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TUMOR VAGINA
In adult fernales, the vagina is seldom a site of
➢ Condyloma is the name given to any primary disease. More often, it is involved
warty lesion of the vulva. Most such secondarily by cancer or infections arising in
lesions can be assigned to one of two adjacent organs (e.g., cervix, vulva, bladder,
distinctive forms rectum)
➢ Condylomata lata, not commonly seen ➢ Vaginitis is a relatively common
today, are flat, moist, minimally condition that is usually transient and of
elevated lesions that occur in secondary no clinical consequence. It is associated
syphilis with production of a vaginal discharge
➢ Condylomata acuminata may be (leukorrhea) vaginitis is characterized
papillary and distinctly elevated or by a curdy white discharge. This
somewhat flat and rugose. organism is part of the normal vaginal
flora in about 5% of women
Carcinoma of the vulva represents about 3% of
all female genital tract cancers, occurring mostly Cervix
in women older than age 60. Approximately Anatomically the cervix consists of the:
90% of carcinomas are squamous cell 1. External vaginal portio (ectocervix) - is
carcinomas; the other tumors are mainly visible on vaginal examination and is
adenocarcino- mas or basal cell carcinomas. covered by a mature squamous epithelium
that is continuous with the vaginal wall.
➢ HPV-related vulvar squamous cell
carcinomas usually are poorly
2. Endocervical canal - The endocervix is precursor lesions, some of which would have
lined by columnar, mucus-secreting progressed to cancer if not treated; in addition, the
epithelium. Pap test can also detect low-stage, highly curable
3. Squamocolumnar junction - The point cancers.
where the squamous and columnar
epithelium meet The accessibility of the cervix to Pap testing
4. Transformation Zone - Columnar cells are and visual exam (colposcopy) as well as the slow
constantly changing into squamous cells in progression from precursor lesions to invasive
this area of cervix carcinoma (typically over the course of years)
provides ample time for screening, detection, and
Inflammations preventive treatment.
Settings that altered vaginal environment promotes
the overgrowth of other microorganisms, which may Pathogenesis
result in cervicitis or vaginitis: High-risk HPVs are by far the most important
● Antibiotic therapy that suppress lactobacilli factor in the development of cervical cancer
can also cause the pH to rise There are 15 high risk HPVs that are currently
● Bleeding identified, but HPV-16 alone accounts for
● Sexual intercourse almost 60% of cervical cancer cases, and
● Vaginal douching HPV18 accounts for another 10% of cases; other
HPV types contribute to less than 5% of cases,
May produce significant acute or chronic cervicitis
and are important to identify due to their association individually.
with upper genital tract disease
● Gonococci High risk HPVs are also implicated in squamous
● Chlamydiae cell carcinomas arising at many other sites,
● Mycoplasmas including:
● HSV ● the vagina
● vulva
Endocervical Polyps ● penis
They vary from small, sessile “bumps” to large ● anus
polypoid masses that may protrude through the ● tonsil
cervical os. ● other oropharyngeal locations.
Endocervical polyps are common benign exophytic
growths that arise within the endocervical canal.
Genital HPV infections are extremely common;
Their main significance: most of them are asymptomatic, do not cause
● the source of irregular vaginal any tissue changes, and therefore are not
“spotting” detected on Pap test.
● or bleeding that arouses suspicion
of some more ominous lesion The duration of the infection is related to HPV
● Simple curettage or surgical type; on average, infections with high-risk HPVs
excision is curative. last longer than infections with low oncogenic
risk HPVs (13 months versus 8 months,
Premalignant and Malignant Neoplasms respectively).
of the Cervix
Worldwide, cervical carcinoma is the third The ability of HPV to act as a carcinogen
most common cancer in women. depends on the viral proteins E6 and E7, which
interfere with the activity of tumor suppressor
No form of cancer better documents the
proteins that regulate cell growth and survival
remarkable benefits of effective screening, early
diagnosis, and curative therapy than does cancer of
the cervix. Another factor that contributes to malignant
transformation by HPV is the physical state of
These dramatic gains belongs to the the virus
effectiveness of the Pap test in detecting cervical
Cervical Intraepithelial Neoplasia (Squamous The average age of patients with invasive
Intraepithelial Lesions) cervical carcinoma is 45 years.
The oldest classification system grouped lesions
as having mild dysplasia on one end and severe Squamous cell carcinoma is the most common
dysplasia/carcinoma in situ on the other. histologic subtype, accounting for approximately
80% of cases.
