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Benign & precancerous
  tumors of female
    genital organs
Benign & precancerous
   tumors of vulva
Urethral Caruncle
• A urethral caruncle is a small, fleshy outgrowth of
  the distal edge of the urethra.
• The tissue of the caruncle is soft, smooth, friable,
  and bright red and initially appears as an eversion
  of the urethra
• They occur most frequently in postmenopausal
  women and must be differentiated from urethral
  carcinomas.
• Urethral caruncles are believed to arise from an
  ectropion of the posterior urethral wall associated
  with retraction and atrophy of the
  postmenopausal vagina.
• The growth of the caruncle is secondary to
  chronic irritation or infection.
• Histologically the caruncle is composed of
  transitional and stratified squamous epithelium
  with a loose connective tissue
• Frequently subdivided by their histologic
  appearance into papillomatous, granulomatous,
  and angiomatous varieties.
• Many women are asymptomatic, whereas others
  experience dysuria, frequency, and urgency.
  Sometimes the caruncle produces point
  tenderness after contact with undergarments or
  during intercourse. Ulcerative lesions usually
  produce spotting on contact more commonly
  than hematuria.
Urethral Caruncle
        • Initial therapy is oral or
          topical estrogen and
          avoidance of irritation.
        • If the caruncle does not
          regress or is symptomatic, it
          may be destroyed by
          cryosurgery, laser therapy,
          fulguration, or operative
          excision.
        • Following operative
          destruction, a Foley catheter
          should be left in place for 48
          to 72 hours.
Papilloma


• Warty sessile growth arises most
  usually from labium major.
Cysts
• The most common large cyst of the vulva is a
  cystic dilation of an obstructed Bartholin's duct.
• Approximately 2% of new gynecologic patients
  present with an asymptomatic Bartholin's duct
  cyst.
• Treatment is not necessary in women younger
  than 40 unless the cyst becomes infected or
  enlarges enough to produce symptoms.
Hydradenoma

• The hidradenoma is a rare, small, benign vulvar tumor that
  originates from apocrine sweat glands of the inner surface of
  the labia majora and nearby perineum. Occasionally, they
  may originate from eccrine sweat glands.
• For unknown reasons, they are discovered exclusively in
  white women between the ages of 30 and 70, most
  commonly in the fourth decade of life. These tumors have
  not been reported prior to puberty. Hidradenomas may be
  cystic or solid. Approximately 50% of hidradenomas are less
  than 1 cm in diameter.
• These tumors have well-defined capsules
• Treatment - surgical
Lipoma

• Lipomas are benign, slow-growing, circumscribed tumors
  of fat cells arising from the subcutaneous tissue of the
  vulva
• The largest vulvar lipoma reported in the literature
  weighed 44 pounds.
• Lipomas are the second most frequent benign vulvar
  mesenchymal tumor. Because of the fat distribution of
  the vulva, most lipomas are discovered in the labia
  majora and are superficial in location.
• They are slow growing, and their malignant potential is
  extremely low.
Fibromas are the
                          most common benign solid
                          tumors of the vulva.
                                  They are more frequent
                          than lipomas, the other common
                          benign tumors of mesenchymal
                          origin.
• Fibromas occur in all age groups and most commonly
  are found in the labia majora.
• However, they actually arise from deeper connective
  tissue. Thus they should be considered as
  dermatofibromas.
• Smaller fibromas are asymptomatic; larger tumors may
  produce chronic pressure symptoms or acute pain when
  they degenerate. Treatment is operative removal if the
  fibromas are symptomatic and/or continue to grow.
  Occasionally they are removed for cosmetic reasons.
Leukoplakia
Lichen sclerosus
   (kraurosis)
Behcet’s
syndrome

• Simultaneous
  ulcerations of
    vulva and
     mouth.
Benign tumors of vagina




• Gaertner cyst of the vagina
Dysontogenetic Cysts
• Dysontogenetic cysts of the vagina are thin-
  walled, soft cysts of embryonic origin. Whether
  the cysts arise from the mesonephros
  (Gartner's duct cyst), the perimesonephrium
  (müllerian cyst), or the urogenital sinus
  (vestibular cyst) is predominantly of academic
  rather than clinical importance. The cysts may
  be differentiated histologically by the epithelial
  lining
• Most of these benign cysts are asymptomatic,
  sausage-shaped tumors that are discovered
  only incidentally during pelvic examination.
  Small asymptomatic Gartner's duct cysts may
  be followed conservatively
Treatment
• Operative excision is indicated for chronic
  symptoms.
• Rarely, one of these cysts becomes infected,
  and if operated on during the acute phase,
  marsupialization of the cyst is preferred.
• Excision of the vaginal cyst may be a much
  more formidable operation than anticipated.
• The cystic structure may extend up into the
  broad ligament and anatomically be in
  proximity to the distal course of the ureter.
Inclusion cysts

• Usually result from birth trauma or
  gynecologic surgery. Often they are
  discovered in the site of a previous
  episiotomy or at the apex of the vagina
  following hysterectomy.
• Histologically, inclusion cysts are lined by
  stratified squamous epithelium. These
  cysts contain a thick, pale-yellow
  substance that is oily and formed by
  degenerating epithelial cells.
Inclusion cysts
• Often these cysts are erroneously called
  sebaceous cysts in the misbelieve that the
  central material is sebaceous.
• Similar to vulvar inclusion cysts, the etiology
  is either a small tag of vaginal epithelium
  buried beneath the surface following a
  gynecologic or obstetric procedure or a
  misplaced island of embryonic remnant that
  was destined to form epithelium.
• The majority of inclusion cysts are
  asymptomatic. If the cyst produces
  dyspareunia or pain, the treatment is
  excisional biopsy.
Vaginal Polyp
• This is a rare tumor which can be seen in
  infants or in adults. The origin from
                           the vaginal
                           mucosa has to
                           be demonstrated
                           to differentiate
                           from much more
                           common urethral
                           caruncles,
                           cervical and
                           uterus polyps.
Vaginal fibroma
• Fibroma of the vagina is a very rare
  tumor. It may be pedunculated and
                         appear at the
                         introitus.
                         Clinically it is a
                         firm benign
                         noninfiltrating
                         growth.
Cervix
Benign cervical lesions
Optional precancerous             Obligatory
          lesions            precancerous lesions
• Cervical erosion       •   Cervical dyplasia
• Leukoplakia (without   •   Leukoplakia (with
  atypia)                    atypia)
• Polyps                 •   Erythroplakia
• Endometriosis          •   Adenomatosis
• Ectropion, scars
• Exo-, endocervicites
• Intraepithelial neoplasia is a spectrum of
  premalignant changes in the epithelium of the
  cervix that histologically show varying degrees
  of cellular atypia. Numerous terms are used to
  describe the severity of the atypias, but there is
  no clearly defined boundary between them.
• During reproductive life the squamocolumnar
  junction is usually on the portio of the cervix
  near the external os. It may be found farther
  away from the os during and after pregnancy
  and usually recedes into the endocervical canal
  after menopause.
• Many cases of cervical intraepithelial neoplasia (CIN)
  do not progress. Some particularly low-grade lesions
  spontaneously regress, but all have the potential for
  progression to malignancy.
• The risk of progression for CIN I (mild dysplasia—
  LGSIL) to a higher grade lesion is approximately
  16%.
• High-grade lesions (carcinoma in situ [CIN III]—
  HGSIL) are at greater risk for malignant progression
  and usually are found in larger abnormal
  transformation zones.
• Malignant progression risk is greatest for CIN III,
  least for CIN I, and intermediate for CIN II.
• Carcinoma in situ with gland involvement is treated
  the same as carcinoma in situ without gland
  involvement.
• The precise cause of CIN is not known but
  appears to be associated with sexual activity
  and HPV infection.
• Females with multiple sex partners are at
  increased risk for CIN, and males with multiple
  sex partners increase the risk of neoplasia for a
  female sex partner.
• Cigarette smoking increases the risk of CIN.
  Increased levels of vitamins A and E may
  decrease the risk.
• Prolonged oral contraceptive use (more than 5
  years) is associated with an increased
  frequency of cervical neoplasia.
Diagram of cervical epithelium showing various
terminologies used to characterize progressive
        degrees of cervical neoplasia
Potential Risk Factors for Cervical Neoplasia
Epidemiologic Characteristics       Other Potential Factors
• Early intercourse             •   Oral contraceptives
• Multiple sex partners         •   Cigarette smoking
• Early marriage                •   Vitamin C
• Early childbearing            •   Prior radiation
• Prostitution                  •   Intrauterine DES
• Male factors — "high-risk"        exposure
  consort                       •   Lupus erythematosus
• Socioeconomic status,         •   Vitamins A and E,
  race                              folates
• STD infection                         Viral Relations
• Immune status, including      •   Papillomavirus
  HIV infection                 •   Herpesvirus
                                •   Cytomegalovirus
Oncogenic Potential of HPV
            Types
  Potential       HPV Types

