Flashcards in Exam 2 Review Deck (74):
What are the general features of endometriosis?
-Endometrial tissue that forms TUMOR-LIKE NODULES (foci) outside the uterus.
-Foci composed of endometrial glands & stroma. (these glands respond to estrogenic stimulation & proliferate with the normal endometrium)
Ovarian endometriosis may present w/ large cystic lesions. The cysts are filled w/ red-brown fluid derived from decomposed blood = Chocolate Cyst.
Where are the common locations of Endometriosis?
OVARY, fallopian tube or on the pelvic peritoneum, but occasionally it may be found outside the pelvis, even on the umbilicus, appendix, and colon.
--Other locations (from pic): pouch of Douglas, vulva, bladder, abdomen
Who is more likely to get Endometriosis?
-20s-30s & 30-40
A disease of women of reproductive life (3rd and 4th decades)
- Women of higher socioeconomic groups
What is the most popular theory for the pathogenesis of Endometriosis?
-Endometrial tissue is regurgitated during normal menstruation & instead of entering vagina, it is transferred upstream, it enters abdominal cavity thru fallopian tubes. The glands implant on the serosa of ovary or peritoneum.
-Forms typical red-brown nodules or plaques. Most foci of endometriosis are located close to orifice of fallopian tubes which support this theory.
What are Leiomyomas (fibroids)?
-What % is benign/ malignant?
Benign tumors originating from the smooth muscle cells of the myometrium.
-98% are benign (leiomyomas), 1-2% are malignant (leiomyosarcomas)
Which tumors are the most common uterine tumors?
-~ 20% of all women of reproductive age have them (under influence of Estrogen, more common in African Americans).
-They are small & clinically inapparent.
What are the 3 types of uterine fibroids?
1) Intramural: embedded within the myometrium
2) Subserosal: Occurs beneath covering serosa of the uterus
3) Submucosa: protrude into the endometrial cavity
*Associated w/ increase risk of miscarriage/infertility b/c decreases ability to implant into uterus
-What are the Risk factors for endometrial adenocarcinoma ?
1) Are taking exogenous estrogen in the form of pills or injections.
2) Have estrogen-producing tumors
3) Obese & form estrogen at an increased rate by fat tissue conversion.
--DM (diabetes) and HTN (hypertension).
4) Are nulliparous or have early menarche & late menopause (related to longer exposure to estrogen)
What can reduce the risk of endometrial carcinoma, why?
-Multiple pregnancies reduce because progesterone, (dominant pregnancy hormone) gives the endometrium long breaks from proliferation.
- Estrogens stimulates proliferation of endometrial glands, (hyperplasias) which undergo malignant transformation.
Why does the beneficial risks of ESTROGEN outweigh the risks for carcinoma?
-B/c endometrial cancer is detected early & treatment is successful.
-“80% of all endometrial cancers are detected while the tumor is confined to the uterus, and affected women have an excellent prognosis.”
What is endometrial hyperplasia ?
-Caused by excessive Estrogenic stimulation of endometrium leading to cystic expansion & thickening of the entire endometrium w/ multi-layering of the endometrial glands with scant endometrial stroma.”
What are the 3 types of endometrial hyperplasia & percentages?
1) Simple Hyperplasia:
-When there is minimal glandular complexity and no cytologic atypia.
-(1% progression to carcinoma)
2) Complex Hyperplasia:
-When there is multilayering of the glands (complexity) w/ crowding, but still NO cytologic atypia.
-(3% may develop adenocarcinoma)
3) Atypical Hyperplasia:
Complexity to glands w/ crowding & there is cytologic atypia. The epi. cells are enlarged & hyperchromatic w/ high N/C.
-(25% of these cases progress to adenocarcinoma)
-What type of cancer is endometrial adenocarcinoma?
-where does it originate from?
-Most common malignant tumor of female genital tract. (50% of GYN malignancies)
-Disease of older women (35 yo+)
-Arises from epithelial cells lining the endometrial glands.
- Tumor appears as fungating mass protruding into uterine lumen. The tissue is "friable" & soft b/c it consists of atypical glands w/ little tissue stroma.
What are the SYMPTOMS of endometrial adenocarcinoma?
What is TX?
