Female Genital Tract and Breast
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Transcript of Female Genital Tract and Breast
Female Genital Tract
& Breast
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Infections of the Female genital tractHerpes Simplex
Vulva, vagina and cervixTeenager, young women1/3 will have clinical symptomsPainful red papule that progress to vesicles and
coalesce to form ulcersFever, malaise, tender inguinal nodes
Yeast (Candida)10 % of women, enhanced by DM, OCPLeukorrhea, priritus
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Infections of the Female genital tractTrichomonas
15 % of women in STD clinicsPurulent vaginal discharge“Strawberry cervix”
MycoplasmaImplicated in spontaneous abortion and
chorioamnionitis
GardnerellaGram negative small bacilli
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Pelvic Inflammatory Disease
Pelvic pain, adnexal tenderness, fever & vaginal discharge Gonococcus, chlamydia & enteric bacteria Puerperal infections: Staphylococci, Streptococci, Clostridia,
coliform bacteria Acute suppurative salpingitis Salpingooophoritis Tuboovarian abscess Pyosalpinx/Hydrosalpinx
Complications Peritonitis Intestinal obstruction from adhesions Bacteremia Infertility
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VULVABartholin Cyst
obstruction of the Bartholin duct, usually by a preceding infection
3 to 5 cm in diameter lined by either the transitional epithelium of the
normal duct or squamous metaplasia. Vestibular Adenitis
Vulvodyniainflammation of the surface mucosa and
vestibular glands chronic, recurrent, and exquisitely painful
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VULVA
Non-Neoplastic Epithelial DisordersLichen sclerosus
also called chronic atrophic vulvitis, atrophy, fibrosis, and scarring
1) atrophy (thinning) of the epidermis, with disappearance of the rete pegs,
2) hydropic degeneration of the basal cells, 3) replacement of the underlying dermis by dense collagenous
fibrous tissue, and 4) a monoclonal bandlike lymphocytic infiltrate
lichen simplex chronicus hyperplastic dystrophy acanthosis & hyperkeratosis
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Lichen sclerosus
lichen simplex chronicus
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VULVA
NeoplasmsBenign
Papillary Hidradenoma labia majora or interlabial folds identical in appearance to intraductal papillomas of the
breast
Condyloma Acuminatum verrucous gross appearance HPV, types 6 and 11 koilocytotic atypia (nuclear atypia and perinuclear
vacuolization)-that is considered a viral "cytopathic" effect
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VULVANeoplasm
Pre-malignant and Malignant Vulvar intraepithelial neoplasia
Pre-cancerous change nuclear atypia in the epithelial cells, increased mitoses, and
lack of surface differentiation Carcinoma
3 % of genital CA 85 % are SCCA, 15 % BCCA, adenoCA, melanoma
Malignant melanoma less than 5% of all vulvar cancers and 2% of all melanomas in
women Pagets
pruritic, red, crusted, sharply demarcated, maplike area, occurring usually on the labia majora
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VAGINACongenital anomaliesGartner duct cyst
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VAGINAMalignant & Pre Malignant Neoplasm
Vaginal Intraepithelial NeoplasiaSquamous cell carcinoma -95 %
HPV asscociated Upper posterior vagina irregular spotting or the development of a frank
vaginal discharge (leukorrhea).
Adenocarcinoma 0.14% DES-exposed young women from their mothers
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Embryonal RhabdomyosarcomaAlso called sarcoma botryoides polypoid, rounded, bulky
masses consistency of grapelike
clusters the tumor cells are crowded in
a so-called cambium layer; but in the deep regions, they lie within a loose fibromyxomatous stroma that is edematous
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CERVIXAcute & chronic cervicitis
Acute cervicitis characterized by acute inflammatory cells, erosion,
and reactive or reparative epithelial change
Chronic cervicitis inflammation, usually mononuclear, with
lymphocytes, macrophages, and plasma cells
HSV-epithelial ulcersC. trachomatis – lymphoid germinal centersT. vaginalis – epithelial spongiosis
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CERVIX
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CERVIXEndocervical polyp
2-5 % of adult women irregular vaginal "spotting" or
bleeding small and sessile to large, 5-cm
masses that may protrude through the cervical os
a loose fibromyxomatous stroma harboring dilated, mucus-secreting endocervical glands, often accompanied by inflammation and squamous metaplasia
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CERVIX – Intraepithelial NeoplasiaPathogenesis
Early age at first intercourse Multiple sexual partners Increased parity A male partner with multiple previous sexual partners The presence of a cancer-associated HPV The persistent detection of a high-risk HPV, particularly
in high concentration (viral load) Certain HLA and viral subtypes Exposure to oral contraceptives and nicotine Genital infections (chlamydia)
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CERVIX – HPV & CA HPV DNA is detected by hybridization techniques in over 95% of cervical CA Specific HPV types are associated with cervical cancer (high risk) versus
condylomata (low risk); low (include types 6, 11, 42, 44, 53, 54, 62, and 66) and high-risk types (include types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68)
Experimental data indicate that viral (E6 and E7) genes of high risk HPVs can disrupt the cell cycle via binding to RB with up-regulation of Cyclin E (E7) and p16INK4;
the two viral oncogenes cooperate to promote DNA synthesis while interrupting p53-mediated growth arrest and apoptosis of genetically altered cells.
