Template:Reproductive system - entire topic

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Author: Mikael Häggström, M.D. [note 1]

Contents

Uterus

For postmenopausal women, it is not a catastrophe if a pathology report causes the uterus to be removed as a precaution. In premenopausal women, on the other hand, any doubt regarding a pathology report that may lead to hysterectomy mandates consultation with a colleague with GYN expertise.


Cervical biopsy

Author: Mikael Häggström [note 1]
This article includes endocervical curettage (ECC).

Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))

Fixation

Generally 10% neutral buffered formalin.

  See also: General notes on fixation


Gross processing

Example report:

(Optionally: A. Container is labeled - __. The specimen is received in formalin and consists of ) 1 fragment(s) of pink-tan tissue with a vaguely recognizable mucosal surface. The tissue measures __ cm. (The surgical margin is inked black. The specimen is bisected and entirely submitted for microscopic examination in one cassette.)

Microscopic evaluation

Anatomic/Histologic location

Describe mucosa as squamous (or ectocervical), endocervical (generally mucinous and glandular) or transformation zone mucosa.

Pathologies

edit
Look for cervical dysplasia. It is mainly seen as nuclei with hyperchromasia, coarse chromatin and irregular contours.[3]

Further information: Cervical dysplasia

edit
Other common findings:

Example report

Endocervix, curettings:
Fragments of squamous and endocervical glandular epithelium without significant histopathologic changes.
Negative for dysplasia.

Notes

  1. 1.0 1.1 For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.

Main page

References

  1. Gulisa Turashvili, M.D., Ph.D.. Cervix Benign / nonneoplastic epithelial lesions. Nabothian cysts.. Pathology Outlines. Last author update: 1 February 2021. Last staff update: 4 April 2022}}
  2. International Federation for Cervical Pathology and Colposcopy (IFCPC) classification. References:
    -. Transformation zone (TZ) and cervical excision types. Royal College of Pathologists of Australasia.
    - Jordan, J.; Arbyn, M.; Martin-Hirsch, P.; Schenck, U.; Baldauf, J-J.; Da Silva, D.; Anttila, A.; Nieminen, P.; et al. (2008). "European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, part 1 ". Cytopathology 19 (6): 342–354. doi:10.1111/j.1365-2303.2008.00623.x. ISSN 0956-5507. PMID 19040546. 
  3. Khaled J. Alkhateeb, M.B.B.S., Ziyan T. Salih, M.D.. HSIL / CIN II / CIN III. PathologyOutlines. Topic Completed: 29 March 2021. Minor changes: 9 February 2022
  4. Source image by Ed Uthman from Houston, TX, USA. Creative Commons Attribution 2.0 Generic (CC BY 2.0) license
  5. Anissa Ben Amor.. Cervical Ectropion. StatPearls, National Center for Biotechnology Information. Last Update: November 14, 2021.
    - This book is distributed under the terms of the Creative Commons Attribution 4.0 International License

Image sources


Cervical cone

Unless otherwise specified, the primary focus is any cervical neoplasia.

Fixation

Generally 10% neutral buffered formalin.

  See also: General notes on fixation

Gross processing

  • Measure length, as well as the transverse and sagittal diameter of the ectocervical surface.[1]
  • Optionally, weight the sample.[1]
  • Note the symmetry of the sample, and the position of the cervical canal.[1]
  • Note whether the circumference is complete. If not, and the directions are indicated on the cone, determine the approximate position of the defect.[1]
  • Cones excised by knife should be inked on the excision surfaces. Those excised by laser do not need inking.[1]

Selection and trimming

Gross preparation of cervical cone.svg
  • If the cone is more than 1 cm long, take transverse slices from the top of the cone and towards the ectocervix, and stop when approximately 1 cm of the ectocervical portion of the cone remains.
  • Cut the portion into radial or sagittal slices. Sagittal slices are made perpendicularly to the portion surface, and should be divided into at least the four quadrants.[note 1][1]

In cases where the cone is small and fragmented, try to orient the preparations and divide them if possible to obtain sagittal slices.[1]

  See also: General notes on gross processing

 

Microscopic evaluation

Anatomic/Histologic location

Describe mucosa as squamous (or ectocervical), endocervical (generally mucinous and glandular) and/or transformation zone mucosa.

Cervical dysplasia

edit
Look for cervical dysplasia. It is mainly seen as nuclei with hyperchromasia, coarse chromatin and irregular contours.[3]

Further information: Cervical dysplasia


Radicality

Locations of non-radicality should be reported in relation to tissue markings (such as needles), or in terms of quadrants or corresponding to a clock face, based on the patient being in supine position.

Look whether there is normal epithelium on each side of all slices where neoplasia is seen, and when the epithelium is missing in any direction, consider ordering additional serial sections or step sections.

HPV changes

Also look koilocytic changes of human papillomavirus (HPV), with such cells typically displaying:

  • Nuclear enlargement (two to three times normal size).
  • Irregularity of the nuclear membrane contour, creating a wrinkled or raisinoid appearance.
  • A darker than normal staining pattern in the nucleus, known as hyperchromasia.
  • Perinuclear cytoplasmic vacuolization ("nuclear halo").

Other findings

edit
Other common findings:

Microscopy report

If a neoplasia is found, the report should include:[1]

  • The histolopathological type and degree of differentiation
  • Location and extent
  • Radicality
Histopathology of CIN 3.jpg

High-grade squamous intraepithelial lesion (CIN-2), present at 3:00 to 12:00.
All margins of excision are negative for CIN-2.

Example report in a normal case:

Cervix at transformation zone without significant histopathologic changes.
Negative for neoplasia/carcinoma.


Endometrial polyp

Author: Mikael Häggström [note 2]

Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))

Fixation

Generally 10% neutral buffered formalin.