This was followed by the cervical intraepithelial
neoplasia (CIN) classification, with: The second most common tumor type is
● mild dysplasia (CIN I) adenocarcinoma, which constitutes about 15%
● moderate dysplasia (CIN II) of cervical cancer cases and develops from a
● severe dysplasia termed (CIN III) precursor lesion called adenocarcinoma in situ.
CIN I renamed low-grade squamous
intraepithelial lesion (LSI L) and CIN II and Adenosquamous and neuroendocrine
CIN III combined into one category referred to carcinomas are rare cervical tumors that
as high-grade squamous intraepithelial lesion account for the remaining 5% of cases
(HSIL)
All of the aforementioned tumor types are
caused by high-risk HPVs.
Complete Mole
Clinical Features - results from fertilization of an egg
Preeclampsia most commonly starts after that has lost its female chromosomes,
34 weeks of gestation but begins earlier in and as a result the genetic material is
women with: completely paternally derived
hydatidiform mole or preexisting - the embryo dies very early in
kidney disease development and therefore is usually
hypertension not identified
coagulopathies
Partial Mole
Eclampsia is heralded by central nervous - Partial moles result from fertilization
system involvement, including convulsions of an egg with two sperm . I n these
and eventual coma. moles the karyotype is triploid (or
Gestational Trophoblastic Disease occasionally tetraploid )
- encompasses a spectrum of tumors - Fetal tissues are typically present
and tumor-like conditions - increased risk of persistent molar
characterized by proliferation of disease, but are not associated with
placental tissue, either villous or choriocarcinoma.
trophoblastic
Clinical Features
The major disorders of this type: In complete moles, human chorionic
hydatidiform mole (complete and gonadotropin (HCG) levels greatly
partial exceed those of a normal pregnancy of
invasive mole similar gestational age.
choriocarcinoma Most moles are successfully removed
placental site trophoblastic tumor by cureĴage
(PSTT) Continuous elevation of HCG may be
indicative of persistent or invasive mole
Hydatidiform Mole Invasive Mole
- are important to recognize because - defined as a mole that penetrates or
they are associated with an increased even perforates the uterine wall
risk of persistent trophoblastic - The tumor is locally destructive and
disease (invasive mole) or may invade parametrial tissue and
choriocarcinoma. blood vessels
- The tumor is manifested clinically by uterine bleeding or amenorrhea and
vaginal bleeding and irregular uterine moderately elevated HCG
enlargement - Histologically, PSTT is composed of
- It is always associated with a malignant trophoblastic cells diffusely
persistently elevated serum HCG infiltrating the endomyometrium
- The tumor responds well to - It may follow a normal pregnancy
chemotherapy but may result in (half of the cases), spontaneous
uterine rupture and necessitate abortion, or hydatidiform mole
hysterectomy
BREAST
Choriocarcinoma ● Supernumerary nipples or breast tissue -
Gestational choriocarcinoma is a malignant found anywhere along the embryonic
ridge (milk line).
neoplasm of trophoblastic cells derived from
● Congenital inversion of the nipple is of
a previously normal or abnormal pregnancy, clinical significance because similar
such as an extrauterine ectopic pregnancy. changes may be produced by an
Choriocarcinoma is rapidly invasive and underlying cancer.
metastasizes widely, but once identified ● Galactocele arises during lactation from
responds well to chemotherapy. cystic dilation of an obstructed duct.
Clinical Features
Uterine choriocarcinoma usually manifests
FIBROCYSTIC CHANGES
as irregular vaginal spotting of a bloody, ● most common breast abnormality seen
brown fluid. in premenopausal women.
This tumor has high propensity for ● This range of changes is the
hematogenous spread consequence of an exaggeration and
The treatment of gestational distortion of the cyclic breast changes
choriocarcinoma depends on the stage of that occur normally in the menstrual
cycle.
the tumor and usually consists of
● Estrogenic therapy and oral
evacuation of the contents of the uterus and contraceptives do not seem to increase
chemotherapy the incidence of these alterations.
Placental Site Trophoblastic Tumor
(PSTT) Nonproliferative Changes
- They are neoplastic proliferations of Cysts and Fibrosis
● most common type of fibrocystic lesions
extravillous trophoblasts, also called
● increase in fibrous stroma associated
intermediate trophoblasts. with dilation of ducts and formation of
- I n normal pregnancy, extravillous variably sized cysts.
