THE FEMALE GENITAL TRACT AND BREAST

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THE FEMALE GENITAL TRACT AND BREAST

• Li chun
• ??

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Genital Tract Anatomy

• Cervix
• Uterus
• Fallopian tubes
• Ovaries

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HISTOLOGY

• Ovary
• cortex, follicles in varying stages of maturation
  are found within the outer cortex
• medulla, made up of a more loosely arranged
  mesenchymal tissue and may contain small clusters
  of round to polygonal, epithelial-appearing cells
  around vessels and nerves

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• Cervix
• Divided into the vaginal portion and the
  endocervix. The vaginal portion is covered by a
  stratified nonkeratinizing squamous epithelium
  continuous with the vaginal vault. Endocervix is
  lined by columnar, mucus-secreting epithelium
  that dips down into the underlying stroma to
  produce crypts.
• Transformation zone a combination of ingrowth of
  the squamous epithelium portion are intrinsic
  squamous differentiation of subcolumnar reserve
  cells(squamous metaplasia) transforms this area
  into squamous epithelium

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• During reproductive life, the squamocolumnar
  junction migrates cephalad on the leading edge of
  the transformation zone and may be invisible to
  the naked eye after menopause.
• The uterus endometrial changes that occur during
  the menstrual cycle are keyed to the rise and
  fall in the levels of ovarian hormones

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Cervix

• Inflammations
• Acute and Chronic Cervicitis
• Some degree of cervical inflammation may be
  found in virtually all multiparous and in many
  nulliparous adult women, and it is usually of
  little clinical consequence

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• Morphology The pathologic correlates of acute
  and chronic cervicitis include intercellular
  edema, submucosal edema, and a combination of
  epithelial and stromal changes. Acute cervicitis
  includes acute inflammatory cells, erosion, and
  reactive or reparative epithelial change. Chronic
  cervicitis includes inflammation, usually
  mononuclear, with lymphocytes, macrophages, and
  plasma cells

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• Endocervical Polyps
• Most polyps arise within the endocervical
  canal and vary from small and sessile to large,
  5-cm masses that may protrude through the
  cervical os. All are soft, almost mucoid, and are
  composed of a loose fibromyxomatous stroma
  harboring dilated, mucus-secreting endocervical
  glands often accompanied by inflammation and
  squamous metaplasia. In almost all instances,
  simple curettage or surgical excision effects a
  cure

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• Intraepithelial and invasive squamous neoplasia
• Pathogenesis
• Sexually transmitted agent
• Early age at first intercourse
• Multiple sexual partners
• A male partner with multiple previous
  
• sexual partners
• Papillomaviruses(HPV) There is mounting
  evidence linding HPV to cancer in general and
  cervical cancer in particular. But the evidence
  does not implicate HPV as the only factor. A high
  percentage of young women are infected with one
  or more HPV types during their reproductive
  years, and only a few develop cancer.

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• Cervical Intraepithelial Neoplasia (precancerous
  changes)
• (1) they represent a continuum of morphologic
  change with relatively indistinct boundaries
• (2) they will not invariably progress to
  cancer and may spontaneously regress, with the
  risk of persisting or progressing to cancer
  increasing with the severity of the precancerous
  change
• (3) they are associated with papillomaviruses,
  and high-risk HPV types are found in increasing
  frequency in the higher grade precursors

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• Morphology
• CIN(cervical intraepithelial neoplasia)
  classification
• CIN? atypical cells in the lower layers of
  the squamous epithelium, involved less than 1/3
  layers
• CIN ? the range of atypical cells involved
  less than 2/3 squamous epithelium layers, but
  more than 1/3 layers
• CIN ? atypical cells involved more and more
  layers of the epithelium, until it is totally
  replaced by immature atypical cells ( carcinoma
  in situ)

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• Atypical cell show changes in nucleocytoplasmic
  ratio varation in nuclear size loss of
  polarity increased mitotic figures, including
  abnormal mitoses and hyperchromasiain other
  words, they take on some of the characteristics
  of malignant cells

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Normal
CIN I
CIN II
CIN III
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Squamous Cell Carcinoma

