vulva

Bartholin

gland Non neoplastic epithelial disorders-lichen sclerosis,lichen simplex chronicus

cyst-acute infection of bartholin

Lichen sclerosis

Chronic atrophic vulvitis leads to atrophy, fibrosis,and scarring. Precancerous lesion Histological features are Hydropic degeneration of basal cells. Replacement of underlying dermis by dense collagenous fibrous tissue. Monoclonal band like lymphocyte infiltrate.

Lichen simplex chronicus

Acanthosis of vulval squamous epithelium with hyperkeratosis. The epithelium is thickened. Increased mitotic activity in basal and prickle layer

Benign neoplasms of vulva

Papillary hidradenoma Condyloma accuminatum(veneral warts) Mucosal polyps Syphilitic condyloma latum

Malignant neoplasms

85% of malignant tumors are squamous cell carcinomas Others are basal cell carcinoma, melanoma and adenocarcinoma Predisposing factors are HPV 16,18 VIN Squamous cell hyperplasia Lichen sclerosis

Squamous cell carcinoma-vulva

HPV associated type develop as VIN lesions-discrete pigmented, hyperkeratotic and raised lesions.microscopicaly invasive growth pattern. Lichen sclerosis associated lesions nodules.microscopicaly exhibit invasive pattern with prominent keratinisation.

Vagina

Malignant neoplasms

Vaginal intraepithelial neoplasia & squamous cell carcinoma 1%of all malignant neoplasm in female genital tract risk factor is previous Ca of cervix or vulva Affects upper posterior vagina at junction with ectocervix

Adenocarcinoma

Increased frequency of clearcell adenocarcinoma among young women whose mothers are treated with diethyl stillbestrol during pregnancy Vaginal adenosis is precursor of the tumor Affect anterior wall of upper third vagina Vacuolated glycogen containing cells(clear cell ca)

Embryonal Rhabdomyosarcoma (Sarcoma botryoides)

Uncommon tumor Found in < 5 yr age group Polypoid, rounded bulky masses in grape like clusters Tennis racket like cells with oval nuclei

Cervix

Inflammations

Acute cervicitis-infiltration with acute inflammatory cells,erosion,reactive epithelial changes Chronic cervicitis-infiltration with lymphocytes, macrophages and plasma cells Endocervical polyps-small, sessile to large masses. composed of loose fibromatous stroma harboring dilated mucus secreting endocervical glands.

Cervical cancer

Most common genital Ca in India Invasive Ca- 40 to 45 yrs. 30 yrs for high grade precancers. Risk factors Early age at first intercourse Multiple sex partners Increased parity Male partner with multiple previous sex partners HPV infection(high risk type 16,18,31,33,35,39,45,51,52,56,58,59,68) Certain HLA and viral types Exposure to OCP and nicotine Genital infection (chlamydia)

CIN

They represent continuum of morphologic changes with indistinct boundaries. Do not invariably progress to cancer & may regress Associated with HPV

CIN

CIN I-nuclear enlargement & hyperchromasia in superficial epithelial cells, cytoplasmic halos(koilocytic atypia) also seen. CIN II-atypical cells in lowerlayers of squamous epithelium but abnormal differentiation towards prickle & keratinizing cell layer. CIN III-epithelium replaced by immature atypical cells exhibiting no surface differentiation. Atypical cells show changes in nucleo cytoplasmic ratio, nuclear pleomorphism, loss of polarity, increased mitotic figures including abnormal mitosis and hyperchromasia.

Normal cervix

Condyloma cervix

Low grade CIN (flat condyloma)

Squamous dysplasia-pap smear high power

High grade CIN(CIN III)

Cervical dysplasia

Cervical HPV infection

Pap smear results

Invasive squamous cell carcinoma

Fungating, ulcerating or infiltrative cancers Histologically-well differentiated(keratinizing) moderately differentiated(nonkeratinizing), poorly differentiated small cell squamous patterns.(specific risk with HPV-18)

CA cervix

Staging of cervical cancer

Stage 0- Ca in situ (CIN III) Stage I- Ca confined to cervix Stage Ia- preclinical Ca diagnosed only by microscopy. Stage Ia1- stromal invasion< 3mm & no wider than 7mm. Stage Ia2- depth of invasion > 3mm & no greater than 5mm taken from base of epithelium, horizontal invasion not more than 7mm. Stage Ib- invasive Ca confined to Cx & greater than Stage Ia2

Staging contd.

Stage II- Ca extends beyond Cx but not on to pelvic walls. Ca involves vagina but not lower third. Stage III- Ca extended beyond on to pelvic walls. Ca involves lower third vagina. Stage IV- Ca extends beyond the true pelvis or has involved the mucosa of bladder or rectum. Metastatic dissemination.

Stage IV CA cervix

Stage IV CA cervix (block dissection)

Infiltrating CA cervix

Other types

Adeno Ca- arise in endocervical glands. Adenosquamous Ca- mixed glandular & squamous pattern Clearcell adeno Ca of Cx- in DES exposed women.