-Most common symptoms: Vaginal bleeding that is spotting between 2 menstruations or as prolonged pronounced menstual bleeding (menorrhagia)
-D&C (dilate cervix and scrape endometrium), -TAH-BSO (hysterectomy w/ or w/o ovaries),
- lymph node removal of metastases
-Radiation for advanced pt's
-Chemo for inoperable cases
-General features of ectopic pregnancy.
-Implantation of the fetus in any other site than normal uterine location.
-Most commonly the ovary, abdominal cavity & 95% occurring in fallopian tubes
-The fertile zygote undergoes normal development w/ formation of placental tissue & amniotic sac.
-Placenta poorly attached to wall of the tube, weakens it w/ the possibility of rupture & intraperitoneal hemorrhage.
Signs and Symptoms of Ectopic Pregnancy?
-Severe abdominal pain w/ rupture & possibility of shock w/ signs of an acute abdomen.
-Pregnancy tests are positive
*****Aspiration of "fresh blood" from the pouch of Douglas (POSTERIOR FORNIX) denotes rupture.
What is helpful in the diagnosis of Ectopic Pregnancy?
-An endometrial biopsy is helpful in diagnosis.
-Absence of chorionic villi is consistent b/c villi are in the tube
-Biopsy will show a decidual reaction of endometrium
*******Ultrasound will show dilation of the fallopian tube.
- ____________ pregnancies are ectopic ?
-Rapture occurs ________ after pregnancy.
-What is the most common cause of ectopic pregnancy ?
***Most common pathologic condition leading to ectopics is chronic salpingitis.
-Other factors: peritubal adhesions as from endometriosis, previous surgeries & leiomyomas.
The intratubal adhesion forms a barrier to normal passage of the zygote, so implants at the site of obstruction.
What are the two MOST common complications of chronic salpingitis from PID ?
1) Sterility (infertility): Risk rs increases w/ each Gonococcus infection, & caused by scarring of fallopian tubes, (occludes the lumen and prevents sperm from reaching the ovulated egg.)
2) Ectopic pregnancy: Increase w/ previous salpingitis.
Most common site for Ectopic being the fallopian tubes
-Abscesses: may develop in the fallopian tubes, ovaries, or peritoneum
-Peritonitis: bacteria may spread from ovaries & fallopian tubes.
Which female reproductive tract cancers are adenocarcinoma ?
-Tissues that are glandular = adenocarcinoma
***Uterus, Fallopian Tubes, & Ovaries are glandular so #1 cancer=adenocarcinomas
*Endometrial Hyperplasia (Non-neo. Uter.)
*Endometrial Polyps (Non-neo. Uter.)
*Endometrial Adenocarcinoma (Neo. Uter.)
*Tumors of fallopian tubes
*Tumors of surface epithelium (Neo. Ovar.)
*Solid Serous Cystadenocarcinoma
Which female reproductive tract cancers are squamous cell?
-Tissues that squamous = squamous cell carcinoma
***Vulva, Vagina, & Cervix are squamous epithelium so #1 cancer=squamous cell carcinomas
*Pyometria (Non-neo. Uter.)
Endometrial Hyperplasia (Non-neo. Uterus)
adenocarcinoma or squamous cell carcinomas?
Caused by excessive estrogenic stimulation of the endometrium leading to cystic expansion of the entire endometrium with focal branching of the glands with scant endometrial stroma.
-When there is minimal glandular complexity & no cytologic atypia, simple hyperplasia (1% progress to carcinoma)
-When there is multilayering of the glands (complexity) with crowding, complex hyperplasia (3% may develop adenocarcinoma)
-Atypical hyperplasia is when there is complexity to the glands with crowding and there is cytologic atypia. The epithelial cells are enlarged and hyperchromatic with high N/C ratios and prominent nucleoli.
-Endometrial Polyps (Non-neo. Uterus.)
-adenocarcinoma or squamous cell carcinomas?
-Benign, localized overgrowths that project from the endometrial surface into the endometrial cavity
-Most arise in the fundus, usually solitary, and vary in size
-Not believed to be pre-neoplastic, but up to 0.5% harbor adenocarcinomas.
-Endometrial Adenocarcinoma (Neo. Uter.)
-adenocarcinoma or squamous cell carcinomas?
