HPV is one of those STD’s you want to tell your kids about. There are multiple strains of this virus, each one causing nasty effects to the body, especially in girls. HPV stand for human papillomavirus and this virus can effect the skin and mucosa of the vulva, vagina, cervix, anus, scrotum, penis, lips, mouth and throat. There are many of strains of HPV and some have been identified that cause different effects on these areas of the body.
The curse of HPV: The “bad” strains of HPV (high risk) such as type 16 and 18 do not usually cause warts that a visible to the naked eye, however they can cause changes to the cells that can turn that tissue into cancer. The “good” strains of HPV (low risk) such as types 6 and 11 do not cause cancer, however they can cause nasty, disfiguring warts that range in size from the head of a pin to a cauliflower floret.
Most people infected with any strain of the HPV virus do not have visible warts- which makes this a dangerous STD. Obviously any person would stay away from a sexual partner with growths on their genitals. This virus can be spread with no visible warts.
What this looks like…
High risk HPV can cause nasty changes to cells microscopically. These changes greatly increase the risk of cancer. Pap smears are done at least annually on sexually active teens and adults to look for these abnormal changes caused by HPV 16 and 18. If atypical cells are seen the remainder of the tissue collected at the pap smear is sent for viral testing. The lab will alert the gynecologist if high risk HPV was detected in the patients specimen. Depending on the level of abnormality seen in the pap smear depends on the management of these patients. The patients can be under surveillance with repeat Pap smears or the gyno may decide to give the patient a biopsy to see exactly what is going on in the tissue of the cervix. If the patient has high risk HPV and moderate to severe atypical cells are seen on the biopsy, the patient will then be send for a cold knife cone biopsy or LEEP excision (Loop electrocautery excision procedure). These are pretty nasty surgical procedures in which they cut out a nice size chunk of the ecto and endocervical portions of the cervix.
A cone biopsy or LEEP is usually enough surgery to excise these lesions cause by high risk HPV. If atypical cells still persist or get more atypical then a hysterectomy will need to be performed. Back in the day, before clinicans and scientists were hip to HPV, cervical cancer was a leading cause of death in woman. Dr. Papanicolaou got hip to these changes in cervical cells and started performed to Pap smears to surveil woman. Since then, the incidence of cervical cancer has dropped significantly.
Low risk HPV on the other hand can form genital warts that can be seen on the genitals. The lesions can be large and disfiguring to the genitals. These lesions rarely lead to cancer.
Treatment for low risk HPV varies on extent of lesions and locations. Topical creams are sometimes used to boost the immune system into destroying HPV infected cells and killing off the warts. Other times cryosurgery (freezing) is used. Surgical excision of the warts is done, usually if warts are large and obstructive to the penis, vagina or anus.
This is what a surgical excision of genital warts can look like. A lesion like this is big to be on the genitals- about 4 cm or 1.5 inches. This is approximately the size of a strawberry.
Other areas of the body effected by the HPV virus include the anus, lips, mouth, tongue, throat and vocal cords. Wart like nodules can appear on these areas as well as precancerous changes to the cells of these areas. Remember oral and anal sex can still transmit these viruses!
Prevention of HPV
The HPV vaccine (Gardasil) is an awesome prevention of the HPV virus. Because there are so many strains of the HPV virus, they can not all be prevented with this vaccine. However, the most common strains of this virus are covered including high risk HPV (16 and 18) and low risk HPV (6 and 11). This vaccine is only recommend at this time for girls under 26 years old, but it is being tested in boy/men since they can also be carriers of the virus and rarely can develop genital warts or genital cancer.
The most reliable prevention is safe sex or abstinence. Preach to your kids to use condoms!
Neural tube defects are fairly uncommon, mild to severe congenital malformations resulting from complete or partial failure of the neural tube to close in the developing embryo. Neural tube defects include anencephaly and different degrees of spina bifida. Craniorachischisis totalis is the most extreme form of a neural tube defect with anencephaly and spina bifida. The fetus shows complete absence of the brain and calvaria and incomplete closure of the entire neural tube.
Approximately 4000 fetuses are affected yearly with a neural tube defect. 1/3 of them are lost during pregnancy because of spontaneous or elective abortion. All infants with anencephaly are stillborn or die shortly after birth.
