Ed Friedlander, M.D., Pathologist
scalpel_blade@yahoo.com
Cyberfriends: The help you're looking for is probably here.
Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com Your confidentiality is completely respected.
DoctorGeorge.com is a larger, full-time service.
There is also a fee site at
www.afraidtoask.com.
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 If you have a Second Life account, please visit my teammates and me at the Medical Examiner's office. |
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With one of four large boxes of "Pathguy" replies. |
I'm still doing my best to answer
everybody.
Sometimes I get backlogged,
sometimes my E-mail crashes, and sometimes my
literature search software crashes. If you've not heard
from me in a week, post me again. I send my most
challenging questions to the medical student pathology
interest group, minus the name, but with your E-mail
where you can receive a reply.
Numbers in {curly braces} are from the magnificent Slice of Life videodisk. No medical student should be without access to this wonderful resource. Someday you may be able to access these pictures directly from this page.
Also:
KCUMB Pathology Club
Freely have you received, freely give. -- Matthew 10:8. My
site receives an enormous amount of traffic, and I'm
handling about 200 requests for information weekly, all
as a public service.
Pathology's modern founder,
Rudolf
Virchow M.D., left a legacy
of realism and social conscience for the discipline. I am
a mainstream Christian, a man of science, and a proponent of
common sense and common kindness. I am an outspoken enemy
of all the make-believe and bunk that interfere with
peoples' health, reasonable freedom, and happiness. I
talk and write straight, and without apology.
Throughout these notes, I am speaking only
for myself, and not for any employer, organization,
or associate.
Special thanks to my friend and colleague,
Charles Wheeler M.D.,
pathologist and former Kansas City mayor. Thanks also
to the real Patch
Adams M.D., who wrote me encouragement when we were both
beginning our unusual medical careers.
If you're a private individual who's
enjoyed this site, and want to say, "Thank you, Ed!", then
what I'd like best is a contribution to the Episcopalian home for
abandoned, neglected, and abused kids in Nevada:
My home page
Especially if you're looking for
information on a disease with a name
that you know, here are a couple of
great places for you to go right now
and use Medline, which will
allow you to find every relevant
current scientific publication.
You owe it to yourself to learn to
use this invaluable internet resource.
Not only will you find some information
immediately, but you'll have references
to journal articles that you can obtain
by interlibrary loan, plus the names of
the world's foremost experts and their
institutions.
Alternative (complementary) medicine has made real progress since my
generally-unfavorable 1983 review linked below. If you are
interested in complementary medicine, then I would urge you
to visit my new
Alternative Medicine page.
If you are looking for something on complementary
medicine, please go first to
the American
Association of Naturopathic Physicians.
And for your enjoyment... here are some of my old pathology
exams
for medical school undergraduates.
I cannot examine every claim that my correspondents
share with me. Sometimes the independent thinkers
prove to be correct, and paradigms shift as a result.
You also know that extraordinary claims require
extraordinary evidence. When a discovery proves to
square with the observable world, scientists make
reputations by confirming it, and corporations
are soon making profits from it. When a
decades-old claim by a "persecuted genius"
finds no acceptance from mainstream science,
it probably failed some basic experimental tests designed
to eliminate self-deception. If you ask me about
something like this, I will simply invite you to
do some tests yourself, perhaps as a high-school
science project. Who knows? Perhaps
it'll be you who makes the next great discovery!
Our world is full of people who have found peace, fulfillment, and friendship
by suspending their own reasoning and
simply accepting a single authority that seems wise and good.
I've learned that they leave the movements when, and only when, they
discover they have been maliciously deceived.
In the meantime, nothing that I can say or do will
convince such people that I am a decent human being. I no longer
answer my crank mail.
This site is my hobby, and I do not accept donations, though I appreciate those who have offered to help.
This page was last updated February 9, 2008.
During the thirteen years my site has been online, it's proved to be
one of the most popular of all internet sites for undergraduate
physician and allied-health education. It is so well-known
that I'm not worried about borrowers.
I never refuse requests from colleagues for permission to
adapt or duplicate it for their own courses... and many do.
So, fellow-teachers,
help yourselves. Don't sell it for a profit, don't use it for a bad purpose,
and at some time in your course, mention me as author and KCUMB as my institution. Drop me a note about
your successes. And special
thanks to everyone who's helped and encouraged me, and especially the
people at KCUMB
for making it possible, and my teaching assistants over the years.
Whatever you're looking for on the web, I hope you find it,
here or elsewhere. Health and friendship!
LEARNING OBJECTIVES:
Cervix:
Uterus:
Give a full account of the etiology, pathogenesis, and clinical correlates of each of the following,
and recognize grossly and/or microscopically as appropriate:
Oviduct:
Ovary:
List each of the three categories of primary ovarian tumors, and for each of these,
the principal tumors and their distinguishing anatomic and clinical features,
risk factors, paraneoplastic syndromes, biological behavior,
and patterns of spread if applicable.
Pregnancy:
Describe how examining the placenta can sometimes help determine
whether twins are identical or fraternal.
If I were asked to what the singular prosperity and growing strength of [the Americans] ought
mainly to be attributed, I should reply, "To the superiority of their women".
-- Alexis de Tocqueville 1789
Never try to impress a woman because if you do, you'll have to keep up that standard for the rest of
your life.
-- W.C. Fields
Not from Adam's brain, to have the same mind as him, nor from Adam's foot, to be subordinate to
him, but from the rib next to Adam's heart, to love and be loved by him.
-- Anonymous
Global views on women's health: Sci. Am. 271(2): Aug., 1994. Good reading, especially for
anyone offering easy, wrong answers to the world's problems.
In sub-Saharan Africa, one woman in 16 dies in childbirth, compared with
one woman in about 5000 in the developed world (Br. Med. J. 326:
567, 2003).
Special thanks to Dr. Tony Racela for the wonderful kodachromes.
You may find them here.
QUIZBANK
I am presently adding clickable links to
images in these notes. Let me know about good online
sources in addition to these:
MedEdPORTAL -- American Association of Medical Colleges. Primarily for medical school faculty.
Pathology Education Instructional Resource -- U. of Alabama; includes a digital library
Pathopic -- Swiss site; great resource for the truly hard-core
Syracuse -- pathology cases
Alabama's Interactive Pathology Lab
"Companion to Big Robbins" -- very little here yet
Alberta
Pathology Images --hard-core!
Alberta Tumor Photos -- and lots more. Highly recommended.
