CECILIA P.

LEPON-CAPATOY, RMT, MD, FPSP

Cebu Institute of Medicine
Vulva
ž Diseases of the vulva in the aggregate constitute only a small
fraction of gynecologic practice.
ž Many inflammatory diseases that affect skin elsewhere on
the body also occur on the vulva, such as psoriasis, eczema,
and allergic dermatitis.
ž Because it is constantly exposed to secretions and moisture,
the vulva is more prone to superficial infections than skin
elsewhere on the body.

ž Most skin cysts (epidermal inclusion cysts) and skin tumors

such as squamous cell carcinoma, basal cell carcinoma and
melanoma can also occur in the vulva.
ž Relatively specific and common vulvar disorders, include
— Bartholin cyst, nonneoplastic epithelial disorders, benign exophytic
lesions, and tumors of the vulva.
Condyloma Acuminatum
ž Condylomata acuminata are benign genital warts caused by
low oncogenic risk HPVs , mainly types 6 and 11.
ž They may be solitary, but are more frequently multifocal, and may
involve vulvar, perineal, and perianal regions as well as the vagina
and, less commonly, the cervix.
ž The lesions are identical to those found on the penis and around
the anus in males.

— On histologic examination, they consist of papillary, exophytic,

treelike cores of stroma covered by thickened squamous
epithelium.
— The normal orderly maturation of the epithelial cells is preserved.
— The surface epithelium shows characteristic viral cytopathic
changes referred to as koilocytic atypia, which manifest as
nuclear enlargement, hyperchromasia and a cytoplasmic
perinuclear halo.

ž Condylomata acuminata are not precancerous lesions.

On the penis these lesions occur most often about the coronal
sulcus and inner surface of the prepuce.

ž They consist of
single or multiple
sessile or
pedunculated, red
papillary
excrescences that
vary from 1 mm to
several millimeters
in diameter.

Condyloma acuminatum
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Condyloma acuminatum of the penis. Low magnification reveals the papillary

(villous) architecture, and thickening of the epidermis.
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Condyloma acuminatum of the penis. The epithelium shows vacuolization

(koilocytosis) characteristic of human papillomavirus infection.
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 Condyloma acuminatum. A, Low-power view showing exophytic, papillary
architecture. B, High-power view reveals HPV cytopathic effect (koilocytic
atypia) characterized by atypical, enlarged, hyperchromatic nuclei with
perinuclear halos (arrow).
The Female Genital Tract
Ellenson, Lora Hedrick, Robbins and Cotran Pathologic Basis of Disease, Chapter 22, 991-1042
Copyright © 2015 Copyright © 2015, 2010, 2004, 1999, 1994, 1989, 1984, 1979, 1974 by Saunders, an imprint of Elsevier Inc.
ANATOMY
ž UTERUS:
— Weighs about 50 grams
— Measures about 8 x 6 x 3 cm in nulliparous
reproductive age
— Up to 70 grams following pregnancies
— Diminish to half its weight and dimension
following menopause
— 3 distinctive anatomic and functional regions:
○ Cervix
○ Lower uterine segment
○ Corpus
CERVIX
ž The point at which the squamous and endocervical
mucinous columnar epithelium meet is termed the
squamocolumnar junction (SCJ)
ž The area of the cervix where the columnar epithelium
is ultimately replaced by squamous epithelium is
termed the transformation zone

ž Metaplasia of glandular epithelium to squamous

epithelium at the squamocolumnar junction produces
multilayered, initially immature, squamous epithelium
known as “squamous metaplasia”
ž These immature squamous cells are susceptible to
human papillomavirus (HPV) infection and it is at the
SCJ where precancerous lesions and cervical
carcinomas develop
 Cervical squamocolumnar junction showing mature, glycogenized (pale)
squamous epithelium, immature (dark pink) squamous metaplastic cells, and
columnar endocervical glandular epithelium.
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 CERVICAL INTRAEPITHELIAL
NEOPLASIA (CIN)
— The reason that Papanicolaou smear screening is so effective in
preventing cervical cancer is that the majority of cancers are
preceded by a precancerous lesion.
— This lesion may exist in the noninvasive stage for as long as 20
years and shed abnormal cells that can be detected on cytologic
examination.
— These precancerous changes should be viewed with the following
in mind:
— (1) they represent a continuum of morphologic change with
indistinct boundaries;
— (2) they do not invariably progress to cancer and may
spontaneously regress, with the risk of persistence or progression
to cancer increasing with the severity of the precancerous change;
— (3) they are associated with papillomaviruses, and high-risk HPV
types are found in increasing frequency in the higher-grade
precursors.

