Female Path 2

Question 1

What are the common sx of PCOD (polycystic ovarian disease). What are you at risk for if you have this?

Answer 1

1. Infertility
2. Oligomenorrhea
3. Hirsutism
4. Type 2 DM

At risk for endometrial carcinoma (^ estrone)

Question 2

What is the hormonal imbalance involved with PCOD?

Answer 2

LH:FSH>2
There is increased androgen production from theca cells that leads to hirsutism and estrone production in adipose tissue.
Increased estrogen causes neg feedback on FSH leading to degeneration of follicles

Question 3

Ovarian tumors come in 3 flavors. What are they and how common is each one?

Answer 3

1. Surface epithelium (75%)
2. Germ cells (15-20%)
3. Stromal cells (less than 5%)

Question 4

What are the common sx of an epithelial ovarian tumor?

Answer 4

Vague abdominal pain/fullness

Signs of compression like urinary frequency

Question 5

What serum maker is effective at monitoring tx response and recurrence of ovarian epithelial tumors?

Answer 5

CA-125

Question 6

Epithelial ovarian tumors come in 2 different flavors that are then divided into 3 sub-flavors. Discuss.

Answer 6

Epithelial ovarian tumors are either SEROUS or MUCINOUS.

Within those 2 categories, they can be benign, borderline, or malignant

Question 7

For serous tumors, tell me:

1. Bilateral or unilateral?
2. Gross appearance
3. Mutations associated with low/high grade
4. Mostly benign or malignant
5. Recurrance rate

Answer 7

1. Bilateral
2. Thin walled cyst with watery, clear fluid
3. Low-grade:KRAS or BRAF (stromal invasion)
   High-grade:p53 or BRCA1 (frank invasion)
4. 60% benign
5. High recurrence

Question 8

For mucinous tumors tell me:

1. Bilateral or unilateral
2. Gross appearance
3. Mostly benign or malignant
4. Recurrence rate

Answer 8

1. Unilateral
2. Multicystic filled with gelatinous mucin
3. 85% benign/borderline
4. Low recurrence

Question 9

What are the histological differences between benign, borderline and high grade ovarian epithelial tumors?

Answer 9

Bengin: single layer of columnar epithelium w/abundant cilia
Borderline: more complexity of stromal papillae, stratification of epithelium, nuclear atypia
High grade: more complex growth, branching papillary architecture + atypia, infiltration, PSAMMOMA bodies

Question 10

Pseudomyxoma peritonei is what? Where does it come from?

Answer 10

Mucinous ovarian tumor that produces mucin leading to lots of mucin in the peritoneum and adhesions. It arises from a mucinous tumor of the appendix. “JELLY BELLY!”/ascites results.

Question 11

A benign cystadenoma has what kind of histology?

Answer 11

One cell layer thick, with tall mucin secreting epithelium

Question 12

A malignant cystadenocarcinoma has what kind of histology?

Answer 12

Complex, solid sheets of neoplastic cells with high N/C ratio and mitoses

Question 13

Endometrioid ovarian tumors arise from what and are usually benign or malignant?

Answer 13

They can arise from endometriosis and are usually malignant . Another type of surface epithelial tumor.

*similar to endometrioid carcinoma of the uterus

Question 14

Would you want to get clear cell adenocarcinoma?

Answer 14

NO, it a surface epithelial tumor that doesn’t respond to therapy and has a very poor prognosis.

It is the bad cousin of endometroid adenocarcinoma. Good thing it’s not super common.

Question 15

A brenner tumor is a surface epithelial tumor that is a_________-like epithelial neoplasm that is usually unilateral/bilateral (pick one)

Answer 15

1. Bladder like
2. Unilateral

*epithalial nests appear inside ovarian stroma. RARE.

Question 16

A cystadenofibroma is benign or malignant?

Answer 16

Benign. It’s rare.

Question 17

Germ cell tumors represent what percentage of all ovarian neoplasms and are usually unilateral or bilateral?

