Female Genitalia Path

Question 1

Herpes simplex clinical symptoms

Answer 1

Clinical symptoms will occur in ~1/3 of affected individuals

• lesions 3-7 days after intercourse
• painful red papules in vulva  vesicles  ulcers (contain virus particles)
• leukorrhea (white discharge) when cervix or vagina is involved
• systemic symptoms: fever, malaise, tender inguinal lymph nodes

Question 2

Herpes simplex lesions & transmission

Answer 2

lesions heal spontaneously in 1-3 weeks, but infection remains latent in the regional nerve ganglia
-2/3 women suffer recurrence
transmission is possible whether active or latent phase
-greatest danger is to the neonate during birth
*may result in fatal systemic infection
-risk greatest during primary, active infections

Question 3

Mycotic and yeast (Candida)

Answer 3

manifests as small white patches, leukorrhea, pruritus
10% of women are carriers
diabetes mellitus, oral contraceptives, and pregnancy promote development of infection
diagnosis: wet mount or culture

Question 4

Trichomonas vaginalis

Answer 4

causes purulent discharge and discomfort
"strawberry cervix"
seen in 15% of women at STD clinics
frothy discharge due to
Trichomonas infection
“strawberry cervix”

Question 5

Bacterial vaginosis

Answer 5

most common vaginal infection in women of childbearing age
imbalance of bacterial flora, favoring harmful types
risk factors: multiple partners, douching, pregnancy, smoking

Question 6

Bacterial vaginosis symptoms

Answer 6

signs/symptoms: fish-like odor; gray discharge; burning/itching; frequently asymptomatic
especially important to treat during pregnancy: associated with PROM/premature birth
may ascend and cause pelvic inflammatory disease

Question 7

Bacterial vaginosis Amsel’s criteria

Answer 7

diagnosis by Amsel’s criteria (3 of the following):
microscopic “clue cells“
fishy odor on adding 10% KOH to secretions
vaginal pH > 4.5
thin homogenous discharge

Question 8

Pelvic Inflammatory Disease (PID)

Answer 8

pelvic pain, adnexal tenderness, fever, vaginal discharge
infection by: gonococci, chlamydiae, enteric bacteria
Postpartum and postabortion infections: staphylococci, streptococci, coliform bacteria, Clostridium perfringes

Question 9

Gonococcal PID

Answer 9

inflammatory changes in affected glands (e.g., Bartholin gland) 2-7 days post inoculation
-acute suppurative reaction; inflammation mainly in the superficial mucosa, submucosa
-cervix involvement
common
organisms may disappear over time; proteolysis of inflammatory cells results in accumulation of serous fluid
treatment: easily controlled with antibiotics in early stages; more difficult if abscesses have formed

Question 10

Gonococcal PID involves & spares

Answer 10

usually spares endometrium and involves tubes

• acute suppurative salpingitis
• tubal serosa hyperemic; layered with fibrin
• tubal fimbriae leak exudate, the fimbriae seal to the ovary causing salpingo-oophoritis; tubo-ovarian abscess may develop

Question 11

Postpartum and Postabortion PID

Answer 11

less exudation in tube lumens or mucosa, but greater deep involvement

• infection spreads throughout the wall to involve the serosa, and spreads up the uterus via lymphatics or blood supply
• bacteremia is a frequent complication
  treatment: much more difficult to control with antibiotics than gonococcal PID; surgical removal of organs may be necessary

Question 12

Vulvar Non-Neoplastic Epithelial Disorders (VNED)

Answer 12

spectrum of inflammatory lesions of the vulva
characterized by white, scaly, plaquelike mucosal thickenings that produce vulvar discomfort and pruritus
-biopsy is indicated to distinguish from other diseases

Question 13

Lichen sclerosus (chronic atrophic vulvitis)

Answer 13

leads to atrophy of labia, subepithelial fibrosis, narrowing of the introitus
most common after menopause

Question 14

Lichen sclerosus histological features

Answer 14

atrophy of the epidermis (disappearance of rete pegs)
degeneration of basal cells of the epidermis
dermal fibrosis
bandlike lymphocytic infiltrate

unclear pathogenesis; believed to be autoimmune

Question 15

Lichen simplex chronicus

Answer 15

non-specific condition that results from rubbing or scratching the skin to relieve pruritus
characterized by acanthosis and hyperkeratosis of vulvar squamous epithelium
-epithelium thickened; may show mitotic activity in basal and prickle layers