There is strong evidence that links these birth defects to a folate deficiency in the mother. The incidence of anencephaly and spina bifida is usually higher in groups with lower socioeconomic status and at least half the cases of neural-tube defects can be prevented if women consumed sufficient amounts of the folic acid before conception and during early pregnancy. Few specific causes of neural tube defects have been recognized aside from folic acid deficiency, except for relatively rare sources of exposure such as maternal diabetes and maternal use of some antiepileptic drugs, such as valproic acid.
Though a fetus may have such a malformation that they’re unable to sustain life independently, the cells in other parts of the body do not know that and the rest of the fetus continues to grow normally. That is why such a catastrophic defect can be present in older fetuses and babies at term.
A positive pregnancy test does not always ensure a normal intrauterine pregnancy. A pregnancy test bought at a drug store or one that is done at a physicians office using a patients urine is only testing for a hormone called hCG or human chorionic gonadotropin. This hormone being present in the urine is just telling the patient and/or the physician that the patient is pregnant. To confirm a pregnancy a quantitative hCG blood test is needed. This indicates 100% the presence of pregnancy hormone in the blood. This test also measures pregnancy hormone levels in the blood. In general the hCG levels will double every 72 hours. The level will reach its peak in the first 8 – 11 weeks of pregnancy and then will decline and level off for the remainder of the pregnancy. If the levels are tested and are too low or high, it can be indicative of a problem. Too low levels can mean there is an active miscarriage, blighted ovum (no embryo) or ectopic pregnancy. Too high levels can mean a molar pregnancy or multiple pregnancy.
Most pregnancies are intrauterine. Actually only 1% of all pregnancies are ectopic (outside the uterus).Ectopic pregnancy occurs when a fertilized egg attaches itself somewhere other than within the uterus. 98% of these ectopic pregnancies occur in the fallopian tube. The fallopian tubes are not designed to hold a growing embryo; the fertilized egg in a tubal pregnancy cannot develop normally and must be treated. 2% of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. The fetus is not typically viable but rare cases a baby has been delivered from an abdominal pregnancy.
Ectopic pregnancies are most common in woman age 35-44. It is more frequently found in woman who have some kind of irregularity of the fallopian tube. Fallopian tubes can be congenitally small. They can also have scarring in the lumen(tube) from pelvic inflammatory disease, previous tubal ligation or any other previous abdominal or pelvic surgeries that cause adhesions. Woman who smoke, have a history of multiple abortions, or have undergone fertility treatments are also at higher risk.
Ectopic pregnancies are at high risk of rupture and are considered a medical emergencies. Symptoms of an ectopic pregnancy are sharp,stabbing pain in the pelvis/abdomen, vaginal bleeding and/ or fatigue and weakness.
An ectopic pregnancy is diagnosed by a low hCG blood test, a pelvic exam and ultrasound. Treatment can be multiple things including methotrexate drug therapy or surgery. Methotrexate may be given, which allows the body to absorb the pregnancy tissue and may save the fallopian tube, depending on how far the pregnancy has developed. Laparoscopic surgery under general anesthesia may be performed. This procedure involves a surgeon using a laparoscope to remove the ectopic pregnancy and repair or remove the affected fallopian tube. If the ectopic pregnancy cannot be removed by a laparoscope procedure, then another surgical procedure called a laparotomy may be done.
When surgery is performed the specimen obtained is sent to my lab. This is what most ectopic pregnancy specimens look like.
This is the anatomy of the fallopian tube.
Below I have circled in black the normal anatomy of the fallopian tube which is the distal/ fimbriated end. The area circled in red is not normal. This is the site where an ectopic pregnancy ruptured. The soft tan-brown spongy tissue in this are is called chorionic villi and is considered immature placental tissue. If this tissue is found in the fallopian tube it indicates an ectopic pregnancy. Sometimes even a little embryo or fetal parts can be found next to this tissue as well.
This is a cross section of the fallopian tube. The tube is grossly dilated and filled with red-brown clotted blood. This is called a hemotosalpinx and is another feature found with ectopic pregnancies.