  See also: General notes on fixation

Microscopic evaluation

The main objectives are:

  • Making a diagnosis of endometrioid polyp. An endometrial polyp may be diagnosed in the presence of 2 of the following 3:
  • Thick-walled vessels
  • Collagenous stroma
  • Epithelium on at least 3 sides
  • Look for signs of atypia or malignancy.

Reporting

Most importantly:

  • Benign versus malignant (or presence or absence of atypia.)
  • ((The size of the polyp.))
  • ((The type of epithelium at both the surface and gland coverings.))

Example of a minimal report:

Benign endometrial polyp.
  See also: General notes on reporting

Notes

  1. Each slice may be individually numbered.
  2. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.

Main page

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
  2. International Federation for Cervical Pathology and Colposcopy (IFCPC) classification. References:
    -. Transformation zone (TZ) and cervical excision types. Royal College of Pathologists of Australasia.
    - Jordan, J.; Arbyn, M.; Martin-Hirsch, P.; Schenck, U.; Baldauf, J-J.; Da Silva, D.; Anttila, A.; Nieminen, P.; et al. (2008). "European guidelines for quality assurance in cervical cancer screening: recommendations for clinical management of abnormal cervical cytology, part 1 ". Cytopathology 19 (6): 342–354. doi:10.1111/j.1365-2303.2008.00623.x. ISSN 0956-5507. PMID 19040546. 
  3. Khaled J. Alkhateeb, M.B.B.S., Ziyan T. Salih, M.D.. HSIL / CIN II / CIN III. PathologyOutlines. Topic Completed: 29 March 2021. Minor changes: 9 February 2022
  4. Source image by Ed Uthman from Houston, TX, USA. Creative Commons Attribution 2.0 Generic (CC BY 2.0) license
  5. Anissa Ben Amor.. Cervical Ectropion. StatPearls, National Center for Biotechnology Information. Last Update: November 14, 2021.
    - This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
  6. Owings, Richard A.; Quick, Charles M. (2014). "Endometrial Intraepithelial Neoplasia ". Archives of Pathology & Laboratory Medicine 138 (4): 484–491. doi:10.5858/arpa.2012-0709-RA. ISSN 1543-2165. 
  7. Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites ". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691. 
    - "Figures - available via license: Creative Commons Attribution 4.0 International"
  8. Rabban, Joseph T.; Gilks, C. Blake; Malpica, Anais; Matias-Guiu, Xavier; Mittal, Khush; Mutter, George L.; Oliva, Esther; Parkash, Vinita; et al. (2019). "Issues in the Differential Diagnosis of Uterine Low-grade Endometrioid Carcinoma, Including Mixed Endometrial Carcinomas ". International Journal of Gynecological Pathology 38: S25–S39. doi:10.1097/PGP.0000000000000512. ISSN 0277-1691. 
  9. Mohamed Mokhtar Desouki. Uterus - Stromal tumors - Leiomyoma. pathology Outlines. Topic Completed: 1 August 2011. Revised: 15 December 2019

Image sources

Endometrial curettings

Gross processing

  • Generally submit all tissue for microscopy, even larger volumes.
  • Look for products of conception if indicated from referral and/or history

Microscopic evaluation

Describe the anatomic/histologic type of epithelium.

Look mainly for:

Anatomic/histologic epithelium type

(Determine the type or phase of the endometrium:) edit

In contrast, endocervical mucosa typically consists of mucinous columnar epithelium and mucinous glands. Evaluate this like a cervical biopsy or cervical cone.

The phases of endometrium through the menstrual cycle:

If you want to specify the phase by day, then it's more accurate to state it as days past ovulation where applicable, since the follicular phase may vary substantially.

Hyperplasia, atypa and/or malignancy

  • Look for signs of atypia or malignancy:

edit

Microscopy report

Example in a normal case:

(Benign endometrium and endocervical mucosa without significant histopathologic changes.) Negative for neoplasia ((or viral cytopathic changes)).


Endometrial thickening

Hysterectomy sampling

A regular hysterectomy grossing is performed, but with the following sampling:[5]

  • 2 longitudinal sections through ecto/endocervix (1 anterior and 1 posterior)
  • 2 longitudinal sections through upper endocervix/lower uterine segment (1 anterior and 1 posterior), immediately adjacent to the sections taken from the cervix
  • 4 full-thickness representative sections of endomyometrium (2 anterior and 2 posterior)
  • Transversely section the remaining anterior and posterior endomyometrium (~1 cm thick). Submit the entire endometrium from the lower uterine segment to the fundus, maintaining orientation.
  • Submit entire fimbriae (longitudinally sectioned) and 2 representative cross-sections on each side.

Microscopic evaluation

  • Look for signs of atypia or malignancy:

edit

Reporting

Most importantly:

  • Presence or absence of atypia.


Hysterectomy

For a freshly received uterus, generally gross it fresh to include either opening it up (small specimen, no suspected malignancy seen) and/or serial sectioning, in order to let the formalin penetrate it properly. Ensure the endometrium is immersed in the formalin (such as having the serosa oriented upwards).

