Aug-Sept 2010

Aplikasi Praktikum

Betty, Jessy Chrestella, Lidya I. Laksmi

Dept. Patologi Anatomi Fak.Kedokteran
Universitas Sumatera Utara Medan
NORMAL ANATOMY
 Case 1 :

A 54-year-old woman notes a 6-month history of

progressive vaginal discharge with an odor. She also has
noted vaginal spotting after intercourse. She had gone
through menopause 2 years earlier and took an oral
contraceptive for 10 years. She has smoked one pack of
cigarettes per day for 20 years. She denies a cough or
dyspnea. She complains of right back pain and right leg
swelling. The speculum examination shows a 4-cm
irregular fungating mass arising from the cervix.

What is the most likely diagnosis?

What is the likely pathophysiology for this
condition?
 Case 1 :

Risk factors : age, history of oral contraceptive use, and a

history of smoking.
Malodorous vaginal discharge and postcoital bleeding
characteristic of cervical cancer.
Most likely diagnosis : Cervical cancer

Likely pathophysiology : Human papillomavirus

(HPV).

Examine the cervix to biopsy the lesion for a definitive

diagnosis.
 Low-risk HPV : types 6, 11 condylomas CIN I
High-risk HPV : types 16, 18, 31, 33 , 35, 39, 51
CIN II/III, squamous carcinoma.
Cervical intraepithelial neoplasia (CIN) is a precursor
to cervical cancer.
Cervical cancer :
80-90% SCC

10-15 % AdenoCa

SCC : Keratinizing/ Non Keratinizing.

The best method for analyzing a visible cervical lesion is
biopsy, not a Pap smear.
Fig. 19.83 A and B, Gross appearance of
invasive squamous cell carcinoma of cervix.
Fig. 19.58 Transition zone of uterine cervix between exocervical squamous cells and
endocervical mucin-producing glandular epithelium.
 Histopathology of HPV cervical specimen
Fig. 19.74 Koilocytotic changes in
Fig. 19.75 HPV-induced cervical
lesion characterized by
cervical squamous epithelium. These
acanthosis, papillomatosis, and
are diagnostic of HPV infection.
koilocytotic changes.
Figure 16.13. Condyloma. This exophytic lesion has
prominent fibrovascular cores (arrowhead) underlying a
thickened and hyperkeratotic squamous epithelium (arrow).
Spectrum of CIN: normal squamous epithelium for comparison; CIN I with koilocytotic atypia;
CIN II with progressive atypia in all layers of the epithelium; CIN III (carcinoma in situ) with
diffuse atypia and loss of maturation.
Bethesda System
Low-grade squamous intraepithelial lesion (LSIL; CIN1) :
a viral cytopathic effect that affects primarily the upper cell
layers of the epithelium.
Pleomorphic, wrinkled, hyperchromatic nuclei with a
perinuclear cleared halo koilocytes.
The basal layer should be maintained, and mitoses should
not be higher than the lower one third.

High-grade squamous intraepithelial lesion (HSIL; CIN23) :

Persistence of immaturity along with dysplastic changes.
The basal cells are like cancerous cell, and are not maturing
and differentiating as they should.
The overall impression is of a denser and darker epithelium
due to the high nuclear/cytoplasmic (N/C) ratios.
Papsmear Cytology
The Pap smear has decreased the incidence of cervical
cancer screening method.
The Bethesda classification for Pap smears reports :
Low grade squamous intraepithelial lesion (LSIL)
human papilloma viral changes and CIN I.
High grade squamous intraepithelial lesion (HSIL) CIN
II and CIN III and carcinoma in situ.
Invasive cancer.
Dysplastic cells in Cytology
Fig. 19.81 . Low-power appearance of microinvasive squamous cell carcinoma of
cervix.
Figure 16.7. Invasive squamous cell carcinoma. Broad fronts of cells push into the
stroma of the cervix, and at the leading edge there is a ragged border with individual
infiltrating cells (arrowhead). Occasional huge and pleomorphic cells are visible (arrow).
Digital Atlas of Gynecologic Pathology by Meenakshi Singh, MD - Department of Pathology, UCD-School of
Medicine. Squamous Cell Carcinoma, Keratinizing Type. The tumor forms abundant squamous pearls. Low power.
Adenocarcinoma of Cervix
Adenocarcinoma of the Cervix.
The neoplastic glands are surrounded by a desmoplastic stromal response. Low power.
Figure 16.2. Endocervical glands. Normal endocervical glands are
composed of tall columnar cells with apical mucin and small basal nuclei.
Case 2 :
A 38 year old female, complain about menorrhagia for
almost ten years. She also felt abdominal heaviness
lately and incontinence in urinating. Shes married
but has no child. Speculum examination reveal theres
a mass in her vagina, coming out of cervical orifice.
USG reveal therere multiple hyperechoic masses in
her womb.
What is the most likely diagnosis ?
 Most likely : multiple leiomyoma/ myoma.
Location : ? According to history??
Submucous
Sub serous
Intra mural
Myoma Geburt
Benign tumor of smooth muscle.
Occur often in reproductive age female.
Associated with hormone.
Uterine leiomyoma
Endometrial polyp:
Pedunculated, red, polyp in the endometrial cavity (arrow). Leiomyomata in the myometrium.
Figure 17.15. Leiomyoma. The low-power impression is that of fascicles or bundles of cells, some parallel to
the slide (arrow) and some coming out at right angles (arrowhead). Inset: The nuclei are tapered and pale, with
occasional paranuclear vacuoles, and sometimes show corkscrew morphology, as though the nucleus was twisted
longitudinally.
Case 6 : Leiomyosarcoma

