OBJECTIVE:
- Review the gross pathologic material along with the images of the gross and microscopic findings with cases of breast and reproductive organ disease. Note the methods for detection and diagnosis.
CASE 1
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History:
- While showering, a 24 year-old woman notes a somewhat firm mass in the upper-outer quadrant of her left breast. She went to see her family physician who also felt the mass, and he determined that it was firm with a rubbery consistency and appeared to be movable. Mammography revealed a uniform, well-circumscribed mass without microcalcifications or cysts.
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Question:
- What is the diagnosis and the prognosis?
- Describe diagnostic methods for breast disease.
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CASE 2
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History:
- The patient in case 1 visited her 49-year-old mother and told her about the biopsy and the results. Her mother remarked, "You know, maybe I should go and see my doctor, because my aunt died of breast cancer." She sees her doctor, who palpates a large irregular firm fixed mass in the right breast as well as overlying skin with a rough, reddened appearance. Mammographically, the mass has irregular borders. A fine needle aspirate is performed of the mass and then a mastectomy is done.
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Questions:
- What is the diagnosis?
- Why did the skin appear to be inflamed?
- What is the significance of the family history?
- What issues must be addressed with informed consent for treatment?
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CASE 3
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History:
- A 39 year-old woman had a sensation of pelvic heaviness and a mucinous vaginal discharge which had persisted for months. A pelvic examination revealed the uterus to be enlarged, and a thick, creamy- yellow discharge to be exuding from the external cervical os. In addition there was a 5 mm diameter translucent mucosal nodule adjacent to the external os. At hysterectomy the uterine enlargement was found to be secondary to an intramural, fundic leiomyoma (benign smooth muscle tumor). The section is taken from the cervix.
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Questions:
- What cell types compose the inflammatory infiltrate?
- What is the diagnosis for the (a) uterine masses and (b) cervix?
- Is further workup indicated?
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CASE 4
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History:
- A 38 year-old woman was found to have highly atypical cells on a routine Pap smear. Her family physician obtains a Pap smear from her each year. She was referred to a gynecologist, who performed a colposcopically directed biopsy of the cervix. The biopsy showed CIN III (severe dysplasia). Because the dysplastic-appearing epithelium involved the endocervical canal and its deep border within the canal could not be visualized, a cone biopsy was proposed. However, after further discussion with her physician, the patient decided to have a vaginal hysterectomy.
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Questions:
- Has the patient been having yearly Pap smears?
- Is there stromal invasion?
- What is the diagnosis?
- What is the natural history of this process?
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CASE 5
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History:
- A 42 year-old woman, who had not had a medical pelvic examination for many years, noted the onset of postcoital bleeding. When she did seek medical attention, she was noted to have a red, roughened, friable area on the anterior lip of the cervix near the external os. A biopsy was followed by a radical hysterectomy. One pelvic lymph node contained a small focus of metastatic squamous cell carcinoma.
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Questions:
- Grade the degree of differentiation of this lesion.
- Is this a microinvasive carcinoma?
- What can you do to prevent this disease?
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CASE 6
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History:
- A 30 year-old woman noted a white plaque on the vulva. She had been sexually active for the past 16 years, with multiple sexual partners. She had no medical problems. Following a punch biopsy, an excisional biopsy was performed.
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Questions:
- Does the tissue represent labia minora or labia majora?
- Why did the lesion appear white?
- Is there stromal invasion?
- Should any additional examinations be performed?
- Explain the pathophysiology of this disease.
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CASE 7
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History:
- A 23 year-old woman, who had not had a menstrual period for seven weeks, began to experience vaginal bleeding and right lower quadrant pain. The urine HCG level was elevated. A small amount of tan tissue was passed per vagina. An incomplete abortion was suspected clinically.
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Questions:
- What is the diagnosis?
- What is a risk factor for this condition?
- What issues are raised when the patient is a minor? Is parental consent required?
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CASE 8
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History:
- A 71-year-old man had increasing hesitancy and frequency on urination over several years' time. He noted difficulty in starting the stream of urine. His physician found that the prostate appeared enlarged to twice normal size and was firm with palpable nodules on physical examination. A urinalysis showed no RBC's but did show 10-15 WBC's/hpf, and the urine was nitrite positive. He was referred to a urologist who performed transrectal biopsies. This was followed by prostatectomy (usually this is a transurethral resection).
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Questions:
- What is the diagnosis?
- What are the consequences of his disease if left untreated?
- Who gets this disease and why?
- Is prostatic hyperplasia a "pre-malignant" condition?
- What therapies are available for this condition?
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