生殖系统疾病 1 子宫颈疾病 2 子宫体疾病 3 妊娠滋养层细胞疾病 4 卵巢疾病 Zhu keqing 竺可青 Pathology Department Zhejiang University School of Medicine

1. Cervix diseases

Schematic of the development of the cervical transformation zone

CERVIX NORMALNORMAL METAPLASIAMETAPLASIA INFLAMMATIONINFLAMMATION POLYPSPOLYPS DYSPLASIADYSPLASIA CINCIN INFILTRATING SCCINFILTRATING SCC

Cervical cancer 病因 Early age at first intercourse Multiple sexual partners Increased parity A male partner with multiple previous sexual partners The presence of a cancer-associated HPV The persistent detection of a high-risk HPV, particularly in high concentration (viral load) Certain HLA and viral subtypes Exposure to oral contraceptives and nicotine Genital infections (chlamydia) 衣原体

Spectrum of cervical intraepithelial neoplasia: normal squamous epithelium for comparison; CIN I with koilocytotic atypia; CIN II with progressive atypia in all layers of the epithelium; CIN III (carcinoma in situ) with diffuse atypia and loss of maturation.

The cytology of cervical intraepithelial neoplasia as seen on the Papanicolaou smear. Cytoplasmic staining in superficial cells (A&B) may be either red or blue. A, Normal exfoliated superficial squamous epithelial cells. B, CIN I. C, CIN II. D, CIN III.

The spectrum of invasive cervical cancer. A, Carcinoma of the cervix, well advanced. B, Early stromal invasion occurring in a cervical intraepithelial neoplasm.

Morphology of cervical cancers. A, Squamous carcinoma. B, Adenocarcinoma in situ (lower), associated with CIN 3 (upper). C, Adenocarcinoma. D, Neuroendocrine carcinoma.

2. 子宫体疾病 –Endometriosis 子宫内膜异位症 – Adenomyosis 子宫腺肌病 –Carcinoma of Corpus Uteri 子宫癌 – Leiomyoma of uterus 子宫平滑肌瘤

The presence of endometrial glands or stroma in abnormal locations beyond the endometrium of uterus. 部位 : ovaries uterine ligaments recto-vaginal septum pelvic peritoneum …. Endometriosis 子宫内膜异位

Adenomyosis 子宫腺肌病 The endometrial glands may extend deep within the myometrium. Pathological changes 显微镜下 : The endometrial glands and the stroma appear in the site of involvement. 大体 : Red-blue or yellow-brown nodules, hemorrhage --- chocolate cysts

Adenomyosis

Carcinoma of Corpus Uteri Incidence: less than carcinoma of cervix, about 1 : 5~8 Peak age: 55~65 yr Arise in : columnar cells

Pathological changes Endometrioid adenocarcinomas 子宫内膜腺癌 » well differentiated » moderate differentiated » poorly differentiated » endometrioid adenocarcinomas with foci of squamous differentiation Carcinoma of Corpus Uteri

Diffuse type of endometrial carcinoma

Metastasis direct extension : fallopian tube, ovary, cervix myometriun, broad ligament, peritoneum, bladder, rectum. lymphoati c : obturator, illic, periaortic, sacral, lumbar, inguinal lymph nodes bloodstream : lung, liver, bone Carcinoma of Corpus Uteri

Clinical presentations Irregular vaginal bleeding and leukorrhea Uterine enlargement In advanced case, tumor can press the nerve, inducing hypogastric, lumbar and leg ’ s pain Carcinoma of Corpus Uteri

Leiomyoma of uterus The most common tumor in women. Incidence: 25% in active reproductive life, estrogen responsive.

Pathological changes Microscopically: whorled bundles of smooth muscle cells Grossly: varying in size, sharply circumscribed, discrete, round, gray-white cut section: whorled pattern of smooth muscle Leiomyoma of uterus

3. Hydatidiform mole 葡萄胎 / Choriocarcinoma 绒癌 The hydatidiform mole is a common complication of gestation 怀孕, occurring about once in every 1000 to 2000 pregnancies in the United States and, curiously, far more commonly in the Far East. It has become possible, by monitoring the circulating levels of human chorionic gonadotropin, to determine the early development of persistent trophoblastic disease. Choriocarcinoma, once a dreaded 恐怖 and uniformly fatal complication, is now highly responsive to chemotherapy.