• may occur at any age from the second decade of
  life to senility. The peak incidence in occurring
  at an increasingly younger age 40 to 45 years

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• Morphology
• Invasive cervical carcinoma manifests in three
  somewhat distinctive patterns
• fungating (or exophytic)
• ulcerating
• infiltrative cancer

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• On histologic examination
• (1) large cell, either keratinizing(well-differ
  entiated) or nonkeratinizing (moderately
  diffferentiated), about 95
• (2) small cell undifferentiated carcinomas
  (neuroendocrine or oat cell carcinomas)
• Ten per cent to 25 of cercical carcinomas
  constitute adenocarcinomas, adenosquamous
  carcinomas, undifferentiated carcinomas. They
  look grossly and behave like the squamous cell
  lesions, but arise in a slightly older age group

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• Cervical cancer is staged as follows
• stage0 Carcinoma in situ(CIN )
• stage? Carcinoma confined to the cervix
• stage? Carcinoma extends beyond the cervix
  but not onto the pelvic wall. Carcinoma involves
  the vagina but not the lower third.
• stage? 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? 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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• Spread(1)direct extension into contiguous
  tissues, including the peritoneum, urinary
  bladder, uterus, rectum, and vagina.
• (2)spread through lymphatics
• (3)spread through blood vessel

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• Clinical Course
• Diagnosis cytologic examination merely detects
  the possible presence of a cervical precancer or
  cancer it does not make an absolute diagnosis,
  which requires histologic evaluation of
  appropriate biopsy specimens
• Ultimately, when these cancers become clinically
  overt, they usually produce irregular vaginal
  bleeding, leukorrhea, bleeding or pain on coitus,
  and dysuria

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• Treatment
• Precarcinoma cryotherapy, laser, wire loop
  excision, and cone biopsy
• Invasive cancers usually result in hysterectomy
  and, for advanced lesions, radiation
• with current methods of treatment, there is a
  5-year survival rate of about 80 to 90 with
  stage?, 75 with stage?, 35 with stage?, and 10
  to 15 with stage?

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Endometrial Hyperplasia

• Endometrial histology in the menstrual cycle

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• Endometrial hyperplasia is related to an
  abnormally high, prolonged level of estrogenic
  stimulation with diminution or absence of
  progestational activity. Thus, hyperplasia occurs
  most commonly around menopause or in association
  with persistent anovulation in younger women.

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• Morphology
• Gross appearance endometrium thicken polyp
• Histologic appearance
• Simple hyperplasia, also known as cystic or
  mild hyperplasia, is characterized by the
  presence of architectural alterations in glands
  of various sizes, producing irregularity in gland
  shape with cystic alterations. The epithelial
  growth pattern and cytology are similar to
  proliferative endometrium. The stroma between
  glands is also frequently increased.

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• Complex hyperplasia, also known as adenomatous
  hyperplasia without atypia, exhibits an increase
  in the number and size of endometrial glands,
  with gland crowding and a disparity in their size
  and irregularity in their shape
• Atypical hyperplasia, or adenomatous hyperplasia
  with atypia. In addition to glandular crowding
  and complexity, epithelial lining is irregular,
  characterized by stratification, scalloping and
  tufting, most cells are atypia. In one study, 23
  of patients with atypical hyperplasias eventually
  developed adenocarcinoma.

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Carcinoma of The Endometrium

• Endometrial carcinoma is the most common invasive
  cancer of the female genital tract. endometrial
  cancers arise mainly in postmenopausal women,
  causing abnormal bleeding.

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• Morphology
• gross apearance
• localized polypoid tumor
• diffuse tumor (involving the entire
• endometrial surface)

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• Histologic appearance most endometrial
  carcinomas(about 85) are adenocarcinomas. Tow
  per cent to 20 of endometrioid carcinomas
  contain foci of squamous differentiation.
  Squamous elements most commonly are
  histologically benign in appearance(called
  adenoacanthoma).less commonly, poorly
  differentiated endometrioid carcinomas contain
  squamous elements that appear frankly malignant.
  Such tumors have also been termed adenosquamous
  carcinomas

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Leiomyomas

• Morphology
• In gross appearance, leiomyomas are sharply
  circumscribed, discrete, round, firm, gray-white
  tumors varying in size from small, barely visible
  nodules to massive tumors that fill the pelvis.
  They can occur within the myometrium(intramural),
  just beneath the endometrium (submucosal), or
  beneath the serosa (subserosal). The cut section
  usually makes characteristic pattern of smooth
  muscle bundles.