-Most common malignant tumor of the female genital tract, accounting for approx. 50% of all GYN malignancies
-Are taking exognous estrogen in the form of pills or injections
-Have estrogen-producing tumors
- obese & form estrogen at an increased rate by fat tissue conversion.
-DM and HTN
-Are nulliparous or have early menarche and late menopause
-Tumors of the fallopian tubes (Fall. Tubes ?
-adenocarcinoma or squamous cell carcinomas?
-Rare, & attributable to the fact that epithelium of the fallopian tube does not shed cyclically, like endometrium. Also the muscularis is thin & has cells that don't respond to estrogenic stimulation as do the myometrial cells.
-Adenocarcinomas are the most common lesion, and these tumors account for 1% of all GYN malignancies
What are the Tumors of surface epithelium (Neo. Ovary)?
-adenocarcinoma or squamous cell carcinomas?
-All tumors of the surface epithelium are either Adenomas or adenocarcinomas.
Which Tumors of surface epithelium (Neo. Ovary) are solid vs cystic?
Serous & Mucinous cystic.
Endometroid & Brenner = more solid.
Describe Serous and mucinous tumors (Tumors of surface epithelium (Neo. Ovary)?
-Classified as what?
-Which the most common form of surface tumors?
-What is Pseudomyxoma Peritonei?
-Classified as benign, borderline (potential), or malignant
-Serous Tumors: (Serous Cystadenoma) Most common form of surface tumors
-Mucinous Tumors : (Mucinous Cystadenoma) Are more often benign (7:1 ratio) and less commonly bilateral (10-30%)
-usually filled with thick, yellowish or clear jelly-like material
-If tumors rupture or the malignant tumors invade the peritoneum, the entire belly is filled w/ mucus. This is called Pseudomyxoma Peritonei.
Describe Endometroid and Brenner tumors (Tumors of surface epithelium (Neo. Ovary)?
Solid tumors composed of glands that resemble endometrial glands
Solid and characterized by a dense fibrous stroma with scattered nests of transitional epithelium
-Malignancies are Transitional Cell Carcinoma
Describe Pyometria (Non-neo. Uterus) ?
-Defined as pus in the endometrial cavity
-Associated w/ any lesion that causes cervical stenosis, (tumor or scarring from surgical treatment of the cervix (conization of cervix)
-Long-standing pyometria may be associated w/ rare chance of developing endometrial squamous cell carcinoma
-Which tumors (4) are derived from the germ cells?
Germ Cell Epithelium Tumors:
1) Benign Cystic Teratoma (Dermoid Cyst)
** "Seminoma" (MEN)
3) Endodermal Sinus Tumor(marker: AFP)
* "Yolk Sac" Tumor in (MEN)
4) Choriocarcinoma(marker: β-HCG).
Which tumors are derived from Surface Epithelium?
Surface Epithelium Tumors:
1) Serous: (most common) CYSTIC
-(Benign, borderline, malignant)
-(Benign, borderline, malignant)
What are Sex Cord Stromal Tumors and Markers?
Thecomas and Granulosa Cell Tumors→Estrogen
Sertoli-Leydig Cell Tumors→ Androgens/Testosterone
ovarian mass / endodermal sinus tumor= a-feto-protein ;
CA-125 cancer antigen
Beta HCG ovarian mass = chorio carcinoma
Ovarian tumors that secrete tumor marks or estrogens or androgens.
-Choriocarcinoma secrete HCG (histologically identical to placenta, endometrial or testicular lesions)
**Three variants of Sex Cord Stromal Tumors:
1) Thecoma: Secrete Estrogen, cause menstrual irregularities & endometrial hyperplasia.
2) Granulosa Tumors: Produce estrogen cause menstrual irregularities. In young girls cause precocious puberty. In older women leads to breast or endometrial cancer.
