Female genital system

Dr Dina Abd-Allah Lecturer of pathology

Cervical polyp

Is a common non-neoplastic lesion which results from overgrowth of the endocervical mucosa that protrudes as a polyp in the endocervical canal Is a common cause of intermittent uterine bleeding Is not associated with increased risk of malignancy

Grossly

It may be single or multiple. It may be small and sessile or large and pedunculated. It is soft and covered by a smooth glistening surface. Mostly arises within the endocervical canal and may protrude through the cervical os.

Microscopically: the polyp is covered with mucus

secreting columnar epithelium similar to that covering endocervical canal. Underlying endocervical glands are cystically dilated and filled with mucus secretion. Stroma is edematous and may contain some inflammatory cells. Superadded chronic inflammation may lead to squamous metaplasia of the covering epithelium and ulceration.

Cervical intraepithelial neoplasia (CIN) and invasive cervical carcinoma

Cervical intraepithelial neoplasia(CIN) Is defined as dysplastic changes of the squamous epithelium of the cervix at the transformation zone .It is recognized as a precursor of squamous cell carcinoma.

Risk factors

Infection with high risk types of human papilloma virus (HPV)( types 16,18)cervical intraepithelial neoplasia (CIN) Sexual activity at an early age Multiple high risk sexual partners. Multiparity. Cigarette smoking Immunosuppression.

CIN lesions include three grades CIN I, CIN II, CIN III -CIN I: dysplastic changes involve the lower third of the epithelium. -CINII: dysplastic changes involve the lower two-thirds of epithelium. -CIN III: epithelial cells are totally replaced by immature atypical cells having no surface differentiation and the basement membrane is intact

CIN I=LSIL (low grade squamous intraepithelial lesion) CINII &CINIII=HSIL(high grade squamous intraepithelial lesion) LSIL: 60% regress, 30%persist, 10% HSIL HSIL: 30%regress, 60%persist,10% carcinoma Early detection by Schiller test, Papanicolaou smear or colposcopy.

Cervical Screening Aim is to detect and treat women with cervical abnormalities which if left untreated could progress into cervical carcinoma All women between 25-65 years should do regular cervical smear

Method; taking an adequate cervical smear which means involving the transformation zone by scraping cells from its surface and spreading the sample on glass slides The smears are stained with Papanicolaou stain and examined to detect squamous epithelial cells showing dyskaryosis Women with CIN 1 are monitored by follow up smears and colpscopy Women with CIN 2 or 3 undergo cervical conization

Cervical screening

Invasive cervical cancer

Age incidence : 50 years. Risk factors Same as in CIN. All cervical invasive squamous cell carcinomas arise from the precursor CIN

Clinical picture

Asymptomatic Abnormal uterine bleeding Intermittent bleeding Post coital Malodorous vaginal discharge

Gross:

Invasive cervical carcinoma may present in 3 forms Ulcerative Exophytic fungating mass Endophytic invasive lesion causing induration or deformities of the cervix ( barrel shaped cervix)

Microscopic types:

Squamous cell carcinoma (keratinizing &non keratinizing) 85% of cases Adenocarcinoma originating from endocervicalglands . Adenosquamous carcinomas. 10% Rare types as small cell carcinoma and undifferentiated carcinoma 5%.

Spread of cervical carcinoma.

Local spread to
the vagina and parametria Rectum urinary bladder obstructing the ureters leading to renal failure which is the most common cause of death.

Metastatic spread to lymph nodes and lung

Staging:

Stage 0: Carcinoma in situ: CIN III. Stage I: Carcinoma confined to the cervix. Stage II: Carcinoma extends beyond the cervix but has not extended into the pelvic wall. The carcinoma extends into the adjacent body of the uterus and upper 2/3 of the vagina. Stage III: Carcinoma invades the pelvic wall, involves the lower 1/3 of the vagina. Stage IV: Carcinoma has extended beyond the true pelvis or involves the mucosa of urinary bladder or rectum. This stage includes those with metastatic dissemination.

Prognosis: Depends on the stage at which the

carcinoma is first discovered. Five years survival rate in stage 0 is 100% and in stage IV is 10%. Death is commonly due to combination of renal failure and sepsis. Fatal hemorrhage from eroded vessels may occur.