
Asherman syndrome
Curettage = scraping away of uterine wall; basalis can be scraped off
Endometrium
- Lack of ovulation
- Results in estrogen-driven proliferative phase without a subsequent progesterone-driven secretory phase
- Proliferative glands break down & shed resulting in uterine bleeding
- Common cause of dysfunctional uterine bleeding
- Especially during menarche & menopause
Pathophysiology
Anovulatory cycle
Endometrium
Bacterial infection of endometrium
Pathophysiology
Acute endometritis
Endometrium
Major cause of acute endometritis
Etiology
Retained products of conception (e.g., after delivery)
* Retained products act as nidus for infection
Endometrium
- Fever
- Abnormal uterine bleeding
- Pelvic pain
Clinical Presentation
Acute endometritis
Endometrium
Chronic endometrial inflammation
Pathophysiology
Chronic endometritis
Endometrium
Characterized by presence of lymphocytes, plasma cells
Histology
Chronic endometritis
Lymphocytes normally in endometrium; plasma cells necessary for Dx
Endometrium
- Retained products of conception
- Chronic pelvic inflammatory disease (e.g., Chlamydia)
- IUD
- TB
Etiology
Chronic endometritis
Endometrium
- Abnormal uterine bleeding
- Pelvic pain
- Infertility
Clinical Presentation
Chronic endometritis
Endometrium
Hyperplastic protrusion of endometrium
Histopathology
Endometrial polyp
Endometrium
Abnormal uterine bleeding
Clinical Presentation
Endometrial polyp
Endometrium
Can arise as side effect of tamoxifen
* Anti-estrogen effects on breast
* Weak pro-estrogen effects on endometrium
Etiology
Endometrial polyp
Endometrium
Endometrial polyp
Hyperplastic protrusion of endometrium w/ lymphocytes & plasma cells
Endometrium
Endometrial glands & stroma outside of uterine endometrial lining
Histology
Endometriosis
Endometrium
Most likely cause of endometriosis
Etiology
Retrograde menstruation with implanatation at an ectopic site
Endometrium
- Dysmenorrhea (pain during menstruation)
- Pelvic pain
- Infertility (possibly)
Clinical Presentation
Endometriosis
Endometriosis cycles just like normal endometrium
Endometrium
- Most common involved site: ovary
- Results in classic chocolate cyst
- Other sites of involvement:
- Uterine ligaments (pelvic pain)
- Pouch of Douglas (pain with defecation)
- Bladder wall (pain with urination)
- Bowel serosa (abdominal pain & adhesions)
- Fallopian tube mucosa (scarring increases risk for ectopic tubal pregnancy)
- Uterine myometrium involvement = adenomyosis
Pathophysiology
Endometriosis
Endometrium
Implants classically appear as yellow-brown “gunpowder” nodules
Gross Appearance
Endometriosis
Endometrium
Complications of endometriosis
Natural History & Complications
Increased risk of carcinoma at site of endometriosis, especially in ovary
Endometrium
Endometriosis, “chocolate” cyst of ovary
Ovary with cystic lesion containing menstrual products
Endometrium
Endometriosis
Yellow-brown “gunpowder” nodules; involvement of soft tissues
Endometrium
Hyperplasia of endometrial glands relative to stroma
Pathophysiology
Endometrial hyperplasia
Endometrium
- Consequence of unopposed estrogen
- Obesity
- Polycystic ovarian syndrome (PCOS)
- Estrogen replacement therapy (ERT)
- Results in continuous proliferative phase with no subsequent secretory or menstrual phase
Etiology
Endometrial hyperplasia
Unopposed proliferation results in hyperplasia
Endometrium
Post-menopausal uterine bleeding
Clinical Presentation
Endometrial hyperplasia