Female Reproductive Pathology Flashcards
(124 cards)
1
Q
What stain is positive in hidradenoma papilliferum?
A
EMA
2
Q
What is the difference between mammary and extramammary Paget’s?
A
Mammary has 95% chance of underlying cancer, underlying extramammary cancer is rare
Paget’s vulva: CK7+, CEA+, mucin+
Paget’s anus: CK20+, CEA+, mucin+
3
Q
What are the different kinds of vaginal cysts?
A
Mullerian: endocervical type
EIC: squamous epithelium (prior surgery or trauma)
Mesonephric / Gartner’s cyst: non mucinous cuboidal epithelial cells (lateral walls) but may have mucinous material in the lumen (they are CD10 positive)
Endometriotic cysts
Bartholin cysts: squamous or transitional or mucinous lining (located at 4 o’clock and 8 o’clock)
4
Q
BQ! Etiology of vaginal adenosis?
A
Exposure to DES
Vaginal adenosis: Upper 1/3 and anterior wall of vagina, 20% have gross congenital malformation of cervix (T shaped uterine cavity)
Benign glandular epithelium with metaplasia
5
Q
Koilocytes in low grade cervical lesions are due to which types of HPV and to expression of what viral protein?
A
HPV 6 and 11
Viral E4 expression
its a productive infection (early and late gene expressed), non integration of viral DNA
6
Q
High grade cervical lesions are due to which types of HPV and to expression of what viral protein?
A
HPV 16 and 18
they are non productive infections
only early E6 and E7 genes expressed
there is integration of viral DNA, E6 binds P53, HPV E7 interacts with Rb protein
7
Q
What is associated with microglandular hyperplasia?
A
oral contraceptives or pregnancy (hormonal stimulation)
8
Q
Stains to differentiate between endocervical and endometrial AIS?
A
Endocervical: CEA, p16
Endometrial: CD10, vimentin
From Dr. Speights:
Endocervical = CEA + and p16 + in cancer, ER negative in cancer, ER + in normal tissue
Endometrial = vimentin + and CD10 + in cancer, PTEN LOSS in cancer, ER negative in both cancer and normal
9
Q
Which type of cervical cancer is associated with lots and lots of eosinophils (also seen in its metastasis)?
A
Glassy cell carcinoma (a variant of adenosquamous carcinoma)–very aggressive tumor
10
Q
What virus is associated with small cell carcinoma of the cervix?
A
HPV18
11
Q
When you see actinomycetes colony microscopically and there is a peripheral hot pink area, what is this called and what is the significance?
A
These are the sulfur granules and it’s called splendora hoeppli phenomenon and the significance is that it is the site of antigen antibody reaction (ie it’s invasive)
12
Q
What kind of diathesis do you see in endometrial carcinoma?
A
Watery diathesis
13
Q
Endometrial dating criteria
In the 28 day cycle, when is the menstrual, proliferative and secretory phases respectively?
A
Menstrual: Day 1-3
Proliferative: Day 4-14
Secretory: Day 14-28
14
Q
What are the FIGO grades?
A
● FIGO 1: resembles microglandular hyperplasia; composed primarily of well formed glands; <5% nonsquamous solid component
● FIGO 2: 6-50% nonsquamous solid component
● FIGO 3: more than 50% nonsquamous solid component; lacks well formed glands, which differentiates it from serous endometrial carcinoma
● FIGO grading excludes serous or clear cell, which are considered high grade (grade 3)
● Raise grade from 1 to 2 or from 2 to 3 if notable nuclear atypia inappropriate for grade (particularly pleomorphism and prominent nucleoli)
● If marked atypia, tumor may be serous without typical papillary architecture (usually p53+)
15
Q
What do you call a endometrial polyp with smooth muscle in a younger patient with lots of squamous morules that is located in the lower uterine segment?
A
Atypical polypoid adenomyoma
16
Q
What is your main differential with papillary serious endometrial carcinoma?
A
Villoglandular endometrial adenoCA
but this will not have hobnailing and the nuclei will be much lower grade
17
Q
What endometrial tumor is shown in the image and what are its features and staining pattern?
A
Low grade endometrial stromal sarcoma
Checkerboard type pattern, mitotic activity is increased, vasoinvasive (sometimes it looks like a bag of worms because it is so angioinvasive)
Staining: Vimentin +, CD 10 +, Actin – focally +, Desmin –, ER / PR +, Beta catenin overexpression
18
Q
Which type of breast cancer may metastasize to the uterus?