  See also: General notes on fixation

Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))
Other legend

<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Link to another page

Gross processing

Gross examination

For orientation:

  • The round ligament lies anterior to the tubes and ovaries.[8]
  • The peritoneum extends further down along the cervix posteriorly than anteriorly.[9] Its ends bluntly posteriorly and sharply anteriorly.[9]

When received the same day as the surgery, perform the following steps at least to serial sectioning before putting (back) in formalin, preferably with paper towels between slices, so that it fixes properly:[8]

  • (Remove the adnexa.[8] Weigh the uterus without the adnexa.)
  • Perform a general inspection
  • Measure the 3 dimensions, including the cervix. (Also measure the length of the cervix, the maximum diameter of the cervix, and the width of the cervical os.)
  • (Ink the surgical margin of the cervix for orientation, such as black on the posterior side.)
  • Open the uterus by transmural radial cuts on both sides of the uterine cavity.[note 1] The cavity is sometimes be squeezed or rolled around a leiomyoma, and you'll you have to improvise and perhaps go around the leiomyoma to open the cavity properly.
  • Inspect the mucosa. If any polyps: Further information: Endometrial polyp
    If more extensive tumor, gross as per endometrial cancer
  • Serially section through almost the entire depth of the myometrium at approximately 1 cm intervals, still keeping the specimen together.
  • Measure the thickness of the mucosa and myometrium
  • Inspect the myometrium. If any tumor: Further information: Smooth muscle tumor

Gross report

Applicable in bleeding disorders, pain, leiomyoma and endometrial hyperplasia:[8]

Components:[8]

  • (Shape of uterus and adnex)
  • Measurements
  • Mucosa, such as smooth or irregular.
  • (Even the absence of) any polyps. Further information: Endometrial polyp
  • Mucosal and endometrial thickness. Further information: Endometrial thickening
  • (Even the absence of) any smooth muscle tumor. Further information: Smooth muscle tumor
Example
(A. Labeled - __. The specimen is received in formalin and consists of a resected) uterus with cervix [and bilateral fallopian tubes and ovaries]. The uterus and cervix measure __ ((cm superior to inferior)) x __ ((cm cornu to cornu)) x __ cm ((anterior to posterior,)) and weighs ___ grams. The serosa is [tan-pink and smooth]. The cervix measures ___ cm in diameter and ___ cm in length. The ectocervical mucosa is [tan-pink and smooth] and the cervical os[ is patent] and measures ___ cm in diameter. The specimen is bisected in the coronal plane. The endocervical canal is [patent and displays a tan-pink smooth mucosa]. The endometrial cavity is [triangular] and is lined by[ smooth] endometrium measuring [0.1] cm in average thickness. The myometrium measures up to ___ cm in thickness.[

- It displays __ intramural leiomyomata measuring up to __ cm in greatest diameter.

] The right ovary measures ___ cm and has a [tan-pink and smooth] capsule. Cut sections show [no gross lesions]. The right fallopian tube measures ___ cm in length and ___ cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. The left ovary measures ___ cm and has a [tan-pink and smooth] capsule. Cut sections show [no gross lesions].The left fallopian tube measures ___ cm in length and ___ cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. Representative sections are submitted for microscopic examination in ___ cassettes.

Slices for microscopy

Applicable in bleeding disorders, pain, leiomyoma and endometrial hyperplasia:[8]

Submit:[8][10]

  • One, (two - at 6 and 12 o'clock), ((or four)) cross-sections from any accompanying ectocervix/endocervix (aiming to include the transformation zone). In subtotal extirpation, a cross-section is taken from the lower resection border.
  • ((A transverse slice through the endocervix, possibly divided into two.))
  • Endometrium and myometrium, by one slice from the front and one from the back wall of the corpus.
  • {{Any mucosal parts with macroscopically abnormal appearance, including polyps.}}
  • {{For any area suspicious for malignancy, submit a full cross-section of the uterine wall that includes the serosa. Use multiple contiguous cassettes if needed.}}
  • {{Samples from all smooth muscle tumors >5 cm in diameter.}} Further information: Smooth muscle tumor

A specific sampling scheme is used in: Endometrial thickening

See also:

Microscopic evaluation

Look for signs of malignancy:

Cervix

edit
Look for cervical dysplasia. It is mainly seen as nuclei with hyperchromasia, coarse chromatin and irregular contours.[11]

Further information: Cervical dysplasia

edit
Other common findings:

Uterine body

(Determine the type or phase of the endometrium:) edit

In contrast, endocervical mucosa typically consists of mucinous columnar epithelium and mucinous glands. Evaluate this like a cervical biopsy or cervical cone.

The phases of endometrium through the menstrual cycle:

If you want to specify the phase by day, then it's more accurate to state it as days past ovulation where applicable, since the follicular phase may vary substantially.

Main pathologic findings

edit

Microscopy report

Examples of reports:

Normal cases
[note 2]
Uterus, cervix, bilateral tubes and ovaries, abdominal hysterectomy and bilateral salpingo-oophorectomy:
  • Benign cervix.
  • Benign atrophic endometrium.
  • Benign ovaries.
  • Benign fallopian tubes.
  • Negative for malignancy.
Microscopy of hysterectomy shows ecto and endocervix without atypia. The glands have columnar epithelium without atypia.

In the uterine cavity, there is endometrial mucosa with ordinary thickness and regularly arranged endometrial glands. (Optionally: Description of likely menstrual phase.) Sharp delimitation between endometrium and myometrium. The myometrium contains no focal changes. No evidence of malignancy.

Endometrial intraepithelial neoplasia
Uterus, cervix, bilateral tubes and ovaries, hysterectomy and bilateral salpingo-oophorectomy:
  • Endometrial intraepithelial neoplasia; entire endometrial/myometrial junction submitted for microscopic exam.
  • Benign lower uterine segment.
  • Benign bilateral tubes and ovaries.


Smooth muscle tumor

Smooth muscle tumor (in this case leiomyoma).

Gross processing

Gross examination

Fibroid locations.

Examine and describe:[8]

  • Location. If in the uterus:
  • Intramural/submucosal/subserosal (see image)
  • (Posterior/anterior/right or left lateral.)
  • Number of tumors, if multiple
  • Size
  • (Presence or absence of any hemorrhage or necrosis.)
  • ((Demarcation))

Selection

In case of hysterectomy, submit pieces from all smooth muscle tumors >5 cm in diameter.[8]

Submit any macroscopically abnormal parts of the tumors (hemorrhagic, necrotic, brittle or softening areas, and areas with blurry delimitation).[8]

Microscopic examination

Distinguish leiomyoma (benign) from leiomyosarcoma (malignant) by looking at the latter's criteria:[16]

  • Marked cellular atypia
  • Mitoses: > 10 mitoses/10 high power fields
  • Necrosis

Diagnosis of conventional leiomyosarcoma requires 2 of these 3 histologic features.[16]

Further information: Evaluation of tumors

Microscopic report

Report:

  • Microscopic findings, including any visible linings
  • Diagnosis or most probable one
  • Any linings or borders.