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Classification Systems for Squamous Cervical
Precursor Lesions
Dysplasia/Carcinoma in Cervical Intraepithelial Squamous Intraepithelial
Situ Neoplasia (CIN) Lesion (SIL), Current
Classification

Mild dysplasia CIN I Low-grade SIL (LSIL)

Moderate dysplasia CIN II High-grade SIL (HSIL)

Severe dysplasia CIN III High-grade SIL (HSIL)

Carcinoma in situ CIN III High-grade SIL (HSIL)

CIN, Cervical intraepithelial neoplasia; SIL, squamous intraepithelial lesion.

Low-grade Squamous Intraepithelial Lesion (LSIL)

Cytology: Koilocytes are superficial or immature squamous cell with large

and irregular, well defined perinuclear halos with cookie cutter border and
cytoplasmic thickening, nuclei are enlarged with undulating (raisin-like)
nuclear membrane and rope-like chromatin; often bi- or multinucleation and
variation in nuclear size
HSIL – High-grade Squamous Intraepithelial Lesion

Cytomorphologic Criteria:
Unequivocal nuclear "dysplastic" changes are present in these relatively small squamous
cells. The nuclear to cytoplasmic ratio suggests moderate dysplasia (CIN2).

Explanatory Notes:
For mild dysplasia (LSIL), more abundant and mature cytoplasm and a lower N/C ratio is
expected. In this case chromatin changes suggest HSIL; however the N/C ratio is on the
low end for HSIL.
HSIL – High-grade Squamous Intraepithelial Lesion
LSIL HSIL
Atypical Squamous Cells Atypical Squamous Cell
of Undetermined cannot rule out a High
Significance (ASC-US) Grade Squamous Lesion
(ASC-H)
Natural History of Squamous Intraepithelial Lesions with
Approximate 2-Year Follow-up

Lesion Regress Persist Progress

LSIL 60% 30% 10% to HSIL

HSIL 30% 60% 10% to

carcinoma *

HSIL, High-grade squamous intraepithelial lesion;

LSIL, low-grade squamous intraepithelial lesion.
* Progression within 2 to 10 years.
SQUAMOUS CELL CARCINOMA
(cervix)
— Squamous cell carcinoma may occur at any
age from the second decade of life to senility.
— The peak incidence is occurring at an
increasingly younger age:
○ 40 to 45 years for invasive cancer and about 30 years for
high-grade precancers.

— This represents the combination of earlier onset

of sexual activity (i.e., earlier acquisition of HPV
infection) and active Papanicolaou smear
screening programs in the United States,
○ which detect either cancers or precancerous lesions at
an earlier point in life.
Squamous cell carcinoma of the cervix..
B, Invasive squamous cell carcinoma.
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Squamous cell carcinoma
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Adenocarcinoma of the cervix.

A, Adenocarcinoma in situ (arrow) showing dark glands adjacent to
normal, pale endocervical glands.
B, Invasive adenocarcinoma.
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Adenocarcinoma in situ of the cervix - Pap smear

Adenocarcinoma, endocervical - Pap smear

 No form of cancer
better documents the
remarkable benefits of
effective screening,
early diagnosis, and
curative therapy than
does cancer of the
cervix.

Worldwide, cervical carcinoma is the third most common cancer in

women, with an estimated 530,000 new cases in 2008, of which more
than half are fatal.
Adenosquamous carcinoma of
the cervix
ž The prognosis of adenosquamous carcinoma of the
cervix compared to the pure cell types of this disease is a
controversial issue.
○ Survival rates vary widely among published series, with
some authors finding the prognosis to be much worse and
others finding it to be equal.

ž We conclude that for early stage cervical cancer treated

by radical hysterectomy, the adenosquamous cell type
does not carry a worse prognosis than either of the pure
cell types.