A
Lobular carcinoma
19
Q
What has happened to this leiomyoma?
A
Carneous (or red) degeneration
Carneous degeneration is a subtype of hemorrhagic infarction of leiomyomas that often occurs during pregnancy. On gross pathology, it is characterized by a red (hemorrhagic) appearance of the leiomyoma. Red degeneration primarily occurs secondary to venous thrombosis within the periphery of the tumor or rupture of intratumoural arteries
20
Q
In MMMT (carcinosarcoma), what is the most common heterologous element and which part is most likely to metastasize?
A
Rhabdomyosarcoma is most common heterologous element and the carcinoma component is more likely to metastasize
21
Q
What is the most common site of endometriosis in the GYN tract?
A
Ovary
22
Q
Name 3 tumors associated with endometriosis:
A
1) Endometroid
2) Clear Cell
3) Stromal sarcoma
23
Q
What is the most common tumor associated with BRCA gene mutation?
A
Serous carcinoma
24
Q
What gene mutation is found in high grade serous carcinoma? Low grade?
A
High grade: p53
Low grade: BRAF, KRAS
25
Which type of borderline tumor is more likely to be associated with endometriosis and be bilateral?
Mucinous muellerian (endocervical type)
The intestinal type is more common overall though
26
Which syndrome is clear cell carcinoma of the ovary associated with?
Lynch Syndrome (HNPCC)
27
What is the only difference microscopically between a malignant Brenner tumor of the ovary and a primary urothelial carcinoma of the ovary (shown here)?
The Brenner tumor will have areas with the normal grooved nuclei (coffee bean nuclei shown here)
28
If you see this picture of a cerebriform ovary, what tumor should you think about?
Stains?
Cytology appearance?
Dysgerminoma
Cytology: tigroid appearance on cytology and small lymphocytes
Stains: CD117, PLAP, OCT3/4, SALL4
29
What stain is positive in yolk sac tumor in addition to AFP?
_Ovary_: Keratin, AFP (yolk sac elements, hepatic or intestinal epithelium in teratomas) and CD10
_Testis_: AFP (diffuse through cytoplasm and hyaline globules), cytokeratin, SALL4, Glypican3 (in hepatoid variant), PLAP (variable), CD117 (in solid pattern)
Yolk sac has red globules similar to clear cell (shown here)
30
What is the entity shown of a peritoneal lesion that is associated with teratomas?
Gliomatosis peritonei
Thought to be a response to teratomas (WEIRD!)
ALSO associated with endometriosis and ventricular peritoneal shunts
31
In the **_ovary_**, what is the most common heterologous element in a carcinosarcoma?
Cartilage
In uterus it is rhabdomyosarcoma
32
What placental lesion is shown here?
Amnion nodosum
Staghorn plaques on membranes, a condition characterized by yellow nodules of compressed squames and hair on the surface and membranes, is associated with severe, long-standing oligohydramnios
33
What are the different staining patterns of extramammary Paget's disease regarding
1) primary vulvar Paget's
2) vulvar Paget's with underlying anorectal CA
3) vulvar Paget's with underlying urothelial CA
Rare lesion of vulva/perianal skin, contrast to Paget’s disease of the nipple in that underlying adenocarcinoma may be rare. Mucin+, CEA+
1) Primary vulvar Paget’s: CK7, GCDFP-15 +; CK20-
2) Vulvar Paget’s secondary to anorectal carcinoma:
CK20+; CK7, GCDFP-15 –
3) Vulvar Paget’s secondary to urothelial carcinoma:
CK7, CK20, UPlakin-III +; GCDFP-15 -
34
What are the components of a pathology report that should be incluced in vulvar squamous cell carcinoma?
• Depth of invasion
* Thickness of the tumor
* Lymphovascular invasion
* Margin status
* Tumor grade (1, 2 or 3)
35
What percentage of cervical SCC constitutes microinvasion and what are the stats on mets with these lesions?
\< 5 mm (or 3mm depending on source) invasion is microinvasion
• \< 1% of microinvasion of 3 mm metastasize
• \< 10% of microinvasion of 3-5 mm metastasize
36
What percentage of adenoCA of the cervix has associated squamous intraepithelial lesions?
30-60%
37
What is the definition of microinvasive squamous cell carcinoma of the vulva? How does that differ from the cervix?
