From The New England Journal of Medicine
The roots of pathology are those of medicine itself and extend back beyond recorded history. However, surgical pathology as we recognize it is only about 100 years old, born of the union of microscopy and surgical observation. But where does gynecologic pathology fit into surgical pathology and medicine today? Currently, the epidemic of sexually transmitted diseases in the United States results in the discovery of abnormal results on Papanicolaou testing in a million or more women each year, and such results often prompt a cervical biopsy. Abnormal uterine bleeding, either spontaneous or associated with oral contraceptive or hormone-replacement therapy, in tens of millions has made endometrial sampling one of the most common surgical procedures in this country. Consequently, these specimens may actually account for the largest single group encountered in some busy practices, and knowledge of gynecologic pathology is essential to the surgical pathologist. Not only is the volume of gynecologic specimens great; so is their complexity. The World Health Organization includes more than 120 histologic types in its classification of ovarian tumors. The inherent difficulty in the interpretation of gynecologic specimens is complicated by the fact that in the female genital tract, even the histologic features that define the norm are variable, fluctuating with the reproductive age (premenarche, menarche, the reproductive years, and menopause) and even the menstrual cycle day in some organs, such as the endometrium. Frequently, this diagnostic challenge is further amplified by iatrogenic alterations due to interventions to augment or diminish fertility or to delay menopause. It is hardly surprising that even experienced pathologists may view an endometrial or cervical biopsy with suspicion or anxiety. Currently available specialized resources in gynecologic pathology include two encyclopedic references (Blaustein's Pathology of the Female Genital Tract [New York: Springer-Verlag, 2002] and Haines and Taylor Obstetrical & Gynaecological Pathology [Edinburgh: Churchill Livingstone, 2003]), several atlases, and numerous monographs on specific genital tract organs. What need might Pathology of the Female Reproductive Tract, edited by Robboy, Anderson, and Russell, fill? The editors' stated objective is to provide a thorough, comprehensive book, written in a style that is easy to read. The authors are experienced, internationally recognized investigators from the United States, the United Kingdom, and Australia. Although eight other contributors have added to various chapters, it is apparent from the seamless and lively literary style that the three editors worked together to generate most of the text. The result represents a thoughtful distillation of the literature and of their and the contributors' experience, with little preexisting knowledge on the part of the reader assumed. The writing is engaging, providing advice where problems are anticipated and pointing out unresolved issues. The flow of the text is not disrupted by citations involving names or the year of publication. Citations of the published literature are about one third as numerous as in more comprehensive books and were for the most part selected from the literature of the past decade. Most readers will probably respond immediately on opening the book, with its visually arresting use of more than 2000 color photographs, charts, tables, and chapter tabs. Surgical pathologists spend much of their lives making diagnoses relying on the reproducible artifacts of sections stained with hematoxylin and eosin, but they still are likely to read of a medical world that is depicted in black and white. This lavishly illustrated book is both textbook and atlas, and I found the clinical photographs of vulvar disease and those of intact gross surgical specimens particularly compelling. The photomicrographs are generally well selected, but future editions would benefit from digitally enhanced color balancing to achieve a more uniform appearance. The subject matter is focused primarily on the pathological criteria on which a diagnosis is based, with only brief descriptions of pathogenesis, clinical presentation, natural history, and treatment. This is not a book for learning about disease, but rather one for learning how to arrive at the correct diagnosis. Immunohistochemical stains and molecular biology are briefly described in selected areas, but the book is grounded in classic gross and microscopical morphology. Specific strengths include the clinically oriented chapters that depict and describe vulvar dermatologic disease and colposcopic abnormalities, the illustrations of embryologic development and disorders of sexual differentiation, the brief overview of cervical intraepithelial neoplasia, and the simplified tables and schematic diagrams, such as the decision tree for distinguishing among unusual smooth-muscle tumors of the uterus. However, some lesions, such as microinvasion in ovarian serous carcinoma, are only briefly addressed, and the description of the benign vulvar angiomyofibroblastoma is not sufficiently detailed to permit confident distinction from the locally infiltrative aggressive angiomyxoma. This book does not provide all the answers to many basic and clinical questions about the natural history, biologic behavior, or therapy of gynecologic diseases, nor does it serve as a comprehensive source of references for further exploration of the primary literature. Other textbooks serve that function. However, with its striking use of color and its readability, Pathology of the Female Reproductive Tract has created a new niche. It represents a pleasing and relatively detailed exploration of gynecologic pathology with a wealth of information and illustrations for the resident in gynecology or pathology or for the practicing pathologist who would like diagnostic assistance when next confronted with a problematic gynecologic biopsy or resection specimen. Richard J. Zaino, M.D.
Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
About the Author
Stanley J. Robboy, MD, Professor of Pathology & Vice Chairman for Diagnostic Services; Head, Gynecologic Pathology, Professor of Obstetrics & Gynecology, Duke University Medical Center, Durham, NC; Malcolm C. Anderson, FRCPath, FRCOG , Emeritus Consultant Histopathologist, University Hospital, Queen's Medical Centre, Nottingham, UK; and Peter Russell, MD, FRCPA, Professor of Pathology and Director, Department of Anatomical Pathology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia