Ch 13 Pathoma - Female Genital System and Gestational Pathology

Question 1

<p>Anatomically includes the skin and mucosa of the female genitalia external to the hymen (labia major and minor, mons pubis, and vestibule) and is lined by \_\_\_\_\_ epithelium.</p>

Answer 1

<p>Vulva; squamous</p>

Question 2

<p>A Bartholin cyst arises from obstruction of the \_\_\_\_\_\_\_\_, (present on each side of the vaginal canal and drains a mucus like fluid in to the lower vestibule). Usually occurs in \_\_\_\_\_\_ and presents as a \_\_\_\_ and \_\_\_\_ cystic lesion.</p>

Answer 2

<p>Bartholin gland; women of reproductive age; unilateral; painful</p>

Question 3

<p>\_\_\_\_\_ is a warty neoplasm of vulvar skin, most commonly due to \_\_\_\_\_. Histologically characterized by \_\_\_\_\_.</p>

Answer 3

<p>Condyloma; HPV 6 or 11 (less commonly secondary syphilis); koilocytes</p>

Question 4

<p>\_\_\_\_\_\_ is characterized by thinning of the epidermis and fibrosis of the dermis. Presents as a \_\_\_\_\_\_ with parchment like vulvar skin. Most commonly seen in \_\_\_\_\_ women. Yes/No increased risk for SCC.</p>

Answer 4

<p>Lichen sclerosis; white patch (leukoplakia); postmenopausal; Yes</p>

Question 5

<p>\_\_\_\_\_\_ is characterized by hyperplasia of the vulvar squamous epithelium. Presents as \_\_\_\_\_\_\_ with thick, leathery vulvar skin. Associated with \_\_\_\_\_\_\_. Yes/No increased risk of SCC.</p>

Answer 5

<p>Lichen simplex chronicus; leukoplakia; chronic irritation/scratching; No</p>

Question 6

<p>Three potential causes of leukoplakia of the vulva</p>

Answer 6

<p>lichen sclerosis, lichen simplex chronicus, vulvar carcinoma</p>

Question 7

<p>Vulvar carcinomas presents as \_\_\_\_\_\_. It can be related or not related to \_\_\_\_. When it is related, it arises from \_\_\_\_\_. When it is not related, it arises most often from \_\_\_\_. Age difference</p>

Answer 7

<p>leukoplakia; HPV; VIN (vulvar intraepithelial neoplasia); lichen sclerosis; HPV related seen in women of reproductive age; HPV non related seen in women >70 yrs</p>

Question 8

<p>\_\_\_\_\_\_ is characterized by malignant epithelial cells in the epidermis of the vulva. Presents as \_\_\_\_, \_\_\_\_\_\_, \_\_\_\_\_\_ vulvar skin. It represents carcinoma in situ usually with no underlying carcinoma (different from \_\_\_\_\_). Must be distinguished from melanoma, done with these three stains.</p>

Answer 8

<p>Extramammary paget disease; erythematous; pruritic; ulcerated; paget disease of the nipple;

~~~
paget = PAS+, keratin+, S100-
melanoma = PAS-, keratin-, S100+</p>

~~~

Question 9

<p>Adenosis; Increased incidence in females who were exposed to \_\_\_\_\_ in utero</p>

Answer 9

<p>focal persistence of columnar epithelium in upper vagina (lower 1/3 of vag is sq epith derived from urogenital sinus, which during development overtakes the columnar epith of the upper 2/3 derived from Mullerian ducts); diethylstilbestrol (DES)</p>

Question 10

_______ is a malignant proliferation of glands with clear cytoplasm. It is a rare complication of ___-associated vaginal adenosis

Answer 10

Clear cell adenocarcinoma; DES

Question 11

Embryonal rhabdomyosarcoma is a malignant ______ proliferation of ______. It presents as ______ and a ____ mass protruding from the vagina or penis of a child (usually

Answer 11

mesenchymal; immature skeletal muscle; bleeding; grape-like; sarcoma botryoides; cross-striations; desmin; myogenin

Question 12

Vaginal carcinoma’s precursor lesion is ______. When spread to regional lymph nodes occur, cancer from lower 1/3 spreads to _____, and cancer from upper 2/3 goes to _____.