Example, for a cervical polyp:

Polyp lined by a single layer of columnar epithelium consistent with endometrium. The interior consists of smooth muscles in a whorled pattern. No atypia. The finding is consistent with a pedunculated submucosal leiomyoma.

Intrauterine device

Gross processing

These are generally just visually described, with no samples for microscopic examination. Example report:

Copper IUD.jpg
T-shaped item with metal-coated arms and stem (Optionally: consistent with an intrauterine device with copper), with attached threads measuring 6.5 cm each.

Products of conception

Gross processing

Look up the gestational age of the pregnancy.

  • Look for fetal tissue (fetus, fetal membranes or chorionic villi). They are generally easier to distinguish from decidua (which is maternal tissue) when fragments are put in clear fluid and shaken, with chorionic villi having a consistency like orange pulp, whereas decidua is more rubbery. The fluid may be formalin if no sample for genetic workup is needed. If chorionic villi are found, no lengthy search is needed for other kinds of fetal tissue, just a quick look for obvious ones. Membranous material is less reliable, and may still indicate further sampling. Inspect any found fetal tissue for gross anomalies. If found, submit one piece of the fetus and one piece of the placenta.[19]
  • If fetal parts are not visually found, search for diagnostic placental tissue, which is soft and shaggy or spongy (as opposed to membranous, which is likely to be decidua or blood clots).[19]
  • If no fetal or placental tissue is found, all presented tissue generally needs to be submitted.

Gross report

(Labeled - products of conception.) The specimen (is received <<fresh / in formalin>>) and consists of multiple fragments of soft tan-pink decidua, blood clots and amniotic sac measuring about 5 cc in aggregate. The intact amniotic sac measures 2.3 cm in greatest dimension. Fetal tissue is identified within the amniotic sac, measuring 1.0 cm in crown-rump length. Representative sections are submitted for microscopic examination (in 1 cassette).

Microscopy

The most important is to detect the presence of chorionic villi.

In the absence of chorionic villi, look for implantation site intermediate trophoblasts (ISITs):

  • In the absence of both chorionic villi and ISITs, preferably perform cytokeratin immunostaining of each tissue sample, such as CAM5.2.[20]
  • In the absence of chorionic villi and ISITs even after staining, call the clinician, since there may be an ectopic pregnancy.

Microscopy report

Examples:

Histopathology of chorionic villi at gestational age of 9 weeks.jpg

((Products of conception:)) Products of conception, including immature chorionic villi, corresponding to first trimester pregnancy. ((Spontaneous abortion, clinically.))

Histology of implantation site intermediate trophoblasts.jpg

((Products of conception:)) Fragments of focally necrotic decidua and implantation site, consistent with intrauterine products of conception. Negative for chorionic villi.


Fallopian tube

Gross processing

Paratubal cysts can be ignored if incidentally found.

(Look in the history for any intra-fallopian coils (Essure devices).)[note 3]

For sterilization
  • Measure length and average diameter of each tube
  • Serially section at 3-4 mm intervals,[21] or 2-3 mm if suspected malignant (including BRCA mutation).[22] Submit
  • Submit 1 (or 3) circumferential transverse sections. If the specimen is only a segment of the tube of less than <5mm((, ink the surgical cut surfaces and)) submit all tissue.[21]

Example gross report:

(A. Labeled - __. The specimen is received in formalin and consists of) two fimbriated segments of fallopian tube measuring __ cm in length and __ cm in average diameter. On sectioning, each displays a patent lumen. No gross abnormalities are identified. The tubes are unoriented. The specimen is serially cross-sectioned and representative sections are submitted for microscopic examination in two cassettes.

Microscopic examination

Fallopian tubes may be substantially edematous and congested, which can generally be attributed to surgery, in which case it does not need mention in the report.
  • Ensure there is at least one full cross-section from each tube, and take further samples otherwise.
  • Check for patency of the lumen.

Tumor

The most common tumor of the fallopian tubes is adenomatoid tumor:[23]

Reporting

Example of a normal report in sterilization:

(Right and left fallopian tubes, laparoscopic bilateral salpingectomy:)
Complete cross-sections of histologically unremarkable fallopian tubes.

When included in a uterus specimen, normal tubes and ovaries may simply be mentioned as:

Bilateral fallopian tubes and ovaries, unremarkable.
Histopathology of an ectopic pregnancy in a fallopian tube, with chorionic villi and implantation site changes Further information: Products of conception .

When done for ectopic pregnancy, report any rupture, either from the gross report or from microscopy, for example:

Benign ruptured fallopian tube with ectopic products of conception, including degenerated immature chorionic villi and implantation site with fresh hemorrhage.

Further information: Products of conception

Notes

    • In the US, the cut goes from side to side, through the cervix and uterine cavity, keeping the anterior and posterior halves attached by a relatively thin connection left at the fundus. It is done by cutting with scissors with the blunt end in the cervix and then uterine cavity, or by a blade guided on each side by the shanks of a pair of forceps inserted through the cervix.
    • In Sweden, the uterus is usually opened at the front in the midline, optionally with an incision towards each corner.
    It can be done by scissors, or by inserting a probe or forceps to guide a long blade.
  1. The first example is used in Connecticut, and the second example is used in Sweden.
  2. For a case with intra-fallopian coils in the medical records, an inability to find them on gross processing must be noted in order to raise the possibility of coil expulsion.