Hydatidiform Mole 1/1000 in USA 1% in Indonesia Also called NON-invasive mole in its most common benign variant, but can also be “invasive” Complete (2% chorioCA incidence) or partial (0% incidence) Grapelike clusters, i.e., swollen villi

The MAIN thing differentiating benign from malignant from worrisome trophoblastic neoplasms is INVASIVENESS of the trophoblast

Complete hydatidiform mole suspended in saline showing numerous swollen (hydropic) villi.

Photomicrograph of partial hydatidiform mole revealing swollen villi and slight hyperplasia of the surface trophoblast.

Complete hydatidiform mole with extensive cytotrophoblastic hyperplasia

A, Invasive mole presenting as a hemorrhagic mass adherent to the uterine wall. B, On cross-section, the tumor invades into the myometrium.

Choriocarcinoma presenting as a bulky hemorrhagic mass invading the uterine wall

Photomicrograph of choriocarcinoma illustrating both neoplastic cytotrophoblast and syncytiotrophoblast.

4. Tumors of the ovary 1. Surface epithelial tumors 上皮 serous 浆液性 / mucinous 粘液性 tumor benign --- cystadenoma borderline malignancy malignant --- cystadenocarcinoma 2. Sex cord -stromal tumors 性索间质 cord-stromal tumors granulosa cell tumor 3. Germ cell tumors 生殖细胞 teratoma seminoma

Serous tumor 浆液性肿瘤 Most common cystic neoplasm Lined by columnar ciliated epithelialcell Filled with clear serious fluid Bilaterality : common

Serous cystadenoma ---- benign Pathologic changes Grossly : one or a few fibrous smooth walled cysts, with a small papillary projections Microscopically: 1) lining epithelium---one layer columnar ciliated epithelium 2) papillae may be found.

cystadenoma

Serous tumors ---- borderline Grossly : Increasing amount of papillary projections Microscopically: 1) 2~3 layers cells; 2) cells with atypia; 3) papillae are more complex

Serous tumors borderline

Serous cystadenocarcinoma ----malignant Grossly : large amount of solid or papillary tumor mass Microscopically: 1) epithelium: >3 layers 2) with more atypia 3) invade capsule and stroma, 4) psammosa body

Serous cystadenocarcinoma

Mucinous tumor 粘液性肿瘤 less common, lined by tall, columnar cell filled with mucin

mucinous cystadenoma ---- benign Grossly : multilocular tumor, with smooth cyst wall, filled with sticky, gelatinous fluid. Microscopically: 1. lining epitheliun -- one layers tall columnar cells 2. with apical mucin, absence of cilia

mucinous cystadenoma

Mucinous cystadenoma

Mucinous tumors ---- borderline G: increasing amount of papillary projections M: 1) 2~3 layers cells 2) cells with atypia 3) no invasion

Mucinous cystadenocarcinoma ----malignant G: larger amounts of solid or papillary tumor mass, often with bleeding and necrosis M: 1) >3 layers epithelial cells 2) cells with more conspicuous atypia 3) invade capsule and stroma

Mucinous cystadenocarcinoma

Sex cord-stromal tumors Granulosa cell tumor 颗粒细胞瘤 1. Functioning tumor — estrogen 2. Small cells are arrranged in sheets, cord 3. Small follicle-like structures (Call-Exner bodies) 4. Nuclear grooves 5. Potentially malignant

Granulosa cell tumor

mature teratoma Germ cell tumors 生殖细胞 Teratoma 畸胎瘤

mature teratoma

Germ cell tumor Dysgeminoma 无性细胞瘤 site: ovary - dysgeminoma testicle - seminoma age: 10~30 yr arise in: germ cell malignant tumor

Pathological changes Microscopically: 1) Dispersed in sheets or cords by fibrous stroma; 2) Tumor cells: large, round, clear cytoplasm and central regular nuclei with prominent nucleoli 3) the stroma is infiltrated with lymphocytes Grossly: solid tumor cut section: soft and fleshy, yellow- white to gray –pink