Bristol Biomedical
Image Archive
EMBBS Clinical
Photo Library
Chilean Image Bank -- General Pathology -- en Español
Chilean Image Bank -- Systemic Pathology -- en Español
Connecticut
Virtual Pathology Museum
Australian
Interactive Pathology Museum
Semmelweis U.,
Budapest -- enormous pathology photo collection
Iowa Skin
Pathology
Loyola
Dermatology
History of Medicine -- National Library of Medicine
KU
Pathology Home
Page -- friends of mine
The Medical Algorithms Project -- not so much pathology, but worth a visit
National Museum of Health & Medicine -- Armed Forces Institute of Pathology
Telmeds -- brilliant site by the medical students of Panama (Spanish language)
U of
Iowa Dermatology Images
U Wash
Cytogenetics Image Gallery
Urbana
Atlas of Pathology -- great site
Visible
Human Project at NLM
Karolinska Institutet -- pathology links
Johns Hopkins CPC's
U. of Virginia Case Studies
Oklahoma Teaching Cases
Indiana U. Teaching Cases
SUNY Histopathology
West Virginia Case of the Month
Upstate NY Cases -- works only on some browsers
Society for Ultrastructural Pathologi -- electron microscope cases
WebPath:
Internet Pathology
Laboratory -- great site
My team:Ed Lulo's Pathology Gallery
Bryan Lee's Pathology Museum
Dino Laporte: Pathology Museum
Tom Demark: Pathology Museum
Dan Hammoudi's Site
Claude Roofian's Site
Medmark Pathology -- massive listing of pathology sites
Pathology Handout -- Korean student-generated site; I am pleased to permit their use of my cartoons
Estimating the Time of Death -- computer program right on a webpage
Pathology Field Guide -- recognizing anatomic lesions, no pictures
St.
Jude's Ranch for Children
I've spent time there and they are good. Write "Thanks
Ed" on your check.
PO Box 60100
Boulder City, NV 89006--0100
More of my notes
My medical students
Clinical
Queries -- PubMed from the National Institutes of Health.
Take your questions here first.
HealthWorld
Yahoo! Medline lists other sites that may work well for you
We comply with the
HONcode standard for trustworthy health
information:
verify
here. 
Vulva and vagina:
Give a full account of the etiology, pathogenesis, and clinical correlates of each of the following,
and recognize grossly and/or microscopically as appropriate:
Herpes simplex
Molluscum
HPV infection
Chlamydia
Garnerella
Candida
Trichomonas
Syphilis
Bartholin abscess
Lichen sclerosus
Condyloma latum
Condyloma acuminatum
Squamous cell carcinoma
Adenocarcinoma of the vagina
Melanoma
Extramammary Paget's
Vaginal adenosis
Gartner duct cysts
Embryonal rhabdomyosarcoma / sarcoma botryoides
Adenocarcinoma of the vagina
Give a full account of the etiology, pathogenesis, and clinical correlates of each of the following,
and recognize grossly, microscopically, and/or cytologically (i.e., on pap smear)
as appropriate:
Herpes simplex
Gonorrhea
Nabothian cyst
Endocervical polyp
Microglandular hyperplasia
Premalignant lesions of the cervix
Squamous carcinoma of the cervix
Adenocarcinoma of the cervix
Remember enough histology to recognize the approximate date of an endometrium,
and especially to spot anovulatory cycles, inadequate luteal phase, and persistent
luteal phase.
Chronic endometritis
Gas gangrene
Endometriosis
Adenomyosis
Endometrial polyps
The various endometrial hyperplasias
Adenocarcinoma of the endometrium and its variants
Mixed mullerian tumors
Leiomyoma and leiomyosarcoma
Give a full account of the etiology, pathogenesis, and clinical correlates of each of the following
and recognize grossly and/or microscopically as appropriate:
Acute and chronic salpingitis
Chlamydia
Gonorrhea
Tuberculosis
Cysts
Actinomycosis
Ectopic pregnancy (also below)
Gestational trophoblastic disease (also below)
Give a full account of the etiology, pathogenesis, and clinical correlates of each of the following
and recognize grossly and/or microscopically as appropriate::
The common simple cysts
Stein-Leventhal syndrome / polycystic ovaries / hyperthecosis
Torsion
Autoimmune disease
Give a full account of the etiology, pathogenesis, and clinical correlates of each of the following
and recognize grossly and/or microscopically as appropriate:
Miscarriage
Ectopic pregnancy
Abruption
Placenta accreta
Placenta previa
Cord problems
Infections
Toxemia of pregnancy
Gestational trophoblastic disease (also above)
Let men tremble to win the hand of a woman, unless
they win also with it the utmost passion of her heart.
-- Nathaniel Hawthorne, THE SCARLET LETTER
Vulva and vagina: Women's problems 13-17, 26-35, 61-62, 67-68, 72
Cervix: Women's problems 80-93
Uterus: Women's problems 1-12, 18, 37-59, 64-66, 69-71, 73-75, 77-79, 94-101
Oviduct: Women's problems 24-25,
Ovary: Women's problems 76, 102-128
Pregnancy: Fetus and pregnancy (all)
Archive of Histologic Images
of Gynecologic & Breast Path
Greek, minimal commentary
Female Reproductive Tract Images
University of Washington
Pictures and comments
Gynecologic and Breast Pathology
Photomicrograph collection
In Portuguese
Reproductive
Utah cases for path students
Juliana Szakacs MD
GYN Pathology
Photos by Tony Racela MD (Thanks!)
Notes by Ed
Female I
Introductory Pathology Course
University of Texas, Houston
Female II
Introductory Pathology Course
University of Texas, Houston
Tulane Pathology Course
Great for this unit
Exact links are always changing
{47710} human female
{15787} normal internal female genitalia
We will cover breast in a separate unit.
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Primordial germ cells from the yolk sac migrate to the ovarian (or testicular) stroma. (Some of these supposedly go astray and end up in other midline structures, explaining why "germ cell tumors" arise in the retroperitoneum, pineal, and anterior mediastinum.)
In female embryos, the mullerian (paramesonephric) ducts result from infolding of the coelomic lining epithelium. They give rise to the surface epithelium of the ovaries, and the lining of the oviducts and uterus. In male embryos, Mullerian inhibitory substance from the testis makes the mullerian ducts regress.
In female embryos, the wolffian (mesonephric) ducts regress, persisting only as little bits of epithelium along the whole female tract. These give rise to "Gardner's duct cysts" along the cervix and vagina. In male embryos, the wolffian (mesonephric) ducts become the epididymis and vas.
Only the upper two thirds of the endometrium ("the functionalis") cycles. The basal third ("the basalis") does not respond to a woman's steroid hormones and stays in place, giving rise to next month's endometrium. The theca cells surrounding the follicle are ovarian stroma that nurture a particular follicle. You can tell when they have luteinized (i.e., become hormonally active) because they plump-up and become pale-staining (from the lipid used to make steroids). There are a few Leydig-like cells in the hilus, able to make testosterone.