Question 16

VNED-associated vulvar cancer

Answer 16

hyperplasia -> 
cellular atypia -> 
VIN (= carcinoma in situ)
treat with steroids
to prevent cancer development

Question 17

Condyloma Acuminatum (Venereal Wart)

Answer 17

benign papillomavirus-induced squamous lesion with verrucous appearance
-typically caused by HPV types 6 and 11
frequently multiple and coalesce
involve perineal, vulvar, and perianal regions, vagina, sometimes cervix

Question 18

Condyloma Acuminatum (Venereal Wart) histological

Answer 18

acanthosis, parakeratosis, hyperkeratosis, koilocytosis

-frequently regress spontaneously and not considered to be precancerous lesions (just STD marker)

Question 19

Carcinoma and Vulvar Intraepithelial Neoplasia (VIN)

Answer 19

1/8th as frequent as cervical cancer
-3% of all genital cancers
most frequent in women 65-75 yoa
-15% in women VIN

Question 20

Carcinoma and Vulvar Intraepithelial Neoplasia (VIN) most frequent symptom & sign

Answer 20

Most frequent symptom = long history of pruritus
-Less common = vulvar bleeding discharge, dysuria, pain
Most common sign = vulvar lump or mass
-May be fleshy, ulcerated, leukoplakic, or warty
-Most unifocal and on the labia majora
-Expert opinion recommends annual visual inspection of the external genitalia, even if the patient is no longer receiving annual Papanicolaou smears

Question 21

Vulvar Carcinoma

Answer 21

No diagnostic features – diagnosis based on biopsy alone
Lymphohematogenous dissemination
-Inguinal and femoral nodes metastasis common; rarely pelvic nodes
-Lungs, liver, other internal organs
A rare variant of squamous cell carcinoma is the verrucous carcinoma, which presents as a fungating tumor that resembles condyloma acuminatum (isn’t associated with HPV, however)  biopsy any condyloma that doesn’t respond to therapy

Question 22

Extramammary Paget Disease

Answer 22

Rare lesion of the vulva (sometimes perianal region) similar to Paget disease of the breast
-Manifests as pruritic, red, crusted lesion, usually on labia majora
*Sharply demarcated
*Sometimes with palpable submucosal thickening or tumor
~Prognosis is poor in uncommon cases associated with underlying carcinoma

Question 23

Extramammary Paget Disease histology

Answer 23

Large tumor cells (Paget cells) distinguished by clear separation (“halo”) from surrounding epithelial cells
-Granular cytoplasm of Paget cells contains mucopolysaccharide that stains with periodic acid-Schiff (PAS)

Question 24

Malignant Melanoma

Answer 24

Rare (5% of all vulvar cancers)
-2% of all melanomas in women
Peak incidence in 6th or 7th decade
Tumors rapidly enter a vertical growth phase following inception
-5-yr survival rate

Question 25

Bartholin Cyst

Answer 25

obstruction of a Bartholin duct (usually due to preceding infection) occur at all ages symptoms: pain, local discomfort cysts may become large (3-5 cm) treatment: excision (recurrence likely) or marsupialization (opens the duct permanently)

Question 26

Vaginal Intraepithelial Neoplasia and Squamous Cell Carcinoma

Answer 26

account for ~1% of malignant neoplasms of female genital tract -(95% are squamous cell carcinomas) most associated with HPV  greatest risk factor is previous cervical or vulvar cancer

Question 27

Vaginal Intraepithelial Neoplasia and Squamous Cell Carcinoma

Answer 27

most often affects upper posterior vagina along junction with ectocervix - usually invades cervix and perivaginal structures by time of diagnosis - metastasize to iliac and inguinal nodes symptoms: - irregular spotting, leukorrhea - may be clinically silent until urinary or rectal fistulas develop

Question 28

Adenocarcinoma(Clear Cell Carcinoma)

Answer 28

increased frequency in young women whose mothers had been treated with diethylstilbestrol (DES) during pregnancy (for a threatened abortion) usually in upper anterior wall of vagina (may also occur in cervix) most commonly discovered between 15-20 yoa tumors contain vacuolated, glycogen-containing cells (= "clear cell")