Answer 12

VAIN (vaginal intraepithelial neoplasia); inguinal nodes; iliac nodes

Question 13

Vulvar intraepithelial neoplasia (VIN), CIN, VAIN are dysplastic precursor lesions characterized by these 4 things.

Answer 13

koilocytic change, disordered cellular maturation, nuclear atypia (high nuclear to cytoplasmic ratio, with hyper chromatic nuclei), and increased mitotic activity

Question 14

Exocervix is lined by ______ and endocervix is lined by _____. The junction between the two is the ______.

Answer 14

nonkeratinizing stratified squamous epithelium; columnar epithelium; transformation zone

Question 15

HPV is a sexually transmitted ___ virus that infects the _____, especially the ____.

Answer 15

DNA; lower genital tract; cervix (transformation zone)

Question 16

High risk HPV types are _____. Low risk HPV types are _____. High risk HPV produces ___ and ___, which result in destruction of ____ and ____ respectively

Answer 16

16, 18, 31, 33
6 and 11
E6 and E7
p53 and Rb

Question 17

p53 recruits ___, which inactivates ____, which normally stabilizes the mitochondrial membrane, so ____ can escape and cause apoptosis

Answer 17

BAX; bcl2; cytochrome c

Question 18

Rb holds ____, which is needed to progress to the cell cycle.

Answer 18

E2F (transcription factor)

Question 19

CIN I involves ___ of the thickness of the epithelium (also answer CIN II and CIN III, and CIS)

Question 20

Cervical carcinoma is invasive carcinoma that arises in the cervical epithelium most commonly in _____ women, and presents as _____ or _____. Key risk factor is ____; 2ndary risk factors include ___ and ____. 80% of cases are ____ and 15% are ____.

Answer 20

middle aged; vaginal bleeding (especially post coital) or cervical discharge; HPV; smoking and immunodeficiency (AIDS defining illness); squamos cell carcinoma; adenocarcinoma

Question 21

In advanced stages of cervical carcinoma, tumors often invade through the ____ into the _____ and blocking the _____. Common cause of death is _____ due to _____.

Answer 21

anterior uterine wall; bladder; ureters; postrenal failure; hydronephrosis

Question 22

The goal of the pap smear is to catch ____ before it develops in to ____. An abnormal pap is followed by ______ and _____. There is limited efficacy in screening for _____.

Answer 22

dysplasia (CIN); carcinoma; confirmatory colposcopy; biopsy; adenocarcinoma

Question 23

The quadrivalent vaccine is effective in preventing HPV types _____.

Answer 23

6, 11, 16, and 18

Question 24

Endometrium

Answer 24

mucosal lining of the uterine cavity (it is hormonally sensitive)

Question 25

______ is the smooth muscle wall underlying the endometrium

Answer 25

myometrium

Question 26

Growth of endometrium is ____ driven (proliferative phase), preparation for implantation is ____ driven (secretory phase), and shedding occurs with loss of _____ support (menstrual phase)

Answer 26

estrogen; progesterone; progesterone

Question 27

_______ is secondary amenorrhea due to loss of the basalis (basal endometrial layer) and scarring. It is a result of overaggressive _____.

Answer 27

Asherman syndrome; dilation and curettage (D&C)

Question 28

________ is the lack of ovulation resulting in an estrogen driven proliferative phase without a _______ phase. Results in dysfunctional ______, especially during menarche and menopause

Answer 28

Anovulatory cycle; progesterone driven secretory phase; uterine bleeding

Question 29

Acute endometritis is a _____ infection of the endometrium, usually due to _____, which presents with these three symptoms.

Answer 29

bacterial; retained products of conception (after delivery/miscarriage); fever, abnormal uterine bleeding, and pelvic pain

Question 30

Chronic endometritis is chronic _____ of the endometrium characterized by the presence of ____ and most importantly _____, and presents with these three symptoms.