• Nononcogenic   6, 11, 42, 43, 44

• Oncogenic      16, 18, 31, 33, 35,
                 39, 45, 51, 52, 56,
                 58, 59, 68
• The false negative rate for properly performed cytology
   smears is approximately 5% to 20%.
• "Rapidly progressing" cervical carcinoma appears
   primarily due to false-negative smears rather than to a
   true rapid progression from normal to malignant
   epithelium.
• Abnormal cells on Pap smears occur with increasing
   frequency in those receiving chemotherapy and in
   patients with lupus erythematosus.
• The colposcope is used to evaluate the cervix if an
   abnormal Pap smear is present. Usually multiple biopsy
   specimens of an abnormal transformation zone are
   needed for an adequate evaluation.
• Colposcopic and cytologic findings do not establish a
   diagnosis; biopsy is necessary.
Narrow brushes for endocervical sampling.

Top, Q-Tip;
middle, Cervix Brush (Unimar);
bottom, Cytobrush (Medscand).
Cytology Technique


                 Scrape of exocervix




    Scrape
of endocervix.
Traditional Classification of Papanicolaou
                  Smear

•   Normal
•   Metaplasia
•   Inflammation
•   Minimal atypia—koilocytosis
•   Mild dysplasia (CIN I)
•   Moderate dysplasia (CIN II)
•   Severe dysplasia—carcinoma in situ (CIN III)
•   Invasive carcinoma
Bethesda Classification (Modified)
• Adequacy of smear
• Infection type
• Squamous abnormalities
  – Reactive (inflammatory change)
  – Epithelial cell abnormalities
     • Atypical type, undetermined
     • Squamous intraepithelial lesions (SILs)
  – Low grade: HPV or mild dysplasia (CIN I)
  – High grade: moderate to severe dysplasia—
    carcinoma in situ (CIN II-III)
  – Glandular cells
     • Atypical and source
     • Adenocarcinoma and source
Evaluation of Abnormal Pap Smear
Antibody-mediated viral
        neutralization.
Neutralizing,
conformational isotopes
are expressed on the
surface of human
papillomavirus (HPV)
virions.
The epitopes (antigens)
are recognized by
lymphocytes, and specific
neutralizing antibodies are
generated. These
neutralizing antibodies
bind specifically to surface
epitopes and inhibit viral
infection.
Therapy of Intraepithelial Neoplasia
           Ablative Treatment
               • Cryotherapy


 Three varieties of
cryotherapy probes.
Therapy of Intraepithelial Neoplasia
            Ablative Treatment
                       Laser Therapy
•   The laser has been widely used in conjunction with
    the colposcope.
•   The energy from the laser beam is absorbed by
    water with resultant vaporization of the target tissue.
•   The laser beam is controlled by a small "joystick,"
    and the spot size of the laser can be varied but is
    usually less than 1 mm.
•   Usually therapy is carried to a depth of 5 to 7 mm
    and a power density of over 600 W/cm2
•   the complications of pain and bleeding are also
    related to the power density and depth of treatment.
Cautery
• Electrocautery was the mainstay of outpatient
  therapy of CIN before the advent of
  cryosurgery, laser therapy, and the LEEP
  procedure.
• The treatment can be accomplished with a hot
  wire unit generating heat to the cervix or an
  electrodiathermy unit, which requires current to
  be passed through the tissues and electrical
  grounding of the patient.
• The treatment is carried out with sufficient
  depth to destroy cervical glands.
• An electrocautery unit is less expensive than the
  laser and appears able to yield comparable
  therapy results to cryosurgery but is infrequently
  used today.
Excisional Therapy
                          • Conization
•   if the colposcopic examination is unsatisfactory,
•   if there is uncertainty regarding the presence of
    invasive disease,
•   if there is neoplasm in the endocervix,
•   if the cells seen on cytologic examination are not
    adequately explained by the biopsy specimens
•   if the biopsy suggests the possibility of microinvasion
•   if invasion is suspected but cannot be confirmed,
    conization is mandatory because the proper diagnosis
    of microinvasion cannot be made from a biopsy
    specimen.
•   excisional therapy is also carried out when childbearing
    function is to be maintained or when a patient prefers
    therapy less extensive than hysterectomy and is willing
    to adhere to a strict protocol for follow-up.
TECHNIQUE
• COLD KNIFE CON
• LASER CONIZATION.
• LOOP ELECTROEXCISION PROCEDURE
  (LEEP)


                  Examples of electrodes
                  used for a LEEP procedure.
A, Cone biopsy for CIN of exocervix. Limits of
lesion were identified colposcopically.
B, Cone biopsy for endocervical disease. Limits of
lesions were not seen colposcopically.
• The goal of treatment in CIN is eradication of all
   abnormal tissue.
• Laser therapy, cryotherapy, and electrocautery have
   been reported to have equivalent results and lead to
   eradication of the lesions in about 90% of the patients
   with carcinoma in situ after initial therapy.
• Cervical stenosis, infertility, and premature birth may
   result from excisional therapy of CIN if large areas of
   the endocervix are destroyed. Limiting the cone or LEEP
   height to less than 1.5 to 2.0 cm decreases this risk.
• Conization for the therapy of CIN is as effective as
   hysterectomy, especially if the margins are free of
   disease.
• Evaluation of the abnormal Pap smear in pregnancy is
   conducted primarily to rule out the presence of invasive
   carcinoma. CIN is evaluated and treated in the
   postpartum period.
• Some CIN lesions discovered during pregnancy
   spontaneously regress postpartum.
• The risk of long-term development (up to 10 years) of
   intraepithelial neoplasia following initial therapy is about
   3%.
• Most short-term recurrences of intraepithelial neoplasia
   occur within 1 to 2 years after initial treatment.
• Patients treated for CIN should have annual cytology
   indefinitely.
Ulcer of the cervix


