patho sheet(2nd of Dr faisal) - Ibrahim murad abdulghani

Vulva

There were terms used by the dentist, gynecologist and sometimes by the clinicians but nowadays they modify these terms to facilitate the classification and the nomenclature, some of these terms are:
Dystrophies: changes in the thickness of the epidermis (stratified squamous epithelium'St.Sq.Epi') whether it is skin or mucous membrane which might be associated with two things:
1- Whitish discoloration
2- Hyperkeratosis (تقشر/تقشع )

Leukoplakia: whitish discoloration of the oral cavity or mucous membrane of the tongue which might be associated with chronic severe heavy smoking (patches of white discoloration with some keratinization), they considered it as pre-malignant but actually the color itself doesn’t necessarily pre-malignant also the change in the thickness of the stratified squamous epithelium doesn’t necessarily pre-malignant

There is what is called Dermatosis whether inflammation or affection (traumatic chemical, physical…) of the vulva and these changes might be in two forms:

1- Lichen Sclerosus: thinning of the epidermis (St.Sq.Epi'), they were call it "Lichen sclerosus et atrophicus":-
*It occurs in all age groups but is most common in the vulva of postmenopausal women but occur in other ages and it may also be encountered elsewhere on the skin (واحد سنة ثالثة طب صابتو بظهرو) so it's a skin lesion but again most commonly affect vulva of old age postmenopausal women
*It’s associated with sclerosis and dermal fibrosis so there is irritation to the skin, disfigurement and contractions around the perineum and even the anal region in the lower female genital tract shows some shrinkage & folding
*The potential malignancy is low
*It’s not unusual

2- Lichen Simplex Chronicus: thickening of the epidermis (St.Sq.Epi'), they were call "hyperplastic dystrophy" :-
*Associated with very very low or even NO potential malignancy
*It might be associated with disfigurement, changes in the color

We talked about condylomata acuminatum always remember that it’s HPV at large 6 or smaller than that HPV 11 and it’s almost always benign but might be associated or adjacent to malignant or high-grade Vulvar Intraepithelial Neoplasia (VIN)

Stratified squamous epithelium has regular & systematic maturation from the deeper layers up to the keratinized layer. In the deeper layer the nucleus is large (N/C ratio is large), this nucleus is regular and have smooth nuclear membrane rather rounded or ovoid (so when you see it the microscopic you will know that it’s benign cuz there is no irregularities, indentation or clumping) & all of them are identical (relation between cell & the other almost the same), as they mature up toward the surface (this is in relation to vulva, vagina and especially to the cervix) there will be a regular maturation from the deepest regular basal cells, the cell body enlarges & the nucleus decrease in size (but it stays regular) until the array of the cell body become horizontal to the basement membrane (they were perpendicular) & the nucleus disappear so now we have keratinization or Desquamation


Now well talk about Dysplaisa (Atypia or Atypism): atypical relation between cell and the other.
Very mild or Mild dysplasia: you will find that in the deepest layers (about 1/3 or 1/4) of the stratified squamous epithelium have their nucleus in relation to the cell enlarges a little bit, hyperchromatic and have some mitotic figures
Moderate severe dysplasia: involve 2/3 of the thickness of the epithelium
Very severe dysplasia: involve the whole thickness, the mitosis increase, indentation of nucleus increase, N/C ratio increase and all the atypia increases but without invasion might be synonymous to carcinoma in-situ (in it’s place) BUT if there is mild infiltration to the underlying C.T so we call it micro-invasive
These changes affect vulva, vagina and especially the cervix

Cervical intraepithelial neoplasia (CIN) which called squamous intraepithelial lesion 'SIL': CIN is classified in grades:-

1- Low grades: coincide with the very mild or mild and may also associated with the moderate dysplasia
2- High grade: may become malignant more readily than the low grade


Vulvar intraepithelial neoplasia (VIN):

1- Grade I: large part of it might regress especially with treatment but only a small part of it will progress to grade II or III end up with carcinoma
2- Grade II: good percentage might regress AND a good percentage might progress to malignancy

Malignant tumors of the vulva most commonly they call it squamous cell carcinoma of the vulva which divided into two types:
1- High-grade:
*Mainly has relation to the HPV especially 16 or may be HPV 18 sometimes
*Preceded by VIN of a higher grade (II or III)
*Affect woman before middle age
*Most of the affected women are smokers
*May progress to cancer

2-Low grade:
*Affect older women (60 or 70)
*Associated with low HPV
*It has NO relation to smoking (الله أعلم شو سببها)
*May associated with Lichen Sclerosus
*Most of it de novo on its own