Answer 30

inflammation; lymphocytes; plasma cells (lymphocytes are normally found in endometrium); abnormal uterine bleeding, pain, and infertility

Question 31

Name four causes of chronic endometritis.

Answer 31

retained products of conception (same as in acute), chronic PID (e.g. chlamydia); IUD; TB (would also see granulomas)

Question 32

______ is a hyperplastic protrusion of endometrium, which presents as _____. Can arise as a side effect of ______, a drug with anti-estrogenic effects of the breast, but weak pro-estrogenic effects on the endometrium

Answer 32

endometrial polyp; abnormal uterine bleeding; tamoxifen

Question 33

Endometriosis is when ______ and _____ are found outside of the uterine endometrial lining, most likely due to ______. It presents as _____ and _____ and may cause ____.

Answer 33

endometrial glands and stroma; retrograde menstruation; dysmenorrhea (pain during menstruation); pelvic pain; infertility

Question 34

The most common site of involvement of endometriosis is the _____, which results in formation of a _______.

Answer 34

ovary; chocolate cyst

Question 35

Aside from the ovary, name the 5 other sites of endometriosis and how they present.

These implants typically appear as _____ nodules.

Answer 35

-uterine ligaments (pelvic pain);
-pouch of Douglas (pain with defecation);
-bladder wall (pain with urination);
-bowel serosa (abd pain and adhesions);
-fallopian tube mucosa (scarring –> ectopic)
yellow-brown/gun powder

Question 36

_____ is endometriosis with involvement of the uterine myometrium

Answer 36

adenomyosis

Question 37

Yes/No to an increased risk of carcinoma at the site of endometriosis

Answer 37

Yes - especially in the ovary

Question 38

Endometrial hyperplasia is hyperplasia of endometrial ____ relative to _____. Occurs as a consequence of unopposed _____ (obesity, PCOD, replacement) and classically presents as ______. Histologically, the growth pattern can be ____ or _____ with the presence or absence of _____.

Answer 38

glands; stroma; estrogen; postmenopausal uterine bleeding; simple or complex; cellular atypia

Cellular atypia is the most important predictor of progression to carcinoma

Question 39

Endometrial carcinoma is a malignant proliferation of endometrial _____. It presents as ______. It can arise from two distinct pathways: _____ and _____

Answer 39

glands; postmenopausal bleeding; hyperplasia (75%) and sporadic (25%)

Question 40

What is the most common invasive carcinoma of the female genital tract?

Answer 40

endometrial carcinoma

Question 41

In the hyperplasia pathway of endometrial carcinoma, it arises from ______ (due to unopposed estrogen). Average age of presentation is ____. Histology is _____. Risk factors are related to ____ exposure.

Answer 41

endometrial hyperplasia; 60; endometrioid; estrogen (early menarche/late menopause, nulliparity, infertility with anovulatory cycles, obesity)

Question 42

In the _____ pathway of endometrial carcinoma, it arises in an _____ endometrium with no evident precursor lesions. Avg age of onset is ____, and histology is usually ____ and characterized by ____ with ____ formation

Answer 42

sporadic; atrophic; 70; serous; papillary structures; psammoma body formation

Question 43

Which pathway of endometrial carcinoma (hyperplasia/sporadic) is associated with a p53 mutation and aggressive tumor behavior?

Answer 43

sporadic

Question 44

Name the four types of cancers with which you see psammoma bodies

Answer 44

• papillary carcinoma of the thyroid
• meningioma
• papillary serous carcinoma
• mesothelioma

Question 45

_____ are concentric lamellated calcified structures seen in certain types of cancer.

Answer 45

Psammoma body

Question 46

______ are benign neoplastic proliferation of smooth muscle arising from myometrium. They are related to ____ exposure. Gross exam shows ____, ______, _____, _____ masses. Usually asymptomatic, but symptoms include these three.

Answer 46

Leiomyoma; estrogen; multiple, well defined, white, whorled; abnormal uterine bleeding, infertility, pelvic mass

common in premenopausal women

Question 47

What is the most common tumor in females?