(intermediate) trophoblasts are found MORPHOLOGY
in nonvillous sites such as: ● A single, large cyst may form within
one breast
the implantation site
● Changes usually are multifocal and
in islands of cells within the placental often bilateral
parenchyma ● cysts: <1cm – 5cm in diameter
in the placental membranes ● Unopened, they are brown to blue (blue
- PSTT presents as a uterine mass, dome cysts) and are filled with watery,
turbid fluid
accompanied by either abnormal
● the secretions within the cysts may ● atypical ductal and lobular hyperplasia
calcify, producing microcalcifications are associated with an increased risk of
on mammograms. invasive carcinoma.
Histologic examination Sclerosing Adenosis
● reveals an epithelial lining that in larger ● contain marked intralobular fibrosis and
cysts may be flattened or even totally proliferation of small ductules and acini.
atrophic. MORPHOLOGY
● lining cells are large and polygonal with ● lesion: has a hard, rubbery consistency,
abundant granular, eosinophilic similar to that of breast cancer.
cytoplasm and small, round, deeply Histologic examination
chromatic nuclei. (apocrine metaplasia) ● shows a characteristic proliferation of
and virtually always is benign. luminal spaces (adenosis) lined by
● the stroma surrounding all types of cysts epithelial cells and myoepithelial cells,
usually consists of compressed fibrous yielding masses of small glands within a
tissue that has lost the delicate, fibrous stroma
myxomatous appearance of normal Relationship of Fibrocystic Changes to Breast
breast stroma. Carcinoma
-the only certain way of making this distinction
Proliferative Change is through biopsy and histologic examination.
Epithelial Hyperplasia -Although fibrocystic changes are benign, some
● normal ducts and lobules of the breast features may confer an increased risk for
are lined by two layers of cells: development of cancer:
o luminal cells • Minimal or no increased risk of breast
o myoepithelial cells. carcinoma: fibrosis, cystic changes, apocrine
● recognized by the presence of more than metaplasia, mild hyperplasia
two cell layers. • Slightly increased risk (1.5- to 2-fold):
● the spectrum ranges from mild and moderate to florid hyperplasia (without atypia),
orderly to atypical hyperplasias with ductal papillomatosis, sclerosing adenosis
features that resemble those of in situ • Significantly increased risk (5-fold): atypical
carcinoma. hyperplasia, whether ductular or lobular
Morphology -Proliferative fibrocystic changes usually are
● The gross appearance is not distinctive bilateral and multifocal and are associated with
● dominated by coexisting fibrous or increased risk of subsequent carcinoma in both
cystic changes. breasts.
Histologic examination INFLAMMATORY PROCESSES
● shows an almost infinite spectrum of - usually associated with pain and
proliferative alterations. tenderness in the affected areas.
● The ducts, ductules, or lobules may be Acute mastitis
filled with orderly cuboidal cells within ● develops when bacteria, usually
which small gland patterns Staphylococcus aureus, gain access to
(fenestrations) can be discerned. the breast tissue through the ducts.
● hyperplasia produces ● The vast majority of cases arise during
microcalcifications on mammography, the early weeks of nursing, when the
raising concern for cancer. skin of the nipple is vulnerable to the
● Atypical lobular hyperplasia -used to development of fissures.
describe hyperplasias that exhibit Mammary duct ectasia (plasma cell mastitis)
changes that approach but do not meet ● a nonbacterial chronic inflammation of
diagnostic criteria for lobular carcinoma the breast associated with inspissation of
in situ. breast secretions in the main excretory
ducts.
● Ductal dilation and eventual rupture - A cut section shows a uniform tan-white color,
leads to reactive changes in the punctuated by softer yellow-pink specks
surrounding tissue that may present as a representing the glandular areas.
poorly defined periareolar mass with Histologic examination shows a loose
nipple retraction, mimicking the fibroblastic stroma containing ductlike,
changes caused by some cancers. epithelium-lined spaces of various shapes and
MORPHOLOGY sizes.
- confined to an area drained by one or more of - in normal breast tissue, these glandular spaces
the major excretory ducts of the nipple. are lined by luminal and myoepithelial cells with
Histologic examination a well-defined, intact basement membrane.
- the most distinguishing features consist of a
prominent lymphoplasmacytic infiltrate and Phyllodes Tumor
occasional granulomas in the periductal stroma. -biphasic, being composed of neoplastic stromal
cells and epithelium-lined glands.
Fat necrosis -uncommon, innocuous lesion that -stromal element of these tumors is more cellular
is significant only because it often produces a and abundant, often forming epitheliumlined
mass. Most women with this condition report leaflike projections (phyllodes is Greek for
some antecedent trauma to the breast. “leaflike”).
MORPHOLOGY -tumors are much less common than
-early stage of traumatic fat necrosis fibroadenomas and arise de novo, not from
● lesion is small, often tender, preexisting fibroadenomas.
