Pathology of Female Genital Tract Short Notes

OVARY clinical pic: -Asymptomatic! -palpable abd mass -sudden abd pain

CERVIX

1. OVARIAN CYSTS from ovarian follicles that becomes abnormally cystic during their development

1. CERVICITIS

 Muco-purulent cervicitis (endocervix)

 FUNCTIONAL CYST  Follicular cyst : non ruptured follicles *lined by granulosa cells  Corpus luteum cyst : CL that fails to collapse & resolve  POLYCYSTIC OVARY (Stein Leventhal )SYNDROME

-Numerous follicle cysts -Superficial cortical fibrosis

- pathogenesis : overproduction of androgens!  impaired maturation of developing follicles & failure of ovulation - pic : menst.irregularities, obesity, hirsutism, anovulation

 ENDOMETROITIC (chocolate) CYST 2. TUMORS OF OVARY - PRIMARY  SURFACE EPITHELIAL TUMORS  Serous tumors  Mucinous tumors mucinous deposits in peritoneum with implantation  Endometrioid tumors *Pseudomyxo peritonei 



Brenner’s tumors

of tumor cells in peritoneum & production of large amount of mucin dt rupture of tumor

 GERM CELL TUMORS  Teratoma (dermoid cyst) ↑ in women risk to >25% of 10% - CIN 3 cervical untreated case fate 2-3% - risk to carcinoma  cervical cerv.carcinoma than CIN 1 carcinoma treatment follow up conization conization -risk factors - infection of hi risk HPV (16,18)  CIN - multiparity - sexual activity at early age - immunosupression - multiple hi risk sexual partners - cigarette smoking

4. INVASINE CERVICAL CARCINOMA - arise from CIN ( dt infection of HPV! ) - 50 years old - gross : fungating, ulcerating, infiltrating mass! - micro type : 1. squamous cell carcinoma(85%) 2. adenocarcinoma (10%) - pic : Asymptomatic, abnormal uterine bleeding, malodorous vaginal discharge

3. ENDOMETRIAL CARCINOMA

4. ENDOMETRIOSIS -red brown nodules ! - presence of functional endometrial tissue outside the uterus - pathogenesis : implantation/metaplastic/metastatic theories - pic : dysmenorrhea, infertility, constipation, rectal pain

5. ADENOMYOSIS - presence of non-functional endometrial tissue within the uterus - menorrhagia, dysmenorrhea

6. TUMORS OF UTERUS  Uterine leimyoma/fibroids - benign smooth muscle tumors of myometrium - X malignant association - gross: multiple, well-defined, non-capsulated, diff.sizes, greyish-white, whorly appearance - subserosal/intramural/submucosal - pic : infertility, abn.uterine bleeding, obstruct of delivery, abortion, twisted & necrotic, some are Asymptomatic!

 Leiomyosarcoma (malignant)  Malignant mixed mullerian tumor (carcinosarcoma)

TUMORS OF THE UTERUS GRAVID UTERUS

INVASIVE MOLE

BENIGN VESICULAR MOLE

NON-GRAVID UTERUS

MALIGNANT CHORIOCARCINOMA

CERVIX

BODY OF UTEURS

CERVICAL CARCINOMA

ENDOMETRIUM

MYOMETRIUM

ENDOMETRIAL CARCINOMA

BENIGN LEIOMYOMA

MALIGNANT LEIOMYOSARCOMA

DISEASES OF PREGNANCY ECTOPIC PREGNANCY BENIGN VESICULAR MOLE

GESTATIONAL TROPHOBLASTIC DISEASE LOCALLY INVASIVE MOLE

PRE-ECLAMPSIA & ECLAMPSIA

MALIGNANT CHORIOCARCINOMA

SURFACE EPITHELIAL TUMORS - arise from small mesothelial lined cysts which become incorporated into the substance of ovary following rupture & repair of ovulation site. - peritoneal mesothelium + epithelial lining all female genital tract = derived from ceolomic epithelium of the embryo - mesothelial cell lining the inclusion cysts of the ovary may become neoplastic & differentiate into epithelial cells which resembles the lining of endocervix, endometrium & FT

SEROUS tumors

-resemble FT epithelium -most commonly bilateral

MUCINOUS -resemble endocervical tumors epithelium *rupture of tumors may result in  pseudomyxoma ENDOMETRIOID tumors