**_Vulva_**: Tumor depth less than 1mm as measured from the basement membrane of the nearest dermal papilla to the point of deepest invasion by tumor and less than 2cm in diameter
**_Cervix_**: Tumor depth less than 3mm as measured from the basal layer of overlying surface epithelium to the point of deepest invasion by the tumor, tumor diameter less than 7mm
\*if invasion is present only adjacent to an involved gland, the measurement is from the top of the gland to the point of deepest invasion by tumor
38
Angiomyofibroblastoma (shown here) and aggressive angiomyxoma are very similar lesions. What stain is helpful in differentiating?
Smooth Muscle Actin
positive in angiomyofibroblastoma and negative in aggressive angiomyxoma (shown here)
39
How are ovarian teratomas graded?
**_Grade 1_** – neoplasms with embryonal tissue absent
or limited to a rare low magnification (X40) field
and not more than one such focus in any slide.
**_Grade 2_** – embryonal tissue does not exceed three
low power microscopic fields in any slide.
**_Grade 3_** – embryonal tissue occupies four or more
low magnification microscopic fields in at least one
slide.
40
What is being shown in this photo and what tumor is it associated with?
Azzopardi effect
Seen in small cell carcinomas when the necrotic tumor cells condense their chromatin material around blood vessels
\*Only seen in lung small cells, NOT in ovarian!
41
What stain is an E-cadherin binding protein which is advocated by some experts for some E-cadherin equivocal cases?
p120
It will show membranous staining in DCIS and cytoplasmic staining in LCIS
42
What stain is positive in almost 100% of lobular carcinoma (in situ and infiltrating)?
GCDFP
43
Metaplastic breast carcinomas are frequently AE1/AE3 (pankeratin) and CAM5.2 negative. Therefore, what stains should always be used to rule it out?
CK903 and p63
44
Paget's disease of the breast ALWAYS has underlying DCIS and 50% of the time has underlying invasive carcinoma. Sometimes it can be hard to tell between Paget's cell and Toker cells of the nipple. What stains can help?
_Paget's cells_ will be CK7, mucin, HER2 positive
_Toker cells_ will be CAM5.2 positive but HER2 and mucin negative
45
What unique translocation is seen in **_high grade_** endometrial stromal sarcomas and must be present to classify as high grade according to 2014 WHO?
t(10;17) (q22;p13) resulting in gene fusion *YWAHAE-FAM22*
The prognosis of this subset of HG-ESS is intermediate between LG-ESS and undiff uterine sarcoma.
About half of endometrial stromal sarcomas have the t(7;17) JAZF1/JJAZ1 gene fusion but recently a fusion associated with higher grades was discovered.
Tumors with YWHAE-FAM22 rearrangements constitute a distinct group of ESS, which is associated with high-grade morphology and aggressive clinical behavior compared to JAZF1 ESS. Thus, their distinction from typical JAZF1 ESS is important for prognostic and therapeutic purposes.
46
What type of HPV is associated with Bowenoid papulosis of the vulva or penis?
HPV 16
47
How often is extramammary Paget's disease associated with underlying invasive carcinoma?
30%
48
What vaginal lesion is shown and what would its location be?
The low cuboidal cells with hyaline material (resembles colloid) should be a clue that this is a mesonephric duct remnant (Gartner's cyst) and they are located on the lateral vaginal wall
CD10 positive
49
What vaginal lesion is shown and what causes it?
Vaginal adenosis
DES exposure
Can become clear cell carcinoma
50
Koilocytosis is related to ______ expression.
_viral E4_
Caused by low risk HPV (6, 11)
Productive infection (early and late gene expressed), non integration of viral DNA
15-30% associated with higher grade lesions
51
Barrel shaped cervix should clue you into what kind of cervical cancer?
Glassy cell carcinoma!
Will be lots of eosinophils!
52
In the western world, what is the most common GYN malignancy?
Endometrial adenoCA
53
What ovarian tumor is shown, what will it stain for and what cytogenetic abnormality can it have?
Granulosa Cell Tumor
* Inhibin
* Calretinin
* Vimentin
* WT1
* CD 99
* S100
* CD56
* SF1 (steroidogenic factor)
_FOXL2 gene abnormality on xsome 3_
54
Regarding MMMT, what is the most common heterologous element in:
1) EM
2) Ovary
1) Rhabdomyosarcoma
2) Cartilage
55
What is the T staging for vulvar cancers?