Answer 47

Leiomyoma

Question 48

Leiomyoma/Leiomyosarcoma - which one presents as single/multiple, white/whorrly vs hemorrhagic/necrotic, premenopausal/postmenopausal

Answer 48

leiomyoma: multiple, white/whorrly, premenopausal
leiomyosarcoma: single, hem/nec, post

Question 49

______ is a malignant proliferation of smooth muscle from the myometrium; on gross exam shows a single lesion with _____ and _____. Histological features include ____, _____, _____.

Answer 49

leiomyosarcoma; areas of necrosis and hemorrhage; necrosis, mitotic activity, cellular atypia

Question 50

True/False: leiomyosarcomas arise from leiomyomas

Answer 50

False - they always arise de novo

Question 51

_____ is the functional unit of the ovary and consists of an oocyte surrounded by ___ and ___ cells.

Answer 51

follicle; granulosa; theca

Question 52

____ acts on theca cells to induce ____ production; ____ acts on granulosa cells to convert _____ to _____. A ____ surge induces a ____ surge, which leads to ovulation.

Answer 52

LH; androgen; FSH; androgen; estradiol; estradiol; LH

Question 53

After ovulation, the residual follicle becomes a _____, which secretes _____. Hemorrhage in to it results in a ______, especially during early pregnancy. Degeneration of follicles results in ____.

Answer 53

corpus luteum; progesterone; hemorrhagic corpus luteal cyst; follicular cysts (which are common and have no clinical significance)

Question 54

Polycystic ovarian disease (PCOD) is characterized by increased ____ and low ____.

Answer 54

LH; FSH (LH:FSH>2)

Question 55

In this disease, increased LH induces excess androgen causing _____. Androgen can be converted to estrone in ____ tissue, causing feedback and subsequent decrease of ____, resulting in cystic degeneration of follicles

Answer 55

Polycystic ovarian disease (PCOD); hirsutism; adipose; FSH

Question 56

PCOD increases/does not effect/decreases the risk for endometrial carcinoma

Answer 56

increases

Question 57

Which disease classically presents as an obese young woman with infertility, oligomenorrhea, and hirsutism; and is often associated with insulin resistance.

Answer 57

Polycystic ovarian disease (PCOD)

Question 58

Ovary is composed of these three cell types, and tumors can arise from any of them

Answer 58

surface epithelium (70%), germ cells (15%), sex-cord stroma

Question 59

Name the four subtypes of surface epithelial ovarian tumors

Answer 59

serous and mucinous (most common 2), endometrioid, Brenner tumor

Question 60

Cystadenomas are benign/malignant tumors composed of a ____ cyst with a ___, ___ lining and most commonly arise in ____ women.

Answer 60

benign; single; simple, flat; pre menopausal (30-40)

these are mucinous or serous surface epithelial ovarian tumors

Question 61

Cystadenocarcinomas are benign/malignant tumors composed of _____ cysts with a ___, ___ lining and most commonly arise in ____ women.

Answer 61

malignant; complex; thick, shaggy; postmenopausal (60-70)

these are mucinous or serous surface epithelial ovarian tumors

Question 62

BRCA1 mutation carriers have an increased risk for ____ of the ovary and fallopian tube

Answer 62

serous carcinoma

Question 63

Endometrioid tumors are usually benign/malignant; brenner tumors are usually benign/malignant, and are composed of ____ epithelium

Answer 63

malignant; benign; bladder-like

Question 64

True or False: 5% of endometrioid carcinomas of the ovary are associated with an independent endometrial carcinoma (endometrioid type)`

Answer 64

False - 15% are

Question 65

Surface tumors (ovary) clinically present early/late with _____ symptoms or signs of _____.

Answer 65

late; vague abdominal (pain/fullness); compression (urinary frequency)

Question 66

How cancers typically like to spread:
Carcinomas –>
Sarcomas –>
Ovary –>

Answer 66

lymphatics
hematogenously
locally to peritoneum

Question 67

Which type of cancer has the worst prognosis of female genital tract cancers?