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• On histologic examination, the leiomyoma is
  composed of whorled bundles of smooth muscle
  cells that resemble the architecture of the
  uninvolved myometrium.mitotic figures are scarce
• Clinical courseLeiomyomas of the uterus, even
  when they are extensive, may be asymptomatic. The
  most important symptoms are produced by
  submucosal leiomyomas (abnormal bleeding),
  compression of the bladder, sudden pain if
  disruption of blood supply occurs, and impaired
  fertility

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Overian Tumors
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Tumors of Surface (Coelomic) Epithelium

• Serous Tumors
• These common cystic neoplasms are lined by
  tall, columnar, ciliated epithelial cells and are
  filled with clear serous fluid. Together the
  benign, borderline, and malignant types account
  for about 30 of all ovarian tumors. About 75
  are benign or of borderline malignancy, and 25
  are malignant. Serous cystadenocarcinomas account
  for approximately 40 of all cancers of the ovary
  and are the most common malignant ovarian tumors

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• Morphology
• Gross appearance
• Serous tumor has one or a few fibrous walled
  cysts averaging 10 to 15 cm in diameter and
  occasionally up to 40 cm.
• Benign tumors contain a smooth glistening cyst
  wall with no epithelial thickening or small
  papillary projections

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• . Borderline tumors contain an increasing amount
  of papillary projections. Larger amounts of solid
  or papillary tumor mass, irregularity in the
  tumormass, and fixation or nondularity of the
  capsule are all important indicators of probable
  malignancy. Bilaterality is common, occurring in
  20 of benign cystadenomas, 30 of borderline
  tumors, and approximately 66 of
  cystadenocarcinomas.

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• Histologic appearance the lining epithelium is
  composed of columnar epithelium with abundant
  cilia in benign tumors. Borderline malignancy
  contain increased complexity of the stromal
  papillae with stratification of the epithelium
  and nuclear atypia, but destructive infiltrative
  growth into the stroma is not seen.

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• Cystadenocarcinomas exhibit even more complex
  growth with infiltration or frank effacement of
  the underlying stroma by solid growth. Concentric
  calcifications (psammoma bodies) characterize
  serous tumors.

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• Clinical course the biologic behavior of serous
  tumors depends on both degree of differentiation
  and distribution. Most benign tumor is no
  symptoms. Borderline tumors are no symptoms, or
  slowly spread, producing intestinal obstruction
  or other complications after many years. Frank
  carcinomas infiltrate the soft tissue and form
  large intra-abdominal masses and rapid
  deterioration.

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• Mucinous Tumors
• These tumors are less common, accounting for
  about 25 of all ovarian neoplasms. They occur
  principally in middle adult life and are rare
  before puberty and after menopause

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• Morphology
• Gross appearance characterized by more cysts of
  variable size and a rarity of surface involvement
  and are less frequently bilateral. They appear
  grossly as multiloculated tumors filled with
  sticky, gelatinous fluid rich in glycoproteins

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• Histologic appearance benign mucinous tumors
  are characterized by a lining of tall columnar
  epithelial cells with apical mucin and the
  absence of cilia, akin to benign cervical or
  intestinal epithelia.

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• Borderline tumors exhibit abundant glandlike or
  papillary growth with nuclear atypia and
  stratification and are strikingly similar to
  tubular adenomas or villous adenomas of the
  intestine.

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• Cystadenocarcinomas contain more solid growth
  with conspicuous epithelial cell atypia and
  stratification, loss of gland architecture, and
  necrosis and are similar to colinic cancer in
  appearance.