The physical state of the virus differs in different lesions, integrated into the host DNA in cancers, free (episomal) viral DNA in condylomata and most precancerous lesions.44
Certain chromosome abnormalities, including deletions at 3p and amplifications of 3q, have been associated with cancers containing specific (HPV-16) papillomaviruses
Recent data indicate that vaccines directed against papillomaviruses can prevent infection and the development of precancerous disorders
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CERVIX – Intraepithelial NeoplasiaCervical
Intraepithelial Neoplasia (CIN) I
Cervical Intraepithelial Neoplasia (CIN) II
Cervical Intraepithelial Neoplasia (CIN) III
Low Grade Squamous Intraepithelial Lesion (LSIL)
High Grade Squamous Intraepithelial Lesion (HSIL)
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CERVIX
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CERVIX
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CERVIX
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Invasive Cervical Carcinoma40 to 45 years for invasive cancer and about
30 years for high-grade precancers. fungating (or exophytic), ulcerating, and
infiltrative cancers extends by
direct spread (peritoneum, urinary bladder, ureters, rectum, and vagina)
LymphaticsDistant metastasis (Liver, lungs, bone marrow )
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Invasive Cervical CarcinomaPatterns
Keratinizing SCCA - (Well differentiated)Non-keratinizing – (moderately diff)Small cell squamous CA – (poorly diff)Small cell undifferentiated –
(neuroendocrine/ oat cell CA) associated with high risk HPV (type 18)
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Staging Cervical Carcinoma
Stage 0. Carcinoma in situ (CIN III) Stage I. Carcinoma confined to the cervix
Ia. Preclinical carcinoma, that is, diagnosed only by microscopy Ia1. Stromal invasion no greater than 3 mm and no wider than 7 mm (so-called
microinvasive carcinoma) Ia2. Maximum depth of invasion of stroma greater than 3 mm and no greater
than 5 mm taken from base of epithelium, either surface or glandular, from which it originates; horizontal invasion not more than 7 mm
Ib. Histologically invasive carcinoma confined to the cervix and greater than stage Ia2
Stage II. Carcinoma extends beyond the cervix but not onto the pelvic wall. Carcinoma involves the vagina but not the lower third.
Stage III. Carcinoma has extended onto pelvic wall. On rectal examination, there is no cancer-free space between the tumor and the pelvic wall. The tumor involves the lower third of the vagina.
Stage IV. Carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum. This stage obviously includes those with metastatic dissemination.
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UTERUSDating the endometrium
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Histology of menstrual cycle
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UTERUS Dysfunctional uterine
bleeding Excessive prolonged
estrogenic stimulation Persistent proliferative
phase Lack of ovulation
Endocrine d/o Ovarian lesion Metabolic disturbance Anovulatory endometrium
with stromal breakdown (DUB)
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UTERUS Endometritis
1) in patients suffering from chronic PID (gonococcal)
(2) in patients with postpartal or postabortal endometrial cavities, usually due to retained gestational tissue
(3) in patients with intrauterine contraceptive devices
(4) in patients with tuberculosis,
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UTERUSEndometriosis
presence of endometrial glands or stroma in abnormal locations outside the uterus.