Question 29

Diethylstilbestrol (DES) during pregnancy

Answer 29

FDA issued advisory in 1971 | used by 4 million females between 1938-1971

Question 30

``` Embryonal Rhabdomyosarcoma (Sarcoma Botryoides) ```

Answer 30

uncommon; most frequent in children

Question 31

Cervicitis

Answer 31

some degree of cervical inflammation may be found in virtually all adult women, and is usually of little clinical significance inflammations common and associated with mucopurulent to purulent vaginal discharge -discharge contains white cells, atypical epithelial cells (due to inflammation), and possible microorganisms *presence of microorganisms IS NOT diagnostic of infectious cervicitis

Question 32

Endocervical Polyps

Answer 32

innocuous, inflammatory tumors 2-5% of adult women; more common in multiparous produce irregular spotting or bleeding cured by curettage or surgical excision; malignant transformation rare (

Question 33

Cervix: Intraepithelial and Invasive Squamous Neoplasia

Answer 33

Invasive carcinomas of the cervix arise from precursor lesions referred to as CIN (cervical intraepithelial neoplasia) = SIL (squamous intraepithelial lesion) Represents a continuum of dysplasia with indistinct boundaries for classification

Question 34

CIN terminology

Answer 34

Represents the precancerous changes that can be detected by cytologic exam Spectrum of morphologic changes, ranging from: CIN I = mild dysplasia; koilocytotic atypia, nuclear enlargement, and hyperchromasia CIN II = moderate dysplasia; loss of polarity, increased mitotic figures, pleomorphism CIN III = severe dysplasia (carcinoma in situ)

Question 35

Important things to remember…

Answer 35

not all lesions start as condylomata or as CIN I; may enter at any point CIN may regress spontaneously (especially CIN I in young women) -Among LSIL lesions (= CIN I) *50-80% regress in adult women *90% regress in women 13-21 Not all CIN will progress to cancer, but we treat as if it will (especially CIN II/III) -When it does progress, may take upwards of 20 years

Question 36

The role of HPV in cervical oncogenesis

Answer 36

HPV is the most important agent in cervical oncogenesis - "carcinogenic" types = 16 (primarily) and 18 - all other HPV types are "probably" or "possibly" carcinogenic (as defined by WHO) except for types 6 and 11 - A recent PCR test of a large international collection of cervical cancer specimens has shown that HPV DNA is present in 99.7% of cases!!!

Question 37

risk factors of cervical cancer

Answer 37

``` cigarette smoking ↑ parity Oral contraceptives? Vit. A or C deficiency host factors ```

Question 38

Invasive Carcinoma of the Cervix

Answer 38

Most (~75%) are squamous cell carcinomas - Occur at any age, but peak incidence is 40-45 years * Peak incidence of high-grade precancers (CIN II/III) is ~30 yoa * >50 yoa in countries with screening programs is rare, as well as

Question 39

CIN and Cervical Cancer: Cytologic Screening

Answer 39

ACS screening recommendations include: Screening should begin approximately 3 years after the onset of vaginal intercourse and no later than 21 yoa. Women who are >70 yoa with an intact cervix and who have had 3 or more consecutive, normal results, with no abnormal cytology in the past 10 years, can elect to cease screening Cervical screening should be performed annually. At age 30, women who have had 3 consecutive normal cytology results may be screened every 2-3 years (unless immunocompromised or were exposed to DES in utero) Screening following total hysterectomy for benign gynecologic disease is not indicated, but should be continued in those with subtotal hysterectomy or history of CIN II/III. WHO is evaluating HPV testing as an adjunct to Pap smear screening

Question 40

CIN and Cervical Cancer: Histologic Diagnosis

Answer 40

Colposcopic exam Many Pap smear abnormalities do not signify a precancerous or cancerous lesion Abnormalities confirmed by punch biopsy

Question 41

CIN I

Answer 41

CIN lesions characterized by white patches on the cervix after application of acetic acid

Question 42

CIN and Cervical Cancer: Treatment

Answer 42

CIN I = Pap smear follow-up CIN II/III = cryotherapy, laser, LEEP (loop electrosurgical excision procedures), cone biopsy Invasive cancer = hysterectomy and lymph node dissection; radiation if advanced -Small cell undifferentiated (oat cell) tumors have worst prognosis

Question 43

CIN and Cervical Cancer: Prevention

Answer 43

Modify risk factors (e.g., cigarette smoking, sexual behavior) Vaccination with papillomavirus-like particles (VLPs) for a variety of oncogenic types