Main page

References

  1. Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India ". Indian Journal of Medical and Paediatric Oncology 30 (4): 131. doi:10.4103/0971-5851.65335. ISSN 0971-5851. 
    - Figure- available via license: Creative Commons Attribution 2.0 Generic
  2. 2.0 2.1 2.2 Owings, Richard A.; Quick, Charles M. (2014). "Endometrial Intraepithelial Neoplasia ". Archives of Pathology & Laboratory Medicine 138 (4): 484–491. doi:10.5858/arpa.2012-0709-RA. ISSN 1543-2165. 
  3. Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites ". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691. 
    - "Figures - available via license: Creative Commons Attribution 4.0 International"
  4. 4.0 4.1 4.2 Rabban, Joseph T.; Gilks, C. Blake; Malpica, Anais; Matias-Guiu, Xavier; Mittal, Khush; Mutter, George L.; Oliva, Esther; Parkash, Vinita; et al. (2019). "Issues in the Differential Diagnosis of Uterine Low-grade Endometrioid Carcinoma, Including Mixed Endometrial Carcinomas ". International Journal of Gynecological Pathology 38: S25–S39. doi:10.1097/PGP.0000000000000512. ISSN 0277-1691. 
  5. Nicole Cipriani (2020-06-22). Gross Pathology Manual. The University of Chicago Department of Pathology.
  6. Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India ". Indian Journal of Medical and Paediatric Oncology 30 (4): 131. doi:10.4103/0971-5851.65335. ISSN 0971-5851. 
    - Figure- available via license: Creative Commons Attribution 2.0 Generic
  7. Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites ". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691. 
    - "Figures - available via license: Creative Commons Attribution 4.0 International"
  8. 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
  9. 9.0 9.1 . General Specimen Orientation Tips. The University of Michigan (2020-01-29).
  10. Nicole Cipriani (2020-06-22). Gross Pathology Manual. The University of Chicago Department of Pathology.
  11. Khaled J. Alkhateeb, M.B.B.S., Ziyan T. Salih, M.D.. HSIL / CIN II / CIN III. PathologyOutlines. Topic Completed: 29 March 2021. Minor changes: 9 February 2022
  12. Source image by Ed Uthman from Houston, TX, USA. Creative Commons Attribution 2.0 Generic (CC BY 2.0) license
  13. Anissa Ben Amor.. Cervical Ectropion. StatPearls, National Center for Biotechnology Information. Last Update: November 14, 2021.
    - This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
  14. Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India ". Indian Journal of Medical and Paediatric Oncology 30 (4): 131. doi:10.4103/0971-5851.65335. ISSN 0971-5851. 
    - Figure- available via license: Creative Commons Attribution 2.0 Generic
  15. Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites ". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691. 
    - "Figures - available via license: Creative Commons Attribution 4.0 International"
  16. 16.0 16.1 Paulette Mhawech-Fauceglia, M.D.. Uterus - Smooth muscle tumors - Leiomyosarcoma. Pathology Outlines. Topic Completed: 5 December 2019. Minor changes: 11 August 2020
  17. Mohamed Mokhtar Desouki. Uterus - Stromal tumors - Leiomyoma. Pathology Outlines. Topic Completed: 1 August 2011. Revised: 15 December 2019
  18. Vijay Shankar, M.D.. Soft tissue - Smooth muscle - Leiomyosarcoma - general. Pathology Outlines. Topic Completed: 1 November 2012. Revised: 11 September 2019
  19. 19.0 19.1 . Gross Pathology Manual, By The University of Chicago Department of Pathology - Products of Conception. Retrieved on 2020-08-13.
  20. Konoplev SN, Dimashkieh HH, Stanek J (2004). "Cytokeratin immunohistochemistry: a procedure for exclusion of pregnancy in chorionic villi-negative specimen. ". Placenta 25 (2-3): 146-52. doi:10.1016/S0143-4004(03)00188-7. PMID 14972447. Archived from the original. . 
  21. 21.0 21.1 Kerryn Ireland-Jenkin and Marsali Newman. Ovary and fallopian tube -benign setting. Royal College of Pathologists of Australasia. Retrieved on 2020-10-16.
  22. Crum, Christopher P.; Mckeon, Frank D.; Xian, Wa (2012). "The Oviduct and Ovarian Cancer ". Clinical Obstetrics and Gynecology 55 (1): 24–35. doi:10.1097/GRF.0b013e31824b1725. ISSN 0009-9201. 
  23. 23.0 23.1 Nicole Riddle, Jamie Shutter. Fallopian tubes & broad ligament - Fallopian tube tumors - Adenomatoid tumor. Pathology Outlines. Topic Completed: 1 September 2013. Minor changes: 13 December 2019

Image sources

Ovary

Gross processing

"Long" and "short" axis.[1]

The ovary is cut in the longitudinal plane (through the "long axis").

Ovaries, including those with cysts, are almost never inked.

Gross report

Template:

(A. Labeled - __. The specimen is received in formalin and consists of) an ovary measuring ___. The ovarian capsule is tan-pink and smooth. Cut sections reveal solid, white and whorled parenchyma, and no gross lesions. Representative sections are submitted for microscopic examination in __ cassettes.

Microscopic examination

Signet ring cell carcinoma metastasis to the ovary, also called Krukenberg tumor: Gross pathology (top, cross-section at right) and histopathology at low and high magnification.[2]

Generally look for signet ring cells, which is a major feature of metastatic tumors to the ovary.