During reproductive life, every month several (not one, as in Big Robbins) follicles mature as graafian follicles. One ovulates and suppresses the others, and becomes a corpus luteum, which will regress when the pregnancy ends or does not occur. It will be recognizable for a few months, gradually being replaced by scar tissue.
The oviduct's mucosa has ciliated cells, secretory cells, and almost-no-cytoplasm "peg cells" ("intercalated cells"). The oviduct's mucosa is thrown up into complicated folds ("plica", or "fimbria" at the end). I've been told that the reason women have orgasms is to make the oviducts wiggle around and be sure to catch the egg if it's just been released. Decide about that for yourself.
HERPES SIMPLEX II
You are already familiar with the classic "herpes cell" seen on Tzanck preparation
or pap smears. Cells with multiple gigantic nuclei, usually bearing a
central viral inclusion, are diagnostic.
If herpes is transmitted to the child during birth, severe sickness, brain damage, and even death are likely to occur.
HUMAN PAPILLOMA VIRUS (HPV)
Today, screening women and men for chlamydia by nucleic acid amplification techniques is becoming a standard part of routine health care maintenance; it can be done on urine. It is fairly expensive but the payoff (preventing pelvic inflammatory disease and ectopic pregnancy) is supposed to make it cost-effective. The Swedes seem to believe it's been a major health blessing; others are not so sure (BMJ 334: 725, 2007).
{11562} chlamydia, pap smear
{25911} chlamydia infection, pap smear
HEMOPHILUS DUCREYI
)
MYCOBACTERIUM TUBERCULOSIS
GARDNERELLA
You can make the diagnosis by observing that the vaginal pH
is more alkaline than the usual 4.5.
Or you can confirm the diagnosis by
adding a drop of dilute potassium hydroxide. This will accentuate
the fish smell.
And the bacteria cling to epithelial cells, creating the fuzzy-looking
"clue cell" in pap smear.
Gardnerella is today's "usual suspect" for producing many cases of
premature rupture of the membranes, premature labor, and premature birth
(Hosp. Med. 61: 475, 2000).
Screening for gardnerella during pregnancy cuts prematurity
dramatically: Br. Med. J. 329: 371, 2004.
CANDIDA
This produces a red, itchy rash that may have fungal colonies visible.
You can scrape them off and see them under the microscope. Biopsy
is unnecessary. The inflammation is superficial and the infection is annoying but not (by itself) dangerous.
Contrary to "Big Robbins", I am not aware of any reason to
believe that some women are more vulnerable because they are "chronic carriers".
The bug is ubiquitous.
Yeast infections are more likely when there is more glucose in the area
(pregnancy, on the oral contraceptive pill, diabetes), or when the normal
bacteria are suppressed with antibiotics.
TRICHOMONAS:
Vulva, vagina, cervix: Trichomonas vulvovaginitis
This produces a bad-smelling, red ("strawberry") inflammation with
a thin discharge. If you are inexperienced and happen
to biopsy it, you'll see
only superficial inflammation.
The protozoan is easily seen in wet mounts, looking like a bouncing pear
moving about with wiggly flagella. Ask a pathologist to show you a pap smear slide
with "Trich"; there is often a second micro-organism, a very long filamentous
bacterium called "leptothrix".
Trichomonas is much less common nowadays thanks to its incidental
discovery on pap smears. As long as both partners are treated, expect
a good result (Lancet 363: 545, 2004).
TB salpingitis
Photo and mini-review
Brown U.
CALYMMATOBACTERIUM
Vulva: Donovoniasis, or "granuloma inguinale".
Have a microbiologist show you donovan bodies.
Vagina: Nonspecific vaginitis / "bacterial vaginosis"
The bacterium is normal flora; it grows best in the presence of semen
but no woman is immune.
{08370} Gardnerella vaginalis on Pap smear (these aren't outstanding examples of "clue cells")
{25908} Gardnerella vaginalis infection, good "clue cell"
Clue cell
Tom Demark's Site
:
Vulva, vagina, cervix: Yeast infection
NON-NEOPLASTIC DISORDERS
Ectopic breast tissue is fairly common on the vulva.
It can enlarge during pregnancy and lactation.
"Acute vulvitis" is nonspecific inflammation of the vulva, by various
surface bacteria.
Distinguishing vulvar cysts:
SKENE'S GLANDS, on either side of the urethra, can also become inflamed,
especially by gonorrhea.
* VESTIBULAR ADENITIS is a poorly-understood inflammatory process
at the entry to the vagina. The glands are inflamed
and very painful. They may be excised surgically for a cure.
SKIN DISEASES including psoriasis, lichen planus, vitiligo,
and familial pemphigoid, are very familiar on the vulva. Sometimes
the epidermis simply undergoes hyperplasia, usually without anaplasia. It
thickens ("acanthosis"), and develops extra keratin ("hyperkeratosis").
We call
this VULVAR HYPERPLASIA. (This is a cancer risk if an only if there
is some anaplasia.)
LICHEN SCLEROSUS ("chronic atrophic vulvitis") is a mysterious
process in which a band of dense, homogeneous, hyaline collagen forms underneath
the epidermis, which is thinned and has a hydropic
basal layer. The skin turns gray and parchment-like
and becomes itchy. It can occur at any age.
Although there is no anaplasia, a few percent turn malignant.
* Of course, lichen sclerosus in a child has gotten parents hauled into
court, where misguided zealots say that it
is "proof of child abuse": Br. Med. J.
320: 331, 2000.
Lichen sclerosus review: Lancet 353: 1777, 1999. Topical
glucocorticoids seem to work better than topical sex steroids.
Today, lasers are being used with good results (Derm. Surg. 30: 1148, 2004).
BENIGN TUMORS
MUCOSAL POLYPS are skin tags, fibrous nodules covered
with normal epithelium.
CONDYLOMA ACUMINATUM is the large, usually multiple warts that can
occur on the vulva, perianal region, and (less often) the vagina and cervix.
Remember HPV strains 6 and 11 as causes of condyloma acuminatum (and its
giant variant, "verrucous carcinoma"). Remember
HPV 16 and 18 (also 31, 33, and 35)
as
causes of ordinary, deadly carcinoma; if strains 16 or 18 produces a wart,
it is likely to be flat rather than tree-like. A woman may have several strains.
* Leave the diagnosis of such entities as "aggressive angiomyxoma",
"angiomyofibroblastoma", and "angiofibroma" to us.