Question 44

Body of Uterus and Endometrium

Answer 44

most common disorders result from endocrine imbalances, complications of pregnancy, and neoplastic proliferation The most common problem is the occurrence of excessive bleeding during or between menstrual periods -Causes are many, but the largest single group is the functional endometrial disorders

Question 45

Anovulatory Cycle

Answer 45

Most common cause of dysfunctional bleeding Results in excessive and prolonged estrogenic stimulation without the development of the progestational phase that regularly follows ovulation In most patients, the etiology is unknown -probably a subtle hormonal imbalance Most commonly occurs at menarche and the perimenopausal period Failure of ovulation results in prolonged, excessive endometrial stimulation by estrogens -The endometrial glands undergo mild architectural changes (persistent proliferation) and stromal breakdown may occur, resulting in bleeding in the middle of the menstrual cycle -May also contribute to endometrial hyperplasia

Question 46

Inadequate Luteal Phase

Answer 46

Refers to the occurrence of inadequate corpus luteum function and a low progesterone output with an irregular ovulatory cycle Manifests clinically as infertility with either increased bleeding or amenorrhea

Question 47

Endometrial changes induced by oral contraceptives

Answer 47

OCs containing synthetic or derivative ovarian steroids induce a wide variety of endometrial changes -Changes most reminiscent of the decidua of pregnancy Changes revert to normal on cessation of use

Question 48

Acute Endometritis

Answer 48

uncommon and limited to bacterial infections that arise post delivery or miscarriage -Retained products of conception are the usual precipitating influence MOs include Group A streptococci, staphylococci, et. al Removal of the gestational fragments by curettage is followed by remission

Question 49

Chronic Endometritis

Answer 49

Occurs in the following settings (secondary disease): patients suffering from chronic PID in patients with postpartal or postabortal endometrial cavities (usually due to retained gestational material) in patients with intrauterine contraceptive devices in patients with TB (miliary spread or more commonly from drainage of tuberculous salpingitis) In about 15% of cases, there is no obvious cause Antibiotic therapy is indicated to prevent other sequelae (e.g., salpingitis)

Question 50

Adenomyosis

Answer 50

the presence of endometrial tissue in the uterine wall (myometrium) - Remains in continuity with the endometrium - Occurs in up to 20% of uteri - These tissues respond to the same hormonal stimulus as the endometrium and may bleed during menses - May cause menorrhagia, colicky dysmenorrhea, dyspareunia, and pelvic pain

Question 51

Endometriosis

Answer 51

the presence of endometrial glands or stroma in abnormal locations outside the uterus - Afflicts ~10% of women - Affects the following sites (in descending order of frequency): ovaries, uterine ligaments, rectovaginal septum, pelvic peritoneum, laparotomy scars, and rarely, in the umbilicus, vagina, vulva, or appendix - It often causes infertility, dysmenorrhea, pelvic pain and other problems - A disease of reproductive age (mostly in 20s and 30s)

Question 52

Risk Factors for Endometriosis

Answer 52

risk ↑ with exposure to endometrial material smoking, obesity ↓ risk

Question 53

Endometriosis:Clinical Course

Answer 53

Signs and symptoms include severe dysmenorrhea, dyspareunia, and pelvic pain due to intrapelvic bleeding and periuterine adhesions -Pain on defecation indicates rectal wall involvement -Dysuria reflects bladder involvement -Intestinal disturbances indicate small intestine involvement Menstrual irregularities are common and infertility in 30-40% of women Malignancy may develop in this endometriotic tissue and may be considered an “at risk” epithelium

Question 54

Endometrial Polyps

Answer 54

sessile masses (usually 0.5-3cm in diameter) that project into the endometrial cavity -May be single or multiple -May be asymptomatic or cause abnormal bleeding Of two histologic types: functional endometrium and, more commonly, hyperplastic endometrium (mostly cystic) Seen in association with tamoxifen Genetic alterations may play a role in their development -Cells are clonal -Contain chromosome rearrangements

Question 55

Endometrial Hyperplasia (Endometrial Intraepithelial Neoplasia)

Answer 55

Another cause of abnormal bleeding Characterized by an increased gland to stroma ratio and abnormalities in epithelial growth relative to normal endometrium Deserves attention because of its relation to endometrial carcinoma