Leiomyosarcoma.
This is a hypercellular spindle cell tumor with nuclear atypia and abundant
mitoses. Low power.
HP :
Classic leiomyoma :
Spindle cell lesion with intersecting fascicles of elongated
cells
The nuclei are long and thin with fine pale chromatin and
small nucleoli.
Corkscrew nuclei, which are characteristic of smooth
muscle.
The stroma may be fibrotic, edematous, myxoid, or even
hemorrhagic;
Absence of nuclear atypia.
Mitotic rate (-/<<).
 Case 3 :
A 25-year-old female presents to your office for workup of
infertility. In giving a history she describes severe pain
during menses and menorrhagia, and she also tells you that
in the past another doctor told her that she had chocolate
in her cysts.
Based on this history, what abnormality would you most
expect to be present in this patient?
a. Metastatic ovarian cancer
b. Endometriosis
c. Acute pelvic inflammatory disease
d. Cancerous lesion
e. A posteriorly located subserosal uterine leiomyoma
Endometriosis
Ectopic endometrial tissue outside of the uterus.
Histologic : endometrial glands, stroma, and hemosiderin
pigment outside the endometrium.
Location :
Myometrium adenomyosis,
Uterine ligaments (assoc. w/ dyspareunia),
Rectovaginal pouch (pain on defecation and low back pain)
Fallopian tubes (infertility and ectopic pregnancies)
Urinary bladder (hematuria),
GI tract (pain, adhesions, bleeding, and obstruction),
Vagina (bleeding).
Ovary (infertility, cyst)
Figure 17.2. Proliferative endometrium.
Multiple donut-shaped glands are visible,
with dark oblong nuclei and frequent mitoses
(arrow).

Figure 17.3. Secretory endometrium,

various phases.
 Adenomyosis causes thickening of the myometrium,
leading to globular enlargement of the uterus.
Occasionally, small cysts may be seen in the affected
myometrium, which are represented by endometrial
glands histologically.
Microscopically, benign endometrial glands and
stroma within the myometrium characterize this
lesion.
Adenomyosis:
Diffuse, asymmetrical thickening of the myometrium.
Adenomyosis of the Uterus.
Note the presence of endometrial glandular and stromal tissue deep within the myometrium. High
power.
Case 4 : Endometrial Hyperplasia
Hyperplasia : increase in the gland-to-stroma ratio, as
crowded glands in a proliferative setting.
Two criteria : architecture (simple vs. complex) and
cytology (with or without atypia).
There are varying degrees of hyperplasia:
Simple hyperplasia
Complex hyperplasia
Atypical hyperplasia
Case 4 : Endometrial Hyperplasia
This lesion is composed of crowded, slightly irregularly
shaped, proliferative endometrial glands.
The normal glands-to-stroma ratio in endometrium is
1:1; note in this case the decreased amount of stroma
relative to glands (a high glands-to-stroma ratio),
which is characteristic of endometrial hyperplasia and
carcinoma.
Figure 17.8. Simple hyperplasia. In this biopsy specimen, Figure 17.9. Complex atypical hyperplasia. (A)
the glands appear proliferative and are too crowded (the At low power, the glands are very crowded,
gland-to-stroma ratio is greater than 1). The cells resemble even back to back, and the gland lumens have
normal endometrium and are not atypical. become branching and irregular (arrow).
 Early Secretory Endometrium.
Subnuclear vacuoles in
endometrial glands are the earliest
histologic evidence of ovulation.
The stroma is edematous. Low
power.

Late Secretory Endometrium.

The glands have a corkscrew
appearance. Low power.
Case 5 :
Endometrial adenocarcinoma
Risk factors :
Obesity, diabetes, hypertension, and infertility with
anovulatory cycles.
Unopposed estrogenic stimulation.

Sagittal section of the uterus shows a friable, tan-yellow

tumor that is filling the uterine cavity and extending
into the myometrium.
Digital Atlas of Gynecologic Pathology by Meenakshi Singh, MD - Department of Pathology.
Endometrioid adenocarcinoma of the endometrium. Bivalved uterus. Endometrioid adenocarcinoma of the
endometrium appears as a single dominant mass in the uterine cavity of an enlarged uterus (black arrow).
Carcinomas are typically exophytic and shaggy. A Leiomyoma is also present in the myometrium (white arrow).
Figure 17.11. Endometrioid carcinoma. Foci of well-differentiated endometrioid carcinoma can be difficult
to distinguish from complex atypical hyperplasia. However, the complicated proliferation of fused and cribriform
glands in this biopsy specimen is diagnostic of carcinoma. The nuclei in this example resemble those of complex
atypical hyperplasia.
Thank you for your attention

JC Sept 2008