T1: confined to vulva and peritoneum measuring 2cm or less in greatest dimension
T1a: stromal invasion less then 1mm
T1b: stromal invasion more than 1mm
T2: \>2cm in greatest dimension and confined to vulva and peritoneum
T3: Evidence of invasion of the lower urethra, vagina or anus
56
What is the staging for cervical squamous cell carcinoma?
Ia: confined to uterus and diagnosed only by microscopy with maximal stromal invasion depth of 5mm and a horizontal spread of 7mm or less
Ib: clinically visible confined to cervix, \>5mm stromal invasion or \>7mm horizontal spread
IIa: extend beyond the uterus but not the pelvic wall or lower one third of vagina and no evidence of parametrial invasion
IIIa: extend to the pelvic wall and involve the lower third of the vagina
IIIb: extend to the pelvic wall or cause hydronephrosis or nonfunctioning kidney
57
What endometrial tumor occurs in young women, has excellent prognosis, associated with high risk HPV and oral contraceptives, are frequently associated with high grade squamous dysplasia or AIS, is the second most common variant of endometrioid CA, and are low grade tumors?
Villoglandular variant of endometrioid CA
58
Peutz Jeghers is associated with development of what in the fallopian tubes?
Mucinous metaplasia
Single layer of mucinous epithelium replacing the usual ciliated-type epithelium of the fallopian tube
59
What organism causes acute villitis with intervillous abscesses in the placenta?
Listeria
60
What organism causes plasmacytic villitis with hemosiderin deposition and villous capillary thrombosis?
CMV
61
What organism causes chronic villitis characterized by multinucleated giant cells?
Varicella
62
What organism is associated with large, heavy pale placenta and microscopically demonstrates chronic villitis with prominent numbers of plasma cells and obliterative endarteritis?
Syphilis
63
What is the most common maternal tumor to metastasize to the placenta or spread to the fetus?
Melanoma
64
Florid epithelial hyperplasia, atypical lobular hyperplasia, atypical ductal hyperplasia and a family history of breast cancer give someone what increased risk for getting breast cancer?
4-5 times risk
65
If you see a fibroadenoma with myxoid stroma, what syndrome should you think about?
Carney's syndrome
\*cardiac and cutaneous myxomas, myxoid FA, endocrine overactivity, pigmentation
66
What is the most common non-invasive lesion seen in fibroadenomas?
Lobular carcinoma in situ
67
Is it necessary to do an axillary lymph node dissection for a Phylllodes tumor?
NO
If these spread, they do so hematogenously
68
What is the increased risk for invasive carcinoma with sclerosing adenosis, radial scar, columnar alteration, papilloma?
1.7 times
69
What breast lesion shown is a mimicker of cancer, does not have a myoepithelial layer and contains PAS with diastase positive hyaline eosinophilic material in the lumens?
Microglandular adenosis
\*No myoepithelial layer but there is intact basement membrane (positive with collagen IV stain)
70
What is the increased risk of cancer with a radial scar?
1.8 times
71
What is the increased cancer risk with moderate/florid epithelial hyperplasia, sclerosing adenosis and radial scar?
1.5-2 times
Family history increases risk
72
What is the increased cancer risk with atypical ductal or lobular hyperplasia?
5X
73
Atypical ductal hyperplasia and DCIS are negative for what stain and have what molecular alterations?
Both negative for CK5/6
**UDH is positive for CK5/6!**
16q-, 17p-, 1q+
They need close follow up and tamoxifen therapy
74
If a patient just has high grade comedo DCIS (no evidence of invasive carcinoma), do you need to do axillary LN dissection?
YES
DCIS can go to nodes
If it's a big lesion, they will do
75
What markers are overexpressed in high grade DCIS?
Her2neu (50-60%)
p53
E-cadherin
76
If a patient has LCIS, what is the risk that there is invasive cancer in either breast?
25% (10x risk)
77
How much DCIS must be present in a cancer to classify it as extensive intraductal component (EIC)?
25%
78
What is Rosen's triad in breast lesions?
The histologic triad of tubular carcinoma (TC), columnar cell lesion (CCL), and lobular carcinoma in situ (LCIS)
\*if you see any of these, look around carefully for the others
79
What tumor is associated with tubular carcinoma of breast?