3) Sertoli-Leydig Cell Tumors: Secrete androgens, cause virilization (deep voice, facial hair, male pattern baldness, hairy chest w/ hypertrophy of the clitoris)
-Know the tissues and or organs where you can find choriocarcinoma
(Remember you can have it in ovary, testes (because a homologue of ovary), endometrium b/c pregnancy or abortion (primary not metastatic)
-Gestational trophoblastic disease: ovarian germ cell tumor (trophoblastic cells)
-Results in hemorrhagic nodules in placental bed, invades thru uterus wall & often implants into vagina, (solid or cystic)
-Arises from: pre-existing complete hydatidiform mole (50%), placental tissue from abortion (25%), normal placenta after delivery (25%)
-Worst germ cell tumor b/c at time of diagnosis tumor has typically already spread thru bloodstream to lungs & other organs (liver, brain, bones)
-Placenta secrete beta-hCG → used as diagnostic marker and monitoring tumor recurrence after chemotherapy
Notes: -Men can get them too as teratocarcinomas
-Histologically, identical to placenta, endometrial, or testicular lesions
-Tx: chemo w/ Methotrexate. 80-100% survival if no metastases
11. What is a dermoid cyst and what is the other name for a dermoid cyst? What age group will you find it?
-A Benign Cystic Teratoma. Presents as a cyst that is lined on the inside w/ hairy skin & wall contains other tissues, such as teeth, bone, & cartilage along w/ skin appendages, such as sweat & sebaceous glands that when the cyst is cut open, responsible for bad odor.
-Most common is the Benign Cystic Teratoma = 95% of all Dermoid Cyst
-Most common ovarian tumor in woman less than 25yrs
What is the homologue tumor of the female dysgerminoma found in males?
*Endodermal Sinus Tumor→Yolk Sac Tumor
-“The ovarian counterpart of the male Seminoma, both macroscopically and microscopically. Grossly tumor is large, firm, w/ fleshy cut surface.”
-Dysgerminoma - It is an uncommon tumor, but makes up half of all malignant germ cell tumors.
Tx. is surgical. - occurs in childhood, all malignant, but only one-third are aggressive. Highly radiosensitive like Seminomas.
-Endodermal Sinus Tumor- ovarian counterpart of the yolk sac tumor of the testes
-produces Alpha fetoprotein (AFP)
What is the most common of all GYN malignancies ?
-Endometrial Adenocarcinoma, most common malignant tumor of female tract accounting for ~ 50% of all GYN malignancies.
-Ovarian cancer is the 2nd most common GYN cancer, but ranks FIRST for DEATHS caused by GYN cancer.
******Causes more deaths than all other tumors of the reproductive tract.
-Know what tumor of surface epithelium and type of tissue they mimic.
Serous Tumors = Fallopian Tube epithelium.
Mucinous Tumors mimic Endocervical epithelium.
Endometriod Tumors resemble Endometrial Glands.
Brenner Tumors mimic a modified Transitional epithelium.
Surface Epithelial Tumors:
-Vast majority of ovarian tumors are ________________
-What is the Ab to a cancer antigen called?
-CA-125 (tumor marker)
Detected in about 1/2 of the epi tumors that are confined to ovary, but 90% that have already spread.
ALL malignant tumors are characterized by ___________ and ___________ both grossly (can see visually) and microscopically
Describe Serous Tumors
-mimic fallopian tube epi
-consists of several cysts lumped together w/in common outer capsule
-60% benign, 15% borderline, 25% malignant
(60% malignant and 30% benign are bilateral)
-Malignant form papillae or papillary projections filled w/ serous fluid, if becomes solid can have hemorrhage & necrosis
-uncommon before puberty, seen older in life
Describe Mucinous Tumors:
-mimic endocervical epithelium
-commonly benign (7:1)
-cavity of tumor filled with thick, yellowish or clear-jelly substance
-if tumor is malignant or ruptures can cause Pseudomyxoma peritonei (invade the peritoneum and fill belly w/ mucus)
Describe Brenner Tumors:
-mimic urinary system epithelium, transitional cell carcinoma
-solid & char by a dense fibrous stroma w/ nests of transitional epithelium
-2% of all neoplasms
-stage III/IV = 8% 5 year survival rate
Describe Endometrioid Tumors:
- mimic endometrial glands, solid tumor w/ endometrial- like gland
-can harbor benign endometriosis (15%)
-15 - 30% accompanied by carcinoma of the endometrium
What do we call the Metastatic Gastric Cancer that specifically goes to the Ovaries as a metastatic disease ?
-Tumor of the GI tract, metastasizes to the ovaries.
-The most common metastatic tumor being a stomach carcinoma that will tend to produce bilateral enlargement of ovaries.
-(Metastatic Ovarian Tumors) These tumors have estrogen receptors which explains their metastasizing to the ovaries
What does a woman usually first have before she has the chance of getting an ectopic pregnancy?