Answer 67

Surface epithelial carcinoma (ovary)

Question 68

Germ cell tumors usually occur in ______. Name the four tumor subtypes and the name of the tumor

Answer 68

WOCBP; (1) fetal tissue (cystic teratoma and embryonal carcinoma); (2) oocytes (dysgerminoma); (3) yolk sac (endodermal sinus tumor); (4) placental tissue (choriocarcinoma)

Question 69

Cystic teratoma is a cystic tumor composed of ____ derived from ____. It is benign, though the presence of ___ or ____ indicates malignant potential. ____ is a teratoma composed of thyroid tissue

Answer 69

fetal tissue; 2 or 3 embryologic layers (skin, hair, bone, cartilage, gut, thyroid); immature tissue (usually neural); somatic malignancy (usually sq cell carcinoma of the skin); Struma ovarii

Question 70

Dysgerminoma is a tumor composed of ____ cells, with ____ cytoplasm, and ____ nuclei (resemble oocytes). It is the most common malignant germ cell tumor; it’s testicular counterpart is called _____. It has a good/poor prognosis and serum ___ may be elevated

Answer 70

large; clear; central; seminoma; good (responds to radiotherapy); LDH

Question 71

______ is a malignant tumor that mimics the yolk sac. It is the most common germ cell tumor in children. Serum ___ is often elevated, and ______ are classically seen on histology.

Answer 71

Endodermal sinus tumor; AFP; Schiller-Duval bodies (glomerulus like structures)

Question 72

Choriocarcinoma is a malignant tumor composed of _____ and ______; it mimics placental tissue but ____ are absent. It is a small, hemorrhagic tumor with ____ spread. High ____ is characteristic. And it may cause ___ in the ovary

Answer 72

cytotrophoblasts and syncytiotrophoblasts; villi; hematogenous; B-hCG; thecal cysts

Poor response to chemo

Question 73

Embryonal carcinoma is a malignant tumor composed of large ____ cells. It is aggressive with early mets

Answer 73

primitive; not surprising it’s aggressive as primitive embryo cells have the ability to grow/spread

Question 74

Name the three types of sex cord-stromal tumors (ovary)

Answer 74

Granulosa-theca cell tumor; Sertoli-Leydig cell tumor; Fibroma

Question 75

Granulose-Theca cell tumors presents with signs of _____. Name these symptoms in a pt prior to puberty, in reproductive age, and postmenopausal, and which one is most common. They are malignant but with minimal risk for mets

Answer 75

estrogen excess; precocious puberty; menorrhagia (heavy bleeding) or metrorrhagia (abn bleeding from uterus); endometrial hyperplasia with postmenopausal bleeding; post menopausal

Question 76

Sertoli Leydig cell tumor is composed of sertoli cells that form tubules and leydig cells (btwn tubules) with characteristic ____. May produce ____ and associated ___ and ___

Answer 76

Reinke crystals; androgen; hirsutism and virilization

Question 77

Meig’s syndrome is a triad of a _____, ____ and ____

Answer 77

ovarian tumor; pleural effusions and ascites

Question 78

____ is a benign tumor of fibroblasts often associated with Meig’s syndrome

Answer 78

fibroma

Question 79

Name two metastatic tumors you see in the ovary

Answer 79

Krukenberg tumor and Pseudomyxoma peritonei

Question 80

Krukenberg tumor is a metastatic ____ tumor that invovles BOTH ovaries; most commonly due to metastatic ____.

Answer 80

mucinous; gastric garcinoma (diffuse type)

Question 81

_____ is massive amounts of mucus in the peritoneum due to a mutinous tumor of the _____. “Jelly Belly”

Answer 81

pseudomyxoma peritonei; appendix

Question 82

_____ is implantation of the placenta in the lower uterine segment where it overlies the ______. It presents as ______ and often requires delivery of fetus by c-section

Answer 82

Placenta previa; cervical os; 3rd trimester bleeding

Question 83

____ is separation of placenta from the decidua (uterine wall) prior to delivery of the fetus. It is a common cause of _____, and presents with _____ and _____.