Question 56

Endometrial Hyperplasia

Answer 56

linked to prolonged estrogen stimulation of the endometrium by anovulation or increased estrogen production -Conditions promoting hyperplasia include: menopause, polycystic ovarian disease, functioning granulosa cell tumors of the ovary, excessive cortical function, and prolonged administration of estrogenic substances (e.g., HRT)

Question 57

Endometrial Hyperplasia subdivision

Answer 57

subdivided in to lower grade (simple) and higher-grade (atypical) subgroups: Simple non-atypical hyperplasia -Uncommonly progress to adenocarcinoma -Reflect response to persistent estrogen stimulation -Frequently evolve into cystic atrophy

Question 58

Complex atypical hyperplasias

Answer 58

aka, endometrial intraepithelial neoplasias (EIN) dysplasia increase in number and size of endometrial glands, with gland crowding, enlargement, and irregular shape 23% of patients eventually develop adenocarcinomas

Question 59

Endometrial Hyperplasia (Endometrial Intraepithelial Neoplasia) gene

Answer 59

shift in morphology from benign to precancerous often involves loss of PTEN gene expression - a tumor suppressor gene - In the absence of a normal gene, endometrial cells become more sensitive to stimulation by estrogens and, thus, prone to hyperplasia and carcinoma

Question 60

Carcinoma of the Endometrium

Answer 60

The most common invasive cancer of the female genital tract -7% of all invasive cancers in women Arise mostly in postmenopausal women (peak at 55-65 yoa) -A higher incidence is seen in obesity, diabetes mellitus, hypertension, and infertility -Tend to be seen in women who are single and nulliparous with a history of anovulation -May be seen in patients with concomitant breast cancer Causes postmenopausal (abnormal) bleeding (permits early detection and cure)

Question 61

Two general groups of endometrial cancer

Answer 61

1) Cancer that develops in relation to prolonged estrogen stimulation and endometrial hyperplasia 2) Cancer that does not exhibit hyperestrinism or pre-existing hyperplasia

Question 62

Carcinoma of the Endometrium:Hyperplasia-associated

Answer 62

Linked to obesity and anovulatory cycles in postmenopausal women, there is greater synthesis of estrogens in body fat Ovarian estrogen-secreting tumors confer higher risk Rare in women with ovarian agenesis and early ovariectomy Increased risk with estrogen replacement therapy Inactivation of PTEN is common Prolonged administration of DES may produce endometrial polyps, hyperplasia, and carcinoma Most common type? adenocarcinoma associated w estrogen excess

Question 63

Carcinoma of the Endometrium:Age-associated

Answer 63

Tend to acquire the cancer at a somewhat older age more often papillary serous carcinomas, clear cell carcinomas, or squamous carcinomas These tumors have a poorer prognosis due to their propensity to exfoliate and implant on peritoneal surfaces

Question 64

Carcinoma of the Endometrium: Clinical Course

Answer 64

May be asymptomatic for periods of time but usually produces irregular vaginal bleeding with excessive leukorrhea

Question 65

Leiomyomas

Answer 65

``` Perhaps the most common tumor in humans -may be present in ~75% of reproductive age females *average 6.5 tumors/uterus! ~but each is a unique clonal entity ~40% have chromosomal abnormalities ```

Question 66

Leiomyomas biopsy

Answer 66

benign tumors of smooth muscle -demonstrate a whorled pattern of smooth muscle bundles on cut section appear as sharply circumscribed, discrete, round, gray-white tumors varying in size from barely visible to massive tumors that can fill the pelvis

Question 67

Leiomyomas odd benign variants

Answer 67

benign metastasizing leiomyoma -consists of a tumor that extends into vessels and migrates to other sites (most commonly lung) disseminated peritoneal leiomyomatosis -presents as multiple small nodules on the peritoneum Leiomyomas may be asymptomatic or cause abnormal bleeding, bladder compression, sudden pain, and infertility May be problematic in pregnancy

Question 68

Leiomyosarcomas

Answer 68

Uncommon malignant neoplasms Arise de novo directly from the myometrium or the endometrial stroma undergoing smooth muscle differentiation Equally common before and after menopause with a peak incidence at 40-60 years of age

Question 69

Leiomyosarcomas | Distinction from leiomyomas based on biopsy

Answer 69

Degree of nuclear atypia, mitotic index, and zonal necrosis More than half metastasize to distant organs (lung, brain, bone) 5-yr survival rate = 40%

Question 70

Fallopian Tubes:Inflammations

Answer 70

Suppurative salpingitis may be caused by any pyogenic organisms (and often >1) A tuberculous salpingitis is common in parts of the world where TB is prevalent -It is rare in the U.S. (1-2%)

Question 71

Paratubal cysts

Answer 71

The most common primary lesions (excluding endometriosis) are minute 0.1-2 cm translucent cysts filled with clear serous fluid Larger varieties found near the fimbriated end or in the broad ligaments are called hydatids of Morganii

Question 72

Fallopian Tubes Tumors

Answer 72

Tumors are uncommon Benign tumors include adenomatoid tumors Primary adenocarcinoma is rare Occult carcinoma of the uterine tubes has been associated with BRCA mutations

Question 73

Ovaries

Answer 73