Impt cause of dysmenorrhea, pelvic pain, infertility & other problem
Endometriotic cyst lining
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UTERUSAdenomyosis
presence of endometrial tissue in the uterine wall (myometrium)
small adenomyotic nests results in menorrhagia, colicky dysmenorrhea, dyspareunia, and pelvic pain
Adenomyosis
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UTERUSEndometrial polyps
sessile masses of variable size that project into the endometrial cavity
single or multiple 0.5 to 3 cm in diameter develop in association
with generalized endometrial hyperplasia
responsive to the growth effect of estrogen but exhibit no progesterone response
Endometrial polypAsymptomatic or may
cause bleeding
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UTERUSEndometrial
Hyperplasiaincreased gland to
stroma ratio inactivation of the
PTEN tumor suppressor gene through deletion and/or inactivation
Simple hyperplasia without atypia
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UTERUSCARCINOMA OF THE ENDOMETRIUM
most common invasive cancer of the female genital tract
peak incidence is in the 55- to 65-year-old woman
Associated with 1) obesity, (2) diabetes (3) hypertension (4) infertility
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UTERUSCARCINOMA OF THE ENDOMETRIUM
85 % are adenocarcinomaspolypoid tumor or as a diffuse tumor involving the entire
endometrial surface grading system is applied to endometrioid tumors and
well differentiated (grade 1), with easily recognizable glandular patterns
moderately differentiated (grade 2), showing well-formed glands mixed with solid sheets of malignant cell
poorly differentiated (grade 3), characterized by solid sheets of cells with barely recognizable glands and a greater degree of nuclear atypia and mitotic activity
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UTERUSCARCINOMA OF THE ENDOMETRIUMStaging of endometrial adenocarcinoma
Stage I. Carcinoma is confined to the corpus uteri itself.
Stage II. Carcinoma has involved the corpus and the cervix.
Stage III. Carcinoma has extended outside the uterus but not outside the true pelvis.
Stage IV. Carcinoma has extended outside the true pelvis or has obviously involved the mucosa of the bladder or the rectum
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UTERUSOther tumors
Carcinosarcomas malignant stromal differentiation malignant mesodermal components, including
muscle, cartilage, and even osteoid Adenosarcomas
large broad-based endometrial polypoid growths malignant appearing stroma, which coexists with
benign but abnormally shaped endometrial glands Stromal tumors
(1) benign stromal nodules (2) endometrial stromal sarcomas.
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UTERUSLEIOMYOMA
75% of females of reproductive age sharply circumscribed, discrete, round,
firm, gray-white tumors whorled pattern of smooth muscle
bundles on cut section usually makes these lesions readily identifiable on gross inspection
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UTERUSLEIOMYOSARCOMA
uncommon malignant neoplasms bulky, fleshy masses that invade the
uterine wall, or polypoid masses that project into the uterine lumen
degree of nuclear atypia, mitotic index, and zonal necrosis ten or more mitoses per ten high-power
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LEIOMYOSARCOMApeak incidence at
40 to 60 years of age
metastasize through the bloodstream to distant organs, such as lungs, bone, and brain
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Fallopian TubeTumors and Cysts
Paratubal cystsHydatids of Morgagni –remanants of
Mullerian duct
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Table 22-3. Ovarian Neoplasms (1993 WHO Classification)
Surface Epithelial-Stromal Tumors Serous tumors
Benign (cystadenoma) Cystadenoma of borderline malignancy Malignant (serous cystadenocarcinoma)
Mucinous tumors, endocervical-like and intestinal type
Benign Of borderline malignancy] Malignant
Endometrioid tumors Benign Of borderline malignancy MalignantEpithelial-stromal
Adenosarcoma Mesodermal (müllerian) mixed tumor Clear cell tumors
Benign Of borderline malignancy Malignant
Transitional cell tumors Brenner tumor
Brenner tumor of borderline malignancy Malignant Brenner tumor Transitional cell carcinoma (non-Brenner
Sex Cord-Stromal Tumors Granulosa-stromal cell tumors
Granulosa cell tumors Tumors of the thecoma-fibroma group Sertoli-stromal cell tumors;
androblastomas Sex cord tumor with annular tubules GYnandroblastoma Steroid (lipid) cell tumors
Germ Cell Tumors TeratomaImmatureMature
(adult)SolidCystic (dermoid cyst)Monodermal (e.g., struma ovarii, carcinoid)
Dysgerminoma Yolk sac tumor (endodermal sinus
tumor) Mixed germ cell tumors Malignant, Not Otherwise Specified
Metastatic Nonovarian Cancer (from Nonovarian Primary)