this ppt about benign ,precancerous and malignant tumors of lower female genital tract

1. Supervisor:
Dr.abdulrazak
Presented by
Nahla humadi
Rash hanoon

2. Vulval anatomy
 Is the part of the female genital tract located between the
genitocrural folds laterally, the mons pubis anteriorly, and the anus
posteriorly.
 Embryologically, it is the result of the junction of the cloacal
endoderm, urogenital ectoderm, and paramesonephric mesodermal
layers.
 This hollow structure contains
 LABIA MAJORA
 LABIA MINORA
 CLITORIS
 VESTIBULE
 URINARY MEATUS
 VAGINAL ORIFICE
 HYMEN
 BARTHOLIN GLANDS
 SKENE DUCTS.

4. Non-neoplastic epithelial
disorders
Classification:
1. Lichen sclerosis.
2. Squamous cell hyperplasia (formerly: hyperplastic
dystrophy).
3. Other dermatoses.
- lichen planus.
- psoriasis.
- seborrhoeic dermatitis
- inflammatory dermatoses.
- ulcerative dermatoses.

5. Lichen sclerosus
 Comprises 70% of benign epithelial disorders
→ epithelial thinning, inflammation &
histological changes in the dermis.
 Aetiology: unknown
 Sx: Itching (commonest), vaginal soreness +
Dyspareunia. Burning and pain are
uncommon.
 Signs: crinkled skin, L. minora atrophy,
constriction of V. orifice, adhesions,
ecchymoses & fissures.
 Dx: Biopsy is mandatory
 Rx: - emollients, topical steroids.
- Testosterone: not effective than petroleum jelly
& → pruritus, pain & virilization.
- Surgery: avoided unless malignant changes

6. Squamous cell hyperplasia
 Df: thickened skin with white hyperkeratotic patches,
excoriation & fissures.
 Histo: hyperkeratosis, cellular epithelial proliferation with
normal maturation & inflammatory response in the
dermis (lymphatic & plasma cell infiltration).
 Aetiology: repetitive surface irritation & trauma from
irritants that causing scratching & rubbing.
 RX: is the same as Lichen sclerosis

7. Benign Vulval lumps
 Bartholin’s cyst.
 Epidermal inclusion cyst.
 Skene’s duct cyst.
 Congenital mucous cysts: arise from mesonephric ducts remnants.
 Cyst of the canal of Nuck: can give rise to hydrocele in labia maqjora.
 Sebaceous cyst.
 Papillomatosis (solid).
 Fibroma (solid).
 Lipoma (solid).
 Condylomata (solid).
 Cysts are either congenital or arise from obstructed glands.
 Manifestations arise from the cysts (cosmotic) or from
infection.

8. Bartholin glands

Two in number.Two in number.
Lie posteriolaterally to theLie posteriolaterally to the
vaginal orifice, one onvaginal orifice, one on
either sideeither side
Normally not seen nor felt.Normally not seen nor felt.
If enlarged, can be aIf enlarged, can be a
painless cyst or painfulpainless cyst or painful
abscessabscess

9. Bartholin Duct Cyst/abcess
 Most common Vulval cyst.
 usually unilateral medial to labia minora usually about 2
cm & contains sterile mucus.
 Usually asymptomatic.
 secondary infections Bartholin's abscess.→
 Rx: excision or MarsupializationMarsupialization
..

10. MarsupalizationMarsupalization

11. Skene's Gland
• are found on each side of
 urethra
• Normally neither seen nor felt
Skenitis
May become swollen and tender, particularly with
GC or chlamydia
Rx: drainage.Rx: drainage.
Culture for GC, ChlamydiaCulture for GC, Chlamydia

12. Inclusion Cysts of the Vulva
Contain creamy, yellowContain creamy, yellow
debris & lined with stratifieddebris & lined with stratified
epithelium.epithelium.
Found in the perineum,Found in the perineum,
posterior V. wall & otherposterior V. wall & other
parts of the vulva.parts of the vulva.
Arise from perineal skinArise from perineal skin
buried at obstetrical injuries.buried at obstetrical injuries.
Usually symptomless.Usually symptomless.
Rx: excision.Rx: excision.

