Pathology Department

Systemic Pathology

Female Genital Tract Pathology

FGT
PBL 1

A.P. Dr. Maather Baqer Hussein

M.B.Ch.B_Msc path_F.E.C.M Obs_Gyn
maather.hussein@qu.edu.iq
PBL 1
A thirty -years-old woman attends the colposcopy clinic complaining of
postcoital bleeding .
Her first sexual relationship started at the age of 16 years and she has had
several partners since that , she diagnosed with HPV infection since 8 years.
She smokes 15–20 cigarettes per day.

Examination
The cervix is macroscopically normal.
At colposcopy, acetic acid is applied and an irregular white area is apparent to the
left of the os. The Lugol’s iodine is applied and the same area stains pale while
the rest of the cervix stains dark brown.
So A biopsy is taken.
Cervical biopsy report: the sample received measures 4 × 2 mm
and contains enlarged cells with irregular nuclei occupied all
thickness of epithelium .
• Q1 --- What is your diagnosis and differential diagnosis of her
presentation ?

• Q2 --- What are classification of this cervical disease ?

• Q3 --- What are the risk factors in this patient scenario to

develop this cervical disease ?

• Q 4--- What is the risk of your diagnosis to develop cervical

malignancy
• Q1 --- A---
1- CIN III

D.DX
1- CIN I,II,& III
2- Cervical cancer
3- Metastatic cervical cancer

• Q2 --- A---
Low - grade or High - grade squamous intraepithelial lesions (LSIL and HSIL,
respectively).

• Q3 --- A---
HPV
CIN Early sexual relationship
Multiple sexual patter Smoking

• Q 4--- A—
CIN-III→10% develop malignancy
PBL 2
A 65-year-old nulliparous (never get pregnancy) woman complain of vaginal
bleeding.
Her last period was at the age of 50 years while her menarch was at 12 years
old. She is sexually active but has noticed vaginal dryness on intercourse
recently.
She is hypertensive and diabetic on medical treatment.
Examination
She is overweight. Abdominal examination is normal. The vulva and vagina
appear thin and atrophic ( post menapousal changes ) , the cervix is normal &
the uterus is small with no palpable adnexal masses.
Investigation:
Trans vaginal ultrasound scan revealed thickning of endometrium .
An outpatient endometrial biopsy that is taken at the time of examination
revealed this picture :-

• Q1 --- What are the differential diagnosis of her presentation

? And What is your most likely diagnosis ?

• Q2 --- What are the risk factors in this patient to develop your
suspicion & whar are the protective factors you suggest ?
Q1 – A-
1- Postmenopausal bleeding is considered to be caused
by endometrial cancer until proven therwise.

2- Causes of postmenopausal bleeding

• Endometrial cancer
• Endometrial/endocervical polyp
• Endometrial hyperplasia
• Atrophic vaginitis (Menapousal physiological changes
causing atrophic genital tissue that dependent on
estrogen)

 Most likely diagnosis is complex endometrial

hyperplasia with atypia
Q2 A – risk factors
• Older age. Any agent/factor that rises the level
• Early menarche. or time of exposure to estrogen is a
risk factor for endometrial
• Late menopause. Hyperplasia & carcinoma
• Nulliparity.
• Unopposed estrogen (Obesity, HRT).
• Hypertension

protective factors
• Multiparity. Any agent/factor that lowers the
• Smoking. level or time of exposure to
estrogen is a protective factor
• COCP. against endometrial hyperplasia &
• Physical activity. carcinoma
Q3 :- Mention your microscopical finding

complex hyperplasia with atypia showing

overcraoded gland with rounded, vesicular
nuclei with prominent nucleoli
PBL 3
A 25-year-old woman has noticed abdominal swelling for 10 months. She
has no abdominal pain and her bowel habit is normal. She feels nauseated
when she eats large amounts. She has urinary frequency but no dysuria or
haematuria.
Her periods are heavy regular, with clots and flooding .
She married since 5 years and she has never been pregnant.

Examination
The woman has a very distended abdomen.
A smooth firm enlarging uterus is palpable extending from the symphysis
pubis to midway between the umbilicus and the xiphisternum (equivalent
to a 32-week size pregnancy). It is non-tender and mobile .
Speculum vaginal examination it is not significant.
Investigation
Pt is anemic
Ultrasound revealed multiple masses occupied the uterine wall
Diagnostic laproscopy finding is as in picture :-

• Q1 --- What is your diagnosis ?