Cribiform carcinoma
\*sometimes difficult to tell between cribiform DCIS. If it's a large expansile mass, it's CA
80
What interesting staining pattern does micropapillary breast carcinoma show with stains?
REVERSE POLARITY
It will show staining opposite the lumen
\*aggressive, don't miss it!
81
What is the staining pattern of PASH?
Positive stains: vimentin, CD34, PR (intense)
Negative stains: Factor 8, Ulex, CD31, ER, keratin
82
How are breast tumors graded?
**_Tubule formation_**
– \>75% = 1
– 10 – 75% = 2
– \<10% = 3
**_Nuclear pleomorphism_**
– Small, uniform = 1
– Variable = 2
– Marked pleomorphism = 3
**_Mitotic count_**
– 0 – 5 = 1
– 6 – 10 = 2
– \>11 = 3
**_Well, moderate and poorly differentiated_**
( I, II, III; 3 -5, 6 – 7, 8 – 9 points)
83
What is Stewart Treves syndrome?
Also known as cutaneous angiosarcoma, refers to a lymphangiosarcoma, a rare complication that forms as a result of chronic, long-standing lymphedema.
84
What is the role of BRCA1 and BRCA2 genes and what cancers are patients at risk for?
**_BRCA1_**: Tumor suppressor gene. Medullary and high grade tumors as well as ovary, prostate, colon
**_BRCA2:_** Possible role in DNA repair. Male breast, ovary, prostate, pancreas
85
What disease is characterized by multiple hamartomas, 10q mutation and a family history of breast and thyroid cancers?
Cowden's disease
86
What is the oncotype DX and mammaprint?
**_Oncotype DX_**:
– 21 gene assay
– ER+ tumors
– Provides quantitative assessment of likelihood of distant metastases
– Assesses benefit from certain cancer chemotherapy
**_Mammaprint_**:
– Analysis of 70 genes
– Provides prognostic profile
87
What mutation is seen in secretory (juvenile) carcinomas of the breast?
t(12;15) ETV6-NTRK3
Not seen in any other breast CA
88
This tumor shown is an ovarian neoplasm and 80% occur in the first three decades and it is NOT generally associated with hormone production. The differential on morphology includes fibroma/thecoma however these are VERY rare after the age of 40 (age is very helpful).
**Sclerosing stromal tumor of the ovary**
## Footnote
These are usually unilateral and shows a pseudolobular pattern with cellular nodules separated by poorly cellular areas of dense collagen. They have prominent thin walled vessels within the nodules and may resemble a hemangiopericytoma.
89
What is the translocation seen in EXTRAUTERINE endometrioid stromal sarcoma?
JAZF1-JJAZ1
t(7;17)
90
When suspecting molar pregnancy on H&E, what TWO stains can you use to help make the diagnosis and how do they help?
**_p57_**: Differentiate between PARTIAL and COMPLETE mole (look for STROMAL staining in partial mole)
**_Ki67_**: Differentiates between MOLAR pregnancy and HYDROPIC pregnancy. \>70% Ki67 staining around most villi is suggestive of MOLAR pregnancy
91
What rare type of invasive pattern is seen in MUCINOUS ovarian neoplasms?
Expansile invasion
clue is when you see REALLY complex glands but no definite invasion
VERY subjective and difficult concept
92
When you see a mucinous lesion in the ovary, what FOUR tumors should you be looking for in the background that can be associated with mucinous tumors?
Brenner Tumor
Carcinoid
Sertoli-Leydig
Teratoma
93
In sertoli-leydig cell tumors of the ovary, what is the most important prognostic factor? What types of heterologous elements are seen in the different grades?
GRADE is the most important prognostic factor (whereas in granulosa cell tumor STAGE is the most important)
Sertoli-Leydig tumors are graded:
**_Well Diff_**: LOTS of sertoli tubules (NO HETEROLGOUS ELEMENTS)
**_Intermediate_**: Solid sheets of blue cells with interspersed leydig cells, possible tubules on periphery of sheets--heterologous elements 80% of the time will be mucinous epithelial
**_Poorly Diff_**: Sarcomatous features--heterologous elements usually skeletal mm and cartilage
94
What stain is positive in thecoma and help differentiates it from fibroma?
Oil Red O
95
What breast lesion is famous for arising in a fibroadenoma?
LCIS
96
What is the recommended margin of excision with a Phyllodes tumor?