13. Vulval Carcinoma
Malignant tumors of the vulva
are uncommon
representing only 4% of
the female lower genital
tract tumors .
 The most tumors are
squamous cell
carcinomas ,with
melanoma
,adenocarcinomas ,basal
cell carcinomas and
. sarcoma occurring much
less frequently

14. Aetiology
 Recent studies suggest two etiologic types of vulvar
cancer
 One type mainly in younger women patients, is related
smoking and human papillomavirus infection (HPV) and
is commomly associated with vulvar intraepithelial
neoplasia (VIN)
 More common type is seen mainly in elderly women and
is unrelated to smoking or HPV infection concurrent VIN
is uncommon but long-standing lichen sclerosus is
common

15. Vulvar intraepithelial
neoplasia (VIN)
Squamous cell carcinoma of the vulva usually forms
slowly over many years. Precancerous
changes often occur first and can last for several
years. The medical term most
often used for this pre-cancerous condition is
vulvar intraepithelial neoplasia (VIN).
"Intraepithelial" means that the abnormal cells are
only found in the surface layer of the
vulvar skin (epithelium).

16. Classification of VIN
 VIN is typed by how the lesions and cells look: usual-type VIN and
differentiated-type VIN.. It is sometimes graded VIN2 and VIN3, with
the number 3 indicating furthest progression toward a true cancer.
 Usual-type VIN occurs in younger women and is caused
by HPV infection. When usual-type VIN changes into
invasive squamous cell cancer, it becomes the basaloid or
warty subtypes.
 Differentiated-type VIN tends to occur in older women
and is not linked to HPV infection. It can progress to the
keratinizing subtype of invasive squamous cell cancer.

17. VIN Dx & Rx
 Dx: colposce + biopsies
 Rx:
- low grade VIN: observation.
- VIN3: local excision or laser vaporization
- ?

18. Vulval Carcinoma
 Squamous cell carcinomas:
 The keratinizing type is most common
 Basaloid and warty types are less common
 Verrucous carcinoma is an uncommon subtype it is slow-growing
and tends to have a good prognosis (outlook). This cancer looks like
a large wart and a biopsy is needed to determine it is not a benign
(noncancerous) growth
Other types that is less common
 Adenocarcinoma ,melanoma , sarcoma , basal
cell carcinomas

19. Stage Characteristics
Stage 0 Carcinoma in situ; intraepithelial neoplasia grade III
Stage I Lesion <2 cm; confined to the vulva or perineum; no nodal metastasis
Stage Ia Lesion <2 cm; confined to the vulva or perineum and with stromal invasion <1
mm; no nodal metastasis
Stage Ib Lesion <2 cm; confined to the vulva or perineum and with stromal invasion
>1mm; no nodal metastasis
Stage II Tumor >2 cm in greatest dimension; confined to the vulva and/or perineum;
no nodal metastasis
Stage III Tumor of any size with adjacent spread to the lower urethra and/or vagina or
anus and/or unilateral regional lymph node metastasis
Stage Iva Tumor invasion of any of the following: upper urethra, bladder mucosa,
rectal mucosa, and/or pelvic bone and/or bilateral regional node metastases
Stage Ivb Any distant metastasis, including pelvic lymph nodes

20. Treatment of Vulval Carcinoma
 Stage I & II :
Radical local excision with 1cm disease–free margin.
 Stage III & IV :
- According to the general health.
- Chemotherapy & radiotherapy to shrink the tumour to permit
surgery which may preserve the urethral & anal sphincter
function.
- radical vulvectomy + inguinal L. nodes dissection.
- reconstructive surgery with skin grafts or myocutaneous flaps for
healing.