ž Harrison TA, Sevin BU, Koechli O, Nguyen HN, Averette HE, Penalver M, Donato DM, Nadji M.
ž Source Gynecol Oncol. 1993 Sep;50(3):310-5.
ž Department of Obstetrics and Gynecology, University of Miami School of Medicine, Florida 33136.
The glandular component in adenosquamous carcinoma of the cervix is
usually endocervical adenocarcinoma. In rare cases, the glandular
component may show endometrioid or signet ring cell differentiation.
 The squamous component is usually moderately differentiated.
In some cases, benign-appearing squamous morules may be seen (as
shown here).
ENDOCERVICAL POLYPS
— Are relatively innocuous, inflammatory tumors that
occur in 2% to 5% of adult women.
○ Perhaps the major significance of polyps lies in their
production of irregular vaginal "spotting" or bleeding that
arouses suspicion of some more ominous lesion.
— Most polyps arise within the endocervical canal and vary
from small and sessile to large, 5-cm masses that may
protrude through the cervical os.
— All are soft, almost mucoid, and are composed of a loose
fibromyxomatous stroma harboring dilated, mucus-
secreting endocervical glands, often accompanied by
inflammation and squamous metaplasia.
— In almost all instances, simple curettage or surgical
excision effects a cure.
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Endocervical polyp composed of a dense fibrous stroma covered with

endocervical columnar epithelium.
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BODY OF UTERUS
ž The uterus has two major components: the myometrium
and the endometrium.
— The myometrium is composed of tightly interwoven bundles
of smooth muscle that form the wall of the uterus.
— The internal cavity of the uterus is lined by the endometrium
composed of glands embedded in a cellular stroma.
ž The uterus is subject to a variety of disorders, the most
common of which result from endocrine imbalances,
complications of pregnancy, and neoplastic proliferation.
— Together with the lesions that affect the cervix (causing
abnormal Pap smears), the lesions of the corpus of the
uterus and the endometrium (causing abnormal vaginal
bleeding) account for most patient visits to gynecologic
practices.
Endometrial Polyps
ž Endometrial polyps are exophytic masses of variable size
that project into the endometrial cavity.

— They may be single or multiple and are usually sessile,

measuring from 0.5 to 3 cm in diameter, but are occasionally
large and pedunculated.

ž Polyps may be asymptomatic or may cause abnormal

bleeding (intramenstrual, menometrorrhagia, or
postmenopausal) if they ulcerate or undergo necrosis.

ž Most commonly the glands within polyps are hyperplastic

or atrophic, but they can occasionally demonstrate
secretory changes (functional polyps).
 DYSFUNCTIONAL UTERINE BLEEDING
ž ANOVULATORY CYCLE
— Results in excessive and
prolonged estrogenic
stimulation without the
development of the
progestational phase that
regularly follows ovulation
— Most common at menarche
and perimenopausal period
ž INADEQUATE LUTEAL
PHASE
— Occurrence of inadequate
corpus luteum function and
low progesterone output, with
an irregularly ovulatory cycle
ž ENDOMETRIAL CHANGES
INDUCED BY ORAL
CONTRACEPTIVES
— Common response pattern is
a discordant appearance
between glands and stroma,
usually with inactive glands
amid a stroma showing large
cells with abundant cytoplasm
reminiscent of the decidua of
pregnancy
ž MENOPAUSAL &
POSTMENOPAUSAL
CHANGES
— Anovulatory cycle à ovarian
failure and atrophy of the
endometrium
— Mild hyperplasia with cystic
dilation of glands à cystic
atrophy
Endometriosis and Adenomyosis
— Endometriosis is the term used to describe the presence of
endometrial glands or stroma in abnormal locations outside
the uterus.

— It occurs in the following sites, in descending order of

frequency:
(1) ovaries; (2) uterine ligaments; (3) rectovaginal septum;
(4) pelvic peritoneum; (5) laparotomy scars; and
(6) rarely in the umbilicus, vagina, vulva, or appendix.

