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
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

Fibroma- most common benign solid tumor of vulva Lipoma Hidradenoma-interlabial sulcus, ‘milk-line’lesion
Benign, non-tender, shells out easily


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
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


Lesions of the Vulva
‘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
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.)


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
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
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
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
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
Fibroma Cystadenoma, Adenofibroma, cystadenofibroma…… Dermoid (Mature teratoma) Endometrioma Brenner’s Tumor

Lesions of the Ovary
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

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.

Sign up to vote on this title
UsefulNot useful