21. Vagina
. The vagina is Muscular dilatable tube averaging 7.5 cm in
length
The vagina goes from the cervix (the lower part of the
uterus) to open up at the vulva (the external female
genitals). The vagina is lined by a layer of flat cells called
squamous cells. Vaginal wall composed of three layers:
mucosa, muscularis, adventitia. Epithelium normally
contains no glands and changes little during reproductive
cycle
 Lymphatic drainage of upper vagina via pelvic nodes
while lower vagina drains via femoral and inguinal nodes.

22. Benign conditions of vagina
 Gartner's Duct Cyst
 Paramesonephric Duct Cyst
 Inclusion Cyst
 Condyloma Acuminatum
 Urethral Caruncle

23. Gartner's Duct Cyst
 develop as a result of incomplete regression of the
mesonephric or wolffian duct during fetal
development . When present, these cysts may be
multiple, and are located submucosally along the
lateral aspects of the upper vagina. Histologic
evaluation reveals nonsecretory, columnar
epithelium. If these cysts are, and located in the
lateral aspects of the upper vagina, no treatment is
indicated. If the diagnosis is in question, or there is a
history of antenatal exposure to synthetic
hormones, adenosis of the vagina must be
considered. Regardless of size, biopsies should be
performed on symptomatic cysts or they should be
excised.

25. Paramesonephric Duct Cyst
 lined with secretory epithelium resembling
endocervix or fallopian tube
 müllerian origin. These cysts may be found
anywhere in the vagina and frequently
contain mucus. The diagnosis is established
with an excisional biopsy if the cyst is large,
symptomatic, or only recently identified.

26. Inclusion Cyst
 result from mucosa trapped in the
submucosal area by surgical procedures such
as episiotomy or trauma including childbirth .
As the cysts enlarge, symptoms may develop.
These cysts are lined with squamous
epithelium and contain keratin and squamous
debris. Treatment involves excision of the
intact cyst and approximation of normal
epithelium.

27. Condyloma Acuminatum
represents the clinical manifestation of human
papillomavirus infection.There are currently
more than 120 human papillomavirus types
identified.6
These lesions may be associated
with condylomata of the cervix and vulva or
appear only as vaginal lesions. Histologic
evaluation confirms the diagnosis and rules
out a dysplastic lesion. The microscopic
description is similar to that for condyloma in
other locations.

28. Precancerous and cancerous conditions
the vaginal carcinomas and neoplasia less uncommon than
counterparts on cervix and vulva
 Predisposing factors:
 Women over 70 years of age
 Women whose mothers took the drug DES while
pregnant with them
 Women infected with the human papillomavirus (high-
risk types of HPV include HPV 16, HPV 18, HPV 31)
 Women infected with HIV
 Women who smoke cigarettes and drink alcohol

29. Vaginal Intraepithelial Neoplasia
(VAIN)
 this pre-cancerous condition “Intraepithelial”
means that the abnormal cells are only found
in the surface layer of the vaginal skin
(epithelium)
 VAIN is more common in women who have
had their uterus removed (hysterectomy)
 and in those who were previously treated for
cervical cancer or pre-cancer.

30.  VAIN is graded 1-3
- VAIN1: mild dysplasia.
- VAIN2: moderate dysplasia.
- VAIN3: severe dysplasia.
 Dx: V. smear, colposcopy, biopsy (even after hysterectomy).
 Rx: low grade: observation. high grade: excision, 5-
fluoroyracil, laser therapy . Alternatively, Radiotherapy.

31. Vaginal Carcinoma
 Vaginal cancer is rare. Only about 1 of every 1,100 women will
develop vaginal cancer in her lifetime.
 Classification:
1. primary: squamous (common, 70%), adenocarcinoma and clear
cell adenocarcinoma (15% especially those exposure to DES)
Malignant melanoma 9% and Sarcoma 4% .
2. secondary: metastasis from the cervix, endometrium,…..others.
 50% in the upper 3rd
, 30% in lower 3rd
& 19% in middle 3rd
.
 Posterior V. lesions more common than anterior & the anterior are
more common than lateral lesions.
 Spread: direct & lymphatic.