Answer 17

1. 15-20%

2. Unilateral

Question 18

What are teratomas made of and what is the key imaging thing you’ll see. Is it benign or malignant? Is it common or uncommon? Tell me everythingggggg

Answer 18

1. Contain all 3 embryonic layers
2. Rokitansky tubercle (nodular protuberance) seen on the cyst wall
3. Bengin
4. COMMON (most common benign germ cell tumor)

Question 19

In a dysgerminoma, what do you see on histology?

Answer 19

Large, cells with clear cytoplasm with round nuclei

Question 20

Dysgerminoma:

1. Common or uncommon?
2. Prognosis?
3. What’s its testicular brother tumor?

Answer 20

1. Common (most common malignant germ cell tumor)
2. Good prognosis (responds to therapy)
3. Seminoma

Question 21

A yolk sac tumor has tons of buzz words. Tell me what you’ll find on labs, histology and who gets this kind of tumor most commonly

Answer 21

BASCIALLY, if you see a CHILD with a tumor that secretes AFP and has SCHILLER-DUVAL bodies on histology, you can be like, yup, this kid’s got yolk sac tumor which is very sad because it is malignant.

Question 22

Now would you want to get choriocarcinoma? Why or why not? Support your answer with details on how you would know you have choriocarcinoma (histology, and labs)

Answer 22

No you would not because this malignant tumor does not respond well to chemo and has early hematogenous spread.

You would know you have it because the proliferating syncytiotrophoblasts would produces lots of hCG, and on histology you would would see placenta like tissue with no villi and lots of hemorrhage

Question 23

Embryonal carcinoma is made of what kind of cells? Is it a nice little tumor or a mean and deadly tumor?

Answer 23

It is made of large primitive cells and it is super mean and aggressive and has early metastasis.

Question 24

Finally we get to the sex-chord stromal tumors which as a whole make up

Answer 24

1. Granulosa cell tumor
2. Fibromas
3. Sertoli-Leydig cell tumor

Question 25

In a granulosa cell tumor, what hormone is SUPER high and what kind of symptoms does this cause?

Answer 25

The proliferation of granulosa and theca cells in this tumor lead to very high levels of ESTROGEN. This causes precocious puberty and menorrhagia or metrorrhagia. It can lead to post-menopause endometrial hyperplasia and uterine bleeding, but has low risk of mets.

Question 26

What is the super high yield syndrome Fibromas are associated with?

Answer 26

This tumor of fibroblasts is associated with MEIGS syndrome, which is a combination of pleural effusions + ascites. When you take out the tumor, Meigs goes away.

Question 27

When I say Sertoli-Leydig Cell tumor, you say __________ crystals!

Answer 27

REINKE

Question 28

What sx will you see in a Sertoli-Leydig Cell tumor?

Answer 28

Excess androgens leading to hirsutism and virilization.

Question 29

Metastatic gastric carcinoma can cause __________ tumor

Answer 29

Krukenberg, a bilateral mucinous ovarian tumor

Question 30

In a spontaneous abortion, what symptoms will you see?

Answer 30

This person will come in with vaginal bleeding and crampy pain because of the passage of fetal tissue. In order for you to call this a miscarriage is has to occur before 20 wks.

Question 31

What are the common causes of spontaneous abortions

Answer 31

1. Chromosomal anomalies (trisomy 16) 2. Antiphospholipid snydrome (hypercoaguable state) 3. Congenital infection 4. Teratogens (esp in 1st 2 weeks of embryogenesis)

Question 32

A woman walks into the ER with acute abdominal pain and vaginal bleeding. You measure her hCG and it's elevated. What is the top dx on your differential and what risk factors does she probably have that led to this dx?

Answer 32

Ectopic pregnancy Risk factors for this include SCARRING, which can be secondary to: 1. PID 2. Endometriosis 3. Chronic salpingitis 4. Previous ectopic 5. Tubal ligation 6. permutable adhesions 7. Reconstructive surgery

Question 33

On histology, what you likely to see with an ectopic pregnancy?