Stages of squamous cell carcinoma of the vulva:

Stage 1: carcinoma in-situ: in the beginning of micro-invasion, about the 5-years survival  if you take 100 affected women 98% of them with treatment will survive

Stage 2: less than 2cm
Stage 3: more than 2cm
Stage 4: if it reaches the vagina and the pelvic wall, about the 5-years survival  only 25 to 30 % will survive


Verrucous carcinoma:
*Resemble condylomata acuminatum with a little modification
*Look-like a dome or cauliflower
*Affects the lower areas and also the oral cavity and anywhere
*There is a controversy about whether or not the irradiation might benefit or injure the verrucous carcinoma, there are some sources stated that if irradiation used on verrucous carcinoma it will dry it & it might flare up and become more aggressive, so they don't do it unless there is no other choice



Vagina

*Congenital anomalies of the vagina are fortunately uncommon
*Some of them might relate to duplication, absence or septate of the vagina
*Cysts of vagina: Para-urethral cyst, Vulvo-vaginal (Bartholin's) cyst "which may cause suppurative infection or Bartholin's abscess"…

*The female genital tract develops at the Mullerian duct line & the other duct which is the Wolffian duct disappears BUT sometimes a remnant of this duct remains in the form of a very small glands or cysts at the wall of the vagina called (Adenosis)

• Gartner's cyst appears from the Wolffian duct
• Mucous cyst appears from the Mullerian duct
*These are congenital cysts (Just know the names)

Inflammation of the vagina:

*Vagina in general resists infection except sometimes there are a lot of micro-organisms that may affect the vagina

*There is something called Atrophic Vaginitis which affects old age & also very young girls because of the absence of ESTROGEN.

*In young girls there is no hypertrophy & hyperplasia in the vagina so the vagina is atrophic & no estrogen to develop the vaginal wall so vagina can’t resist the infection, they call it Vaginitis of infancy.
*In older women it’s called Postmenopausal atrophy.
*Both are rare now because there is better medical care.

*Vaginosis: inflammation of the vagina caused by multiple micro-organisms and associated usually with vaginal discharge & mild degree vaginitis (NOTE: vaginal discharge isn’t always inflammatory, frequently it’s physiological so sometimes they may think it’s vagintis but it’s not)



Benign Vaginal Neoplasia:

Polyps: almost always they’re benign unless proven otherwise


Malignant tumors of the vagina:

*Embryonal rhabdomyosarcoma (ERMS):
- Malignant tumor of the skeletal muscle usually affects surfaces of the lower uro-genital tract in both males & females (urinary bladder & vagina)
- Also may affect the mucous membrane of the head & neck
- Affect young girls 4-5 yrs in the vagina
-It present with bleeding & great life mass coming out of the vagina
-It’s called Sarcoma botryoides (grape bunches)


*Clear cell adenocarcinoma of the vagina:
-Vaginal clear cell adenoma is common in women in their late teens and early 20's whose mothers took diethylstilbestrol (DES) (type of estrogen used by the pregnant women to reduce the risk of pregnancy complications and losses) during pregnancy.
-May affect the cervix



Body of Uterus

Endometriosis:
-Endometrium is the inner membrane of the uterus
-Abnormal focus of endometrium elsewhere most commonly on the ovary
-Menstrual bleeding from the ovary may occur so blood will go out
-May be associated with dysmenorrhea and pelvic pain as a result of intrapelvic bleeding and periuterine adhesions
-This may lead to ectopic pregnancy, infertility…


Inclusion cyst:
-Stratified squamous epithelium from mucous membrane entrapped underneath the surface epithelium because of manipulation or trauma (sometimes at the time of delivery the babies head may be larger than the opening passage so this cause irregular tearing of lower vagina)
-Keratin containing cyst
-Gynecologist may do surgical wound in the lower vagina (posterio-lateral wall) to prevent the irregular tearing then after delivery they stitch it, this is called episiotomy
- All these cysts and especially Bartholin’s cyst usually removed surgically or by excision if the cyst is large, and sometimes they do what is called marsupialization





Cervix

*Anatomical structure:
-Exo-cervix
-Endo-cervix
-Cervical os

*When the gynecologist inserts (el nnador) what he can see is only the os which is between the endo-cervical canal & the exo-cervix
*Exo-cervix is the lips of the cervix and it’s exposed to the vagina and lined by St.Sq.Epi
*Endo-cervix lined by columnar epithelium


Ibrahim murad abdulghani
14/3/2011 patho #2 of DR.Faisal