32.  Squamous cell carcinomas: most common
tumor with mean age 60 years .30% of
patients with primary vaginal carcinomas
have a history of invasive or in situ cervical
cancer that was treated at least 5 years
earlier. On physical examination ,ulcerative ,
exophytic or infiltrative growth pattern may
be seen

33.  Adenocarcinoma : most of adenocarcinomas are
metastatic from cervix ,endometrium or ovaries
but occasionally from more distant site such as
kidney ,breast or colon .most primary vaginal
adenocarcinomas are clear cell carcinomas in
female offspring of women who ingested
diethylstilbestrol during pregnancy . primary
adenocarcinomas not related to DES is rare but
may arise in residual gland of mullerain duct ,or
foci of endometriosis

34. Signs and symptoms
 Usually asymptomatic
 Abnormal vaginal bleeding or postmenopausal bleeding ,or post-
coital bleeding .
 Vaginal discharge that smells or is blood stained (30%)
 Pain during sexual intercourse
 A lump or growth in the vagina (10%)
 A vaginal itch that won't go away

35. Vaginal Carcinoma
Clinical Staging (F.I.G.O.):
 Stage I: tumour confined to vagina.
 Stage II : tumour invades paravaginal tissue but not
to pelvic sidewall.
 Stage III : tumour extends to pelvic sidewall.
 Stage IV :
a) tumour invades mucosa of bladder or rectum
and/or beyond the true pelvis.
b) Distant metastasis.

36. TREATMENT
 Stage 1:
1. Tumour < 0.5 cm deep:
a. surgery: local excision or total vaginectomy with reconstruction.
b. radiotherapy.
2. Tumour > 0.5 cm deep: (a) wide vaginectomy, pelvic
lymphadenectomy + reconstruction of vagina.
(b) radiotherapy
 stage 2: (a) radical vaginectomy, lymphadenectomy
 (b) radiotherapy
 Stage 3: radiotherapy.

37. Cervix
 The cervix (Latin for neck) is the inferior part
of th The cervix measures 2.5-3 cm in
diameter and 3-5 cm in length. The normal
anatomic position of the cervix is angulated
slightly downward and backward. Inferiorly,
the cervix projects into the vagina as the
portio vaginalis with the opening of the
cervical canal into the vagina called the
external cervical os (Latin for mouth).

38.  The external os is usually small and round in
nulliparous women but can be seen as a
transverse slit in those who have had cervical
dilation during labor. The anterior and posterior
fornices delimit the portio (exocervix). The
cervical canal measures approximately 8 mm
wide and contains longitudinal ridges. The
opening of the cervical canal into the uterus is
called the internal cervical os. The area between
the endocervical and endometrial cavity is called
the isthmus or lower uterine segment. e uterus
protruding into the vagina.

39. Benign disorders of the cervix
 Erosion of the Cervix
 Nabothian cysts
 Condylomata accuminata
 Equamous papilloma
 Endometriosis

40. Erosion of the Cervix
 Characterized by columnar epithelium replacing squamous
epithelium, grossly resulting in an erythematous area
 Causes:
 Physiological:
 Cervicitis: Acute or Chronic
 Hormonal therapy

41.  SMEAR
 If infection---- Treat cause
 IF CIN ------ Manage according to stage

43. NABOTHIAN CYSTS
 A common benign finding, they represent occlusion of
the mucus-secreting glands of the cervix underneath a
squamous covering with mucin collecting in a cystic
area . Usually these are small (less than 0.5 cm) and can
be multiple. They should have a smooth glistening
surface with clear or slightly milky contents . Deviations
from this smooth surface, such as erosions or vascular
anomalies, should be further investigated with
colposcopy and biopsy. very large cysts have secondary
symptoms (such as pressure, heaviness, or urinary
retention) the majority of nabothian cysts are
symptomless

44. treatment
 The majority of nabothian cysts require no
treatment
 Large nabothian cysts may benefit from
being opened with a loop electroexcision
procedure (LEEP) or direct cauterization