CARCINOMA OF THE VULVA
Most squamous carcinomas are caused by HPV, and are preceded by
dysplasia and carcinoma in situ ("vulvar intraepithelial neoplasia"; "vulvar intraepithelial lesion" is better),
which is analogous to the lesions in the cervix. A physician may notice
the premalignant lesions and excise them before cancer develops.
Squamous cell carcinomas not caused by HPV usually arise in lichen sclerosus
or idiopathic hyperkeratosis. These are more aggressive.
* Pathologists distinguish a host of subtypes of vulvar squamous carcinomas,
including keratinizing (most common), basaloid, spindle cell, warty,
and verrucous. Don't worry about these for now.
EXTRAMAMMARY PAGET'S DISEASE is mucin-rich cancer cells
growing within
the epidermis of the vulva or perineum. Local excision should be curative. The pathologist will do
frozen sections to help see if the margins are free.
Even without excision,
the lesion is likely to remain stable for a long time.
Vulva
"Pathology Outlines"
Nat Pernick MD
VULVAR VESTIBULITIS (various names)
is a pain syndrome in which the vulva becomes tender and intercourse
is painful.
Long considered "mental", it is now pretty clear that this is a fairly
common organic disease. The pathology features (1) too many mast cells, and (2) too
many nerves (Gyn. Ob. Inv. 58: 171, 2004; Ob.Gyn. 91: 572, 1998).
There may also be red speckles visibly grossly, and/or squamous metaplasia of
the vulvar glands and/or T-cells and plasma cells.
{49364} acute vulvitis
BARTHOLIN GLANDS on either side of the vaginal
introitus are prone to acute infection by ordinary
bacteria, chlamydia, or gonorrhea. They can resolve, leaving the duct obstructed, and a cyst
can form. You'll learn how to marsupialize (i.e., make a pouch) these
on rotations.
{27119} Bartholin gland cyst, vulva
It's now clear that both vulvar hyperplasia and lichen sclerosus are caused
by genetic mutations in the epidermis,
though these have not yet caused anaplasia
(Gyn. Onc. 77: 1717, 2000).
{27110} lichen sclerosis of vulva, histology
* PAPILLARY HIDRADENOMA is an intraductal papilloma of
the breast, only in the vulva along the embryonic milk like.
Microscopically, the pathologist sees a branching fibrous stalk with
a thickened epithelium exhibiting these features of HPV infection:
{27113} condyloma acuminatum of vulva, histology (HPV)
{06026} HPV effect ("koilocytes") in pap smear from cervix
{11470} HPV effect ("koilocytes") in pap smear from cervix
"Who has what strain?" In preparation for tomorrow's studies
of the efficacy of the vaccine, the Saskatchewan pathologists find that HPV-16's
still the commonest, that there's a LOT
of HPV-31 and not much HPV-18. Stay tuned (Arch. Path. Lab. Med. 132: 54, 2008).
Verrucous Carcinoma
Photo and mini-review
Brown U.
Most vulvar cancers are squamous cell carcinomas, with adenocarcinomas,
melanomas, and basal cell carcinoma being less common. (The latter are
unlikely to be caused by sunlight; they "just happen").
{25666} melanoma of vulva, gross
{24592} squamous cell carcinoma of vulva, gross
{25664} squamous cell carcinoma of vulva, gross
{25665} squamous cell carcinoma of vulva, gross
{27005} squamous cell carcinoma of vulva, histology
{27008} squamous cell carcinoma of vulva, histology
{25662} carcinoma in situ of vulva, gross
{25663} carcinoma in situ of vulva, gross
It presents as a red,
itchy rash. We don't know exactly where the cancer cells come from.
Unlike in breast, there is seldom an underlying solid cancer.
The pathologist will see tumor cells in the epidermis, as in
the breast. They present clear cytoplasm that will stain for some sort of
mucin.
{11499} Paget's disease of the vulva, gross
{08903} Paget's disease of the vulva, histology
{08906} Paget's disease of the vulva, histology
NON-NEOPLASTIC LESIONS
The only common non-iatrogenic birth defect is a septate vagina, from
failure of the mullerian ducts to fuse. There will also be a double
uterus. The only common
non-infectious, non-neoplastic, acquired lesion of the vagina
is a Gartner duct cyst, from the Wolffian duct remnants.
CANCER OF THE VAGINA
Melanomas are thankfully uncommon, but do occur sporadically.
ADENOCARCINOMA of the vagina arises from the glands of girls
exposed to DES, usually in their teens. Fortunately, only one in about 1000 of girls
exposed in this way get cancer, but the impact is devastating. The cells
are glycogen-rich, hence the name "clear cell adenocarcinoma".
EMBRYONAL RHABDOMYOSARCOMA, in its form of "sarcoma botryoides",
is a common cancer of young children.
* There are many other rare tumors. Don't worry about these just now.
Remember the lymphatic drainage. Cancer in the lower two-thirds
of the vagina metastasizes to the inguinal lymph nodes. Cancer of the
upper third metastasizes to the iliac nodes.
Normal vagina with cervix
WebPath
Vagina
"Pathology Outlines"
Nat Pernick MD
Girls exposed in utero to diethylstilbestrol (DES) often have
glands in the upper vagina. These appear as red bumps against the
normally-pink mucosa. They may look like endocervical glands with
squamous metaplasia, or like endometrial glands / oviduct without stroma.
These turn cancerous in fewer only about 1 of 700 of affected girls, but when this happens
it is devastating.
{27050} vaginal adenosis (DES exposure in utero), histology
Bacteria on vaginal smears
Rogues' gallery
Yutaka Tsutsumi MD
SQUAMOUS CELL CARCINOMA is rare, and caused by HPV.
This arises in the setting of dysplasia ("intraepithelial neoplasia";
"squamous intraepithelial lesion") that may have been
visible.
Melanoma of the vagina
Pittsburgh Pathology Cases
Clear cell carcinoma
Vagina -- DES exposure
WebPath Case of the Week
The sarcoma contains strap- or tadpole-like cross-striated
rhabdomyoblasts, especially
dense in the "cambium layer" beneath the epithelium. They are locally
destructive and can metastasize late. Surgery and chemotherapy usually
bring about a cure.
{08914} normal histology of uterine cervix (endocervix is left, ectocervix is right)
{10271} normal ectocervix histology
{10274} normal endocervix histology
{36059} normal endocervical cells, pap smear
INFLAMMATION
Obviously herpes
NON-TUMORS ENDOCERVICAL FIBROEPITHELIAL POLYPS are fibrous nubbins covered with epithelium,
hanging out of the cervical os. They act as a wick, drawing bacteria
into the endocervix and endometrial cavity. They are easily cured with curettage.