Benign (cystadenoma) - 60% -usually cystic -30-40 yrs - 20% are bilateral

Malignant (cystadenocarcinoma) -25% -partly cystic -34-60 yrs - 66% are bilateral

- unilocular smooth-lined cyst filled with clear serous fluid

-complex multilocular cyst with focal solid areas & nodular irregularities

- cyst wall lined by single layer of columnar ciliated cells

- stratified tumor cells, showing atypical nuclear features - tufting & papillary structures - psammoma bodies - stromal invasion detected! -spread by seeding of peritoneal cavity -lymphatic spread to regional LN -secretes tumor marker : CA125! - 10% - 20% are bilateral - better prognosis than serous carcinoma

- 80% - 5% are bilateral - large multilocularcystic masses filled with mucinous material - tumor cell is mucin secreting

-resemble endometrial epithelium

TERATOMA (dermoid cyst)  cystic ! - formed of elements from all 3 germ layers Ectoderm : skin hair, neural tissue Mesoderm : bone, cartilage, fat Endoderm : bronchial & gastrointestinal mucosal lining -complication : torsion of the ovary!

*MALIGNANT TERATOMA = teratocarcinoma (1%) - Usually squamous cell carcinoma

SEX CORD STROMAL TUMOR FIBROMA

THECOMA

- benign non-functioning tumor formed of fibroblasts!

- benign

C.S: solid, grey-white in colour firm consistency

solid, firm, with yellow cut surface dt high steroid content of tumor cells formed of spindle cells that contain fat

Microscopic:

- may be associated with right pleural effusion & ascites (Meig’s syndrome)

- secrete estrogen  endometrial hyperplasia + uterine bleeding

GRANULOSA CELL TUMOR - may occur at any age -most are benign *25% may recur / metastasize during 10 years following diagnosis  considered potentially malignant! solid, yellowish with cystic element

formed of granulosa cells that may form Call-Exner bodies, like the normal granulosa cells in the ovarian follicles - often produce excess estrogen clinical presentation : * depends on age! -prepubertal  precocious puberty -reproductive age  irregular menses -postmenopausal  post menopausal uterine bleeding

SERTOLI-LEYDIG CELL TUMOR biphasic tumor that contains cells resembling -testicular sertoli cells -leydig cells

-secrete androgens  cause virilization

KRUKENBERG TUMORS (secondary!) : bilateral ovarian metastasis of mucin-secreting gastrointestinal adenocarcinoma, most of gastric origin

incidence precursor lesion cause risk factor

gross

microscopic types

clinical picture

spread

INVASIVE CERVICAL CARCINOMA 50 years Cervical Intraepithelial lesion (CIN)

ENDOMETRIAL CARCINOMA 50 – 60 years Endometrial hyperplasia

Infection of HPV - infection of hi risk HPV (16,18)  CIN - multiparity - sexual activity at early age - immunosupression - multiple hi risk sexual partners - cigarette smoking

Hyperestrenemia - obesity - DM & hypertension - infertility & nulliparity - anovulatory cycle - polycystic ovary - early menarche & late menopause - estrogen-producing tumor - estrogen replacement therapy - endometrial hyperplasia - exophytic polypoidal (fungating) mass projecting into uterine cavity - invasive infiltrating lesion extending into myometrium - diffuse thickening on endometrium Endometrioid Papillary serous adenocarcinoma carcinoma - post menopausal - older women - related to - X related to hyperestrenism hyperestrenism *develops against the background of endometrial atrophy -better prognosis -worse prognosis

- ulcerative - exophytic fungating mass - endophytic invasive (infiltrating)lesion causing induration/deformities of the cervix (barrel-shaped cervix)

1. Squamous cell carcinoma(85%) 2. Adenocarcinoma originating from endocervical glands(10%) 3. Small cell carcinoma/Undiff. Carcinoma (5%)

- Asymptomatic - abnormal uterine bleeding (intermittent/post-coidal) - malodorous vaginal discharge - local vagina, parametria, rectum, UB (obstructing ureters leading to renal failure – the most common cause of death) - meastatis  LN & lungs

- local  myometrium, cervix & surrounding organs - lymphatics  regional LN - hematogenous  distant sites commonly the lung!

