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Pathology and Neoplasia

„ 1. Describe the pathogenesis and


epidemiology of the common
nonmalignant neoplasms that affect the
external and internal genitalia.
„ 2. Describe the role of oncogenes in the
pathogenesis of premalignant lesions of the
external and internal genitalia.
Lesions of the Vulva
„ Cysts
„ Bartholin’s duct- most common large cyst of vulva,
need treatment for symptoms or infection
„ Inclusion or sebaceous- most common small cyst of
the vulva
„ Tumors
„ Fibroma- most common benign solid tumor of vulva
„ Lipoma
„ Hidradenoma-interlabial sulcus, ‘milk-line’lesion
„ Benign, non-tender, shells out easily
„ Others
Lesions of the Vulva
„ Dermatological conditions
„ Vulvar intraepithelial neoplasia
„ Condyloma
„ Nevus
„ Psoriasis
„ Seborrheic Dermatitis
„ Lichen Planus
„ Lichen Sclerosis
„ Lichen Simplex Chronicus
„ Hidradenitis Suppurativa
Lesions of the Vulva
„ VIN
„ Infection with HPV 18
„ Also increased risk with LSC w/o HPV
„ HIV+, post-menopausal, smoking
„ Treatment is excision or ablation
„ Recurrence rate is high, 15-50%
„ Appearance ‘Patriotic’
„ Red, white, and blue (hyperpigmented)
Lesions of the Vulva
„ Condyloma acuminatum
„ AKA Genital warts
„ Associated with infection with HPV
„ Often low risk types of HPV are found
„ 6, 11, 42, 43, 44
Condyloma
Lesions of the Vulva
„ Nevus
„ ‘mole’
„ localized clusters of melanocytes. May not
be pigmented until puberty.
„ ‘Normal’ is raised, smooth borders, and may
have hair.
„ 5-10% of malignant melanomas occur on the
vulva and 50% of malignant melanomas
arise from pre-existing nevi.
Lesions of the Vulva
„ Psoriasis
„ Multi-factorial genetic susceptibility
„ 30% positive family history
„ May be 1st manifestation of HIV infection
„ Of affected females, 20% have involvement of vulva
„ Lesions are red-yellow papules, classic ‘silver scales’
may be absent
„ Treat with topical steroids
„ Triggers exacerbate lesions
„ Cold, stess, drugs, infections
Lesions of the Vulva
„ Seborrheic Dermatosis
„ Hard to distinguish from psoriasis
„ Etiology may be from yeast
„ Treat with steroids
„ If refractory, may try ketoconazole
Lesions of the Vulva
„ Hidradenitis Suppurativa
„ Chronic refractory infection of skin and
subcutaneous tissue
„ Deep scars with foul smelling discharge
„ Initially treat with antibiotics and steroids
„ Usually results in chronic infection of
apocrine glands with multple draining
abscesses with need for wide local excision
Hidradenitis Suppurtiva
Lesions of the Vulva
„ Lichen planus
„ Probably autoimmune
„ Lesions may be purple, well-demarcated,
papules or erythematous erosive lesions
„ Treat with steroids, emollients
„ Biopsy to differentiate from similar lesions:
syphilis, herpes, chancroid
Lesions of the Vulva
„ Lichen Sclerosis
„ Affects the young and old
„ Most often caucasian women
„ Chronic progressing lifelong condition
„ Should biopsy due to need for prolonged treatment
„ 3-5% Increased risk of squamous cell carcinoma
„ Thin white parchment paper appearance
„ Ulcers, fissures, hypo or hyperpigmentation, introital
stenosis
„ Treat with steroids (not testosterone), most
commonly with clobetasol.
Lichen Sclerosis
Lesions of Vulva
„ Lichen Simplex Chronicus
„ End stage of prolonged inflammation
„ Appears red with overlying grey-white
keratin layer, ‘leathery’, raised
„ Increased risk of squamous cell carcinoma
„ Atypia on biopsy makes it VIN
„ Treat underlying inflammation/irritation,
steroids
Lichen Simplex Chronicus
Lesions of the Vagina
„ Urethral Diverticulum or Caruncle
„ Cysts
„ Inclusion
„ Dysontogenetic (Gartner’s duct, etc.)
„ Trauma
„ Hematoma
„ Vaginal intraepithelial neoplasia (VAIN)
„ Condyloma
Lesions of the Vagina
„ Urethral Diverticulum
„ Appears as ‘mass’ of anterior vaginal wall
„ Permanent epithelialized sac-like projection
from the posterior urethra
„ Non-specific symptoms: frequency, urgency,
post-void dribbling, h/o recurrent UTI,
dysparunia
„ Treat if persistence of symptoms or recurrent
infection via excision
Urethral Diverticulum
Lesions of the Vagina
„ Urethral Caruncle
„ Usually in post-menopausal women
„ Fleshy outgrowth of distal edge of urethra
„ Arise from the posterior urethral wall with
retraction and atrophy of post menopausal
vagina
„ If seen in children, think URETHRAL
PROLAPSE
Lesions of the Vagina
„ Dysontogenetic cysts
„ Thin walled cysts of embryonic origin
„ Gartner’s Duct Cyst
„ one of the most common
„ primarily of mesonephric origin