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Teratomas

• Teratomas are divided into three categories
• (1)mature (benign)
• (2) immature (malignant)
• (3) monodermal or highly specialized

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• Mature Teratomas
• Most benign teratomas are cystic and are better
  known in clinical parlance as dermoid cysts.
  These neoplasms are presumably derived from the
  ectodermal differentiation of totipotential
  cells. Cystic teratomas are usually found in
  young women during the active reproductive year.

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• Morphology
• In gross appearance, benign teratomas are
  bilateral in 10 to 15 of cases.
  Characteristically, they are unilocular cysts
  containing hair and cheesy sebaceous material. On
  section, they reveal a thin wall lined by an
  opaque, gray-white wrinkled, apparent epidermis.
  From this epidermis hair shafts frequently
  protrude. Within the wall, it is common to find
  tooth structures and areas of calcification

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• On histologic examination, the cyst wall is
  composed of stratified squamous epithelium with
  underlying sebaceous glands, hair shafts, and
  other skin adnexal structures. In most cases,
  structure from other germ layers can be
  identified, such as cartilage, bone, thyroid
  tissue, and other organoid formations

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• Immature malignant teratomas
• These are rare tumors that differ from benign
  teratomas in that the component tissue resembles
  that observed in the fetus or embryo rather than
  the adult. The tumor is found chiefly in
  prepubertal adolescents and young women, the mean
  age being 18 years

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• Morphology
• In gross appearance, the tumors are bulky and
  have a smooth external surface. On section, they
  have a solid or predominantly solid structure.
  There are areas of necrosis and hemorrhage. Hair,
  grumous material, cartilage, bone, and
  calcification may be present

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• On microscopic examination, there are varying
  amounts of immature tissue differentiation toward
  cartilage, glands, bone, muscle, nerve, and
  others. An important risk for subsequent
  extraovarian spread is the histologic grade of
  tumor, which is based on the proportion of tissue
  containing immature neutoepithelium

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• Immature teratomas grow rapidly and frquently
  penetrate the capsule with spread or metastases

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Gestational and Placental Disorders

• Hydatidiform Mole (Complete and Partial)
• Pathogenesis Cytogenetic studies of these moles
  show

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• Morphology
• Gross appearance In most instances, moles
  develop within the uterus, but they may occur in
  any ectopic site of pregnancy. The uterine cavity
  is filled with a delicate, friable mass of
  thin-walled, translucent, cystic, grapelike
  structures. Fetal parts are frequently seen in
  partial moles but are never found in complete
  moles.

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• On microscopic examination, the complete mole
  shows hydropic swelling of most chorionicvilli
  and virtual absence or inadequate development of
  vascularization of villi. The central substance
  of the villi is a loose, myxomatous, edematous
  stroma, and they may be covered by a layer of
  chorionic epithelium, both cytotrophoblast and
  syncytiotrophoblast. In partial moles, the
  villous edema involves only a proportion of
  villi, and the trophoblastic proliferation is
  focal and slight.

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• Clinical Course
• Most patients have abnormal uterine bleeding
  uterine enlargement more rapid than anticipated.
  Ultrasound examination permits a definitive
  diagnosis in most cases. Once the diagnosis is
  made, the mole must be removed by thorough
  curettage. From many studies, it is clear that
  80 to 90 of these moles remain benign and give
  no further difficulty. Ten per cent develop into
  invasive moles and 2.5 into choriocarcinoma

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• Invasive Mole
• Defined as a mole that penetrates and may even
  perforate the uterine wall. There is invasion of
  the myometrium by hydropic chorionic villi,
  accompanied by proliferation of both
  cytotrophoblast and syncytiotrophoblast.

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• The tumor is locally destructive and may invade
  parametrial tissue and blood vessels. Hydropic
  villi may embolize to distant sites, such as
  lungs and brain, but do not grow in these organs
  as true metastases, and even before the advent of
  chemotherapy, they eventually regressed unless
  fatal hemorrhage occurred. The tumor is
  manifested clinically by vaginal bleeding and
  irregular uterine enlargement, persisting
  elevated human chorionic gonadotropin level. The
  tumor responds well to chemotherapy.