Answer 33

Hemorrhage, blood clots and chorionic villi in the fallopian tube lumen (or where ever the ectopic is). Chronic presentation will include plasma cells and lymphocytes.

Question 34

What is the difference between placenta previa and placental abruption?

Answer 34

In placenta previa, the placenta implants in the lower uterine segment so that it overlies the cervical os. It presents with 3rd trimester bleeding and the fetus will be delivered via C-section. On the other hand, in placental abruption there is separation of the placenta from the decidua before the fetus is delivered, which means you'll still have 3rd trimester bleeding but also have fetal insufficiency since nutrient/O2 transport to the baby is compromised. This will commonly lead to a still birth.

Question 35

If your patient has a difficult delivery of the placenta and then has postpartum bleeding, what dx should you think of? What is the treatment?

Answer 35

Think of a placenta accrete, which is when the placenta implants into the myometrium (not where its supposed to be obviously) leaving little or no intervening decidua. The treatment for this is hysterectomy.

Question 36

What 3 criteria make you think "Oh, this person probably has preeclampsia!"

Answer 36

1. HTN (>140/90) 2. Proteinuria (>300mg/24hr) 3. Edema

Question 37

What is the cause of preeclampsia and when does it usually present?

Answer 37

Remember, it is caused by an abnormality of the vascular interface of the placenta, and it usually presents in the 3rd trimester of pregnancy.

Question 38

How is eclampsia different from preeclampsia and how might you prevent/treat it?

Answer 38

Eclampsia is preeclampsia with seizures. In a woman with preeclampsia you may give MgSO4 prophylactically or for treatment

Question 39

HELP, What is HELLP??

Answer 39

H: Hemolysis EL: Elevated Liver enzymes LP: Low Platelets Basically this is preeclampsia with a super bad liver disorder (liver thrombotic microangiopathy) added as an extra bonus.

Question 40

Your patient comes in with hCG way higher than is appropriate for her gestational age and a gigantic uterus. What do you think she has? What is she possibly at risk for?

Answer 40

Molar pregnancy. Can be either complete or partial. If she has a complete molar pregnancy, then she is at increased risk for choriocarcinoma.

Question 41

How do you tell the different between complete and partial molar pregnancies based on genotype?

Answer 41

Complete: A nonviable egg (one that has lost its DNA) is fertilized by a sperm that duplicates itself or by 2 sperm, and then it implants into the uterus. You get a genotype of 46XX or 46XY. Partial: An egg is fertilized by a sperm that duplicates itself or by 2 sperm and implants into the uterus. You get a genotype of 69XXY or 92XXXY.

Question 42

How will you tell the difference between complete and molar pregnancies based on histology?

Answer 42

Complete: There is no fetal tissue, you have edematous, hydropic villi, and there is diffuse proliferation of trophoblasts around the hydropic villi Partial: There is fetal tissue, and you have mostly normal villi with some hydropic villi. There is only focal proliferation of trophoblasts around the hydropic villi.

Question 43

Can the mole go through the uterine wall? If so, where can it go/what can it cause?

Answer 43

YES it can. This is called an invasive mole. It can embolize to the lung or brain or cause hemorrhage due to uterine rupture.

Question 44

What type of cells is a gestational choriocarcinoma made of? Does it have a good prognosis?

Answer 44

This rapidly invasive malignancy is made of syncytiotrophoblasts and cytotrophoblasts (cells that make up the placenta) but there are no chorionic villi. It has a good prognosis despite the fact that it is prone to hematogenous spread

Question 45

Placental Site Trophoblastic Tumor is made of a specific type of trophoblastic cell. What are they, and what's the general prognosis of this tumor?

Answer 45

Intermediate trophoblastic cells (arise from cytotrophoblastic cells) This tumor is confined to the uterine cavity so has an excellent prognosis. Tx is surgery.