                      • A true ulcer
                        with loss of
                        epithelial
                        covering is
                        seen in the
                        anterior lip
                        of cervix
Lacerations
• Cervical lacerations frequently occur with both
  normal and abnormal deliveries.
• Lacerations may occur in non-pregnant women with
  mechanical dilation of the cervix.
• Obstetric lacerations vary from minor superficial tears
  to extensive full-thickness lacerations at 3 and 9
  o'clock, respectively, which may extend into the
  broad ligament. In gynecology the atrophic cervix of
  the postmenopausal woman predisposes to the
  complication of cervical laceration when the cervix is
  mechanically dilated for a diagnostic dilation and
  curettage.
• Acute cervical lacerations bleed and should be
  sutured.
• Cervical lacerations that are not repaired may give
  the external os of the cervix a fish-mouthed
  appearance; however, they are usually
  asymptomatic.
Lacerations
• The use of laminaria tents to slowly soften and dilate
  the cervix before mechanical instrumentation of the
  endometrial cavity has reduced the magnitude of
  iatrogenic cervical lacerations.
• Furthermore, the practice of routine inspection of the
  cervix, stabilized with one or more ring forceps,
  following every second- or third-trimester delivery
  has enabled physicians to discover and repair
  extensive cervical lacerations.
• Lacerations should be palpated to determine the
  extent of cephalad extension of the tear.
• Extensive cervical lacerations especially those
  involving the endocervical stroma may lead to
  incompetence of the cervix during a subsequent
  pregnancy.
Ectropion
Cervical polyp
• Endocervical and cervical polyps are the most common
  benign neoplastic growths of the cervix.
• Cervical polyps usually present as a single polyp, but
  multiple polyps do occur occasionally. The majority are
  smooth, soft, reddish-purple to cherry red, and fragile.
  They readily bleed when touched. Endocervical polyps may
  be single or multiple and are a few millimeters to 4 cm in
  diameter.
• The classic symptom of an endocervical polyp is
  intermenstrual bleeding, especially following contact such
  as coitus or a pelvic examination. Sometimes an associated
  leukorrhea emanates from the infected cervix. Many
  endocervical polyps are asymptomatic and recognized for
  the first time during a routine speculum examination. Often
  the polyp seen on inspection is difficult to palpate because
  of its soft consistency.
• Histologically the surface epithelium of the polyp is
  columnar or squamous epithelium, depending on the site of
  origin and the degree of squamous metaplasia
Cervical polyp
Cervical Myomas
• Cervical myomas are smooth, firm masses that
  are similar to myomas of the fundus.
• A cervical myoma is usually a solitary growth in
  contrast to uterine myomas, which in general,
  are multiple.
• Depending on the series, 3% to 8% of myomas
  are categorized as cervical myomas.
• Because of the relative paucity of smooth
  muscle fibers in the cervical stroma, the
  majority of myomas that appear to be cervical
  actually arise from the isthmus of the uterus.
Fibroma of the cervix
Cervical Myomas
• Most cervical myomas are small and asymptomatic.
  When symptoms do occur, they are dependent on the
  direction in which the enlarging myoma expands. The
  expanding myoma produces symptoms secondary to
  mechanical pressure on adjacent organs. Cervical
  myomas may produce dysuria, urgency, urethral or
  ureteral obstruction, dyspareunia, or obstruction of the
  cervix.
• Occasionally a cervical myoma may become
  pedunculated and protrude through the external os of
  the cervix. These prolapsed myomas are often
  ulcerated and infected. A very large cervical myoma
  may produce distortion of the cervical canal and upper
  vagina. Rarely, a cervical myoma causes dystocia
  during childbirth.
• The diagnosis of a cervical myoma is by inspection and
  palpation.
Diffuse Capillary Haemangioma
UTERUS
Endometrial Polyp
• Endometrial polyps are localized overgrowths of
  endometrial glands and stroma that project beyond the
  surface of the endometrium.
• They are soft, pliable, and may be single or multiple.
  Most polyps arise from the fundus of the uterus.
• Polypoid hyperplasia is a benign condition in which
  numerous small polyps are discovered throughout the
  endometrial cavity.
• Endometrial polyps vary from a few millimeters to
  several centimeters in diameter, and it is possible for a
  single large polyp to fill the endometrial cavity.
• Endometrial polyps may have a broad base (sessile) or
  be attached by a slender pedicle (pedunculated).
Endometrial Polyp
• The majority of endometrial polyps are asymptomatic.
  Those that are symptomatic are associated with a wide
  range of abnormal bleeding patterns. No single
  abnormal bleeding pattern is diagnostic for polyps;
  however, menorrhagia, premenstrual and postmenstrual
  staining, and scanty postmenstrual spotting are the
  most common. Occasionally a pedunculated endometrial
  polyp with a long pedicle may protrude from the
  external cervical os. Sometimes large endometrial
  polyps may contribute to infertility.
• Polyps are succulent and velvety, with a large central
  vascular core. The color is usually gray or tan but may
  occasionally be red or brown. Histologically an
  endometrial polyp has three components: endometrial
  glands, endometrial stroma, and central vascular
  channels
Endometrial Polyp
• Malignant change, when found in an endometrial polyp,
  is usually curable, and the endometrial carcinoma is most
  often of a low stage and grade.
• It is interesting that benign polyps have been found in
  approximately 20% of uteri removed for endometrial
  carcinoma. Recently, unusual polyps have been described
  in association with chronic administration of the
  nonsteroidal anti-estrogen tamoxifen.
• The incidence of endometrial abnormalities associated
  with chronic tamoxifen therapy is polyps 20% to 35%,
  endometrial hyperplasia 2% to 4%, and endometrial
  carcinoma 1% to 2%.
• The management of endometrial polyps is removal by
  curettage or via the hysteroscope.
• Because of the frequent association of endometrial polyps
  and other endometrial pathology, it is important to
  examine histologically both the polyp and the associated
  endometrial lining. Polyps, because of their mobility, often
  tend to elude the curette.
Tiny hysteroscopic scissors,
                          about as big around as the
                          ink tube on a standard writing
                          pen, are used to cut the stalk.