● rarely more than 2 cm in diameter -In the past, they had the tongue-tangling name
● sharply localized. cystosarcoma phyllodes—an unfortunate term
-It consists of a central focus of necrotic fat cells because these tumors usually are benign.
surrounded by neutrophils and lipid-laden -Ominous changes suggesting malignancy
macrophages, sometimes with giant cells. include
-Calcifications may develop in either the scar or ● increased stromal cellularity
the cyst wall. ● Anaplasia
● high mitotic activity
TUMORS OF THE BREAST ● rapid increase in size
Most important lesions of the female breast. ● infiltrative margins.
● Fibroadenoma Fortunately, most phyllodes tumors remain
- Most common benign neoplasm of the localized and are cured by excision; malignant
female breast. lesions may recur, but they also tend to remain
- A biphasic tumor composed of localized.
fibroblastic stroma and epithelium-lined
glands
-typically appear in young women with Intraductal Papilloma
a peak incidence in the third decade of ● Benign neoplastic papillary growth
life. They usually manifest as solitary, ● Seen in premenopausal women
discrete, mobile masses. ● Found within the principal lactiferous
-An absolute or relative increase in ducts or sinuses
estrogen is thought to contribute to their
development. CLINICAL PRESENTATION:
- In addition, fibroadenomas may
● Serous/bloody nipple discharge
enlarge late in the menstrual cycle and
during pregnancy; after menopause, they ● Presence of small subareolar tumor
may regress and calcify. ● Nipple retraction (rare instances)
MORPHOLOGY CARCINOMA
- The fibroadenomas form discrete masses, 1 cm
to 10 cm in diameter and of firm consistency
● Second to lung cancer (cause of cancer- ● Lobular carcinoma in situ (LCIS)
related death: women) o Has uniform appearance
o Monomorphic cells with band,
EPIDEMIOLOGY AND RISK FACTORS
round nuclei and occur in
● AGE: after menopause (80 y/o) loosely cohesive vacuoles are
75% (50 y/o) common
5% (40 y/o) o Current treatment:
● Geographic Variations: varies in - Chemoprevention with
countries tamoxifen
Higher in North America and - Bilateral prophylactic
northern Europe than Asia and Africa. mastectomy
● Race/Ethnicity: highest rate in non
B. Invasive (infiltrating)
Hispanic young women
● Other risk factors: ● Invasive ductal carcinoma
o Prolonged exposure to o 70 to 80% of cancers
exogenous estrogens o Usually associated with DCIS
o Oral contaceptives and rarely LCIS
o Ionizing radiation ● Invasive lobular carcinoma
o Obesity o Concists of cell
o Alcohol consumption morphologically identical to the
o Diet in high fat cell of LCIS
● Inflammatory carcinoma
MORPHOLOGY o Defined by the clinical
● Most common location of tumors within presentation of an enlarged,
the breast: swollen, erythematous breast,
o Upper quadrant (50%) usually without palpable mass
o Central portion (20%) ● Medullary carcinoma
o bilateral primary tumors or o Rare subtype of carcinoma
sequential lesions in the same o <1% of breast cancer
beast (4%) ● Colloid carcinoma (mucinous
carcinoma)
MAIN FORMS OF BREAST CARCINOMA: o Also a rare subtype
o Tumor cells produce abundant
A. Noninvasive (in situ) carcinoma
quantities of extracellular
● Ductal carcinoma in situ (DCIS) mucin which dissects into the
o Fill and distort ductal spaces surrounding stroma
o Architectural patterns: solid, ● Tubular carcinoma
comedo, cribriform, papillary, o Rarely present as palpable
micropapillary and “clinging” masses
o Necrosis may be present o 10% invasive carcinomas <1cm
o Name derived from toothpaste- with mammorgraphic screening
like necrotic tissue
LESIONS OF THE MALE BREAST
o Current treatment: surgery and
irradiation 1. Gynecomastia
o Paget disease of the nipple ● Enlargement of the male breast (in
- caused by extention of DCIS response to absolute or relative estrogen
- lactiferous ducts and into the excesses)
contigious skin of the nipple ● Morphologic features:
o Increase in connective tissue
and epithelial hyperplasia of
the ducts
o Rare lobule formation
● Clinically, button-like, subareolar
swelling develops, usually both breasts
but occasionally in only one
2. Carcinoma
● Breast cancer is rare in men (1%)
● Typically diagnosed in advanced age
● Because of scant amount of breast tissue
in men, the tumor rapidly infiltrates the
overlying skin and underlying thoracic
wall
● Resembles invasive carcinomas seen in
women