\>5mm (0.5cm) margin
These tumors spread hematogenously
97
What is this breast lesion?
PASH
98
What is this breast lesion?
Myofibroblastoma
## Footnote
Note the alternating collagenous and spindle cell patterns. These tumors are CD34 positive/cytokeratin negative. In women they may have pseudoepithelioid features which can create diagnostic problems.
99
What is this breast lesion?
Fibromatosis
100
What is this breast lesion?
Angiosarcoma
101
What is this breast lesion?
Adenomyoepithelioma
## Footnote
Basically this is mass producing sclerosing adenosis. It is myoepithelial rich as demonstrated by the biphasic pattern in this pic
102
What is this breast lesion and what stain is positive?
Granular cell tumor
S100 positive
103
What breast lesion is this?
Collagenous spherulosis
## Footnote
This is a fibrocystic change in which myoepithelial cells produce basal lamina-like material akin to that seen in adenoid cystic carcinoma. The cribriform like pattern resembles low grade ductal carcinoma in situ. The laminated appearance of the basal lamina-like material - and presence of myoepithelium in the population - however, are useful in distinguishing this lesion from ductal carcinoma in situ. Keep in mind that LCIS may arise in collagenous spherulosis.
104
Papilloma or papillary cancer?
Papilloma
## Footnote
papilloma is more cohesive and more eosinophilic in character
105
Papilloma or papillary cancer?
Papillary Cancer
## Footnote
papilloma is more eosinophilic
106
Is this ADH or UDH?
UDH
\*UDH is positive for CK5/6
107
What is the T and N staging for invasive breast cancer?
pT1: Tumor ≤20 mm in greatest dimension
pT1mi: Tumor ≤1 mm in greatest dimension (microinvasion)
pT1a: Tumor \>1 mm but ≤5 mm in greatest dimension
pT1b: Tumor \>5 mm but ≤10 mm in greatest dimension
pT1c: Tumor \>10 mm but ≤20 mm in greatest dimension
pT2: Tumor \>20 mm but ≤50 mm in greatest dimension
pT3: Tumor \>50 mm in greatest dimension
pT4: Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules). Note: Invasion of the dermis alone does not qualify as pT4.
pT4a: Extension to chest wall, not including only pectoralis muscle adherence/invasion
pT4b: Ulceration and/or ipsilateral satellite nodules and/or edema (including peau d’orange) of the skin which do not meet the criteria for inflammatory carcinoma
pT4c: Both T4a and T4b
pT4d: Inflammatory carcinoma
pN1a: Metastases in 1 to 3 axillary lymph nodes, at least 1 metastasis greater than 2.0 mm
pN2a: Metastases in 4 to 9 axillary lymph nodes (at least 1 tumor deposit greater than 2.0 mm)
pN3a: Metastases in 10 or more axillary lymph nodes (at least 1 tumor deposit greater than 2.0 mm)
108
High yield!
What lesion is this in the breast?
Micropapillary carcinoma of the breast
109
What is simplex (differentiated) VIN?
A subset of VIN is un-related to HPV virus.
It occurs in older patients.
It is a histologically subtle lesion and may be underdiagnosed, especially in a superficial biopsy.
**There is greater risk of progression to invasive squamous cell carcinoma than HPV-related VIN.**
110
How is depth of invasion measured in the cervix vs the vulva?
Vulva: Depth, measured from the uppermost dermal papillae (NOT basement membrane)
Critical Level: 1.0mm
Cervix: Depth, measured from the basement membrane of surface epithelium or endocervical gland.
FIGO Ia : depth width
Clinically visible tumors are stage Ib, regardless of size
111
What is the difference between atypical leiomyoma and leiomyosarcoma?
Both have atypia but then count mitosis.
## Footnote
Atypical LM: Contains bizarre multinucleated tumor cells (moderate/severe atypia), less than 10 mitotic figures/10 HPF and NO tumor cell necrosis
If there is atypia AND necrosis, it is LMS regardless of mit count
\>10 = LMS
112
How is immaturity in a teratoma graded?
Grade 1: Rare foci of immature neural tissue
Grade II: 2-3 LPF
Grade III: 4 or more LPF
113
What genetic alteration is consistently seen in juvenile granulonsa cell tumors?