Photo taken during
Hysteroscopy of a small
endometrial polyp.
Notice the stalk.
Leiomyomas
• Leiomyomas, also called myomas, are benign tumors of
  muscle cell origin.
• These tumors are often referred to by their popular
  names, fibroids or fibromyomas, but both terms are
  semantic misnomers if one is referring to the cell of
  origin.
• Most leiomyomas contain varying amounts of fibrous
  tissue, which is believed to be secondary to
  degeneration of some of the smooth muscle cells.
• Leiomyomas are the most frequent pelvic tumors, with
  the highest prevalence occurring during the fifth decade
  of a woman's life.
• Although leiomyomas arise throughout the body in any
  structure containing smooth muscle, in the pelvis the
  majority are found in the corpus of the uterus.
• Occasionally, leiomyomas may be found in the fallopian
  tube or the round ligament, and approximately 5% of
  uterine myomas originate from the cervix.
• Myomas may be single but most often are multiple.
  Myomas are discovered in one of four white women and
  one of two black women.
• They vary greatly in size from microscopic to
  multinodular uterine tumors that may weigh more than
  50 pounds and literally fill the patient's abdomen.
• Myomas are more prone to grow and become
  symptomatic in nulliparous women. The question as to
  why some women develop myomas while others do not
  is unanswered. However, genetic determinants definitely
  contribute to their development. Symptomatic uterine
  leiomyomas are the primary indication for approximately
  30% of all hysterectomies.
• Initially most myomas develop from the myometrium,
  beginning as intramural myomas. As they grow, they
  remain attached to the myometrium with a pedicle of
  varying width and thickness.
• Myomas are classed into subgroups by their relative
  anatomic relationship and position to the layers of the
  uterus.
• The three most common types of myomas are
  intramural, subserous, and submucous, with special
  nomenclature for broad ligament and parasitic myomas.
• Continued growth in one direction determines which
  myomas will be located just below the endometrium
  (submucosal) and which will be found just beneath the
  serosa (subserosal)
• The most common symptoms related to myomas are
  pressure from an enlarging pelvic mass, pain including
  dysmenorrhea, and abnormal uterine bleeding. The
  severity of symptoms is usually related to the number,
  location, and size of the myomas. However, the
  majority of women with uterine myomas are
  asymptomatic.
Benign & precancerous tumors of female genital organs
• Laparoscopic view of a uterus with a
  pedunculated posterior myoma
• A fibroid in this location should not affect
  chances for pregnancy or miscarriage
• However, if it were pushing into the cavity of
  the uterus, it might cause problems
Diagnosis
• The majority of uterine myomas may be
  diagnosed by pelvic examination, difficult cases
  will benefit from ultrasound examination or a
  search for concentric calcifications on an
  abdominal x-ray film.
• There are several recent reports of computed
  tomography (CT) and magnetic resonance
  imaging (MRI) studies of uterine myomas.
• However, these imaging techniques are more
  expensive than ultrasound.
• Until CT and MRI can distinguish between benign
  and malignant myomas, they will rarely be
  ordered in routine clinical management of
  myomas.
Treatment
• The management of a woman with small,
  asymptomatic myomas is judicious observation. When
  the tumor is first discovered, it is appropriate to
  perform a pelvic examination at 6-month intervals to
  determine the rate of growth. The majority of women
  will not need an operation, especially those women in
  the perimenopausal period, where the condition
  usually improves with diminishing levels of circulating
  estrogens.
• Women with abnormal bleeding and leiomyomas
  should be investigated thoroughly for concurrent
  problems such as endometrial hyperplasia. If their
  symptoms do not improve with conservative
  management, operative therapy may be considered.
  The choice between a myomectomy and hysterectomy
  is usually determined by the patient's age, parity, and
  most important, future reproductive plans.
• Classic indications for a myomectomy
  include:
  – a rapidly expanding pelvic mass,
  – persistent abnormal bleeding,
  – pain or pressure,
  – enlargement of an asymptomatic myoma
    to more than 8 cm in a woman who has
    not completed childbearing.
• Two associated but rare diseases should be noted:
  intravenous leiomyomatosis and leiomyomatosis
  peritonealis disseminata. Intravenous leiomyomatosis is a
  rare condition in which benign smooth muscle fibers
  invade and slowly grow into the venous channels of the
  pelvis. The tumor grows by direct extension and grossly
  appears like a "spaghetti" tumor. Only 25% of tumors
  extend beyond the broad ligament; however, case reports
  exist of tumor growth into the vena cava and right heart.
• Leiomyomatosis peritonealis disseminata (LPD) is a benign
  disease with multiple small nodules over the surface of the
  pelvis and abdominal peritoneum. Grossly, LPD mimics
  disseminated carcinoma. However, histologic examination
  demonstrates benign-appearing myomas. This disorder is
  usually associated with a recent pregnancy.
Ovary
Adenomatoid Tumors
• The most prevalent benign tumor of the oviduct is the
  angiomyoma or adenomatoid tumor.
• They are small, gray-white, circumscribed nodules, 1 to
  2 cm in diameter.
• These tumors are usually unilateral and present as
  small nodules just under the tubal serosa.
• These small nodules do not produce pelvic symptoms
  or signs.
• These benign tumors also are found below the serosa
  of the fundus of the uterus and the broad ligament.
• Microscopically they are composed of small tubules
  lined by a low cuboidal or flat epithelium. Histologic
  studies have established that the thin-walled channels
  that comprise these tumors are of mesothelial origin.
• These tumors do not become malignant; however, they
  may be mistaken for a low-grade neoplasm when
  initially viewed during a frozen-section evaluation.
Follicular Cysts
• Follicular cysts are by far the most frequent
  cystic structures in normal ovaries.
• The cysts are frequently multiple and may
  vary from a few millimeters to as large as 15
  cm in diameter.
• However, a normal follicle may physiologically
  become cystic, and therefore it is important
  to have a minimal diameter for a follicular
  cyst.
• This diameter is generally considered to be
  between 2.5 and 3 cm. Follicular cysts are not
  neoplastic and are believed to be dependent
  on gonadotrophins for growth.
• Enlarged polycystic
                                              ovary following
                                              laparoscopic
                                              cauterization




Follicular cysts are translucent, thin walled, and are filled with a watery,
clear to straw-colored fluid. If a small opening in the capsule of the cyst
suddenly develops, the cyst fluid under pressure will squirt out. These
cysts are situated in the ovarian cortex, and sometimes they appear as
translucent domes on the surface of the ovary.
Corpus Luteum Cysts
• Corpus luteum cysts are less common than follicular
  cysts, but clinically they are more important.
• Corpus luteum cysts may be associated with either
  normal endocrine function or prolonged secretion of
  progesterone. The associated menstrual pattern may be
  normal, delayed menstruation, or amenorrhea.
• Most corpus luteum cysts are small, the average
  diameter being 4 cm.
• Corpus luteum cysts vary from being asymptomatic
  masses to those causing catastrophic and massive
  intraperitoneal bleeding associated with rupture.
• Many corpus luteum cysts produce dull, unilateral, lower
  abdominal and pelvic pain. The enlarged ovary is
  moderately tender on pelvic examination. Depending on
  the amount of progesterone secretion associated with
  cysts, the menstrual bleeding may be normal or delayed
  several days to weeks with subsequent menorrhagia.
• Corpus luteum cyst with thickened cyst
  wall and definite lutein cell lining
  recognized by its color. Cyst is filled
  with hemorrhagic gelatinous material.
Benign Cystic Teratoma (Dermoid Cyst,
          Mature Teratoma)
• Benign ovarian teratomas are usually cystic structures
  that on histologic examination contain elements from
  all three germ cell layers.
• The word teratoma was first advanced by Virchow and
  translated literally means "monstrous growth."
• Teratomas of the ovary may be benign or malignant.
  Although dermoid is a misnomer, it is the most
  common term used to describe the benign cystic tumor,
  composed of mature cells, whereas the malignant
  variety is composed of immature cells (immature
  teratoma).
• Dermoid is a descriptive term in that it emphasizes the
  preponderance of ectodermal tissue with some
  mesodermal and rare endodermal derivatives.
• Malignant teratomas that are immature are usually solid
  with some cystic areas and histologically contain
  immature or embryonic-appearing tissue.
• From 50% to 60% of dermoids are asymptomatic and
  are discovered during a routine pelvic examination,
  coincidentally visualized by an abdominal x-ray or
  ultrasound examination, or found incidentally at
  laparotomy.
• Presenting symptoms of dermoids include pain, and the
  sensation of pelvic pressure.
• Specific complications of dermoid cysts include torsion,
  rupture, infection, hemorrhage, and malignant
  degeneration.
• Three medical diseases also may be associated with
  dermoid cysts: thyrotoxicosis, carcinoid syndrome, and
  autoimmune hemolytic anemia. Torsion of a dermoid is
  the most frequent complication
• Benign cystic teratoma. This section
  from the tumor demonstrates areas of
  hair (dark arrows) and solid sebaceous
  material (S).
Fibroma
• Fibromas are the most common benign, solid neoplasms
  of the ovary. Their malignant potential is low, less than
  1%. These tumors comprise approximately 5% of benign
  ovarian neoplasms and approximately 20% of all solid
  tumors of the ovary.

• The pelvic symptoms that develop with growth of
  fibromas include pressure and abdominal enlargement,
  which may be secondary to both the size of the tumor
  and ascites.
• Smaller tumors are asymptomatic because these tumors
  do not elaborate hormones. Thus there is no change in
  the pattern of menstrual flow.
• Fibromas may be pedunculated and therefore easily
  palpable during one examination yet difficult to palpate
  during a subsequent pelvic examination.
• Sometimes on pelvic examination the fibromas appear to
  be softer than a solid ovarian tumor because of the
  edema and/or occasional cystic degeneration.
Meigs' syndrome
• Meigs' syndrome is the association of an
  ovarian fibroma, ascites, and
  hydrothorax. Both the ascites and the
  hydrothorax resolve after removal of
  the ovarian tumor. The ascites is
  caused by transudation of fluid from the
  ovarian fibroma.
• Fibroma of ovary. Cut surface shows
  somewhat edematous, interlacing
  bundles of connective tissue.
Transitional Cell Tumors—Brenner Tumors
• Brenner tumors are rare, small, smooth, solid,
  fibroepithelial ovarian tumors that are generally
  asymptomatic. The semantic classification of
  neoplasms changes and the current preferred term for
  benign Brenner tumor is transitional cell tumor. The
  benign, proliferative (low malignant potential), and
  malignant forms together comprise approximately 2%
  of ovarian tumors.
• These tumors usually occur in women aged 40 to 60
  years.
• Grossly, Brenner tumors are smooth, firm, gray-white,
  solid tumors that grossly resemble fibromas. Similar to
  fibromas, transitional cell tumors are slow growing
• Management of Brenner tumors is operative, with
  simple excision being the procedure of choice.
Adenofibroma and Cystadenofibroma
• Adenofibromas and cystadenofibromas are closely
  related. Both of these benign firm tumors consist of
  fibrous and epithelial components.
• The epithelial element is most commonly serous, but
  histologically may be mucinous and endometrioid or
  clear cell.
• They differ from benign epithelial cystadenomas in that
  there is a preponderance of connective tissue.
• Most pathologists emphasize that at least 25% of the
  tumor consists of fibrous connective tissue. Obviously,
  cystadenofibromas have microscopic or occasional
  macroscopic areas that are cystic.
• The varying degree of fibrous stroma and epithelial
  elements produces a spectrum of tumors, which have
  resulted in a confusing nomenclature with terms such as
  papillomas, fibropapillomas, and fibroadenomas.
Adenofibroma and Cystadenofibroma
• Smaller tumors are asymptomatic and are
  only discovered incidentally during abdominal
  or pelvic operations. Large tumors may cause
  pressure symptoms or, rarely, undergo
  adnexal torsion.
• Because adenofibromas are usually
  discovered in postmenopausal women, the
  treatment of choice is bilateral salpingo-
  oophorectomy and total abdominal
  hysterectomy. Because these tumors are
  benign and because malignant transformation
  is rare, simple excision of the tumor and
  inspection of the contralateral ovary is
  appropriate in younger women.
THE END