**********Chronic salpingitis: The MOST COMMONN pathologic condition leading to ectopics is chronic salpingitis, b/c 95% of ectopic pregnancies occur in fallopian tubes.
-NUG: Other factors include peritubal adhesions from endometriosis, previous surgeries or leiomyomas
What is a Hydatidiform Mole?
A placental abnormality marked by trophoblastic proliferation & hydropic degeneration of chorionic villi
What is the MOST COMMON form of a hydatidiform mole ?
-What is androgenesis?
-What happens without maternal chromosomes?
THE COMPLETE MOLE:
-The fetus cannot be identified in the amniotic sac.
-Results from abnormal fertilization, where all of the chromosomes are PATERNAL in origin due to loss of maternal chromosomes from zygote at the time of fertilization.
Androgenesis = Paternal 23,X set of chromosomes re-duplicates to create 46 chromosomes.
-Without maternal chromosomes, embryo cannot develop, & placenta undergoes hydropic degeneration.
Describe an Incomplete hydatidiform mole
-Evolve from oocytes fertilized with 2 spermatozoa, therefore, cells have 69 chromosomes (1 maternal set, 2 paternal sets).
-This combination is LETHAL, but embryo DOESN'T die immediately, so parts of embryo are found encased among the hydropically altered placental villi & normal placental tissue.
What is the diagnosis of Hydatidiform Moles based on ?
-H. moles is RARE
-Based on enlarged uterus for
the corresponding, calculated duration of the pregnancy, without any signs of fetal movement.
- Ultrasound is the best method for early detection. Look for Snowstorm Pattern with no fetal heartbeat or movement.
-High serum & urine levels of hCG are typically found. They are aborted spontaneously mid-pregnancy.
-It is important to remove all parts of abnormal placenta. Any remaining trophoblastic cells could give rise to malignant tumors.
What is Wharton’s Jelly?
-Mucous connective tissue in umbilical cord
-Gelatenous substance of umbilical cord that provides insulation & protection
-Also the site of umbilical cord stem cells.
What is Meconium?
- Fetal feces & first feces of newborns.
-Sticky, tarry, yucky
What is Decidua?
-As the blastocyst implants, into the endometrium it stimulated the Decidual Reaction.
-The cells of the endometrial stroma (fleshy endometrial tissue between glands of inner lining endometrium) accumulate lipids & glycogen, become plump, & are transformed into decidual cells.
-This stroma thickens & becomes highly vascularized, & the endometrium is called DECIDUA & is READY for blastocyst implantation
What are Meconium-Stained Placentas?
-Green-colored staining of the fetal membranes that easily rinses off.
-Found in 18% of placentas & occurs most commonly in placentas from pregnancies that are prolonged beyond 42nd wks of gestation.
-Related to acute fetal hypoxia & distress, but this recently has been challenged.
-Major complication of thick meconium is aspiration causing a fetal chemical pneumonitis
-Histologically, there are meconium-laden macrophages w/in fetal membranes.
Know the differences between placenta accreta, increta, and percreta based on the levels into the myometrium and beyond
-Placenta Accreta: the attachment of the villi to the level of the myometrium without further invasion
-Can result in uterine rupture, hemorrhage (due to fragments)
-Placenta Increta: villi invade the underlying myometrium
-Placenta Percreta: villi penetrate the full-thickness of the uterine wall
Normal parameters of the placenta
-~ 22-24 cm in diameter, and 2.5-3.0 cm thick.
-Weighs approximately 500 gms. (1 lb.)
-The maternal surface is dark red/ maroon in color & divided into lobules or cotyledons. It is important that this structure be complete with no missing cotyledons.
-The fetal surface is shiny, gray & translucent enough to see the color of underlying cotyledons. Fetal membranes (amnio-chorion) are gray, shiny, wrinkled & translucent.
Normal parameters of the umbilical cord
-At birth is pearly white, 1-2 cm in diameter, & 50-60cm long.
-It is eccentrically positioned, & contains the right/left umbilical arteries, the left umbilical vein, & mucous connective tissue called Wharton’s Jelly.
-The right/left umbilical arteries carry DEoxygenated blood from fetus to placenta. The umbilical vein carries oxygenated blood from placenta to fetus.