Answer 83

Placental abruption; still birth; 3rd trimester bleeding and fetal insufficiency

Question 84

_____ is improper implantation of the placenta (can be in the myometrium) with little or no intervening decidua. It presents with _____ and _____. Often requires ____

Answer 84

Placenta accreta; difficult delivery of the placenta and postpartum bleeding; hysterectomy
(increta = in the myometrium)

Question 85

Preeclampsia is pregnancy induced ____, ____, and ____ usually in 3rd trimester (seen in 5% of pregnancies). Due to abnormality of the _____ in the placenta. Eclampsia is preeclampsia + _____.

Answer 85

HTN (can cause headaches and visual abnormalities), proteinuria, edema; maternal-fetal vascular interface; seizures

Question 86

HELLP is preeclampsia with _____ involving the ____. It stands for:
It warrants immediate delivery (as dose eclampsia)

Answer 86

thrombotic microangiopathy; liver

Hemolysis, Elevated Liver enzymes, Low Platelets

Question 87

Sudden Infant Death Syndrome is when healthy infant age _____ dies without obvious cause (usually during ____). Name three risk factors

Answer 87

1 month to 1 year; sleep; sleeping on stomach, exposure to cigarette smoke, prematurity

Question 88

_____ is an abnormal conception characterized by swollen and edematous villi with proliferation of trophoblasts

Answer 88

Hydatidiform mole

Question 89

With a hydatidiform mole, the uterus is larger/smaller than in normal pregnancy and the B-hCG is higher/lower. It classically presents in the ____ trimester as passage of ____ through the vaginal canal. On US, fetal heart sounds are absent and a ____ appearance is seen. Tx is ____.

Answer 89

larger; higher; 2nd; grape-like masses; snowstorm; suction curettage (also need to monitor B-hCG to ensure adequate removal and to screen for development of choriocarcinoma)

can be complete or partial

Question 90

Choriocarcinoma may arise as a _____ (spontaneous abortion, normal pregnancy, hydatidiform mole) or as a _____. Which one responds well to chemo?

Answer 90

complication of gestation; spontaneous germ cell tumor

gestational pathway

Question 91

_____ mole has an empty ovum fertilized by two sperm (46 chromosomes), absent fetal tissue, edematous villi, proliferation of trophoblasts around all vili, and a 2-3% risk for choriocarcinoma

Answer 91

Complete mole
Partial has 69 chromosomes (ovum fertilized by 2 sperm or one sperm that duplicates chromosomes) - has fetal tissue; some of everything else (instead of all); minimal risk

Question 92

Name the teratogen effect: alcohol, thalidomide, cocaine, cigarette smoke

Answer 92

most common cause of mental retardation, also facial abnormalities and microcephaly; limb defects; intrauterine growth retardation and placental abruption; intrauterine growth retardation

Question 93

Name the teratogen: spontaneous abortion, hearing and visual impairment; discolored teeth; fetal bleeding; digit hypoplasia and cleft lip/palate

Answer 93

isotretinoin; tetracycline; warfarin; phenytoin

Question 94

Spontaneous abortion (before 20 weeks) presents with these 3 symptoms.

Answer 94

vaginal bleeding, cramp-like pain, passage of fetal tissue

Question 95

Spontaneous abortion is most often due to these 4 causes

Answer 95

chromosomal anomalies (esp trisomy 16); hyper coagulable states (antiphospholipid syndrome seen in lupus); congenital infxn; exposure to teratogens (esp during first two weeks)

Question 96

Effect of teratogen based on time of exposure
First 2 weeks –>
weeks 3-8 –>
months 3-9 –>

Answer 96

spontaneous abortion
organ malformation
organ hyoplasia

Question 97

____ is a polypoid inflammatory lesion near the female urethral meatus which elicits pain and bleeding - occurs in women, most frequently after menopause.

Answer 97

Caruncle

presents as an exophytic, often ulcerated polypoid mass of 1-2 cm diameter