Placenta

Gross processing

  • Determine the shape of the placenta
  • Look for any accessory lobes
  • Determine the completeness of placental membranes, opacity, color and consistency (slimy/slippery?)
  • Determine the point of rupture from nearest margin
  • Note where the membranes are inserted
  • Examine the umbilical cord
  • Measure the distance between the insertion point and the nearest placental margin
  • Measure the cord length and give proximal and distal diameter. In placental pathology, the proximal umbilical cord refers to the segment closest to the placenta, and distal is the segment closest to the fetus.[note 1]
  • Count the number of vessels away from the insertion
  • Weigh the trimmed disk, after having trimmed away the cord and membranes, and after having removed excess amounts of loose retroplacental blood clots over the maternal surface.
  • Examine the fetal surface (chorionic plate):
  • Note its color, in particular if it is green (often faint and tan-green, brown-green to yellow-green (which indicates meconium staining).
  • Look for any pathologies including granular excrescences, subchorionic fibrin or subamniotic hemorrhage
  • Look at the integrity and extent of the vasculature, including any traumatic damage. Also palpate the vasculature for any thrombosis. If a thrombus is grossly found for a live birth, the baby may have thrombosis, so the finding must immediately be reported to the clinician in care of the baby.
  • Examine the maternal surface (basal plate) for completeness, adherent blood clots, depressions, calcifications and fibrin
  • Take a membrane roll and cord sections, before sectioning the placenta
  • With the fetal surface down on the cutting board, cut the placenta at 1cm intervals so that it can be reconstructed.
  • Palpate the parencyhmal sections for areas of induration.
  • Note the color of the parenchyma and describe any pale areas, cysts, thrombi, increased fibrin, calcifications and infarcts. For possible infarcts, estimate the total amount of infarcted tissue as a percentage of the placental volume. Infarction is clinically significant if it involves at least 5-10% of the placental volume.
Gross pathology of placental disorders.[3]

If you see a true knot (rather than "false knots" which are merely bulges or protuberances that may look like knots), report whether the diameter of the cord is significantly different before versus after the knot (which is a sign of constriction caused by the knot).

Tissue selection

  • Distal (toward fetus) membrane roll and cross section of distal cord. It should include the area of rupture.
  • Proximal (toward placenta) membrane roll and cross section of proximal cord ( 2-3 cm from insertion). They should include membranes up to the chorionic plate.

A membrane roll is created by cutting a strip, about 3 cm wide, of membrane, from the rupture site to the placental insertion. Hold the edge with forceps and roll it around the forceps, and then cut a transverse section of the roll.
Cord sections should be no thicker than 4mm.

  • Placental section including fetal surface ( full thickness if possible)
  • Placental section including maternal surface (full thickness if possible)
  • Any lesions or abnormalities

Avoid taking placental sections near the margin

Gross report

Placenta weight by gestational age.

Example in a normal case:

(A. Labeled with patient's name and medical record number. The specimen is received fresh and consists of a) placenta with attached membranes and umbilical cord. The membranes are tan-red( with a marginal insertion. The site of rupture is __ cm from the nearest placental margin. There is no accessory lobe.) The trimmed placental weight is __ gramsTemplate:Comprehensive-begin-Corresponding to the __th percentile for the gestational age)). The placental disc measures __ cm and varies in thickness from __ to __ cm. The umbilical cord is tan-pink and eccentrically inserted(, __ cm from the nearest placental margin, and measures __ cm in length, __ cm in proximal diameter and __ cm in distal diameter.) Cut sections of the cord reveal three blood vessels. The fetal surface is blue-pink, smooth with normal vasculature and << minimal / moderate / major>> subchorionic fibrin deposition. The maternal surface is complete with <<minimal / moderate / major>> physiologic calcifications. Sectioning reveals a red, spongy, homogenous parenchyma without gross lesions. (Representative sections are submitted for microscopic examination in 4 cassettes.)

KEY OF SECTIONS (example):

  • 1- distal membranes and umbilical cord
  • 2- proximal membranes and umbilical cord
  • 3- placental section including fetal surface
  • 4- placental section including maternal surface

Microscopic examination

  • Look for inflammation, especially by the fetal surface in the intervillous spaces and around the fetal blood vessels.
  • At least if there is a suspicion of meconium in the amniotic fluid (from clinical history and/or the gross exam), look for the following histopathologic signs of it:[5]

Other relatively common findings

Microscopy report

Generally, also include major gross findings, such as an area of placental abruption.

Example of normal report:

(Placenta, <<vaginal/Caesarean>> delivery:)
Third trimester placenta with term villous histology. Placental weight (__ gm), at __th percentile for gestational age. Membranes without significant histopathologic changes((, negative for chorioamnionitis)). Trivascular umbilical cord, with no significant histopathologic changes((, negative for funisitis)).

Mild to moderate inflammation in the decidua alone can be ignored (as it is most commonly a physiological response and doesn't have a clinical significance for the fetus).


Vulva

Gross processing

Generally as per skin.

Microscopic examination

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Histopathology of high-grade squamous intraepithelial lesion (HSIL) of vulva (left in image) with full thickness dysplasia, compared to normal epithelium at right.

Mainly look for squamous vulvar intraepithelial lesions:

  • Low-grade squamous intraepithelial lesion (LSIL):[7]
  • Acanthosis, papillomatosis, and/or atypical koilocytosis in upper layers
  • Usually mild atypia and mitoses, limited to the lower third of stratum spinosum and basale
  • Binucleated epithelial cells
  • High-grade squamous intraepithelial lesion (HSIL):[7]
  • Enlarged atypical nuclei and mitoses involving middle and upper third of the epithelium.
  • Also telling are atypical mitoses and/or extension in hair follicles and skin appendages.