``` The most common types of lesions encountered in the ovary include functional or benign cysts Intrinsic inflammations (öophoritis) are uncommon and usually accompany tubal inflammation Rarely, a primary inflammatory disorder involving the ovarian follicles (autoimmune öophoritis) occurs and is associated with infertility ```

Question 74

Non-Neoplastic and Functional Cysts: Follicular and luteal cysts

Answer 74

Cystic follicles in the ovary are so common as to be virtually physiologic -They originate in unruptured graafian follicles or in follicles that have ruptured and immediately sealed Granulosa luteal cysts (corpora lutea) are normally present in the ovary -They occasionally rupture and cause a peritoneal reaction

Question 75

Polycystic ovarian disease (PCOS)

Answer 75

formerly Stein-Leventhal syndrome affects 3-6% of reproductive-age women The central pathologic abnormality is numerous cystic follicles or follicle cysts Patients with PCOS have persistent anovulation, obesity (40%), hirsutism (50%), and rarely, virilism -Often associated with oligomenorrhea

Question 76

PCOS enzymes

Answer 76

It is now thought that a variety of enzymes involved in androgen synthesis are poorly regulated and are involved in the pathogenesis Recent studies link PCOS to insulin resistance -Administration of insulin mediators associated with resumption of ovulation

Question 77

Stromal hyperthecosis

Answer 77

disorder of ovarian stroma most commonly seen in postmenopausal women characterized by uniform enlargement of the ovary (up to 7 cm) -involvement is usually bilateral Clinical presentation is similar to PCOS

Question 78

Ovarian Neoplasms

Answer 78

Among cancers of the female genital tract, the incidence of ovarian cancer ranks only below carcinoma of the cervix and endometrium -Because many of these cancers cannot be detected early in their development, they account for a disproportionate number of fatal cancers ~ 80% of these tumors are benign and occur in between 20 and 45 yoa -Malignant tumors are more common between 40 and 65 yoa

Question 79

Ovarian Neoplasms risk factors

Answer 79

Pathogenesis risk factors are less clear than for other genital cancers Nulliparity, family history, and heritable mutations play a role Gonadal dysgenesis in children is associated with a higher risk of ovarian cancer Use of OCs and having a tubal ligation reduce risk in ♀s 40-59 yo Genetic factors such as mutations in BRCA1 and BRCA2 increase susceptibility

Question 80

Ovarian neoplasms symptoms

Answer 80

Most are nonfunctional and tend to produce relatively mild symptoms until they have reached a large size The most common symptoms are abdominal pain and distention, urinary and GI symptoms due to compression by tumor or cancer invasion, and abdominal and vaginal bleeding -Benign forms may be entirely asymptomatic or incidental findings

Question 81

Ovarian Neoplasms:Tumors of Mullerian Epithelium

Answer 81

Most primary neoplasms fall into this category There are three major types of such tumors: serous, endometrioid, and mucinous May be small and grossly imperceptible or may fill the pelvic or abdominal cavities They may be cystic (cystadenomas), cystic and fibrous (cystadenofibromas), and predominantly fibrous (adenofibroma) The risk of malignancy is directly proportional to the amount of solid growth

Question 82

Tumors of Mullerian Epithelium Serous tumors

Answer 82

The benign and borderline types are most common between the ages of 20 and 50, and cystadenocarcinomas occur later in life on average Bilaterality is common -Should always exclude possibility of non-ovarian origin (metastatic spread) Concentric calcifications (psammoma bodies) are characteristic Biologic behavior depends on degree of differentiation, distribution, and characteristics of any peritoneal implants -Unencapsulated surface tumors more likely to spread to peritoneum