— Endometriosis is an important clinical condition; it often

causes infertility, dysmenorrhea, pelvic pain, and other
problems.
— The disorder is principally a disease of women in active
reproductive life, most often in the third and fourth decades, and
afflicts approximately 10% of women.
Endometriosis and Adenomyosis
— A closely related disorder, adenomyosis, is defined as the
presence of endometrial tissue in the uterine wall
(myometrium).
— Adenomyosis remains in continuity with the endometrium,
presumably signifying downgrowth of endometrial tissue
into and between the smooth muscle fascicles of the
myometrium. Adenomyosis occurs in up to 20% of uteri.
— On microscopic examination, irregular nests of endometrial
stroma, with or without glands, are arranged within the
myometrium, separated from the basalis by at least 2 to 3 mm.
— In some patients, the most important consequence of
adenomyosis is shedding of the endometrium during the
menstrual cycle.
— Hemorrhage within these small adenomyotic nests results in
menorrhagia, colicky dysmenorrhea, dyspareunia, and pelvic pain,
particularly during the premenstrual period.
 Adenomyosis is defined as the presence of endometrial tissue within the
myometrium. The endometrial tissue should be at least 100x field (about 2.5 mm)
deep from the endomyometrial junction. The surrounding myometrium is usually
hyperplastic. The endometrial glands may be inactive or hormonally responsive.

In some cases, the glands are scant or absent and such cases may be mistaken
for low-grade endometrial stromal sarcoma.
 Higher power view showing endometrial glands and stroma surrounded by
hyperplastic myometrium.
In some cases where the stroma is sparse or atrophic, the endometrial glands
may be found deep within the myometrium.
Endometrial Hyperplasia
ž Endometrial hyperplasia, an important cause of abnormal
bleeding, is defined as an increased proliferation of the
endometrial glands relative to the stroma, resulting in an
increased gland-to-stroma ratio when compared with normal
proliferative endometrium.

ž Endometrial hyperplasia deserves special attention because of

its relationship with endometrial carcinoma.
ž Clinicopathologic and epidemiologic studies have supported the
malignant potential of endometrial hyperplasia and the concept
of a continuum of proliferative glandular lesions culminating, in
some cases, in carcinoma.

ž Molecular studies have confirmed this relationship, since

endometrial hyperplasia and carcinoma share specific
molecular genetic alterations.
Endometrial hyperplasia is associated with prolonged
estrogenic stimulation of the endometrium, the same
influences postulated to be of pathogenic significance in some
endometrial carcinomas

ž • Obesity (peripheral conversion of androgens to estrogens)

ž • Menopause

ž • Polycystic ovarian syndrome

ž • Functioning granulosa cell tumors of the ovary

ž • Excessive ovarian cortical function (cortical stromal

hyperplasia)

ž • Prolonged administration of estrogenic substances

(estrogen replacement therapy)
The classification of endometrial hyperplasia has
undergone a number of changes over the years to keep
pace with new insights into the disorder.

ž In the recent past, the most widely used system divided

endometrial hyperplasia into four categories:
— simple hyperplasia without atypia;
— complex hyperplasia without atypia;
— simple atypical hyperplasia; and
— complex atypical hyperplasia.

ž However, the most current World Health Organization

(WHO) classification recommends collapsing the four
categories into two major categories:
○ Non-atypical hyperplasia and
○ Atypical hyperplasia
— also referred to as endometrial intraepithelial neoplasia,
— which differ in appearance and in their propensity to progress to
carcinoma.
Simple hyperplasia without atypia with architectural abnormalities
including mild glandular crowding and cystic glandular dilatation.
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B, Complex hyperplasia without atypia demonstrates increased glandular

crowding with areas of back-to-back glands with cytologic features
similar to proliferative endometrium.
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C, Complex hyperplasia with atypia has architectural features similar to

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D, High magnification of complex hyperplasia with atypia showing

rounded, vesicular nuclei with prominent nucleoli (arrow).

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Endometrial carcinoma is the most common
invasive cancer of the female genital tract .

ž It accounts for 7% of all invasive cancer in women,

excluding skin cancer.
ž At one time endometrial carcinoma was far less
common than cancer of the cervix,
— but earlier detection and eradication of the precursor lesions
of cervical carcinoma,
— coupled with an increase in endometrial carcinomas in
younger women, have reversed this ratio.