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Benign & precancerous tumors of female genital organs

  • 1. Benign & precancerous tumors of female genital organs
  • 2. Benign & precancerous tumors of vulva
  • 3. Urethral Caruncle • A urethral caruncle is a small, fleshy outgrowth of the distal edge of the urethra. • The tissue of the caruncle is soft, smooth, friable, and bright red and initially appears as an eversion of the urethra • They occur most frequently in postmenopausal women and must be differentiated from urethral carcinomas. • Urethral caruncles are believed to arise from an ectropion of the posterior urethral wall associated with retraction and atrophy of the postmenopausal vagina.
  • 4. • The growth of the caruncle is secondary to chronic irritation or infection. • Histologically the caruncle is composed of transitional and stratified squamous epithelium with a loose connective tissue • Frequently subdivided by their histologic appearance into papillomatous, granulomatous, and angiomatous varieties. • Many women are asymptomatic, whereas others experience dysuria, frequency, and urgency. Sometimes the caruncle produces point tenderness after contact with undergarments or during intercourse. Ulcerative lesions usually produce spotting on contact more commonly than hematuria.
  • 5. Urethral Caruncle • Initial therapy is oral or topical estrogen and avoidance of irritation. • If the caruncle does not regress or is symptomatic, it may be destroyed by cryosurgery, laser therapy, fulguration, or operative excision. • Following operative destruction, a Foley catheter should be left in place for 48 to 72 hours.
  • 6. Papilloma • Warty sessile growth arises most usually from labium major.
  • 7. Cysts • The most common large cyst of the vulva is a cystic dilation of an obstructed Bartholin's duct. • Approximately 2% of new gynecologic patients present with an asymptomatic Bartholin's duct cyst. • Treatment is not necessary in women younger than 40 unless the cyst becomes infected or enlarges enough to produce symptoms.
  • 8. Hydradenoma • The hidradenoma is a rare, small, benign vulvar tumor that originates from apocrine sweat glands of the inner surface of the labia majora and nearby perineum. Occasionally, they may originate from eccrine sweat glands. • For unknown reasons, they are discovered exclusively in white women between the ages of 30 and 70, most commonly in the fourth decade of life. These tumors have not been reported prior to puberty. Hidradenomas may be cystic or solid. Approximately 50% of hidradenomas are less than 1 cm in diameter. • These tumors have well-defined capsules • Treatment - surgical
  • 9. Lipoma • Lipomas are benign, slow-growing, circumscribed tumors of fat cells arising from the subcutaneous tissue of the vulva • The largest vulvar lipoma reported in the literature weighed 44 pounds. • Lipomas are the second most frequent benign vulvar mesenchymal tumor. Because of the fat distribution of the vulva, most lipomas are discovered in the labia majora and are superficial in location. • They are slow growing, and their malignant potential is extremely low.
  • 10. Fibromas are the most common benign solid tumors of the vulva. They are more frequent than lipomas, the other common benign tumors of mesenchymal origin. • Fibromas occur in all age groups and most commonly are found in the labia majora. • However, they actually arise from deeper connective tissue. Thus they should be considered as dermatofibromas. • Smaller fibromas are asymptomatic; larger tumors may produce chronic pressure symptoms or acute pain when they degenerate. Treatment is operative removal if the fibromas are symptomatic and/or continue to grow. Occasionally they are removed for cosmetic reasons.
  • 12. Lichen sclerosus (kraurosis)
  • 13. Behcet’s syndrome • Simultaneous ulcerations of vulva and mouth.
  • 14. Benign tumors of vagina • Gaertner cyst of the vagina
  • 15. Dysontogenetic Cysts • Dysontogenetic cysts of the vagina are thin- walled, soft cysts of embryonic origin. Whether the cysts arise from the mesonephros (Gartner's duct cyst), the perimesonephrium (müllerian cyst), or the urogenital sinus (vestibular cyst) is predominantly of academic rather than clinical importance. The cysts may be differentiated histologically by the epithelial lining • Most of these benign cysts are asymptomatic, sausage-shaped tumors that are discovered only incidentally during pelvic examination. Small asymptomatic Gartner's duct cysts may be followed conservatively
  • 16. Treatment • Operative excision is indicated for chronic symptoms. • Rarely, one of these cysts becomes infected, and if operated on during the acute phase, marsupialization of the cyst is preferred. • Excision of the vaginal cyst may be a much more formidable operation than anticipated. • The cystic structure may extend up into the broad ligament and anatomically be in proximity to the distal course of the ureter.
  • 17. Inclusion cysts • Usually result from birth trauma or gynecologic surgery. Often they are discovered in the site of a previous episiotomy or at the apex of the vagina following hysterectomy. • Histologically, inclusion cysts are lined by stratified squamous epithelium. These cysts contain a thick, pale-yellow substance that is oily and formed by degenerating epithelial cells.
  • 18. Inclusion cysts • Often these cysts are erroneously called sebaceous cysts in the misbelieve that the central material is sebaceous. • Similar to vulvar inclusion cysts, the etiology is either a small tag of vaginal epithelium buried beneath the surface following a gynecologic or obstetric procedure or a misplaced island of embryonic remnant that was destined to form epithelium. • The majority of inclusion cysts are asymptomatic. If the cyst produces dyspareunia or pain, the treatment is excisional biopsy.
  • 19. Vaginal Polyp • This is a rare tumor which can be seen in infants or in adults. The origin from the vaginal mucosa has to be demonstrated to differentiate from much more common urethral caruncles, cervical and uterus polyps.
  • 20. Vaginal fibroma • Fibroma of the vagina is a very rare tumor. It may be pedunculated and appear at the introitus. Clinically it is a firm benign noninfiltrating growth.
  • 22. Benign cervical lesions Optional precancerous Obligatory lesions precancerous lesions • Cervical erosion • Cervical dyplasia • Leukoplakia (without • Leukoplakia (with atypia) atypia) • Polyps • Erythroplakia • Endometriosis • Adenomatosis • Ectropion, scars • Exo-, endocervicites
  • 23. • Intraepithelial neoplasia is a spectrum of premalignant changes in the epithelium of the cervix that histologically show varying degrees of cellular atypia. Numerous terms are used to describe the severity of the atypias, but there is no clearly defined boundary between them. • During reproductive life the squamocolumnar junction is usually on the portio of the cervix near the external os. It may be found farther away from the os during and after pregnancy and usually recedes into the endocervical canal after menopause.
  • 24. • Many cases of cervical intraepithelial neoplasia (CIN) do not progress. Some particularly low-grade lesions spontaneously regress, but all have the potential for progression to malignancy. • The risk of progression for CIN I (mild dysplasia— LGSIL) to a higher grade lesion is approximately 16%. • High-grade lesions (carcinoma in situ [CIN III]— HGSIL) are at greater risk for malignant progression and usually are found in larger abnormal transformation zones. • Malignant progression risk is greatest for CIN III, least for CIN I, and intermediate for CIN II. • Carcinoma in situ with gland involvement is treated the same as carcinoma in situ without gland involvement.
  • 25. • The precise cause of CIN is not known but appears to be associated with sexual activity and HPV infection. • Females with multiple sex partners are at increased risk for CIN, and males with multiple sex partners increase the risk of neoplasia for a female sex partner. • Cigarette smoking increases the risk of CIN. Increased levels of vitamins A and E may decrease the risk. • Prolonged oral contraceptive use (more than 5 years) is associated with an increased frequency of cervical neoplasia.
  • 26. Diagram of cervical epithelium showing various terminologies used to characterize progressive degrees of cervical neoplasia