Q1 – A 1
The woman has a large uterine fibroid (leiomyoma). This is causing menorrhagia
and hence the microcytic anemia from iron deficiency is developed.
Urinary frequency occurs due to the pressure of the large mass on the bladder.
It is also likely that the fibroid is accounting for her infertility history, although
this warrants investigation as a separate problem.
 Q2 – what are the anatomical types or sites for this
tumor??

A:-
Anatomicaly Leiomyoma
can occur as
 A = Subserosal fibroids
 B = Intramural fibroids
 C = Submucosal fibroid
 D=Pedunculated
submucosal fibroid
 E =Cervical fibroid
 F = Fibroid of the broad
ligament
 Q3 – after excised the tumor with uterus, the tumor
gross & hitology appears as picture , Describe the
characteristic featurs for this tumor

Microscopical :-
well differentiated, regular
spindle-shaped smooth muscle Gross :- Cut surfase
cells associated with
whorled appearance
hyalinization
PBL 4
A 18-year-old female presents with lower abdominal pain since 3 months
which has gradually become more frequent and severe with no changing
with her periods . She is also complaining with urinary frequency , urgency
without dysuria
General and Abdominal examination:
The woman is slim and the abdomen is soft with a palpable firm , mobile
moderately tender mass in the left iliac fossa.
Speculum examination: is normal.
Bimanual examination: confirms an 8 cm mass in the left adnexa . The
uterus is palpable separately and is mobile and anteverted. The right
adnexa is normal.

Investigation
Imaging study is performed :- Transvaginal
ultrasound scan shaw appearance is of mixed
echogenicity with ‘acoustic shadowing’
 Cystectomy is performed revealed cyst in this two pictures :-

• Q1- What is your diagnosis for this tumor ?

• Q2- What is composition & original tissue for this tumor ?
• Q3- What is its risk to developing malinancy ?
• Q4- Describe its histological composition
– Answers –
Q1---A- This appearance is typical for a dermoid cyst (also known as a benign
teratoma).
Q2- --A- Germ cell derived tumor.
Q3- --A- Mature cystic Teratoma .
usually benign , malignancy occurs in up to 1 per cent of dermoid cysts

Q4 --A
- Cystic cavities lined by Mesoderm
mature epidermis (immature
 Extremely common: cartilage),

* skin appendages
* neural (particularly glial)
tissue Ectoderm
 Also: (epidermis)
* cartilage
* respiratory tissue
* gastrointestinal tract tissue Endoderm (gastrointestinal
glands
• PBL 5
A 4th decade nullipara woman reports a two-month history of abdominal
bloating , constipation and distention , she also reported a urinary frequency
and some times shortness of breathing.
Her family history is notable for a sister diagnosed with breast cancer at age
45, and a paternal aunt who died of ovarian cancer at 50.
Her physical exam is non-specific and normal.
Abdominal exam show abilateral tenderless cystic adnexal mass .
Ultrasound confirm a bilateral complex ovarian cyst .
 • On cystectomy the lesions appear mostly composed of solid tissue
and has invaded outside of the ovary, with papillations seen over the
surface.

Q1 --- What are the likely differential diagnosis for this discovered mass?
Q2 --- What is most likely composition & original tissue for this mass ?
Q3 --- What is the most likely diagnosis?
Q4 --- What is the characteristic microscopical finding could be seen under
microscop ?
• Q1 --- A –
• Primary ovarian tumor
• Secondary ovarian tumor

• Q2 ---- A –
• Epithelial derived ovarian tumor
• 5 basic histological groups resembling :-
1. SEROUS-------------Fallopian tube 42%
2. Mucinous. ----------Cervix 12%
3. Endometroid. -----Endometrium 15%
4. Brenner’s. Transitional epithelium 2%
5. Mixed variety: 6%
 • Q3 --- A –
• Serous ovarian tumors

• Q4 --- A –

Here is a serous cystadenocarcinoma in

which there is more pronounced papillary
small concretions called .growth with more hyperchromatic cells
.psammomma bodies