45. Large nabothian cyst of the cervix

46. CONDYLOMATA ACCUMINATA
 Cervical condyloma can take various forms but
generally they appear as one or multiple clearly
delineated, elevated, white plaques on the
cervical portio and often onto the vaginal apex as
well. Small lesions may only be apparent through
colposcopic The larger of these are commonly
friable and can have symptoms of postcoital
bleeding that would raise issues of malignancy
 RX:direct removal through the use of biopsy
forceps, cautery, LEEP, or laser

47. A. Condylomata. B. Condylomata, clinically
unapparent, seen after acetic acid
application.

48. SQUAMOUS PAPILLOMA
 Papillomas that are not HPV-related can
occur in the cervix and usually originate from
the exocervix near the squamocolumnar
junction (transformation zone). These are
thought to be related to or inflammation
scarring and are usually less than 1 cm. Their
natural history is not well described, as the
usual intervention for these papillomas is
excision to assure that this does not represent
malignancy

49. Benign squamous papilloma of the
cervix.

50. Endometriosis
 When present in the cervix, endometriosis is
usually an incidental finding. However, it may
present as a mass or abnormal bleeding,
particularly postcoital. Grossly, it may appear
as a bluish-red or bluish-black lesion, typically
1-3 mm in diameter. Diagnosis is made by
colposcopy and colposcopically directed
biopsy

51.  PREMALIGNANT AND MALIGNANT
CONDITION S OF CERVIX

52. Cervical intraepithelial
neoplasia CIN
 The cervix is a tubular structure. It is
composed of stromal tissue which is lined by
sequamous epithelium in the vagina
(ectocervix) and columnar epithelium within
the cervical canal (endocervix).
 The meeting of the two types of the
epithelium is called squamocolumnar
junction SCJ and this is usually at the
ectocervix.

53. The position of the SCJ changes throughout the
reproductive years.
 In children it lies at the ectocervix that is just
at the external os.
 At puberty and during pregnancy it extends
outwards as the cervix enlarges and in adult
life it returns to the ectocervix through the
process of metaplasia

54.  CIN is a condition characterized by new cellular
growth (neoplasia) in a normal tissue Once CIN is
diagnosed this alarm us that an abnormal tissue has
been diagnosed in the cervix of that lady
 CIN I: minimal dysplasia.
 CIN II: moderate dysplasia.
 CIN III: sever dysplasia or CIS carcinoma in situ ( CIN
III, sever dysplasia and CIS are all different names for
the same thing that is early cervical cancer)

55. Classification of CIN
 A revised classification has been introduced:
 Low – grade lesion CIN I and HPV associated changes
with unknown but a likely low progressive potential.
 High-grade lesion CIN II and CIN III that is likely to
behave as cancer precursors.
 Simpler classification is according to Bethesda
divided to:
 Low grade squamous intraepithelial lesion (LSIL) =
CIN I.
 High grade squamous intraepithelial lesion (HSIL) =
CIN II and CIN III

56. Risk factores

57.  Early epidemiological data demonstrated a direct causal
relationship between cervical cancer and sexual activity.
 Major risk factors include:
 Low socioeconomic state
 Smoking
 sex at a young age,
 multiple sexual partners,
 history of sexually transmitted diseases (HPV type 16,18 ,
31 responsible for 70% cervical cancers)
 Long term use of contraceptive pill.
 Immunosupression or use of anticancer drugs.
 Being born to mother used diethylstilbestrol.

58. Clinical feature:
 Often it’s a symptomatic and diagnosed
during routine annual Pap smear,
 non-specific:
 Genital lesion (wart)
 Abnormal lower genital bleeding.
 Abnormal vaginal discharge.
 Vague lower abdominal pain.