„ found laterally in the vagina


Lesions of the Vagina
„ VAIN
„ Similar to VIN and CIN
„ HPV, smoking included in risks
„ Often asymptomatic, found on colposcopy
after abnormal pap smear
„ Treat with ablation or excision
Lesions of the Cervix
„ Polyps
„ Nabothian Cysts-mucous retention cysts,
translucent/opaque, caused by normal
healing process or cervix
„ Fibroids
„ Cervical intraepithelial neoplasia (CIN)
„ Condyloma
Lesions of the Cervix
„ CIN
„ High risk HPV: 16, 18, 31, 45
„ Oncogenes of these HPV types are E6 and E7
„ These oncogenes inactivate the tumor suppressor genes.
E6- p53, E7-Rb
„ Risks include HPV infection, smoking, multiple
sexual partners, early intercourse, HIV,
immunosuppression
„ Diagnosis on biopsy after abnormal screening
Lesions of the Uterus
„ Polyps
„ Fibroids
„ Intramural
„ Subserous
„ Submucous
„ Intravenous leiomyomatosis
„ Leiomyomatosis peritonealis disseminata
Lesions of the Uterus
„ Polyps
„ Localized overgrowth of endometrial glands and
stroma
„ Usually at the fundus
„ Symptoms include pre- and post-menopausal
bleeding irregularities
„ Must have 3 components: endometrial glands,
endometrial stroma, central vascular channel
„ Diagnosis made on USG, SHG, Hysteroscopy, or
post hysterectomy
Lesions of the Uterus
„ Fibroids
„ Most frequent pelvic tumors
„ Can occur anywhere there is smooth muscle
„ Usually in the 5th decade
„ ¼ white women, ½ black women
„ Most develop from myometrium, as
intramural and then continued growth decides
site
Lesions of the Uterus
„ Fibroids continued
„ 5-10% are submucosal, but are most symptomatic
„ Monoclonal
„ 60% with normal karyotype, 40% with abnormal
karyotype
„ Have both estrogen and progesterone receptors
„ Have limited blood supply, so increased growth
causes increased degeneration
„ Types of degeneration: hyaline(65%), myxomatous
(15%), calcific (10%), cystic, fatty, red, necrosis
Fibroids (aka-Fireballs)
Lesions of the Uterus
„ Intravenous leiomyomatosis
„ ‘spaghetti tumor’, smooth muscle fibers invade and
grow into venous channels
„ Usually confined to broad ligament
„ Reports of invasion of IVC and Right heart
„ Leiomyomatosis peritonealis disseminata
„ Multiple lesions over surface of pelvis and abdominal
peritoneum
„ Mimics disseminated carcinoma, may have problems
with bowel obstruction
Leiomyomatosis peritonealis
disseminata
Lesions of the Oviduct
„ Fibroids
„ Adenomatoid Tumors
„ aka-angiomyoma, most prevalent benign
tumor of oviduct, usually unilateral and
aymptomatic
„ Paratubal Cysts
„ If near the fimbria, hydatid cysts of
Morgagni, mesonephric origin
Lesions of the Ovary
„ Functional cysts
„ Follicular
„ Corpus luteum
„ Theca lutein
Lesions of the Ovary
Theca lutein cysts
Lesions of the Ovary
„ Theca lutein cysts
„ Least common of the three listed functional cysts
„ Almost Always Bilateral
„ ‘Honeycombed’ appearance
„ Present in 50% of molar pregnancies and 10% of
choriocarcinomas
„ Can be associated with normal pregnancy, but also
with large placenta, twins, diabetes, Rh sensitization
„ Rarely, found in newborn infants as result of
maternal gonadotropins
„ Treatment is conservative…Be careful at c-section!
Lesions of the Ovary
„ Tumors
„ Fibroma
„ Cystadenoma, Adenofibroma,
cystadenofibroma……
„ Dermoid (Mature teratoma)
„ Endometrioma
„ Brenner’s Tumor
Lesions of the Ovary
„ Fibroma
„ Most common benign solid ovarian neoplasm
„ May get large, mistaken for fibroids preop
„ Increased diameter associated with ascites
„ 50% of tumors >6 cm have ascites
„ Meig’s syndrome
„ Triad of ovarian fibroma, ascites, and hydrothorax
„ Resolves with removal of mass
Lesions of the Ovary
„ Dermoid (Mature Teratoma)
„ Among the most common ovarian tumor
„ The most common germ cell tumor
„ 10-15% are bilateral
„ 50% are found in women ages 25-50
„ The most common ovarian neoplasm in prepubertal
girls
„ Associated with 3 medical conditions
„ Thyrotoxicosis, autoimmune hemolytic anemia, carcinoid
syndrome
Lesions of the Ovary
„ Dermoids continued
„ Appear white, shiny, opaque
„ Have thick sebaceous fluid, hair, teeth and cartilage
when opened
„ The sebaceous material can produce a severe
chemical granulomatous peritonitis
„ Thought to arise from a single germ cell after the first
meiotic division
„ Struma ovarii is a teratoma that is composed
primarily of thyroid tissue and comprises 2-3% of
dermoids
Lesions of the Ovary
„ Brenner’s Tumor (transitional cell tumor)
„ Rare, smooth, solid, fibroepithelial tumors
„ Usually asymptomatic
„ Thought to result from metaplasia of
coelomic epithelium to uroepithelium
„ Appear smooth, firm, grey-white (similar to
fibroma)
„ Histologically, have masses or nests of
epithelial cells surrounded by fibrous stroma
References
„ Comprehensive Gynecology/ Morton A.
Stenchever…et al. 4th edition. 2001.
„ Precis: an update in obstetrics and gynecology.
Gynecology 2nd edition. Oncology 2nd edition.
„ Obstetrics and gynecology: principles for
practice. Ling, Duff. 2000.
„ Urogynecology and reconstructive pelvic surgery.
Walters, Karram. 2nd edition. 1999.