ž In 2012 in the United States, 47,130 new endometrial

cancers and 8,010 deaths were predicted.
ž Worldwide there are approximately 280,000 new cases
of endometrial cancer per year.
Characteristics of Type I and Type II Endometrial Carcinoma
Characteristics Type I Type II
Age •55-65 yr •65-75 yr
Clinical setting •Unopposed estrogen •Atrophy
•Obesity •Thin physique
•Hypertension
•Diabetes
Morphology •Endometrioid •Serous
•Clear cell
•Mixed müllerian tumor
Precursor •Hyperplasia •Serous endometrial
intraepithelial carcinoma
Mutated genes/genetic •PTEN •TP53
abnormalities •ARID1A (regulator of •Aneuploidy
chromatin) •PIK3CA (PI3K)
•PIK3CA (PI3K) •FBXW7 (regulator of
•KRAS MYC, cyclin E)
•FGF2 (growth factor) •CHD4 (regulator of
•MSI * chromatin)
•CTNNB1 (Wnt signaling) •PPP2R1A (PP2A)
•TP53
Behavior •Indolent •Aggressive
•Spreads via lymphatics •Intraperitoneal and
lymphatic spread
* MSI, Microsatellite instability; CTNNB1, beta-catenin gene
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Schematic diagram depicting the development of type I endometrial carcinoma

arising in the setting of hyperplasia.
The most common molecular genetic alterations are shown at the time they are
most likely to occur during the progression of the disease.
*MI, microsatellite instability.

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 ENDOMETRIAL CANCER
ž 85% are adenocarcinomas characterized by more or less
well-defined gland patterns closely resembling normal
endometrial epithelium (endometrioid tumors)
ž 3-step grading system
— Grade 1 – well-differentiated, with easily recognizable glandular
patterns
— Grade 2 – moderately differentiated, showing well-formed glands
mixed with solid sheets of malignant cells (50% or less of the tumor)
— Grade 3 – poorly differentiated, char. by solid sheets of cells (greater
than 50%) with barely recognizable glands and a greater degree of
nuclear atypia and mitotic activity

ž Papillary serous carcinomas and clear cell carcinomas are

managed as grade 3 carcinomas irrespective of histologic
pattern.
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Type I carcinoma.
A, Endometrial adenocarcinoma presenting as a fungating mass in the fundus of the uterus.
B, Well-differentiated (grade 1) endometrioid adenocarcinoma with preserved glandular architecture
but lack of intervening stroma, distinguishing it from hyperplasia.
C, Moderately differentiated (grade 2) endometrioid adenocarcinoma with glandular architecture
admixed with solid areas.
D, Poorly differentiated (grade 3) endometrioid adenocarcinoma with predominantly solid growth.
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 Endometrioid Adenocarcinoma, FIGO Grade 1

The image shows irregular glands lined by columnar epithelium with

pseudostratified nuclei and mild cytologic atypia.
The tumor contained less than 5% overall of solid areas and was classified as
Grade 1.
 Endometrioid Adenocarcinoma, FIGO Grade 2

Grade 2 tumors contain 6% to 50% of solid, non-morular component.

This case contained approximately 30% solid areas.
Grade 2 tumors make up approximately 35% of all endometrial adenocarcinomas.
 Endometrioid Adenocarcinoma, FIGO Grade 3

Grade 3 tumors contain solid areas comprising more than 50% of the tumor.
They make up approximately 15% of all endometrial adenocarcinomas.

In tumors with squamous differentiation, only the glandular component is

considered for grading purposes.
The image shows transition from the glandular component on the right to solid
areas on the left.
 Endometrioid Adenocarcinoma, FIGO Grade 1,
with Squamous Differentiation

Up to 20% of endometrioid carcinomas contain foci of squamous differentiation.

Squamous elements may be histologically benign-appearing when they are associated with
well-differentiated adenocarcinomas.
Less commonly, moderately or poorly differentiated endometrioid carcinomas contain
squamous elements that appear frankly malignant.
Current classification systems grade the carcinomas based on glandular differentiation
alone and ignore areas of solid squamous differentiation.
 Endometrioid Adenocarcinoma, FIGO Grade 1,
with Squamous Differentiation

Well-formed squamous morules surrounded by the glandular component.

The squamous elements arise by metaplasia of the tumor glands. These
tumors are also referred to as adenoacanthomas.

WHO recommends that the terms adenoacanthoma and adenosquamous

carcinoma should no longer be used.
Type II (Serous) Carcinoma.
ž These generally occur in women who are about 10
years older than those with type I carcinomas, and in
contrast to type I carcinoma they usually arise in the
setting of endometrial atrophy.