MICROGLANDULAR HYPERPLASIA results from progesterone stimulation
of the endocervix (i.e., pregnancy, old-fashioned contraceptive pills).
The glands are abundant and have only a lacy
stroma between them, along with many neutrophils.
{09755} normal cervical pap smear (do you know the cell types?)
Worldwide, cancer of the cervix is the #2 cancer killer of women, second only
to breast cancer.
Often women die during
their reproductive life. Ther are about 190,000 deaths
yearly (Am. J. Ob. Gyn. 189(s4): S37, 2003).
In the poor nations, it is still the #1 cancer killer
of women.
In the US, there are presently
around 10,000 new cases of invasive
cancer yearly, and almost 4000 deaths. The elderly, the poor, and especially
those who are not routinely screened are by far the most common victims
(Cancer 101: 1051, 2004).
In the US, the pap smear technique has greatly reduced
a woman's risk of dying of the disease; as recently as the 1950's,
it was as common a killer as breast cancer is today.
"Low grade SIL (squamous intraepithelial lesion) usually corresponds to
mild dysplasia / CIN I, or a flat or exophyic condyloma. "High grade SIL"
usually corresponds to moderate/severe dysplasia (CIN II/III) or carcinoma in situ.
Fun to know: The average is around 10,000 cells
on a routine pap smear, and 5000 on one of the newer liquid thin-prep smears.
The vast majority (80%) of cancers of the cervix are squamous cell carcinomas
caused by HPV.
Long before HPV was understood, we knew cancer of the cervix to be a sexually
transmitted disease, with the great risk factors being the number of
male sexual partners, and the number of previous female partners that the
husband had. Update on HPV and cervical cancer: Lancet 370:
890, 2007. Other possible risk factor include
smoking (still discussed: JAMA 285: 2995, 2001)
and having an uncircumcised husband (seems to be due to circumcision
protecting him from HPV).
The virulence factor is the E6 and E7 oncogenes,
which differ for low-risk and high-risk HPV strains. (See Am. J. Path. 153:
1741, 1998; Cancer 83: 2346, 1998; lots more since. These bind p53
and Rb gene products. This is a favorite question to tell who really knows
basic medical science. Finding a virulence
factor is proof of causation -- it has replaced Koch's / Henle's postulates.)
Update on HPV and cancer of the cervix: Lancet 370: 890, 2007.
Around 1 infected woman in 10 will get at least premalignancy.
DYSPLASIA OF THE CERVIX ("cervical intraepithelial neoplasia", today
"cervical intraepithelial lesion") can exist for years or decades
before invasive squamous cancer happens. (And of course, usually it never happens.
But nobody wants to leave these lesions alone.) Or it can progress
very rapidly.
CIN II: Plenty of atypical cells in the lower portions, normal maturation toward
the surface. (The old "moderate dysplasia" and "severe dysplasia").
CIN III: The cells no longer mature as they reach the surface. (The old
"carcinoma in situ").
INVASIVE CANCER arising in from CIN III is usually squamous.
* There are some less common cancers, also:
It is not always clear whether microinvasion has taken place, and today's
hard-core pathologists use double immunostaining for keratin (the cancer cells)
and collagen IV and/or laminin (for basement membrane). See Arch. Path.
Lab. Med. 129: 747, 2005.
Surprisingly, there's no consensus about what lymph node is most list likely to
receive
the first metastasis ("sentinel node") in cancer of the cervix.
The best bet is "somewhere in the external iliac,
obturator, or parametrial regions." Am. J. Ob. Gyn. 197: 678.e1-7, 2007.
Future pathologists: Staining pap smears routinely for p16INK 4a, whichis
strongly overexpressed in premalignant / malignant cervical epithelial cells,
may soon be routine as a way to help screeners. Though not specific, it seems
98% sensitive in picking up high-grade lesions (Cancer 105: 461, 2005).
Follow-up, using p16 and Ki-67, shows they greatly reduct the number of "don't know"
pap smears (Arch. Path. Lab. Med. 131: 1343, 2007).
Juan Peron's previous wife had also died of cancer of the cervix.
Pap smears were in use in the developed world in the late 1940's, but
had not caught on in Argentina.
In January 1950, Ms. Peron fainted in public and was found to be anemic,
evidently as the result of iron deficiency from blood loss due to her cancer.
It's not clear whether her cancer was found at the time,
but she continued to have heavy vaginal bleeding.
She was taken to surgery and operated by an American "ghost surgeon";
she was never informed of what had been done, who operated her,
or the nature of her illnesss.
How much of this was the "fifties" mentality ("beneficience" / "paternalism" /
"the duty NOT to tell a cancer patient the diagnosis" / the
general concealing of unpleasant truths)?
How much was the "VIP syndrome", in which prominent people get their
health problems concealed from the public? You'll have to decide this for yourself.
Ms. Peron was enormously popular with her people, especially for her advocacy
for the poor. She was one of the most beautiful and charismatic women of her era -- perhaps any era.
My reading tells me that most of today's historians consider her a
thoroughly genuine humanitarian. You can read about her final illness in
Lancet 355: 1988, 2000.
Medical school undergraduates do not really need to learn to read pap
smears, but it's enriching. The old-fashioned pap smear (you smear the specimen
on a slide) includes more cells than the newfangled "liquid thin prep" (you put the specimen in
fixative; easier to read Cancer 99: 342, 2003),
despite early claims (Br. Med. J. 326:
733, 2003) it's really neither better nor worse in terms of sensitivity
or specificity compared to the ordinary old smears (Ob. Gyn. 111:
167, 2008). Computers ("Auto-Pap"/"Focalpoint") now screen pap smears with accuracy about equal
to a human cytotechnologist (Cancer 99: 129, 2003).
And even experienced pathologists do not always make the
right call on either type of test: Arch. Path. Lab. Med. 127: 1413, 2003;
Arch. Path. Lab. Med. 128: 17, 2004).
If a pap smear that you obtained on one of your patients
does not include
any endocervical cells (columnar or squamous-metaplastic, we can tell),
we'll let you know that you probably did not sample the "transformation zone",
where ectocervix joins endocervix and most dysplasia / carcinoma-in-situ and
invasive
cancers begin.
And of course, there are both squamous and glandular cells that look just a little
bit strange, and no one knows what they mean (Ob. Gyn. 107: 701, 2006 ).
Your lecturer predicted in 2003
that the routine pap smear
would soon be supplemented in most cases
by routine DNA probing for the high-risk HPV strains,
with pap smear/biopsy limited to those who are positive.
See Arch. Path. Lab. Med. 127: 940 & 969 & 984 & 991 & 995, 2003;
Arch. Path. Lab. Med. 128: 298, 2004; Postgrad. Med. 118: 37, 2005.