Question 83

Tumors of Mullerian Epithelium Mucinous tumors

Answer 83

Occur principally in middle life (rare before puberty and after menopause) 80% are benign and 20% malignant characterized by more cysts of variable size and less surface involvement frequently bilateral Associated with a condition called pseudomyxoma peritonei -Ovarian tumor with extensive mucinous ascites, cystic epithelial implants on the peritoneal surfaces, and adhesions -May result in intestinal obstruction and death

Question 84

Tumors of Mullerian Epithelium Endometrioid tumors

Answer 84

Account for ~ 20% of all ovarian cancers -usually in older women (50-70 yoa) Most are carcinomas 15-30% are accompanied by a carcinoma of the endometrium and 15% coexist with endometriosis

Question 85

Tumors of Mullerian Epithelium | Clear Cell Carciooma

Answer 85

An uncommon pattern of tumors of müllerian epithelium Sometimes occur in association with endometriosis or endometrioid carcinoma of the ovary 5year survival rate of ~65% when tumors are confined to the ovary

Question 86

Tumors of Mullerian Epithelium | Cystadenofibroma

Answer 86

Tumors in which there is more pronounced proliferation of fibrous stroma that underlies the columnar epithelium

Question 87

Tumors of Mullerian Epithelium | Brenner tumor

Answer 87

Uncommon adenofibromas in which the epithelial component consists of nest of transitional cells resembling those lining the urinary bladder Most are benign, but borderline and malignant types have been reported

Question 88

Ovarian Neoplasms:Clinical Course

Answer 88

All ovarian epithelial carcinomas produce similar clinical manifestations Most commonly lower abdominal pain and abdominal enlargement GI complaints, urinary frequency, dysuria, pelvic pressure Malignant forms tend to cause progressive weakness, weight loss and cachexia If the peritoneal cavity becomes seeded, massive ascites is common

Question 89

Ovarian Neoplasms: Clinical Course 2

Answer 89

Since ovarian carcinomas often remain undiagnosed until they are large or originate on the ovarian surface from which they readily spread to the pelvis, many patients already have lesions no longer confined to the ovary - Probably the reason for such poor 5 and 10 year survival rates - A potential screening tool is the use of a biological marker CA-125 * Present in > 80% of serous and endometrioid carcinomas

Question 90

Ovarian Neoplasms:Prevention

Answer 90

Fallopian tubal ligation and OC therapy are associated with significant reductions in risk Long term OC use or uterine tube ligation in patients with familial history (BRCA) have a reduction in risk by ~1/2

Question 91

Germ Cell Tumors: Mature (Benign) Teratomas

Answer 91

Most are cystic and known as dermoid cysts -Derived from ectodermal totipotent cells Usually found in young women during the reproductive years -Are bilateral in 10-15% of cases Characteristically are unilocular cysts containing hair and cheesy sebaceous material -Within the wall, it is common to find tooth structures and calcification About 1% undergo malignant transformation of any one of the components -squamous cell carcinoma most common The karyotype of all benign teratomas is 46,XX

Question 92

Germ Cell Tumors: Monodermal or Specialized Teratomas

Answer 92

almost always unilateral Most common are struma ovarii -composed entirely of mature thyroid tissue that can hyerfunction and cause hyperthyroidism carcinoid tumors may arise from teratomal intestinal tissue

Question 93

Granulosa-Theca Cell Tumor

Answer 93

produce large amounts of estrogen - bleeding - linked to endometrial hyperplasia, endometrial carcinoma, breast carcinoma

Question 94

Metastatic tumors to ovary

Answer 94

uncommon may appear as a large mass and resemble a primary tumor: a so-called "Krukenberg" tumor of ovary -signet ring histologic pattern = adenocarcinoma -usually metastatic from a GI primary

Question 95

Fibrothecoma

Answer 95

A right-sided hydrothorax in association with this tumor is known as Meig's syndrome.