Staging of vulvar cancer

Tumors of the vulva are staged as per the AJCC, 8th Ed:[8]

Primary tumor (T)
TNM FIGO Criteria
TX Primary tumor cannot be assessed
T0 No evidence of a primary tumor
Tisa Carcinoma in situ (preinvasive)
T1a IA Lesions ≤2 cm, confined to the vulva or perineum and with stromal invasion ≤1 mmb
T1b IB Lesions >2 cm or any size with stromal invasion >1 mm, confined to the vulva or perineum
T2 II Tumor of any size with extension to adjacent perineal structures (distal third of the urethra, distal third of the vagina, anal involvement)
T3 IVA Tumor of any size with extension to any of the following proximal two thirds of the urethra, proximal two thirds of the vagina, bladder mucosa, or rectal mucosa or fixed to pelvic bone
Regional lymph nodes (N)
TNM FIGO Criteria
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 1 or 2 regional (inguinofemoral) lymph nodes with the following features (see N1a, N1b)
N1a IIIA 1 or 2 lymph node metastases, each < 5 mm
N1b IIIA 1 regional lymph node metastasis ≥5 mm
N2 Regional (inguinofemoral) lymph nodes with the following features (see N2a, N2b, N2c)
N2a IIIB 3 or more lymph node metastases, each < 5 mm
N2b IIIB 2 or more regional lymph node metastases ≥5 mm
N2c IIIC Regional lymph node metastasis with extracapsular spread
N3 IVA Fixed or ulcerated regional lymph node metastasis
Distant metastasis (M)
TNM FIGO Criteria
M0 No distant metastasis
M1 IVB Distant metastasis (including to pelvic lymph nodes)


Cervical cytology

Clinical information

It is not necessary to look through more than readily available reports from previous cervical cytologies.

Magnification

While being fairly new to cervical cytology, preferably start looking at a high magnification such as 20x objective (with 10x eye piece). For suspicious findings, you may magnify up to maximum. On the other hand, once the pattern feels repetitive you can try switching to a slightly lower magnification such as 10x.

Adequacy

Adequacy should always be stated, either as "Satisfactory" or "Unsatisfactory". For estimating the number of cells, determine the following:

  • The area of your field of view at high power (see the Evaluation chapter)
  • The total size of the relevant area on the microscope slide. A ThinPrep is about 360 mm2.
  • Look at 10 representative high power fields (HPFs) within that area, and calculate the average number of cells per high power field.
HPF example on a ThinPrep (about 360 mm2). If 10 fields gives a total of 40 cells, it will be 4 cells per HPF. The area of this field is 0.23 mm2. Therefore, total cellularity is estimated to be:
4 cells * 360mm2 / 0.23mm2 = 6260 cells.
Total number of cells = Average number of cells per HPF * Total size of area
HPF area

Conventional smear cellularity should be at least 8,000 cells. Liquid-based cytology cellularity should be at least 5,000 cells. Also a conventional smear is inadequate if >75% of cells are obscured by blood, exudate or air-drying artefact.[9]

Eventually you will be able to tell when most cases are adequate or inadequate without performing a detailed calculation.

Transformation zone presence

Squamous metaplasia also counts as endocervix. Typical features are annotated. Pap stain.

State whether the endocervical/transformation zone is present or absent. Count an endocervical component as present if there are 10 or more endocervical or squamous metaplastic cells.[10]

In patients with previous hysterectomy, simply report glandular or squamous metaplastic cells as such, rather than stating the presence of a transformation zone, since they are likely vaginal in origin in such patients.[11]

Very common findings

Main conditions to exclude or confirm

Squamous atypia, seen mainly as cells with increased nucleus/cytoplasm ratio, nuclear hyperchromasia and irregular nuclear outline.

Cytopathology of squamous cell carcinoma, nonkeratinizing variant, with typical features.[13] Pap stain. Necrotic debris (dirty background) is a feature that generally makes a HSIL case "suspicious for invasive squamous cell carcinoma".[14] In contrast to the more distinct keratinizing variant, these findings are overall less specific, and most can be seen in other cancers such as adenocarcinoma as well (which, however, tends to have fine chromatin)[15]

Clinical implication

If you are uncertain of the degree of dysplasia, it can be useful to look up how much difference it will likely make for the management of the patient. You may make an Internet search for the management of abnormal cervical screening in your region (such as The ASCCP tool for management in the US). A change from close follow-up to colposcopy is not that big of a deal, but if one of the alternatives will lead to a diagnostic excision, make sure that the case is looked upon by commensurate expertise.


Report

Example in a normal case:

Cervical/endocervical ThinPrep:
Negative for intraepithelial lesion or malignancy (NILM).


Male reproductive system

Phimosis

Gross processing

Generally sample one or two representative sections in a cassette, in addition to sections of any grossly visible lesions.

  See also: General notes on gross processing

Microscopic evaluation

Look for:

Optionally, note any sclerosis and/or fibrosis.

Reporting

  • Description of objective findings, and any suspected underlying disease.
  • Presence or absence of dysplasia.


Vas deferens

Gross processing in sterilization

In sterilization:[18]

  • Measure length and diameter.
  • Serially section
  • Submit 2 cross sections measuring 5 mm in length.

Communicate to the histology lab to section the specimen as tubular structures, in order to get proper cross-sections.

Microscopic examination in sterilization

Confirm that there is a complete cross-section from each side. Example images of normal vas deferens:

Report

Example report:

Right and left vas deferens segments, excisions:
Complete cross-sections of vasa deferentia without significant histopathologic changes.

Notes

  1. In contrast, in embryology and fetal medicine, the proximal umbilical cord refers to the segment closest to the fetus:
    - Wyburn GM (1939). "The formation of the umbilical cord and the umbilical region of the anterior abdominal wall. ". J Anat 73 (Pt 2): 289-310.9. PMID 17104757. PMC: 1252509. Archived from the original. . 
    Harvey J. Kliman, M.D., Ph.D. (2006-10-29). The Umbilical Cord (from The Encyclopedia of Reproduction). Yale School of Medicine.