  • 27. Potential Risk Factors for Cervical Neoplasia Epidemiologic Characteristics Other Potential Factors • Early intercourse • Oral contraceptives • Multiple sex partners • Cigarette smoking • Early marriage • Vitamin C • Early childbearing • Prior radiation • Prostitution • Intrauterine DES • Male factors — "high-risk" exposure consort • Lupus erythematosus • Socioeconomic status, • Vitamins A and E, race folates • STD infection Viral Relations • Immune status, including • Papillomavirus HIV infection • Herpesvirus • Cytomegalovirus
  • 28. Oncogenic Potential of HPV Types Potential HPV Types • Nononcogenic 6, 11, 42, 43, 44 • Oncogenic 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68
  • 29. • The false negative rate for properly performed cytology smears is approximately 5% to 20%. • "Rapidly progressing" cervical carcinoma appears primarily due to false-negative smears rather than to a true rapid progression from normal to malignant epithelium. • Abnormal cells on Pap smears occur with increasing frequency in those receiving chemotherapy and in patients with lupus erythematosus. • The colposcope is used to evaluate the cervix if an abnormal Pap smear is present. Usually multiple biopsy specimens of an abnormal transformation zone are needed for an adequate evaluation. • Colposcopic and cytologic findings do not establish a diagnosis; biopsy is necessary.
  • 30. Narrow brushes for endocervical sampling. Top, Q-Tip; middle, Cervix Brush (Unimar); bottom, Cytobrush (Medscand).
  • 31. Cytology Technique Scrape of exocervix Scrape of endocervix.
  • 32. Traditional Classification of Papanicolaou Smear • Normal • Metaplasia • Inflammation • Minimal atypia—koilocytosis • Mild dysplasia (CIN I) • Moderate dysplasia (CIN II) • Severe dysplasia—carcinoma in situ (CIN III) • Invasive carcinoma
  • 33. Bethesda Classification (Modified) • Adequacy of smear • Infection type • Squamous abnormalities – Reactive (inflammatory change) – Epithelial cell abnormalities • Atypical type, undetermined • Squamous intraepithelial lesions (SILs) – Low grade: HPV or mild dysplasia (CIN I) – High grade: moderate to severe dysplasia— carcinoma in situ (CIN II-III) – Glandular cells • Atypical and source • Adenocarcinoma and source
  • 35. Antibody-mediated viral neutralization. Neutralizing, conformational isotopes are expressed on the surface of human papillomavirus (HPV) virions. The epitopes (antigens) are recognized by lymphocytes, and specific neutralizing antibodies are generated. These neutralizing antibodies bind specifically to surface epitopes and inhibit viral infection.
  • 36. Therapy of Intraepithelial Neoplasia Ablative Treatment • Cryotherapy Three varieties of cryotherapy probes.
  • 37. Therapy of Intraepithelial Neoplasia Ablative Treatment Laser Therapy • The laser has been widely used in conjunction with the colposcope. • The energy from the laser beam is absorbed by water with resultant vaporization of the target tissue. • The laser beam is controlled by a small "joystick," and the spot size of the laser can be varied but is usually less than 1 mm. • Usually therapy is carried to a depth of 5 to 7 mm and a power density of over 600 W/cm2 • the complications of pain and bleeding are also related to the power density and depth of treatment.
  • 38. Cautery • Electrocautery was the mainstay of outpatient therapy of CIN before the advent of cryosurgery, laser therapy, and the LEEP procedure. • The treatment can be accomplished with a hot wire unit generating heat to the cervix or an electrodiathermy unit, which requires current to be passed through the tissues and electrical grounding of the patient. • The treatment is carried out with sufficient depth to destroy cervical glands. • An electrocautery unit is less expensive than the laser and appears able to yield comparable therapy results to cryosurgery but is infrequently used today.
  • 39. Excisional Therapy • Conization • if the colposcopic examination is unsatisfactory, • if there is uncertainty regarding the presence of invasive disease, • if there is neoplasm in the endocervix, • if the cells seen on cytologic examination are not adequately explained by the biopsy specimens • if the biopsy suggests the possibility of microinvasion • if invasion is suspected but cannot be confirmed, conization is mandatory because the proper diagnosis of microinvasion cannot be made from a biopsy specimen. • excisional therapy is also carried out when childbearing function is to be maintained or when a patient prefers therapy less extensive than hysterectomy and is willing to adhere to a strict protocol for follow-up.
  • 40. TECHNIQUE • COLD KNIFE CON • LASER CONIZATION. • LOOP ELECTROEXCISION PROCEDURE (LEEP) Examples of electrodes used for a LEEP procedure.
  • 41. A, Cone biopsy for CIN of exocervix. Limits of lesion were identified colposcopically. B, Cone biopsy for endocervical disease. Limits of lesions were not seen colposcopically.
  • 42. • The goal of treatment in CIN is eradication of all abnormal tissue. • Laser therapy, cryotherapy, and electrocautery have been reported to have equivalent results and lead to eradication of the lesions in about 90% of the patients with carcinoma in situ after initial therapy. • Cervical stenosis, infertility, and premature birth may result from excisional therapy of CIN if large areas of the endocervix are destroyed. Limiting the cone or LEEP height to less than 1.5 to 2.0 cm decreases this risk. • Conization for the therapy of CIN is as effective as hysterectomy, especially if the margins are free of disease.
  • 43. • Evaluation of the abnormal Pap smear in pregnancy is conducted primarily to rule out the presence of invasive carcinoma. CIN is evaluated and treated in the postpartum period. • Some CIN lesions discovered during pregnancy spontaneously regress postpartum. • The risk of long-term development (up to 10 years) of intraepithelial neoplasia following initial therapy is about 3%. • Most short-term recurrences of intraepithelial neoplasia occur within 1 to 2 years after initial treatment. • Patients treated for CIN should have annual cytology indefinitely.
  • 44. Ulcer of the cervix • A true ulcer with loss of epithelial covering is seen in the anterior lip of cervix
  • 45. Lacerations • Cervical lacerations frequently occur with both normal and abnormal deliveries. • Lacerations may occur in non-pregnant women with mechanical dilation of the cervix. • Obstetric lacerations vary from minor superficial tears to extensive full-thickness lacerations at 3 and 9 o'clock, respectively, which may extend into the broad ligament. In gynecology the atrophic cervix of the postmenopausal woman predisposes to the complication of cervical laceration when the cervix is mechanically dilated for a diagnostic dilation and curettage. • Acute cervical lacerations bleed and should be sutured. • Cervical lacerations that are not repaired may give the external os of the cervix a fish-mouthed appearance; however, they are usually asymptomatic.
  • 46. Lacerations • The use of laminaria tents to slowly soften and dilate the cervix before mechanical instrumentation of the endometrial cavity has reduced the magnitude of iatrogenic cervical lacerations. • Furthermore, the practice of routine inspection of the cervix, stabilized with one or more ring forceps, following every second- or third-trimester delivery has enabled physicians to discover and repair extensive cervical lacerations. • Lacerations should be palpated to determine the extent of cephalad extension of the tear. • Extensive cervical lacerations especially those involving the endocervical stroma may lead to incompetence of the cervix during a subsequent pregnancy.
  • 48. Cervical polyp • Endocervical and cervical polyps are the most common benign neoplastic growths of the cervix. • Cervical polyps usually present as a single polyp, but multiple polyps do occur occasionally. The majority are smooth, soft, reddish-purple to cherry red, and fragile. They readily bleed when touched. Endocervical polyps may be single or multiple and are a few millimeters to 4 cm in diameter. • The classic symptom of an endocervical polyp is intermenstrual bleeding, especially following contact such as coitus or a pelvic examination. Sometimes an associated leukorrhea emanates from the infected cervix. Many endocervical polyps are asymptomatic and recognized for the first time during a routine speculum examination. Often the polyp seen on inspection is difficult to palpate because of its soft consistency. • Histologically the surface epithelium of the polyp is columnar or squamous epithelium, depending on the site of origin and the degree of squamous metaplasia