It's now clear that pap smears miss about a quarter of patients with high-risk
HPV infection and (?) smoldering premalignancy: Cancer 111: 1, 2007.
Women with high-grade dysplasia or invasive cancer apparently ALL
test positive for HPV: Am. J. Ob. Gyn. 189: 118, 2003.
It is now clear that this does indeed reduce the rate of high-grade
lesions in the upcoming years; expect it to be standard soon,
perhaps even replacing the routine pap smear (NEJM 357: 1579 & 1589, 2007).
The HPV vaccine ("Gardasil"): NEJM 356: 1915 & 1928, 2007; J. Inf. Dis. 196:
1438, 2007. The latter reports that the quadrivalent gives essentially complete protection
against HPV-6, -11, -16, and -18 so long as she has not yet met that particular strain.
It's an expensive and painful injection, and the politics are especially weird.
After the opposition from "social conservatives" was overcome and the vaccine
was made available, several state governments tried to require immunization of girls
as a condition of attending public schools (Clin. Pharm. Ther. 82: 760, 2007).
If you can't see why this was senseless, please review your basic principles
of public health (Clin. Pharm. Ther. 82: 760, 2007). Thankfully, none of the activism succeeded.
The popular explanation (put forward in For. Sci. Int. 87:
219, 1997) is that she had taken the quack cancer remedy dimethylsulfoxide
(DMSO), and that
it gave rise to the poison gas dimethyl sulfate.
Is this credible?
Yes!
No!
* In the monster movie Godzilla 2000, a photomicrograph of the monster's
skin is examined by a group of scientists. Fascinatingly,
it appears identical to normal
human ectocervix.
Cervix
"Pathology Outlines"
Nat Pernick MD
All adult women have some inflammatory cells in the endocervical canal.
This is to be expected, given the abundant bacteria that thrive on the
glycogen in this area.
,
gonorrhea, and chlamydia will produce inflammation.
Especially if you see a lot of
lymphocytes with germinal centers, think of chlamydia.
Chronic cervicitis
WebPath
NABOTHIAN CYSTS are endocervical glands that have become plugged
"by the inflammation", and fill with mucus. Most women have a few of these.
{39991} endocervical polyp, gross
* LAMINAR HYPERPLASIA of the glands is quite common and poorly-understood.
The glands are slender but branch.
* Future pathologists: Don't mistake
the scrambled pattern and enlarged nuclei for adenocarcinoma.
{27137} cervix, micro-glandular hyperplasia, histology
CANCER OF THE CERVIX (Lancet 361: 2217, 2003; Ob. Gyn. 107: 1152, 2006)
Cytopathology
University of Texas, Houston
Lots of good pictures
Cytopathology gallery
International Agency for Research on Cancer
Huge site
Bethesda System Atlas -- National Cancer Institute
Authoritative, great photos
Very nice
Cytopathology Atlas
Dr. J. C. Prolla
For the student with a special interest
You'll learn on rotations about how to perform a pap smear, and
what the reports look like, and how smears are categorized and followed-up.
You are already familiar with the concept of dysplasia and intraepithelial
neoplasia. Here are some guidelines for applying the older "CIN" system,
from mildest to most severe. A pathologist can tell on pap smear, and confirm
on biopsy; the latter is more precise as long as you get the right spot (which is
made easier by the fact that CIN doesn't stain as well as normal cervix with
iodine ("Schiller test"), and will turn white on application of acetic acid, the acetowhite test,
done during colposcopy).
CIN I: Koilocytes only: Perhaps a condyloma acuminatum or a flat wart. Or perhaps
there is simply squamous metaplasia of the endocervix. Maybe some atypical
cells in the lower third. (the old "mild dysplasia").
{11789} dysplasia of uterine cervix, histology
{11789} cervix, dysplasia, histology
{41963} cervix, dysplasia, histology
{25939} cervix, dysplasia, pap smear
{27101} cervix, dysplasia, pap smear
{27104} cervix, dysplasia, pap smear
{11790} severe dysplasia of uterine cervix, histology
Glassy cell carcinoma
of the cervix
Pittsburgh Pathology Cases
{08911} uterine cervix, carcinoma in situ, histology
{08912} uterine cervix, carcinoma in situ, histology
{46209} cervical conization specimen. One may cure
CIS by removing the entire ring of abnormal cells.
As noted in the above caption, it's usual and customary to cure CIN III by
conization, i.e., removing the ring of cancer cells. Women are still at some increased
risk for eventually (up to decades, and into old age) developing an invasive cancer
(BMJ 335: 1053, 2007), but it is far, far less than if the lesion is ignored.
* Worth recognizing: Inter-observer variation in culscopy is surprisingly large.
See Ob. Gyn. 110: 833, 2007.
Pathologists distinguish subtypes of squamous cancer based on their histology
and resemblance to the cells of the normal cervix.
{25962} cervix, carcinoma in situ, pap smear
{34775} carcinoma in situ of cervix, pap smear
{10292} carcinoma of the cervix, gross
{10583} carcinoma of the cervix, gross; bladder is above, rectum below
{10913} carcinoma of the cervix; bladder is right, rectum is left
{46321} carcinoma of cervix, gross
{46322} carcinoma of cervix, gross
Squamous Cell Carcinoma, Cervix
Photo and mini-review
Brown U.
"Microinvasive carcinoma" implies invasion no deeper than 5 mm (Europe)
or 3 mm (US) with no evidence of vascular invasion.
Microinvasive carcinoma will be treated with cervical conization,
preserving fertility; more deeply invasive carcinoma needs hysterectomy.
* Sending the entire conization specimen for frozen section
seems like the best option to assure that as little tissue as possible is taken:
Am. J. Clin. Path. 122: 383, 2004.
* THE DEATH OF EVA PERON
Eva Peron ("Evita"), wife of Argentina's left-wing dictator Juan Peron,
died in January 1952 of cervical cancer.
ADENOCARCINOMA of the cervix constitutes only
around 15% of cervical
cancers, but it is less likely to be detected during its in-situ
phase (if it has any in-situ phase; leave the diagnosis of "adenocarcinoma in
situ" to us; it's difficult Arch. Path. Lab. Med. 128: 153, 2004;
Cancer 99: 323, 2003.)
Of course, the two occur together fairly often (Cancer 102: 218, 2004).
Complying with recommendations for routine pap smears
greatly decreases, but does not eliminate, a woman's risk for this
cancer (Cancer 99: 336, 2003).
* "The Toxic Lady!"
Gloria Ramirez died in a California emergency
room as a result of cancer of the cervix causing ureteral obstruction
and kidney failure.