59. DAIGNOSIS
 Pap smear
 Colposcopy and biopsy

60. treatment
 The aim of treatment is to make the post-
treatment test negative while minimizing harm to
the patient.
 Low grade lesion will regress spontaneously in
over 60% of cases and usually they require no
treatment but careful follow up by with
colposcopy and cytology in next six month after
initial diagnosis.
 If CIN is not resolve on follow up tests or progress
to high grade then treatment is needed to avoid
development of active disease.

61. Could be out patient or in patient
Excisional methods like:
 Loop electrosurgical excision (LEEP) and
large loop excision of TZ (LLETZ)
 Laser TZ excision
 Knife, laser or loop cone biopsy.
 Hysterectomy

62.  Cone biopsy or conization is both treatment
and diagnosis and done under anesthesia.
 If hysterectomy is performed (usually after
completion of family), annual vault smears
should be performed.

63. Ablative methods:
 Cryocautery.
 Electrodiathermy
 Coagulation
 Laser.

64. cervical carcinoma
 is the second most common malignancy in women
worldwide
 it is the leading cause of cancer-related death for women
in developing countries.
 In the United States, cervical cancer is relatively
uncommon.
The incidence of invasive cervical cancer has declined
steadily in the United States over the past few decades;
however
it continues to rise in many developing countries.
 The change in the epidemiological trend in the United
States has been attributed to mass screening with
Papanicolaou tests.

65.  In the United States 11,150 new cases of
cervical cancer are diagnosed each year. In
addition, more than 50,000 cases of carcinoma in
situ are diagnose
 Internationally, 500,000 new cases are diagnosed
each year.
 Mortality/Morbidity
 Of the 11,150 patients with cervical cancer, 3,670
will die from their disease each year in the United
States. This represents 1.3% of all cancer deaths
and 6.5% of deaths from gynecologic cancers.

66.  Age
 Cervical cancers usually affect women of
middle age or older, but it may be
diagnosed in any reproductive-aged
woman.

67. Signs and symptoms
 abnormal Papanicolaou test result on routine
screening In asymptomatic patient
 the first symptom is abnormal vaginal bleeding,
usually postcoital and intermenstrual bleeding .
 Vaginal discomfort, malodorous discharge and blood
stained .
 Pain : develop late and indicate extend of growth
beyond the cervix and involve the pelvic nerves
 Incontinence for urine and some times for feces
following the extension to bladder and rectum and
fistula formation
 Death from uremia following the blockage of both
ureters or ascending pyelonephritis

68. FIGO Staging of cervical
cancer

69. Staging description
Stage 0 carcinoma in situ
Stage I The carcinoma has grown deeper into the cervix, but has not spread beyond
it
A Invasive carcinoma which can be diagnosed only by microscopy, with
deepest invasion <5 mm and the largest extension <7 mm
A1 Measured stromal invasion of <3.0 mm in depth and extension of <7.0 mm
A2 Measured stromal invasion of >3.0 mm and not >5.0 mm with an extension
of not >7.0 mm
B Invasive cancer (clinical evidence disease )and >5.0 mm in depth
Stage2 Tumor extend outside the cervix
A To upper part of vagina
B To the parametrium but not reaching the pelvic wall
Stage III Tumor extend outside the cervix
A Involve the lower third of vagina
B Extend to pelvic wall and obstructing the ureter
Stage IV

76. Diagnosis and staging
 Tests and procedures to evaluate the extent
of the disease include the following:
 CT scan.
 Positron emission tomography scan.
 Cystoscopy.
 Laparoscopy.
 Chest x-ray.
 Ultrasound.[2]
 Magnetic resonance imaging.[2]

77. Treatment
 Treatment of invasive cervical carcinomas is
either by surgery or radiotherapy or both
 If the disease confined to the cervix so one of
them can be equally effective
 Once the disease spread outside the cervix
(parametrium) then radiotherapy is the
method of treatment

78. Surgery
 Stage IA-cone biopsy ,or trachelectomy
(removal of the cervix) or simple
hysterectomy
 Stage IB-IIA –need radical surgery
wertheim’s hysterectomy :wich radical
hysterectomy with bilateral pelvic
lymphadenectomy