(Presence of 1 umbilical artery within cord is abnormal = cardiovascular abnormality)
____________ carries the HIGHEST amount of oxygenated blood from the placenta to the fetus.
The UMBILICAL VEIN
Normal parameters of the amniotic fluid ?
-Amniotic fluid volume INCREASES thru the 7th month & DECREASES in the last 2 months.
-At birth volume of amniotic fluid is around 1 liter. Rate of water exchange w/in the amniotic sac is 400-500 ml/hr.
-The term fetus swallows 400ml of amniotic fluid & excretes 500ml of urine daily.
What does the Amniotic fluid components contain?
-Electrolytes, carbohydrates, amino acids, lipids, proteins (hormones, enzymes,& alpha-fetoproteins), urea, creatinine, desquamated fetal cells, fetal urine & feces (meconium) & fetal lung liquids (lecithin & sphingomyelin), useful in fetal lung maturity.
-Maternally derived water is similar to blood plasma (continually produced & constantly resorbed)
**L/S ratio - higher (2:1) correlates with lung maturity
What are cotyledons and where would you expect to find them?
-15 to 30 divisions of placenta
-found on the maternal side of placenta
-consists of main stem of chorionic villus
-cotyledons remaining in mother AFTER birth causes post-partum hemorrhaging
Which hormone secreted from the placenta is known as the growth hormone for the fetus?
-Human Placental Lactogen (hPL):
protein hormone that induces lipolysis thus elevating free fatty acid content in mom
What is the differenece between succenturiate placenta vs circumvallate placenta?
(Accessory) Succenturiate = EXTRA lobes
-linked by thin chorionic tissue
- No clinical importance, unless a portion of lobe is retained after birth - post-partum bleeding
Circumvallate = rolled & raised ring of fetal membrane
over fetal surface instead of edge of placenta (chorionic plate < basal plate).
-The blood vessels at chorionic plate stop at raised membranes & run deeper under membranes.
-Associated w/ Prematurity
Prenatal bleeding, Placental abruption or Multiplarity (more than on fetus)
What is the Normal distribution of umbilical cord, how many arteries and veins?
-Wharton’s Jelly - mucous connective tissue
Left and right umbilical arteries:
Carry DE-oxygenated blood FROM fetus to placenta
Carry oxygenated blood from placenta TO fetus
What is the condition of amnion nodosa?
-Numerous small, gray /yellow nodules on fetal surface of placenta, associated with:
***Oligohydramnios(low amount of amniotic fluid)
***Renal Agenesis (POTTERS SYNDROME) as a result of oligohydramnios (decrease amt of amniotic fluid, can leads to-->no endometrium cushion-->pulmonary disorder)
What is the most common complication of a baby being born with amniotic fluid thick with meconium?
Aspiration causing fetal chemical pneumonitis
What is acute chorioamnionitis and what organisms can cause this condition? What is the most common cause of chorioamnionitis?
Infection/Inflammation of fetal membranes (amnion & chorion) due to bacterial infections from:
-Genital Mycoplasma species (M. hominis and U. urealyticum)
-anaerobic Bacteroides group
-Aerobe Group B Streptococcus, E. coli & Gardnerella vaginalis
- Caused by premature rupture of amniochorionic membranes (PROM)
-Amniontic fluid = cloudy and walls opaque, malodorous & edematous.
What is funisitis?
Inflammation of umbilical cord caused by intrauterine infection; acute fetal inflammatory response
-Signs/symptoms: Vasculitis of umbilical vessels, PMN infiltration after extension of Wharton’s jelly
-Causes: meconium exposure, spread of chorioamnionitis, Candida, Actinomyces, HSV, Syphilis
-Can be necrotizing (infiltration through vessel into Wharton’s Jelly), or peripheral (microabscesses on surface)
--What tumor presents with pseudomyxoma peritonei
Mucinous cystic adenocarcinoma (NOT a serous tumor)
--Which ovarian mass is same as the yolk sac tumor in the male?
Endodermal Sinus Tumor
-Rich in AFP
-Rare tumor that grows aggresive and rapid
-Nodular tan-white firm masses
-SEEN in children & young adults
--Where are all the locations that can harbor choriocarcinoma
Placenta primarily. Also in endometria (ovaries) and testicles. It can metastasize to bone, liver and lungs.