  • 50. Cervical Myomas • Cervical myomas are smooth, firm masses that are similar to myomas of the fundus. • A cervical myoma is usually a solitary growth in contrast to uterine myomas, which in general, are multiple. • Depending on the series, 3% to 8% of myomas are categorized as cervical myomas. • Because of the relative paucity of smooth muscle fibers in the cervical stroma, the majority of myomas that appear to be cervical actually arise from the isthmus of the uterus.
  • 51. Fibroma of the cervix
  • 52. Cervical Myomas • Most cervical myomas are small and asymptomatic. When symptoms do occur, they are dependent on the direction in which the enlarging myoma expands. The expanding myoma produces symptoms secondary to mechanical pressure on adjacent organs. Cervical myomas may produce dysuria, urgency, urethral or ureteral obstruction, dyspareunia, or obstruction of the cervix. • Occasionally a cervical myoma may become pedunculated and protrude through the external os of the cervix. These prolapsed myomas are often ulcerated and infected. A very large cervical myoma may produce distortion of the cervical canal and upper vagina. Rarely, a cervical myoma causes dystocia during childbirth. • The diagnosis of a cervical myoma is by inspection and palpation.
  • 55. Endometrial Polyp • Endometrial polyps are localized overgrowths of endometrial glands and stroma that project beyond the surface of the endometrium. • They are soft, pliable, and may be single or multiple. Most polyps arise from the fundus of the uterus. • Polypoid hyperplasia is a benign condition in which numerous small polyps are discovered throughout the endometrial cavity. • Endometrial polyps vary from a few millimeters to several centimeters in diameter, and it is possible for a single large polyp to fill the endometrial cavity. • Endometrial polyps may have a broad base (sessile) or be attached by a slender pedicle (pedunculated).
  • 56. Endometrial Polyp • The majority of endometrial polyps are asymptomatic. Those that are symptomatic are associated with a wide range of abnormal bleeding patterns. No single abnormal bleeding pattern is diagnostic for polyps; however, menorrhagia, premenstrual and postmenstrual staining, and scanty postmenstrual spotting are the most common. Occasionally a pedunculated endometrial polyp with a long pedicle may protrude from the external cervical os. Sometimes large endometrial polyps may contribute to infertility. • Polyps are succulent and velvety, with a large central vascular core. The color is usually gray or tan but may occasionally be red or brown. Histologically an endometrial polyp has three components: endometrial glands, endometrial stroma, and central vascular channels
  • 57. Endometrial Polyp • Malignant change, when found in an endometrial polyp, is usually curable, and the endometrial carcinoma is most often of a low stage and grade. • It is interesting that benign polyps have been found in approximately 20% of uteri removed for endometrial carcinoma. Recently, unusual polyps have been described in association with chronic administration of the nonsteroidal anti-estrogen tamoxifen. • The incidence of endometrial abnormalities associated with chronic tamoxifen therapy is polyps 20% to 35%, endometrial hyperplasia 2% to 4%, and endometrial carcinoma 1% to 2%. • The management of endometrial polyps is removal by curettage or via the hysteroscope. • Because of the frequent association of endometrial polyps and other endometrial pathology, it is important to examine histologically both the polyp and the associated endometrial lining. Polyps, because of their mobility, often tend to elude the curette.
  • 58. Tiny hysteroscopic scissors, about as big around as the ink tube on a standard writing pen, are used to cut the stalk. Photo taken during Hysteroscopy of a small endometrial polyp. Notice the stalk.
  • 59. Leiomyomas • Leiomyomas, also called myomas, are benign tumors of muscle cell origin. • These tumors are often referred to by their popular names, fibroids or fibromyomas, but both terms are semantic misnomers if one is referring to the cell of origin. • Most leiomyomas contain varying amounts of fibrous tissue, which is believed to be secondary to degeneration of some of the smooth muscle cells. • Leiomyomas are the most frequent pelvic tumors, with the highest prevalence occurring during the fifth decade of a woman's life. • Although leiomyomas arise throughout the body in any structure containing smooth muscle, in the pelvis the majority are found in the corpus of the uterus.
  • 60. • Occasionally, leiomyomas may be found in the fallopian tube or the round ligament, and approximately 5% of uterine myomas originate from the cervix. • Myomas may be single but most often are multiple. Myomas are discovered in one of four white women and one of two black women. • They vary greatly in size from microscopic to multinodular uterine tumors that may weigh more than 50 pounds and literally fill the patient's abdomen. • Myomas are more prone to grow and become symptomatic in nulliparous women. The question as to why some women develop myomas while others do not is unanswered. However, genetic determinants definitely contribute to their development. Symptomatic uterine leiomyomas are the primary indication for approximately 30% of all hysterectomies. • Initially most myomas develop from the myometrium, beginning as intramural myomas. As they grow, they remain attached to the myometrium with a pedicle of varying width and thickness.
  • 61. • Myomas are classed into subgroups by their relative anatomic relationship and position to the layers of the uterus. • The three most common types of myomas are intramural, subserous, and submucous, with special nomenclature for broad ligament and parasitic myomas. • Continued growth in one direction determines which myomas will be located just below the endometrium (submucosal) and which will be found just beneath the serosa (subserosal) • The most common symptoms related to myomas are pressure from an enlarging pelvic mass, pain including dysmenorrhea, and abnormal uterine bleeding. The severity of symptoms is usually related to the number, location, and size of the myomas. However, the majority of women with uterine myomas are asymptomatic.
  • 63. • Laparoscopic view of a uterus with a pedunculated posterior myoma • A fibroid in this location should not affect chances for pregnancy or miscarriage • However, if it were pushing into the cavity of the uterus, it might cause problems
  • 64. Diagnosis • The majority of uterine myomas may be diagnosed by pelvic examination, difficult cases will benefit from ultrasound examination or a search for concentric calcifications on an abdominal x-ray film. • There are several recent reports of computed tomography (CT) and magnetic resonance imaging (MRI) studies of uterine myomas. • However, these imaging techniques are more expensive than ultrasound. • Until CT and MRI can distinguish between benign and malignant myomas, they will rarely be ordered in routine clinical management of myomas.
  • 65. Treatment • The management of a woman with small, asymptomatic myomas is judicious observation. When the tumor is first discovered, it is appropriate to perform a pelvic examination at 6-month intervals to determine the rate of growth. The majority of women will not need an operation, especially those women in the perimenopausal period, where the condition usually improves with diminishing levels of circulating estrogens. • Women with abnormal bleeding and leiomyomas should be investigated thoroughly for concurrent problems such as endometrial hyperplasia. If their symptoms do not improve with conservative management, operative therapy may be considered. The choice between a myomectomy and hysterectomy is usually determined by the patient's age, parity, and most important, future reproductive plans.
  • 66. • Classic indications for a myomectomy include: – a rapidly expanding pelvic mass, – persistent abnormal bleeding, – pain or pressure, – enlargement of an asymptomatic myoma to more than 8 cm in a woman who has not completed childbearing.