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• Choriocarcinoma
• These is an epithelial malignant neoplasm of
  trophoblastic cells. Choriocarcinoma is a rapidly
  invasive, widely metastasizing malignant
  neoplasm, but once it is identified, it responds
  well to chemotherapy

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• Morphology
• Gross appearance a soft, fleshy, yellow-white
  tumor with a marked tendency to form large pale
  areas of ischemic necrosis, foci of cystic
  softening, and extensive hemorrhage

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• Histologic appearance a purely epithelial
  cellular malignancy that does not produce
  chorionic villi and that grows by the abnormal
  proliferation of both cytotrophoblast and
  syncytiotrophoblast. The tumor invades
  myometrium, frequently penetrates blood vessels
  and lymphatics, and in some cases extends out
  onto the uterine serosa and adjacent structure.
  In its rapid growth, it is subject to hemorrhage,
  ischemic necrosis, and secondary inflammatory
  infiltration.

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• In fatal cases, metastases are found in the
  lungs, brain, bone marrow, liver, and other
  organs. On occasion, metastatic choriocarcinoma
  is discovered without a detectable primary in the
  uterus, presumably because the primary has
  undergone total necrosis

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The Female Breast
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• Fibrocystic Changes
• These are common disease disorder of the breast,
  and it is found frequently between the ages of 20
  to 40 years. There are three principal patterns
  of morphologic change (1) cyst formation, often
  with apocrine metaplasia (2) fibrosis and (3)
  adenosis

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• Morphology
• Cysts in gross appearance, there are numerous
  small cysts within one or bilateral breast. On
  microscopic examination, cysts are lined by
  columnar epithelium (in larger cysts, lining
  cells may be flattened or may be totally
  atrophic). Frequently, cysts are lined by large
  polygonal cells resembling the apocrine
  epithelium of sweat glands(apocrine metaplasia)

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• Fibrosis cysts frequently rupture with release
  of secretory material into the adjacent stroma.
  The resulting chronic inflammation and scarring
  fibrosis contribute to the palpable formness of
  the breast.

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• Adenosis Adenosis is recognized as an increase
  in the number of acinar units per lobule. The
  gland lumens are often enlarged (blunt duct
  adenosis) and are not distorted as is seen in the
  distinctly proliferative lesion. Calcifications
  are occasionally present within lumens.

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Proliferative breast disease

• Epithelial hyperplasia
• Morphology Epithelial hyperplasia is usually not
  grossly evident. The proliferating epithelium
  takes the form of solid masses extending and
  encroaching into the duct lumen, partially
  obliterating into the duct lumens (fenestrations)
  can usually be discerned at the periphery of the
  cellular masses. Various degrees of cellular and
  architectural atypia may be present (atypical
  hyperplasia)

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• Sclerosing Adenosis
• Morphology
• On gross inspection, areas of sclerosing adenosis
  sometimes have a hard cartilaginous consistency
  that begins to approximate that found in breast
  cancer. On section, the involved area is not well
  localized and does not have the chalky
  yellow-white foci and streaks that identify
  breast carcinoma, an important gross differential
  feature.

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• On histologic examination, the number of acine
  per terminal duct is increased. The lobuar
  arrangement is maintained. The acini are
  compressed and distorted in the central portions
  of the lesion but characteristically dilated at
  the periphery. Myoepithelial cells are often
  prominent. On occasion, stromal fibrosis may
  totally compress the lumens to create the
  appearance of solid cords or double strands of
  cells lying with dense stroma

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• Current evidence suggests that the increased risk
  of cancer is proportional to the type of
  proliferative breast disease and to the presence
  of atypia. Fortunately, among women undergoing
  breast biopsies for benign disease, about 50
  with proliferative changes, only 5 to 10 will
  have atypical hyperplasia. Of the latter, less
  than 15 will develop cancer.

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Cancinoma of The Breast

• Among breast carcinomas small enough for their
  general areas of origin to be identified,
  approximately 50 arise in the upper outer
  quadrant 10 in each of the remaining quadrants
  and about 20 in the central or subareolar
  region. Carcinoma is divided into noninvaseve or
  in situ carcinomas and invasive carcinomas.