ž Type II tumors are by definition poorly differentiated

(grade 3) tumors and account for approximately 15% of
cases of endometrial carcinoma.
ž The most common subtype is serous carcinoma ,
referred to as such because of morphologic and biologic
overlap with ovarian serous carcinoma.

ž Several less common histologic subtypes (clear cell

carcinoma and malignant mixed müllerian tumor) are
also included within this category.
Serous Carcinoma
ž Presumably begins as a surface epithelial
neoplasm that extends into adjacent gland
structures and later invades endometrial
stroma.
ž Their generally poorer prognosis is thought to
be a consequence of a propensity to exfoliate,
travel through the fallopian tubes, and implant
on peritoneal surfaces like their ovarian
counterparts.
ž They have often spread outside of the uterus at
the time of diagnosis.
MORPHOLOGY
ž Generally, serous carcinomas arise in small atrophic uteri and are
often large bulky tumors or deeply invasive into the myometrium.

ž The precursor lesion, serous endometrial intraepithelial

carcinoma, consists of malignant cells identical to those of serous
carcinoma that are confined to the epithelial surfaces.

ž The invasive lesions may have a papillary growth pattern composed of

cells with marked cytologic atypia including
— high nuclear-to-cytoplasmic ratio, atypical mitotic figures, hyperchromasia, and
prominent nucleoli.
ž However, they can also have a predominantly glandular growth
pattern; in such cases they are distinguished from endometrioid
carcinoma by the
— marked cytologic atypia.

ž Serous carcinoma, despite relatively superficial endometrial

involvement, may be associated with extensive peritoneal disease,
suggesting spread by routes (i.e., tubal or lymphatic transmission)
other than direct invasion.
Type II endometrial carcinoma.
A, Endometrial intraepithelial carcinoma, the precursor to serous carcinoma showing malignant cells
(arrow) with morphologic features identical to serous carcinoma lining the surfaces of the endometrial
glands without obvious stromal invasion.

B, Strong, diffuse expression of p53 as detected by immunohistochemistry in endometrial intraepithelial

carcinoma.

C, Serous carcinoma of the endometrium with papillary growth pattern consisting of malignant cells with
marked cytologic atypia including high nuclear-to-cytoplasmic ratio, atypical mitotic figures, and
hyperchromasia.

D, As with the previous lesion, there is an accumulation of p53 protein in the nucleus.

The Female Genital Tract Ellenson, Lora Hedrick, Robbins and Cotran Pathologic Basis of Disease, Chapter 22, 991-1042 Copyright © 2015 Copyright © 2015, 2010, 2004, 1999, 1994, 1989, 1984, 1979, 1974 by Saunders,
an imprint of Elsevier Inc.
LEIOMYOMAS
— Uterine leiomyomas (commonly called fibroids) are
perhaps the most common tumor in humans.

— These benign tumors may be present in about 75% of

females of reproductive age, and each uterus harbors an
average of 6.5 tumors.

— Leiomyomas are sharply circumscribed, discrete, round,

firm, gray-white tumors varying in size from small, barely
visible nodules to massive tumors that fill the pelvis.

— They can occur within the myometrium (intramural), just

beneath the endometrium (submucosal), or beneath the
serosa (subserosal).
— On histologic examination, the leiomyoma is composed of
whorled bundles of smooth muscle cells that resemble the
uninvolved myometrium.
— The individual muscle cells are uniform in size and shape and have the
characteristic oval nucleus and long, slender bipolar cytoplasmic
processes. Mitotic figures are scarce.

— The most important symptoms are produced by submucosal

leiomyomas (abnormal bleeding), compression of the bladder
(urinary frequency), sudden pain if disruption of blood supply
occurs, and impaired fertility.

— Myomas in pregnant women increase the frequency of

spontaneous abortion, fetal malpresentation, uterine inertia, and
postpartum hemorrhage.

— Malignant transformation (leiomyosarcoma) within a leiomyoma is

extremely rare.
Leiomyomas of the uterine myometrium
A, The uterus is opened to reveal multiple tumors in submucosal (bulging into the
endometrial cavity), intramural, and subserosal locations that display a firm white
appearance on sectioning.

