Clinical Topics Conference:Chapter 18/19, Female Reproductive System and Breast

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  1. 45 year-old female with a breast mass
  2. Post-menopausal 58-year-old G6 P4 AB2 with vaginal bleeding
  3. 40-year-old pregnant multigravida with vaginal bleeding
  4. 50-year-old woman with of irregular vaginal bleeding and mild lower quadrant pain
  5. 35-year-old G5 P4 AB1 woman with irregular vaginal bleeding, leukorrhea, and pain upon coitus

Clinical vignette 1

A 45-year-old woman whose mother and older sister both have had breast cancer noticed a lump in her left breast. On breast examination the doctor noticed a 2 cm firm non-mobile mass that led to nipple retraction and dimpling of the overlying skin. Mammographic examination showed abnormal calcification. A needle biopsy showed an invasive mammary carcinoma, ductal type with a minor in situ carcinoma of the comedo type. Various treatment options were discussed with the patient, who chose to undergo a lumpectomy followed with intra-operative radiation implants. A left axillary lymph node dissection was also performed. The pathologic examination revealed a firm, non-encapsulated, gritty 2 cm mass composed of solid cords and nests of epithelial cells with occasional gland formation. These glands were surrounded by a dense collagenous fibrous stroma. Tumor metastases were found in 2 of 16 lymph nodes examined. Additional studies showed that the tumor cells to have estrogen and progesterone receptors and are Aneuploid. A large number of tumor of the cells reacted with p53 and Her-2-neu monoclonal antibodies.

Discussion topics

  1. List and compare the various types of in-situ and invasive carcinoma of the breast.

  2. Discuss the prognostic factors of breast cancer.

  3. Discuss the pathogenesis of breast cancer.

  4. List the main pathologic features and prognostic significance of fibrocystic changes.

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    Clinical vignette 2

    A 58-year-old G6 P4 AB2 diabetic menopausal woman who weighed 122.6 Kg (270 lb) experienced an episode of vaginal bleeding. On pelvic examination a slightly enlarged uterus was noted. The patient was admitted to the hospital for dilatation and curettage (D & C). The endometrial biopsy showed a well differentiated adenocarcinoma (FIGO I, nuclear grade 1). One week later, an abdominal radical hysterectomy with bilateral salpingo-oophrectomy was performed. A 2.5 x 2 cm polypoid fungating mass was noted in the endometrium. Frozen section confirmed the previous diagnosis of endometrial cancer. There was no evidence of myometrial or vascular invasion. The post-operative course was uneventful.

    Discussion topics

    1. Describe the gross and microscopic pathology of endometrial adenocarcinoma, and discuss the prognostic significance of grading and staging of this tumor.

    2. List the main clinical features of endometrial cancer and relate them to the underlying pathology.

    3. Compare the various forms of endometrial hyperplasia and their relationship to cancer.

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    Clinical vignette 3

    A 40-year-old pregnant multigravida presented to the emergency room 10 weeks after her last menstrual period, complaining of severe vaginal bleeding. Pelvic examination revealed an enlarged gravid uterus extending to the level of the umbilicus. Her serum hCG was 100,00 mIU/ml. No fetal movements were noticed. Ultrasound showed no gestational sac or fetus. An endometrial curettage showed enlarged avascular edematous villi lined by multi-layered trophoblastic epithelium. No fetal parts could be identified. On Karyologic analysis the freshly isolated placental tissue was diploid. The uterus was evacuated and the patients serum hCG levels gradually dropped to normal in 2 weeks. Follow-up physical examination and hCG determination every 2 weeks, then monthly for 1 year were normal.

    Discussion topics

    1. Discuss the epidermology of gestational trophoblastic diseases.

    2. Compare the pathology of complete and partial hydatidiform mole.

    3. Explain the chromosomal findings in complete and partial hydatidiform mole and relate these to their pathogenesis.

    4. Describe the pathology of choriocarcinoma and relate it to clinical symptoms.

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    Clinical vignette 4

    A 50-year-old woman presented to her physician with the chief complaint of irregular vaginal bleeding and mild lower quadrant pain. Her menses were heavy and occurred every 5-6 weeks. Pelvic bimanual examination disclosed that the uterus is irregular and nodular filling most of the pelvis. Because of severe discomfort, the patient chose to have a hysterectomy. The uterus was enlarged and distorted by multiple leiomyomas. On the cut surface, they were smooth, solid, pinkish-white and had a whorled appearance. Microscopically, they were composed of bundles of benign smooth muscle fibers. The patient was discharged 5 days after hysterectomylater.

    Discussion topics

    1. Describe the gross and microscopic features of uterine leiomyoma.

    2. Compare the clinical symptoms caused by to submucosal, intramural and subserosal leiomyomas.

    3. Compare the clinical and pathologic features of leiomyoma and 3. leiomyosarcoma.

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    Clinical vignette 5

    A 35-year-old G5 P4 AB1 woman sought medical advice for irregular vaginal bleeding, leukorrhea and pain on coitus for 6 weeks. The significant aspect of her past history included: menarche at age 10; first intercourse at age 12; first pregnancy at age 14; multiple sexual partners ever since. She smokes 3 packs of cigarettes a day. At age of 30 years, she was told that she had vaginal abnormalities in her Pap smear. The medical record reveals that the Pap smear at that time showed dysplastic squamous cells with human papilloma virus changes (CIN II) on a routine Papanicolaou smear. The patient did not seek medical attention at the time, and was lost for follow-up. Colposcopic examination revealed a 1.5 x 1 cm fungating ulcerated mass at the squamo-columnar junction. A biopsy was taken from the lesion and showed an invasive moderately differentiated squamous cell carcinoma. A radical hysterectomy was performed. The tumor was localized to the uterine cervix and did not extend into the uterus or the vagina.

    Discussion topics

    1. Describe the pathologic features of CIN and carcinoma of the uterine cervix.

    2. Discuss the role of HPV in the pathogenesis of CIN and carcinoma of the uterine cervix.

    3. Discuss the risk factors for uterine cervical carcinoma.

    4. Discuss the treatment and prognosis of uterine cervical carcinoma.

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