Question 96

Ectopic Pregnancy

Answer 96

most common site = fallopian tubes (~90%) also ovary, abdominal cavity, and the intrauterine portion of the fallopian tube (cornual pregnancy) According to your text, the most important predisposing condition (35-50% of cases) is PID w/chronic salpingitis sudden onset of severe abdominal pain and vaginal bleeding ~6-7 wks after normal menstrual period -the invading placenta causes intratubal hematoma (hematosalpinx) and/or intraperitoneal hemorrhage -tube rupture leads to pelvic hemorrhage → shock Clinical examinations are not diagnostic, and no combination of physical exam findings exclude ectopic pregnancy -~30% have no vaginal bleeding -only 10% have palpable adnexal mass

Question 97

Ectopic Pregnancy diagnostic

Answer 97

ultrasound -test of choice -transabdominal ultrasound: EP suspected if no intrauterine gestational sac and β-hCG >6500mIU/ml -transvaginal ultrasound: EP suspected if no intrauterine gestational sac and β-hCG >1500mIU/ml urine pregnancy test β-hCG measurement (should rise throughout normal pregnancy) diagnostic curettage (could terminate desired pregnancy)

Question 98

Placental Abnormalities

Answer 98

Unlike first trimester bleeding, second and third trimester bleeding is usually secondary to abnormal placental implantation. -occurs (on average) at 27-32 weeks gestation

Question 99

Abruptio placentae

Answer 99

premature separation, either partial or total, of a normally implanted placenta after 20 weeks of gestation should be considered when there is a sudden onset of pain, with or without vaginal bleeding

Question 100

Placenta previa

Answer 100

implantation of the placenta over or near the internal os of the cervix unknown etiology, but thought to be multifactorial -multiple gestations, advanced maternal age, previous cesarean delivery, previous abortion, and possibly, smoking

Question 101

Placenta accreta

Answer 101

partial or complete absence of the decidua with adherence of the placenta directly to the myometrium

Question 102

Preeclampsia

Answer 102

formerly known as "toxemia of pregnancy", but not associated w/bloodborne toxin preeclampsia is the development of hypertension and proteinuria after 20 weeks of gestation -your text includes edema, but this is no longer a diagnostic criterion -severe preeclampsia may include oliguria, cerebral or visual disturbances, pulmonary edema, or cyanosis

Question 103

eclampsia

Answer 103

eclampsia is the new onset of seizures in a woman with preeclampsia -occurs in 48 hours after delivery

Question 104

Gestational Trophoblastic Disease

Answer 104

constitutes a spectrum of tumors and tumor-like conditions characterized by proliferation of pregnancy-associated trophoblastic tissue of progressive malignant potential traditionally divided into 3 overlapping morphologic categories: hydatidiform mole, invasive mole, and choriocarcinoma -range from benign (hydatidiform mole) to highly malignant (choriocarcinoma) -all elaborate hCG, and detected in higher amounts than in normal pregnancies (titers positively correlated with malignant potential)

Question 105

Hydatidiform Mole

Answer 105

characterized by cystic swelling of the chorionic villi ("bunch of grapes") with variable trophoblastic proliferation most patients present with spontaneous pregnancy loss or undergo curettage due to abnormalities in ultrasound traditionally discovered at 12-14 wks (gestation "too large for dates") but found earlier by hCG detection (hCG levels far exceed that of pregnancy's age) most common 40 yoa; higher incidence in Asian countries

Question 106

Invasive Mole

Answer 106

a complete mole that penetrates and/or perforates the uterine wall -invades myometrium → may cause rupture and cause life-threatening hemorrhage *hysterectomy may be required -may spread locally to broad ligament and vagina may embolize to different sites (lungs, brain) but do not grow as true metastases less likely to be completely removed by curettage, so monitoring of hCG levels important

Question 107

Choriocarcinoma

Answer 107

rapidly invasive, widely metastasizing malignant neoplasm that arises from gestational chorionic epithelium or (less frequently) totipotential cells in the gonads or elsewhere may derive from any form of previously normal or abnormal pregnancy -much more common in some African countries (e.g., Nigeria) -most arise from complete hydatidiform moles (~50%) *previous abortions (~25%) *normal pregnancies (~22%)

Question 108

in contrast to the moles, choriocarcinoma...

Answer 108

in contrast to the moles, choriocarcinoma does not classically produce a large, bulky mass -are a hemorrhagic, necrotic mass produces a bloody, brown, sometimes foul-smelling discharge -usually appears after miscarriage, curettage, or normal pregnancy -may not appear until months after pregnancy by the time the tumor is discovered locally, has already metastasized -favored sites (descending order) = lungs, vagina, bone, brain, liver, kidney despite aggressiveness, current chemotherapy regimens have resulted in 100% cure rate