PATHOLOGY LABORATORY

Female Reproductive Lab I

Case 1: slide 33

Clinical history: A 42 year old black woman consulted her gynecologist with a chief complaint of menorrhagia. She also had occasional urinary frequency and constipation. On bimanual pelvic examination the uterus contour was distorted by multiple smooth round nodules. No adnexal masses were felt. A pregnancy test was negative. Vaginal cytology was normal. Uterine curettage showed a secretory endometrium. An abdominal hysterectomy was performed.

1.   Is the tumor epithelial or mesenchymal?    mesenchymal

 

2.  What is the main criterion for the differentiation of benign vs malignant in this type of neoplasm? What other features must be considered?    Mitotic activity is the main criterion. Other features to consider include cellular atypia, abnormal mitotic figures, extent of necrosis, and presence of myometrial or vascular invasion.

 

3.  Is this a common uterine neoplasm?   Yes, the most common uterine neoplasm

 

4.   What are the three most common uterine sarcomas?  Mixed muellerian tumor, leiomyosarcoma, endometrial stromal sarcoma

Case 2: Slide 36

Clinical history: A 59 year old woman had a persisting white plaque of the vulvar skin which was biopsied and then resected.

1.   Is the lesion primarily an inflammatory process or a neoplastic process?   Neoplastic

2.   Describe the histologic changes which are present.   Atypical cytologic changes including increased nuclear-cytoplasmic ratio, loss of polarity, increased mitotic activity and pleomorphism of the epithelial cells in the epidermis, in some foci extending almost throughout the full thickness of the epidermis.

3.   Is the lesion invasive or not and how can you tell?   Not invasive. The basement membrane is intact and there is not fibroblastic response in the surrounding tissues.

4.   What is your diagnosis?   CIN 3 (Severe dysplasia to CIS)

5.   What HPV type is often present with this lesion?    HPV 16 and 18

6.   How does this lesion differ from extramammary Paget's disease?   Paget cells have pale vacuolated cytoplasm, lack intercellular bridges and contain glycosaminoglycans which stain with PAS and mucicarmine. In contrast to Paget's disease of the breast which is almost always associated with underlying adenocarcinoma of the ducts, extra-mammary Paget's is only rarely associated with and adenocarcinoma of the skin adnexa.

Case 3: Slide 144

Clinical history: A 36 year of woman consulted her gynecologist because of pain on coitus, post-coital spotty bleeding and leukorrhea (whitish vaginal discharge). The patient had a history of early age at first intercourse and many different sexual partners. On examination the external os was surrounded by granular areas which bled slightly on gentle rubbing. The areas were not stained by the Schiller's iodine test. A cone biopsy was performed.

1.   What histologic features are present?

a.   Atypical changes involving less than 1/3 of the thickness of the epithelium

b.   Atypical changes involving 1/3 to 1/2 of the thickness of the epithelium

c.   Atypical changes involving 2/3 to full thickness of the epithelium, but not invasion

d.   Full thickness atypical changes as well as invasion of the underlying connective tissue

Ans.=d. full thickness atypia and invasion

2.   Was this lesion likely to regress without treatment?   No

3.  Why did the cervix not stain with the Schiller iodine test?    Schiller iodine test did not stain some areas of the cervix because the neoplastic cells there lacked glycogen

4.      What is the prognosis (5-year survival) for this type of lesion?   Varies with the stage: Stage 0: 100%, I: 80-90%, II: 75%, III: 35%, IV: 10-15%

  1. What is the typical cause of death in patients with progressive lesions?    Urethral obstruction, pyelonephritis and uremia
  2. What virus plays an important role in development of this lesion?    HPV (esp. types 16-18)

Case 4: Slide 104

Clinical history: An obese 57 year old woman saw her gynecologist for abnormal uterine bleeding. On physical examination the uterine corpus was slightly enlarged, and one small, firm nodule was present, but no adnexal masses were present. After cervical cytologies and endometrial biopsy were evaluated, a hysterectomy was performed.

Gross: In the uterine wall was a firm circumscribed grayish white whorled nodule. The endometrium was thickened, shaggy and tan with focal hemorrhage. In some areas the endometrium appeared to extend into the underlying myometrium.

1.   Which of the following histologic features fit this lesion?

a.   Increase in glands relative to stroma, with cystically dilated glands, but no cellular atypia

b.   Complex, crowded glands with little intervening stroma, but no cytologic atypia

c.   Complex, crowded glands with cytologic atypia, but some stroma intervening between glands.

d.   Complex, crowded, back to back glands with cytologic atypia and some glands with a cribriform pattern

e.   Complex, crowded, back to back glands with cytologic atypia and cribriform pattern as well as many solid areas of tumor

Ans.=d. Complex, crowded, back to back glands with cytologic atypia and some glands with a cribriform pattern

2.   Is the lesion limited to the endometrium or does it involve the myometrium?

Does this indicate invasion or a form of endometriosis (adenomyosis)?    Invades the myometrium.   Invasion

3.   What is your diagnosis?   Grade I endometrial carcinoma

4.   Is this a common lesion?    Yes, the most common invasive neoplasm of the female genital tract in the U.S.

  1. What are the risk factors for developing this tumor?   Type I low grade carcinoma which occurs from unopposed estrogen, in pre and perimenopausal white women in association with hyperplasia and minimal myometrial invasion and stable behavior. Type II, high grade carcinoma which occurs in the absence of unopposed estrogen, in postmenopausal back women, without associated hyperplasia and deep myometrial invasion and progressive behavior.

Case 5:           slide 103

Clinical history: A 25 year old woman saw her gynecologist for lwer abdominal pain and bloody vaginal discharge which had foll0wed a period of amenorrhea, nausea, and vomiting. After several test, and exploratory laporatomy was performed and a bloody adnexal mass was resected. Examine slide 103.

1.      What is your diagnosis?   Diagnosis is ectopic pregnancy (tubal pregnancy).

 

2.      Is this a common location for this process?   Yes, this is a common location. Over 95% of ectopic pregnancies occur in the fallopian tube, mostly in the distal and middle thirds.

 

3.      What factors may predispose to this process?   Predisposing factors include mucosal adhesions or abnormal tubal motility secondary to inflammation or endometriosis.

 

4.      What tests may be useful I making the diagnosis prior to laparotomy?    Pregnancy test, sonography, laparoscopy and possibly endometrial curretage are tests or procedures that can be helpful in the diagnosis. The endometrium shows Arias-Stella reaction in 60% of the cases, but may show only normal phase of the endometrium.

 

  1. Is early diagnosis important in this lesion? Why?    Diagnosis of ectopic pregnancy is important since total rupture is life threatening from rapid exsanguinating hemorrhage.