Emergency room personnel who were present for the resuscitation
became acutely sick (lacrimation, fainting).
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INTRODUCTION
Following deliveries, the uterus may prolapse.
Words to know:
Leave the dating of endometrial samples to pathologists. You will usually get one of these diagnoses:
The endometrium is very resistant to bacterial infection.
Infection by common bacteria (strep A,
staph)
is usually the
result of retained products of conception. Surgical removal of
the remnants
is the mainstay of therapy.
Pyometra is thankfully rare. It is a purulent infection of the uterus, as when products of conception are retained or the os is closed.
Other infections after childbirth or natural or induced
abortion include strep,
staph,
and E. coli. In the Bad Old Days before
common-sense hygiene, physicians carried these infections from woman to woman
on the delivery unit.
Acute endometritis (i.e., neutrophils) often has no obvious cause;
various mycoplasma are the "usual suspects" and this is now being
confirmed with PCR: Lancet 359: 765, 2002
Chronic endometritis is, by definition, the presence of plasma cells
in the endometrium. Usually this is the result of gonococci or chlamydia
having their home base in the oviducts (confirmed by response to therapy:
Am. J. Ob. Gyn. 190: 305, 2004), or else simply the effect
of compression by a nearby leiomyoma (nobody knows how).
* There seems to be only a minor or no correlation with
bacterial vaginosis (Am. J. Ob. Gyn. 195: 1611, 2006).
Less often, retained products
of conception are the cause. Obviously an intrauterine contraceptive
device will produce chronic inflammation.
On the Coontagiousness
of Puerperal Fever
Oliver Wendell Holmes MD
* Future pathologists: Since chronic endometritritis may be the only
explanation for a woman's bleeding, it's important to spot those few plasma cells, which may
be difficult.
Using the syndecan-1 stain to do so: Arch. Path. Lab. Med. 128: 1000, 2004.
Also remember TB, especially in the poor nations.
Thankfully, nobody still uses the magnesium-rich super-absorbent tampons
that proved such a good culture medium for the
staphylococci that
produce toxic shock syndrome.
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ADENOMYOSIS ("endometriosis interna")
It's easy to tell this isn't cancer, since the glands are benign and there is stroma with them.
A common criterion for diagnosis is glands-plus-stroma one medium-power field width below the endometrial-muscular junction. However, pathologists differ widely in whether they "call" it. One recent study (which suggested that previous instrumentation can be a cause, which makes sense) found about half of uteruses removed for whatever reason to contain at least "pathologist's adenomyosis" (Ob. Gyn. 104: 1034, 2004). Obviously this can cause discomfort just before and during menstruation. You'll be told that adenomyosis is one of the major causes of menstrual cramps, and there is no question that some women with adenomyosis have no other clear cause and do get relief from hysterectomy. Irregular bleeding is also attributed to the process.
An adenomyoma is a nodule where there is a great deal of adenomyosis. More often, the process is diffuse, and if severe will expand the uterus.
* Contrary to old work, at least new studies confirm that adenomyosis lesions do in fact contain progesterone receptors (Gyn. Ob. Inv. 45: 126, 1998; Eur. J. Gyn. Onc. 254: 222, 2004).
{14330} adenomyosis, histology
ENDOMETRIOSIS ("endometriosis externa", BMJ 334:
249, 2007)
Don't worry about the etiology. The various ideas ("regurgitation", i.e.,
retrograde menstruation; metaplasia of the coelomic epithelium; metastases
via lymphatics) all probably operate at different times.
* Your lecturer is unimpressed with claims that the growths
are clonal or bear distinctive mutations; all the recent ones
have come from
studies of already-established cell cultures.
Being on the oral contraceptive pill seems to prevent endometriosis from forming.
At least one women in 10 will have symptoms of endometriosis during
reproductive life. Endometriosis cycles like endometrium does.
The gross appearance of endometriosis depends on how extensive
the disease is. Longstanding ovarian lesions present "chocolate cysts", full of old blood.
Large lesions where the blood has organized present extensive
fibrosis. This can obliterate the pouch of Douglas, obstruct the bowel,
obstruct the oviduct,
and so forth.
Infertility often accompanies endometriosis; exactly how this happens
is a minor mystery.
ENDOMETRIAL POLYPS
The histology may seem normal, or show some cystic hyperplasia (see below).
The tipoff that curettings contain a polyp is the presence of thick-walled
blood vessels (i.e., they've had time to develop and not been shed every month.)
Removal by curettage usually is curative.
ENDOMETRIAL HYPERPLASIA
Nobody really knows the "risk of turning into adenocarcinoma",
since the diagnosis is made only on biopsy and this itself affects
the illness (curettage may be curative).
Hyperplasia, and its distinction from well-differentiated adenocarcinoma,
is still best called on cyto-architecture rather than cytologic features (Cancer 108: 77, 2006).
That sounds easy, but reproducability of diagnosis is poor, even among subspecialist
pathologists (Cancer 106: 804, 2006).
SIMPLE HYPERPLASIA ("cystic hyperplasia", "mild hyperplasia", "endometrial hyperplasia without atypia")
features:
ENDOMETRIAL ADENOCARCINOMA
The risk factors are well-known.
Also remember
Patients present with bleeding because of the invasion of the inner wall.
Thankfully, these tumors usually announce themselves early. Only about one woman
in six with cancer of the endometrium will die from it.
Grossly, the lesions look like cottage cheese.
Microscopically, in the common "endometrioid adenocarcinoma" (about 80%
of these cancers) the pathologist sees back-to-back glands. Solid
sheets of cells are more ominous. The grading system for endometrioid cancer:
Increase the grade by one if the nuclei are unusually ugly.
By no means are the G1's particularly tame. Around 15% of them
will spread beyond the uterus (Am. J. Ob. Gyn. 198: 216.e1-5, 2008).
If there is benign-looking squamous metaplasia, the pathologist describes
an "adenoacanthoma". If the squamous areas are anaplastic, the pathologist
describes "adenosquamous carcinoma". This is of little significance.
Metastases eventually can occur, usually via the lymphatics.
SEROUS ADENOCARCINOMA OF THE ENDOMETRIUM (Cancer 101: 2214, 2004; Cancer 104: 1391, 2005 -- HER2/neu amplification and all that this implies)
and CLEAR CELL CARCINOMA OF THE ENDOMETRIUM are perhaps more aggressive,
look like the corresponding ovarian lesions, and is less likely to
be linked to high estrogen or to previous hyperplasia.
* As elsewhere, HER-2/neu amplification is a strong predictor of
bad outcome in the papillary serous lesion (Cancer 104: 1391, 2005).
Watch for herceptin
as an agent to treat these patients.