Trisomy 12
114
Lef Q:
## Footnote
A 54yo patient underwent resection of this ovarian mass. You would be MOST concerned about:
a) ascites
b) metastases
c) bilaterality
d) endometrial hyperplasia
e) intestinal obstruction
**d) endometrial hyperplasia**
## Footnote
This is a fibrothecoma of the ovary. The characteristic yellow hue reflects its potential endocrine function. These lesions may be **estrogenic** leading to unopposed estrogen stimulation to the EM with subsequent risk of HP or carcinoma
115
What is the difference in measuring depth of invasion for vulvar melanoma and vulvar SCC?
Melanoma: from the surface of the epithelium discounting the acellular keratin layer
SCC: from the adjacent basement membrane of the closest dermal papilla
116
In addition to Cowden's syndrome, PTEN mutations are implicated in many other cancers. Regarding the immunostain, what are its main uses by pathologists?
**LOSS OF NUCLEAR PTEN**
## Footnote
(positive staining in almost all body tissues, similar to INI1 in that way)
- seen in adenomatous thyroid nodules part of Cowden's syndrome
- distinguishes intraductal prostatic carcinoma from HGPIN
- seen in EM hyperplasia and cancer (early marker)
117
Lef Q:
## Footnote
The MOST COMMON malignancy arising out of a mature teratoma?
a) immature teratoma
b) adenoCA
c) carcinoid
d) SCC
e) melanoma
**SCC**
I personally would have thought immature teratoma but these **DO NOT** arise from mature teratomas and instead occur de novo
118
What is this ovarian neoplasm and what is it associated with?
Gonadoblastoma
## Footnote
Most often seen in the context of mixed gonadal dysgenesis with Y chromosomal material being present as well as in patients with other intersex conditions (ie XO:XY mosaicism)
Composed of nests of both germ cells and sex cord cells.
**Increased risk of developing dysgerminoma**
This is different from POLYEMBRYOMA (shown here) which is a distinct pattern of mixed germ cell tumor that attempts to recapitulate embryonic architecture. In this image, three embryoid bodies are seen. Each is composed of a central portion of embryonal carcinoma between a ventral yolk sac tumor component and a dorsal amnion-like space.
119
Lef Q:
## Footnote
The BEST diagnosis for this vaginal biopsy is:
a) squamous metaplasia
b) condyloma accuminatum
c) vaginal intraepithelial neoplasia
d) Bartholin's cyst
e) adenosis
**e) adenosis**
## Footnote
The presence of subepithelial glandular tissue is the hallmark of adenosis. Although squamous metaplasia is part of the constellation of findings, it is the presence of the glands in a usually nonglandular tissue that is the major feature.
Associated with DES expoxsure in-utero although it can occur as an isolated finding.
120
Lef Q;
## Footnote
This tissue was submitted after a surgical procedure on a vulvar cyst at the 4 o'clock position at the introitus. The MOST LIKELY diagnosis is:
a) Bartholin's gland cyst
b) Endometriosis
c) EIC
d) Skene's duct cyst
e) Gartner's duct cyst
**a) Bartholin's gland cyst**
## Footnote
In diagnosing these cysts, location and type of lining is important. This location is classic for Bartholin's glands which are located at 4 o'clock and 8 o'clock at the introitus. The gland acini are mucinous and the duct epithelium usually is a mix of mucinous, transitional and squamous.
Skene's ducts may be mucinous but occur in a **periurethral** location.
Gartner's (Wollian) duct cyts occur in the **anterolateral vaginal wall** and may have a simple columnar lining
121
Lef Q:
A 15yo girl is brought in for medical attention for a mass protruding out of the vagina with the histology shown. The MOST LIKELY diagnosis is:
a) sarcoma botyroides of the cervix
b) yolk sac of the vagina
c) sarcoma botyroides of the vagina
d) condyloma accuminatum
e) condyloma latum
**a) sarcoma botyroides of the cervix**
## Footnote
Sarcoma botyroides of the vagina is a rare tumor usually occuring in girls **under the age of 5**.
A histologically similar but less aggressive lesion is the sarcoma botyroides arising from the cervix which is more likely to occur in adolescents and early adulthood
122
This is body in a cervical cytology specimen. What is this structure called and what is it associated with?
Donovan body from granuloma inguinale caused by Calymmatobacterium granulomatis
123
What are the mitotic cutoffs for the uterine smooth muscle tumors?
124
High Yield!
What lesion is this in the breast?
Micropapillary carcinoma of the breast