The pathologist needs to see a slide with chorionic villi tissue to confirm the diagnosis of ectopic pregnancy. The chances of having a successful pregnancy after an ectopic pregnancy may be lower than normal, but this will depend on why the pregnancy was ectopic and the patients medical history. If the fallopian tubes have been left in place, there is approximately a 60% chance of having a successful pregnancy in the future.
Melanoma is probably what most people think of when you think skin cancer. Melanoma is not the most common type of skin cancer though, but it is one the rise. It would probably be considered the nastiest skin cancer because of its ability to spread to other body sites and organs. We see anywhere from 2-5 specimens for melanoma a day from various parts of the body. There are multiple different variants of melanoma. Most commonly, melanoma arises from atypical changes that begin to develop in melanocytes. Melanocytes are the cells in the skin responsible for producing pigment or your skin color. These atypical changes usually occur in preexisting moles, or can form a new lesion, usually in Caucasian patients like the one seen below. Patients at the highest risk are usually light skinned individuals, who either live in sunny climates or spend lots of time in the sun, people who go tanning, people who burned or blistered as a child, relatives with a history of melanoma or certain individuals born with dysplastic nevi (atypical moles). Less commonly patients can form melanoma in areas of the body that are rarely or never exposed to the sun including the eye, the bottom of the foot, in between the toes, under fingernails and in the vagina.
This is a typical kind of specimen we would receive on a patient with melanoma called a LOCAL WIDE EXCISION. Basically the surgeon clearly cuts around the lesion, and we evaluate the surgical margins or the edge the surgeon cut, to determine if he removed all the cancer. The first thing I would do is measure this tumor and then measure how close it is to each edge. The most important margin in melanoma cases is not the sides actually its the bottom or deep margin. Melanoma tends to spread deep (vertical). This particular melanoma is about 2cm or almost 1″, pretty big for a mole…
This is a side view of the specimen. This shows how much subcutaneous fat tissue the surgeon cut out with the skin.
Next I will ink the subcutaneous fat tissue blue. This ink can be seen under the microscope and that is how the pathologist knows where the surgical margin is. Because melanoma produces pigment, microscopically these tumor cells can have a blackish color. Because of this, some pathologists prefer we do not use black ink to ink the surgical margin because it is too similar to the melanoma pigment, so I always encourage PA’s and residents to use another color with known melanoma cases.
This is a view of the inked deep margin, the most important margin in these cases.
Next I will serially section the specimen and lay out all my sections in a row. You can see that the lesion goes deeper into the subcutaneous fat tissue than it appeared before it was cut.
Next I will pick the section where I believe the tumor is coming closest to the deep margin. This will be the most important section for the pathologist to look at microscopically. In this slice I will first tell the pathologist that the tumor itself is 1.1cm in depth…
Then I will tell the pathologist that grossly the tumor comes to within 0.8cm of the closest approach to the inked deep margin. This section is what I tell PA’s and resident is the “money section”. This is the slide the pathologist needs to stage this patients tumor. Microscopically the pathologist will be able to see exactly how close the tumor cells are to the ink. The size of the tumor and depth of invasion all play a role in cancer staging.
The reason melanomas are such nasty tumors and spread easily can be easily appreciated now. The vertical growth of the tumor occurs when the melanoma invades deeper layers of skin. At this point the melanoma becomes dangerous as it now has the ability to enter either the blood stream or lymphatic system and spread to distant parts of the body.
The spread of melanoma through the blood stream is called hematogenous. For hematogenous spread to take place, melanoma cells must break away from the original tumor, find their way through a blood vessel wall and into the blood stream. When this happens melanoma can go to places such as the heart and brain.
Lymphogenous spread or the spread of melanoma by the lymphatic system occurs in much the same way as hematogenous. In the case of lymphogenous the melanoma cells travel through the lymphatic system and lodge in lymph nodes, which usually enlarge. Once the melanoma cells lodge in the lymph nodes they can spread to the vascular system.
When melanoma spreads from the original primary through the local lymphatic system and into the surrounding skin cells, they form what are known as satellite nodules. Satellite nodules are small deposits of melanoma cells spread around the original primary tumor. These present as palpable lumps usually in the vicinity of the original tumor.
The estimated 5 year survival rate of melanoma is as follows:
98% if cancer is found early before it has spread
62% if cancer has spread locally
15% if cancer has metastasized
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