MIXED MULLERIAN / MESENCHYMAL TUMORS
There is often a history of previous radiation. They tend to be
aggressive and to metastasize
as adenocarcinomas.
ENDOMETRIAL STROMAL TUMORS are of three types. Leave the
diagnosis to us; their histology is not for medical school undergrads.
LEIOMYOMAS (Lancet 357: 293, 2001; Ob. Gyn. 104: 393, 2004)
The etiology is mysterious. They grow in response to estrogen, and shrink (and often vanish)
after menopause.
Usually leiomyomas are asymptomatic, or cause problems by mass effect.
A submucosal leiomyoma can produce bleeding between periods, and interfere
with fertility. Large leiomyomas can cause problems with pregnancy.
The tumors are rubbery white spheres.
Grossly, the "whorled silk" pattern seen on cross-section is famous.
Tumors may calcify, show central necrosis (watershed infarct; when this
becomes infected it's a "pyomyoma"), and/or fatty ingrowth.
The new procedure of embolizing these tumors under fluoroscopy, rather than removing
the uterus, seems safe and effective (Am. J. Ob. Gyn. 190: 1697, 2004;
Ob. Gyn. 106: 52 & 1309, 2005; AJR 184: 399, 2005).
The most serious risk is infection in the necrotic debris (OB Gyn 104: 1161, 2004
And prior to surgery, leiomyomas may be shrunk using a GNRH antagonist
(BJOG 112: 638, 2005). Anastrazole (the aromatase inhibitor) for
leiomyomas: Ob. Gyn. 110: 643, 2007.
Adenomyosis
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery
This is endometrium outside the uterus.
The most common site is the ovary. Almost as common are the ligaments
of the pelvis, and in surgical scars of the abdomen. But it can occur
in the vulva, vagina, intestine, umbilicus (!) or even the airways (!!).
The new laparoscopic hysterectomy techniques have resulted in massive
endometriosis when the uterus is morcellated and fragments of endometrium
spread all over the peritoneum (Ob. Gyn. 102: 1125, 2003).
* Hormones remain mysterious. Watch metformin (?!)
as a drug to arrest endometriosis (J
Minor lesions look like powder burns under the serosal surface.
To make the diagnosis, the pathologist must find two of three:Understandably, these lesions can produce dyspareunia (pain on intercourse),
constipation, and dysmenorrhea (pain on menstruation).
* For some reason, fertilized
eggs in women with endometriosis typically fail to implant, indicating
that something is wrong with all the endometrial tissue. This is
confirmed by cutting-edge gene profiling: Endocrinology 144: 2870, 2003.
{25284} endometriosis, histology
{46270} endometriosis, histology
{39843} endometriosis of appendix, gross
{10283} ovarian endometriosis, gross ("chocolate cyst")
Endometriosis of Ovary
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery
These curious lesions are probably
clonal overgrowths of endometrium that do not cycle
with the rest of it. The result is a nodule on the endometrium that is
likely to bleed between cycles.
If the cause is loss of a gene that is required for proper
monthly shedding, as seems reasonable, it remains
undiscovered. The lesions are not premalignant.
{24593} endometrial polyp, gross
{49375} endometrial polyp, gross
{24447} endometrial polyp, histology
Endometrial polyp
WebPath
This is an overgrowth of endometrium, but without the ability to
metastasize (yet). We still haven't sorted out how much is
due to a disturbed hormonal milieu, and how much is due to mutations
(selected-for in a disturbed hormonal milieu).
If a lady has this at the time of her last period,
she will have a cystic endometrium throughout postmenopausal life.
This is quite common at autopsy.
{00096} endometrial hyperplasia, gross
{00099} endometrial hyperplasia, gross
{10907} endometrial hyperplasia, gross
{38986} endometrial hyperplasia, gross
{08918} "cystic hyperplasia" of endometrium, histology
{08919} "cystic hyperplasia" of endometrium, histology
COMPLEX HYPERPLASIA ("complex / adenomatous hyperplasia without atypia")
ATYPICAL HYPERPLASIA ("higher grade hyperplasia")
Leave the details up to the pathologists, including the various metaplasias
that may occur in hyperplastic endometrium. All of these lesions are
prone to regress on administration of progesterone.
{27164} "adenomatous hyperplasia" of endometrium
This is a common cancer in women over age 40. Today, it is the most common of the
gynecologic malignancy, with about 36,000 diagnoses of invasive disease yearly.
The primary lesion is likely to be tiny, but to disseminate
over the peritoneal surfaces, probably by reflux out the oviducts.
{05319} uterine carcinoma, radiograph
{08437} endometrial adenocarcinoma, gross
{39635} carcinoma of the endometrium, gross
{18782} adenocarcinoma of the endometrium, gross
{18783} adenocarcinoma of the endometrium, gross
{21075} endometrial adenocarcinoma, gross
{10586} carcinoma of the endometrium; dissection with bladder at bottom, uterus and vagina in
middle, rectum at top
{10589} carcinoma of the endometrium, cross-section of uterus
{27161} adenocarcinoma of endometrium; notice glands-within-glands
{08916} adenocarcinoma of endometrium, low magnification
{08917} adenocarcinoma of endometrium, high magnification
{10694} adenocarcinoma of the endometrium, cytology
Endometrial adenocarcinoma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery
MIXED MULLERIAN TUMORS arise from the endometrium and contain
both malignant glands and malignant mesenchymal elements.
In addition
to bizarre spindle cells, there may be muscle, bone, fat, and/or cartilage;
nevertheless, these will usually stain with epithelial markers.
Endometrial Stromal Sarcoma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery
These are the banal "fibroids" of the myometrium.
At least 25% of women have these during reproductive life.
They are more common in blacks.
Submucosal leiomyomas can produce bleeding. Subserosal
leiomyomas are visible on the surface but don't mean anything.
Microscopically you will have no trouble recognizing smooth muscle.
Even if you see some odd cells, don't be concerned about malignancy
unless you see mitotic figures.
{08438} leiomyoma of uterus, gross
{09774} leiomyoma of uterus, gross
{10910} leiomyoma of uterus, gross
{24703} leiomyoma of uterus, gross
{39636} leiomyoma of uterus, gross
{49380} leiomyoma of uterus, gross
{08728} leiomyoma, histology
{08729} leiomyoma, histology
{49383} lipoleiomyoma
{20184} calcified uterine leiomyomas, radiograph
Large uterine leiomyoma
Whorls on cross-section
KU Collection
Normal female internal organs
Normal female internal organs
Normal female internal organs
HPV koilocytes
HPV koilocytes
Squamous cell carcinoma of the cervix
Carcinoma in situ
Prolapsed uterus
Endometriosis