ENDOMETRIAL HYPERPLASIA Types: (according to extends of increase of the number of glands & presence of atypia) Simple endometrial hyperplasia Complex endometrial hyperplasia Complex endometrial hyperplasia with atypia

- increase number of endometrial glands, some are cystically dilated with intervening cellular stroma - glands are crowded & branching - stroma is relatively scanty - endometrial glands appear crowded & irregular - lining epithelial cells show nuclear atypia

ENDOMETRIOSIS Common site : OVARY, OVARIAN & UTERINE ligaments, DOUGLAS pouch, serosa of bowel & urinary bladder, peritoneal cavity Pathogenesis: IMPLANTATION theory endometrial deposits arise when endometrial glands are regurgitated into peritoneal cavity thru FT during menstruation, then implant in peritoneal surface. METAPLASTIC theory arise due to metaplasia of peritoneal surface epithelium into endometrial type epithelium, * both arise from the same embryonic cell ( ceolomic epithelium) METASTATIC theory hematogenous spread if endometrial tissue which enter the circulation at menstruation *explains cases if endometriosis affecting organs such as lungs ADENOMYOSIS : presence of non-functional endometrial tissue within the uterus - surrounding myometrial smooth muscle cells undergo HYPERTROPHY and result in enlargement of uterus

Pathogenesis/Etiology 1. Follicular cyst : unruptured follicles 2. Luteal cyst : CL that fails to collapse & resolve 3. Polycystic ovary : overproduction of androgen by ovaries (defect in hypothalamic control of pituitary secretion) 4. Chocolate (endometriotic) cyst : endometriosis of the ovary 5. Surface epithelial tumor : - arise from small mesothelial lined cysts which become incorporated into the substance of ovary following rupture & repair of ovulation site. *peritoneal mesothelium + epithelial lining all female genital tract = derived from ceolomic epithelium of the embryo - mesothelial cell lining the inclusion cysts of the ovary may become neoplastic & differentiate into epithelial cells which resembles the lining of endocervix, endometrium & FT 6. Mucopurulent cervicitis : Chlamydia Trachomatis, Neisseria gonorrhoea 7. Chronic persistent/recurrent infection of squamous epith of exocervic : HPV, HSV 8. Cervical polyp : non-neoplastic lesion dt overgrowth of endocervical mucosa that protrudes as a polyp in the endocervical canal 9. CIN : dysplastic changes of squamous epithelium of cervix at transformation zone 10. Invasive cervical carcinoma : - arise from CIN ( dt infection of HPV!) 11.Endometrial polyp : solitary polypoidal lesion in uterine cavity covered by endometrial surface epithelium 12. Endometrial Hyperplasia & Endometrial carcinoma : prolonged unopposed estrogen stimulation of endometrium 13. Endometriosis : - presence of functional endometrial tissue outside the uterus 14. Adenomyosis : presence of non-functional endometrial tissue within the uterus Ages! 1. Functional cysts : most common in women in the reproductive age 2. Follicular cyst : most common ovarian mass 3. Corpus luteal cyst : most common ovarian mass in pregnancy * Ovarian tumor : 80% are benign, occurs mostly in young women aged 20-45 years : 2nd most common group of tumors in female genital tract : malignant ovarian tumors are seen inolder women aged 45-65 years! 1. Surface epithelial tumors : most common tumors of the ovary 2. Serous tumors : most frequent ovarian tumors & most commonly bilateral! - Benign serous tumor : most common benign ovarian tumor - Serous cystadenocarcinoma : most common malignant ovarian tumor 3. Teratoma : most common germ cell tumor in women younger than 25 years old , most common benign germ cell tumor of ovary 4. Fibroma : most common sex cordal stromal tumor! 1. Invasive cervical carcinoma : least common gynaecologic cancer 2. Leiyomyoma/fibroids : most common benign tumor of female genital system 3. Leiomyosarcoma : most common sarcoma of uterus Hormone-secreting diseases Follicular cyst Polycystic ovary Struma Ovarii Thecoma & Granulosatheca cell tumor Sertoli-leydig tumor Yolk sac carcinoma Choriocarcinoma Surface epithelial tumor

↑ estrogen ↑ androgen

↑ estrogen ↑ androgens ↑ α feto protein ↑ HCG glycoprotein CA-125

endometrial hyperplasia impaired maturation of developing follicles & fsilure of ovulation  oligomenorrhea, hirsutism, infertility hyperthyroidism endometrial hyperplasia & uterine bleeding virilization