  • 67. • Two associated but rare diseases should be noted: intravenous leiomyomatosis and leiomyomatosis peritonealis disseminata. Intravenous leiomyomatosis is a rare condition in which benign smooth muscle fibers invade and slowly grow into the venous channels of the pelvis. The tumor grows by direct extension and grossly appears like a "spaghetti" tumor. Only 25% of tumors extend beyond the broad ligament; however, case reports exist of tumor growth into the vena cava and right heart. • Leiomyomatosis peritonealis disseminata (LPD) is a benign disease with multiple small nodules over the surface of the pelvis and abdominal peritoneum. Grossly, LPD mimics disseminated carcinoma. However, histologic examination demonstrates benign-appearing myomas. This disorder is usually associated with a recent pregnancy.
  • 68. Ovary
  • 69. Adenomatoid Tumors • The most prevalent benign tumor of the oviduct is the angiomyoma or adenomatoid tumor. • They are small, gray-white, circumscribed nodules, 1 to 2 cm in diameter. • These tumors are usually unilateral and present as small nodules just under the tubal serosa. • These small nodules do not produce pelvic symptoms or signs. • These benign tumors also are found below the serosa of the fundus of the uterus and the broad ligament. • Microscopically they are composed of small tubules lined by a low cuboidal or flat epithelium. Histologic studies have established that the thin-walled channels that comprise these tumors are of mesothelial origin. • These tumors do not become malignant; however, they may be mistaken for a low-grade neoplasm when initially viewed during a frozen-section evaluation.
  • 70. Follicular Cysts • Follicular cysts are by far the most frequent cystic structures in normal ovaries. • The cysts are frequently multiple and may vary from a few millimeters to as large as 15 cm in diameter. • However, a normal follicle may physiologically become cystic, and therefore it is important to have a minimal diameter for a follicular cyst. • This diameter is generally considered to be between 2.5 and 3 cm. Follicular cysts are not neoplastic and are believed to be dependent on gonadotrophins for growth.
  • 71. • Enlarged polycystic ovary following laparoscopic cauterization Follicular cysts are translucent, thin walled, and are filled with a watery, clear to straw-colored fluid. If a small opening in the capsule of the cyst suddenly develops, the cyst fluid under pressure will squirt out. These cysts are situated in the ovarian cortex, and sometimes they appear as translucent domes on the surface of the ovary.
  • 72. Corpus Luteum Cysts • Corpus luteum cysts are less common than follicular cysts, but clinically they are more important. • Corpus luteum cysts may be associated with either normal endocrine function or prolonged secretion of progesterone. The associated menstrual pattern may be normal, delayed menstruation, or amenorrhea. • Most corpus luteum cysts are small, the average diameter being 4 cm. • Corpus luteum cysts vary from being asymptomatic masses to those causing catastrophic and massive intraperitoneal bleeding associated with rupture. • Many corpus luteum cysts produce dull, unilateral, lower abdominal and pelvic pain. The enlarged ovary is moderately tender on pelvic examination. Depending on the amount of progesterone secretion associated with cysts, the menstrual bleeding may be normal or delayed several days to weeks with subsequent menorrhagia.
  • 73. • Corpus luteum cyst with thickened cyst wall and definite lutein cell lining recognized by its color. Cyst is filled with hemorrhagic gelatinous material.
  • 74. Benign Cystic Teratoma (Dermoid Cyst, Mature Teratoma) • Benign ovarian teratomas are usually cystic structures that on histologic examination contain elements from all three germ cell layers. • The word teratoma was first advanced by Virchow and translated literally means "monstrous growth." • Teratomas of the ovary may be benign or malignant. Although dermoid is a misnomer, it is the most common term used to describe the benign cystic tumor, composed of mature cells, whereas the malignant variety is composed of immature cells (immature teratoma). • Dermoid is a descriptive term in that it emphasizes the preponderance of ectodermal tissue with some mesodermal and rare endodermal derivatives. • Malignant teratomas that are immature are usually solid with some cystic areas and histologically contain immature or embryonic-appearing tissue.
  • 75. • From 50% to 60% of dermoids are asymptomatic and are discovered during a routine pelvic examination, coincidentally visualized by an abdominal x-ray or ultrasound examination, or found incidentally at laparotomy. • Presenting symptoms of dermoids include pain, and the sensation of pelvic pressure. • Specific complications of dermoid cysts include torsion, rupture, infection, hemorrhage, and malignant degeneration. • Three medical diseases also may be associated with dermoid cysts: thyrotoxicosis, carcinoid syndrome, and autoimmune hemolytic anemia. Torsion of a dermoid is the most frequent complication
  • 76. • Benign cystic teratoma. This section from the tumor demonstrates areas of hair (dark arrows) and solid sebaceous material (S).
  • 77. Fibroma • Fibromas are the most common benign, solid neoplasms of the ovary. Their malignant potential is low, less than 1%. These tumors comprise approximately 5% of benign ovarian neoplasms and approximately 20% of all solid tumors of the ovary. • The pelvic symptoms that develop with growth of fibromas include pressure and abdominal enlargement, which may be secondary to both the size of the tumor and ascites. • Smaller tumors are asymptomatic because these tumors do not elaborate hormones. Thus there is no change in the pattern of menstrual flow. • Fibromas may be pedunculated and therefore easily palpable during one examination yet difficult to palpate during a subsequent pelvic examination. • Sometimes on pelvic examination the fibromas appear to be softer than a solid ovarian tumor because of the edema and/or occasional cystic degeneration.
  • 78. Meigs' syndrome • Meigs' syndrome is the association of an ovarian fibroma, ascites, and hydrothorax. Both the ascites and the hydrothorax resolve after removal of the ovarian tumor. The ascites is caused by transudation of fluid from the ovarian fibroma.
  • 79. • Fibroma of ovary. Cut surface shows somewhat edematous, interlacing bundles of connective tissue.
  • 80. Transitional Cell Tumors—Brenner Tumors • Brenner tumors are rare, small, smooth, solid, fibroepithelial ovarian tumors that are generally asymptomatic. The semantic classification of neoplasms changes and the current preferred term for benign Brenner tumor is transitional cell tumor. The benign, proliferative (low malignant potential), and malignant forms together comprise approximately 2% of ovarian tumors. • These tumors usually occur in women aged 40 to 60 years. • Grossly, Brenner tumors are smooth, firm, gray-white, solid tumors that grossly resemble fibromas. Similar to fibromas, transitional cell tumors are slow growing • Management of Brenner tumors is operative, with simple excision being the procedure of choice.
  • 81. Adenofibroma and Cystadenofibroma • Adenofibromas and cystadenofibromas are closely related. Both of these benign firm tumors consist of fibrous and epithelial components. • The epithelial element is most commonly serous, but histologically may be mucinous and endometrioid or clear cell. • They differ from benign epithelial cystadenomas in that there is a preponderance of connective tissue. • Most pathologists emphasize that at least 25% of the tumor consists of fibrous connective tissue. Obviously, cystadenofibromas have microscopic or occasional macroscopic areas that are cystic. • The varying degree of fibrous stroma and epithelial elements produces a spectrum of tumors, which have resulted in a confusing nomenclature with terms such as papillomas, fibropapillomas, and fibroadenomas.
  • 82. Adenofibroma and Cystadenofibroma • Smaller tumors are asymptomatic and are only discovered incidentally during abdominal or pelvic operations. Large tumors may cause pressure symptoms or, rarely, undergo adnexal torsion. • Because adenofibromas are usually discovered in postmenopausal women, the treatment of choice is bilateral salpingo- oophorectomy and total abdominal hysterectomy. Because these tumors are benign and because malignant transformation is rare, simple excision of the tumor and inspection of the contralateral ovary is appropriate in younger women.