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In Situ Carcinoma

• Ductal Carcinoma In Situ (DCIS)
• DCIS are divided into comedocarcinoma and
  noncomedo DCIS
• Comedocarcinoma is characterized by solid sheets
  of high-grade malignant cells and central
  necrosis. The necrosis commonly calcifies.
  Punctate areas of necrotic material
  (comedone-like) can be seen grossly.

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• Noncomedo DCIS can have nuclear grades ranging
  from low to high. Calcifications are seen
  associated with central necrosis, but more
  commonly when there are intraluminal secretions.
  The cells appear monomorphic. In cribriform DCIS,
  intraepithelial spaces are evenly distributed and
  regular in shape. Papillary DCIS typically lacks
  the normal myoepithelial cell layer.
  Micropapillary DCIS is recognized by bulbous
  protrusions without a fibrovascular core, often
  forming complex intraductal patterns.

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• Lobular Carcinoma In Situ (LCIS)
• LCIS is manifested by proliferation, in one or
  more terminal ducts or ductules (acini), of a
  monomorphic population of cells that are loosely
  cohesive, are somewhat larger than normal, and
  have oval or round nuclei with small nucleoli.
  Signet-ring cells containing mucin are commonly
  present. LCIS rarely distorts the underlying
  architecture, and the involved lobules remain
  recognizable. LCIS is an incidental finding in
  biopsies performed for other reasons because it
  is only rarely associated with calcifications and
  never forms a mass

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Invasive Carcinoma

• Invasive Ductal Cafrcinoma, No Special type (NST)
• On palpation, they may have an infiltrative
  attachment to the surrounding structures with
  fixation to the underlying chest wall, dimpling
  of the skin, and retraction of the nipple. The
  mass is characteristic on cut section. It is
  retracted below the cut surface, has a hard
  cartilaginous consistency, and produces a grating
  sound when scraped. Within the central focus,
  there are small pinpoint foci or streaks of
  chalky white elastotic stroma and occasionally
  small foci of calcification

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• On histologic examination, the tumor consists of
  malignant cells disposed in cords, solid cell
  nests, tubules, anastomosing masses, and mixtures
  of all these invading into stroma. The cytologic
  detail of tumor cells varies from small cells
  with moderately hyperchromatic regular nuclei to
  huge cells with large irregular and
  hyperchromatic nuclei. Frequently, invasion of
  lymphatic and perineural spaces is readily
  evident.

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• Medullary carcinoma
• Morphology
• Grossly soft, fleshy consistency and well
  circumscribed
• Histology
• solid, syncytium-like sheets of large cells
  frequent mitoses
• A moderate to marked lymphoplasmacytic infitrate
• A pushing (noninfiltrative border)

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• Invasive Lobular Carcinoma
• Although making up only 5 to 10 of breast
  carcinomas, invasive lobular carcinomas are of
  particular interest for the following reasons
• (1) they tend to be bilateral (about 20) far
  more frequently than other subtypes.
• (2) they tend to be multicentric within the same
  breast.
• (3) they more frequently metastasize to
  cerebrospinal fluid, serosal surfaces, ovary and
  uterus, and bone marrow compared with other
  subtypes

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• Morphology
• On gross appearance, the tumor is rubbery and
  poorly circumscribed but sometimes appears as a
  typical scirrhous type.

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• On histologic examination, strands of
  infiltrating tumor cells, often only one cell in
  width (in the form of a single file), are loosely
  dispersed throughout the fibrous matrix. The
  cells have the same cytologic features of LCIS
  and lack cohesion without formation of tubules or
  papilae. Signet-ring cells are common.
  Irregularly shaped, solid nests may also occur in
  continuity with the single-file pattern.

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• A number of factors influence the prognosis of
  women with breast cancer without distant
  metastases
• (1) lymph node metastases (2) locally
  advanced disease (3) tumor size (4) histologic
  subtypes (5) tumor grade (6) estrogen and
  progesterone receptors Seventy per cent of
  tumors with estrogen receptors regress after
  hormonal manipulation. Cancers with high levels
  of hormone receptors have a slightly better
  prognosis than those without receptors. (7)
  lymphovascular invasion