Main page

References

  1. Pellerito, John; Polak, Joseph F. (2012). Introduction to Vascular Ultrasonography (6th ed.). Elsevier Health Sciences. p. 559. ISBN 978-1-4557-3766-6. 
  2. Nakamura, Yoshiaki; Hiramatsu, Ayako; Koyama, Takafumi; Oyama, Yu; Tanaka, Ayuko; Honma, Koichi (2014). "A Krukenberg Tumor from an Occult Intramucosal Gastric Carcinoma Identified during an Autopsy ". Case Reports in Oncological Medicine 2014: 1–5. doi:10.1155/2014/797429. ISSN 2090-6706. 
    - Creative Commons Attribution 3.0 Unported (CC BY 3.0) license
  3. Chen, Yukun; Zhang, Zhuomin; Wu, Chenyan; Davaasuren, Dolzodmaa; Goldstein, Jeffery A.; Gernand, Alison D.; Wang, James Z. (2020). "AI-PLAX: AI-based placental assessment and examination using photos ". Computerized Medical Imaging and Graphics 84: 101744. doi:10.1016/j.compmedimag.2020.101744. ISSN 08956111. 
    - Fig 5- available via license: Creative Commons Attribution 4.0 International.
  4. Kim, Chong Jai; Romero, Roberto; Chaemsaithong, Piya; Chaiyasit, Noppadol; Yoon, Bo Hyun; Kim, Yeon Mee (2015). "Acute chorioamnionitis and funisitis: definition, pathologic features, and clinical significance ". American Journal of Obstetrics and Gynecology 213 (4): S29–S52. doi:10.1016/j.ajog.2015.08.040. ISSN 00029378. 
  5. Mandolin S. Ziadie. Placenta - Nonneoplastic placental conditions and abnormalities - Noninfectious - Meconium staining. Pathology Outlines. Topic Completed: 1 October 2011. Minor changes: 27 August 2020
  6. Chapter 3. Placental Calcification: Its Processes and Impact on Pregnancy, Kachewar, Sushil (2013). Calcification : processes, determinants and health impact . New York: Nova Science Publishers, Inc. ISBN 978-1-62618-155-7. OCLC 840507829. 
  7. 7.0 7.1 Matthias Choschzick. Vulva, vagina & female urethra - Squamous carcinoma and precursor lesions - HPV associated SIL. PathologyOutlines. Topic Completed: 6 January 2021. Minor changes: 11 June 2021
  8. Amin, Mahul (2017). AJCC cancer staging manual (8 ed.). Switzerland: Springer. ISBN 978-3-319-40617-6. OCLC 961218414. 
    - For access, see the Secrets chapter of Patholines.
    - Copyright note: The AJCC, 8th Ed. is published by a company in Switzerland, and the tables presented therein are Public Domain because they consist of tabular information without literary or artistic innovation, and therefore do not fulfil the inclusion criterion of the Swiss Copyright Act (CopA) which applies to "literary and artistic intellectual creations with individual character" (see Federal Act on Copyright and Related Rights (Copyright Act, CopA) of 9 October 1992 (Status as of 1 January 2022)). edit
  9. 9.0 9.1 . Criteria for adequacy of a cervical cytology sample. EuroCytology. Retrieved on 2022-08-29.
  10. Cibas, Edmund S.; Ducatman, Barbara S. (2021). Cytology : diagnostic principles and clinical correlates . Philadelphia, PA. p. 9. ISBN 978-0-323-63637-7. OCLC 1138033641. 
  11. Ramirez NC, Sastry LK, Pisharodi LR (2000). "Benign glandular and squamous metaplastic-like cells seen in vaginal Pap smears of post hysterectomy patients: incidence and patient profile. ". Eur J Gynaecol Oncol 21 (1): 43-8. PMID 10726617. Archived from the original. . 
  12. - Image annotated by Mikael Häggström
    - Reference for entries: Gulisa Turashvili, M.D., Ph.D.. Cervix - Squamous cell carcinoma and variants. Pathology Outlines. Last author update: 24 September 2020. Last staff update: 4 April 2022.
    - Source image from National Cancer Institute (Public Domain)
  13. - Image annotated by Mikael Häggström
    - Reference for entries: Gulisa Turashvili, M.D., Ph.D.. Cervix - Squamous cell carcinoma and variants. Pathology Outlines. Last author update: 24 September 2020. Last staff update: 4 April 2022.
    - Source image by Ravi Mehrotra, Anurag Gupta, Mamta Singh and Rahela Ibrahim (Creative Commons Attribution 2.0 Generic license.)
  14. Alrajjal A, Pansare V, Choudhury MSR, Khan MYA, Shidham VB (2021). "Squamous intraepithelial lesions (SIL: LSIL, HSIL, ASCUS, ASC-H, LSIL-H) of Uterine Cervix and Bethesda System. ". Cytojournal 18: 16. doi:10.25259/Cytojournal_24_2021. PMID 34345247. PMC: 8326095. Archived from the original. . 
  15. Authors: Caroline I.M. Underwood, M.D., Alexis Musick, B.S., Carolyn Glass, M.D., Ph.D.. Adenocarcinoma overview. Pathology Outlines. Last staff update: 19 July 2022
  16. Clemmensen, Ole J.; Krogh, John; Petri, Michael (1988). "The Histologic Spectrum of Prepuces from Patients with Phimosis ". The American Journal of Dermatopathology 10 (2): 104–108. doi:10.1097/00000372-198804000-00002. ISSN 0193-1091. 
  17. Alcides Chaux, Antonio L. Cubilla. Penis and scrotum - Inflammatory lesions - Phimosis. PathologyOutlines. Topic Completed: 1 February 2010. Revised: 13 February 2019
  18. . Vas Deferens (Sterilization). Gross Pathology Manual - By The University of Chicago Department of Pathology. Retrieved on 2021-08-27.
  19. Vas deferens image available in Public Domain. See https://patholines.org/File:Vas_deferens.jpg

Image sources