B, Leiomyoma showing well-differentiated, regular, spindle-shaped smooth muscle

cells associated with hyalinization.
The Female Genital Tract
Ellenson, Lora Hedrick, Robbins and Cotran Pathologic Basis of Disease, Chapter 22, 991-1042
Copyright © 2015 Copyright © 2015, 2010, 2004, 1999, 1994, 1989, 1984, 1979, 1974 by Saunders, an imprint of Elsevier Inc.
LEIOMYOSARCOMAS
ž These uncommon malignant neoplasms are thought to arise from
the myometrium or endometrial stromal precursor cells, rather
than leiomyomas.
ž They grow within the uterus in two somewhat distinctive patterns:
— (1) bulky, fleshy masses that invade the uterine wall or
— (2) polypoid masses that project into the uterine lumen

ž They exhibit a wide range of cytologic atypia, from extremely well

differentiated to highly anaplastic.
ž The distinction from leiomyoma is based on
— nuclear atypia, mitotic index, and zonal necrosis.

— With few exceptions, the presence of 10 or more mitoses per 10 high-

power (400×) fields indicates malignancy, particularly if accompanied by
cytologic atypia and/or necrosis.
— If the tumor contains nuclear atypia or large (epithelioid) cells, five mitoses
per 10 high-power (400×) fields are sufficient to justify a diagnosis of
malignancy.
 Leiomyosarcoma.
The tumor cells are irregular in size and have hyperchromatic nuclei.
Numerous mitotic figures are present (arrows).
The Female Genital Tract
Ellenson, Lora Hedrick, Robbins and Cotran Pathologic Basis of Disease, Chapter 22, 991-1042
Copyright © 2015 Copyright © 2015, 2010, 2004, 1999, 1994, 1989, 1984, 1979, 1974 by Saunders, an imprint of Elsevier Inc.
PAP SMEAR THE BETHESDA SYSTEM 2014
SPECIMEN TYPE:
(X) Conventional smear ( ) Liquid-based preparation
SPECIMEN ADEQUACY:
(X) Satisfactory for evaluation
( ) Unsatisfactory for evaluation:
( ) Specimen rejected/not processed due to: _______________________
( ) Specimen processed and examined but unsatisfactory for evaluation of epithelial abnormality due to: __________________
INTERPRETATION/RESULT:
(X) NEGATIVE FOR INTRAEPITHELIAL LESION OR MALIGNANCY
Non-Neoplastic Findings Organisms
(X) Non-neoplastic cellular variations (X) Trichomonas vaginalis
(X) Squamous metaplasia ( ) Fungal organisms morphologically consistent with Candida spp.
( ) Keratotic changes ( ) Shift in flora suggestive of bacterial vaginosis
( ) Tubal metaplasia ( ) Bacteria morphologically consistent with Actinomyces spp.
( ) Atrophy (X) Cellular changes consistent with herpes simplex virus
( ) Pregnancy-associated changes ( ) Cellular changes consistent with cytomegalovirus
(X) Reactive cellular changes associated with:
(X) Inflammation (includes typical repair)
( ) Radiation
( ) Intrauterine contraceptive device (IUD)
( ) Glandular cells status post hysterectomy
OTHER
( ) Endometrial cells (in a woman >45 years of age)
( ) EPITHELIAL CELL ABNORMALITIES
( ) SQUAMOUS CELL ( ) GLANDULAR CELL
( ) Atypical squamous cells ( ) Atypical
( ) of undetermined significance (ASC-US) ( ) endocervical
( ) cannot exclude HSIL (ASC-H) ( ) endometrial
( ) Low-grade squamous intraepithelial lesion (LSIL) ( ) glandular cells
( ) High-grade squamous intraepithelial lesion (HSIL) ( ) Atypical
( ) Squamous cell carcinoma ( ) endocervical cells, favor neoplastic
( ) glandular cells, favor neoplastic
( ) OTHER MALIGNANT NEOPLASMS ( ) Endocervical adenocarcinoma in situ
_________________________________________ ( ) Adenocarcinoma
( ) endocervical ( ) extrauterine
( ) endometrial ( ) not otherwise specified (NOS)
Trichomonas vaginalis
Trichomonas vaginalis
Fungal organisms morphologically
consistent with Candida spp.
Fungal organisms morphologically
consistent with Candida spp.
Shift in flora suggestive of
bacterial vaginosis
Cellular changes consistent
with herpes simplex virus
Cellular changes consistent
with cytomegalovirus
T. Vaginalis

HSV