Fung: Gyn Pathology Flashcards by Megan Foggia

Anatomically includes the moist hair bearing skin & mucosa of the female genitalia external to the hymen
Lined by squamous epithelium

vulva

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Most disorders of the vulva are (blank). List some examples of disorders of the vulva.

inflammatory;

contact dermatitis, eczymatous dermatitis, infections

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Characterized by thinning of the epidermis & fibrosis of the dermis
Presents as a white patch with parchment-like vulvar skin

lichen sclerosis

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Who gets lichen sclerosis?

postmenopausal women, who get a thinning of the dermis

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Is lichen sclerosis benign or malignant?

benign, but associated with a slight increased risk for squamous cell carcinoma

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Characterized by hyperplasia of the vulvar squamous epithelium
Presents as leukoplakia with thick, leathery vulvar skin
Associated with chronic irritation & scratching

Lichen simplex chronicus

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Is lichen simplex chronicus benign or malignant?

benign

no increased risk of squamous cell carcinoma

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Warty neoplasm of the vulvar skin, often very large
Most commonly due to HPV 6 & 11
Secondary syphilis is a less common cause
Rarely progresses to carcinoma

condyloma

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What is vulvar intraepithelial neoplasia? What is it related to?

dysplasia of the epithelium lining the vulva, which progresses to vulvar carcinoma;
associated with HPV 16 & 18, 31 & 33 (high risk)

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What are the levels of vulvar intraepithelial neoplasia?

VIN 1-3 –> carcinoma

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What are the two etiologies of vulvar carcinoma?

HPV related - occurs in women ages 40-50, begins as dysplasia, which progresses to cancer

non-HPV related - occurs in women greater than 70yo - reactive changes - lichen sclerosis

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Characterized by malignant epithelial cells in the epidermis of the vulva
Presents as erythematous, pruritic, ulcerated vulvar skin
Represents carcinoma in situ with no underlying carcinoma

Extramammary paget’s disease

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How can you distinguish extramammary paget disease from a melanoma, which can rarely occur on the vulva?

Paget cells are PAS +, keratin +, and S100-

Melanomas are PAS-, keratin -, and S100+

**PAS is a marker of mucous in epithelial cells, keratin is also found in epithelial cells

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Malignant proliferation of glands with clear cytoplasm

Rare, but feared complication of DES-associated vaginal adenosis

clear cell adenocarcinoma

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Focal persistence of columnar epithelium in the upper vagina
During development, squamous epithelium from the lower 1/3 of the vagina grows upward to replace the columnar epithelium of the upper 2/3 of the vagina

adenosis

**increased incidence in females who were exposed to DES in utero

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This kind of epithelium lines the mucosa of the vagina

non-keratinizing squamous epithelium

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What are the two division of the cervix? What is each lined by?

endocervix - lined by a single layer of columnar cells

exocervix - lined by nonkeratinizing squamous epithelium

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The junction between the exocervix & the endocervix is called the (blank) zone

transformation

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Circular double-stranded DNA virus
Over 200 known types which are species specific and tissue specific
Infects the lower genital tract, especially the cervix in the transformation zone
Cause epithelial proliferations: warts to carcinoma

HPV

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Persistent infection with HPV leads to an increased risk for (blank)

cervical intraepithelial neoplasia (CIN)

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What are the high risk HPV types? Low risk?

high risk: 16, 18, 31, 33

low risk: 6, 11

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High risk HPV produces E6 & E7 proteins which result in destruction of tumor suppressor genes (blank) and (blank) respectively

p53; Rb

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Characterized by koilocytic change, disordered cellular maturation, nuclear atypia, & increased mitotic activity w/i the cervical epithelium

cervical intraepithelial neoplasia

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What are the four grades of cervical intraepithelial neoplasia?

CIN 1: involves less than 1/3 of the thickness of the epithelium

CIN 2: involves less than 2/3 of the thickness of the epithelium

CIN 3: involves slightly less than the entire thickness of the epithelium

Carcinoma in situ: involves the full thickness of the epithelium

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CIN classically progresses in a stepwise fashion through CIN 1, 2, 3, and carcinoma in situ to become (blank)

invasive squamous cell carcinoma

Is progression to invasive squamous cell carcinoma inevitable?

nooo CIN often regresses the higher the grade of dysplasia, the more likely it is to progress to carcinoma & the less likely it is to regress to normal

Who gets cervical carcinoma?

middle aged women (ages 40-50)

How does cervical carcinoma present?

``` vaginal bleeding (esp after sex) cervical discharge ```

Key risk factors for cervical carcinoma? | Secondary risk factors?

HPV infection | secondary: smoking & immunodeficiency

What are the most common subtypes of cervical carcinoma?

squamous cell carcinoma (80%) | adenocarcinoma (15%)

This is a common cause of death in advanced cervical carcinoma

hydronephrosis with postrenal failure **advanced tumors often invade thru the anterior uterine wall into the bladder

What are the recommendations for pap screening?

21+, cytology alone every 3 yrs 30-65, HPV & cytology cotesting every 5 yrs greater than 65 - no screening if adequate negative prior screening

(blank) is the mucosal lining of the uterine cavity | (blank) is the smooth muscle wall underlying the endometrium

endometrium; myometrium

The endometrium is hormonally sensitive. Growth of the endometrium is (blank) driven, while preparation of the endometrium for implantation (secretory phase) is (blank) driven. Shedding occurs with loss of (blank) support.

estrogen; progesterone; progesterone

Bacterial infection of the endometrium Usu due to retained products of conception, which act as a nidus for infections Presents as fever, abnormal uterine bleeding & pelvic pain

acute endometritis

Chronic inflammation of the endometrium Characterized by lymphocytes & plasma cells (plasma cells are necessary for the diagnosis) Caused by retained products of conception, pelvic inflammatory disease, IUD, & TB Presents as abnormal uterine bleeding, pain, & infertility

chronic endometritis

What is endometriosis?

endometrial glands & stroma outside of the uterine endometrial lining

What kinds of things can cause abnormal bleeding?

anovulatory cycles polyps hyperplasia carcinoma

Lack of ovulation Results in estrogen-driven proliferative phase w/o a subsequent progesterone-driven secretory phase Proliferative glands break down & shed resulting in uterine bleeding

anovulatory cycle

Hyperplastic protrusion of the endometrium Presents as abnormal uterine bleeding Can be a result of tamoxifen which has weak pro-estrogenic effects on the endometrium

endometrial polyp

What is endometrial hyperplasia?

hyperplasia of the endometrial glands relative to stroma | occurs as a consequence of unopposed estrogen

What causes endometrial hyperplasia? What are the different kinds?

unopposed estrogen - obesity, PCOS, estrogen replacement simple vs complex & cellular atypia

What is the most important predictor for progression of endometrial hyperplasia to carcinoma?

cellular atypia

How does endometrial hyperplasia present?

postmenopausal uterine bleeding

Malignant proliferation of endometrial glands | Most common invasive carcinoma of the female genital tract

endometrial carcinoma

There are two pathways for endometrial carcinoma. What are they?

1. hyperplasia --> carcinoma arises from endometrial hyperplasia - histology is endometrioid, average age is 60yo 2. sporadic --> carnoma arises in an atrophic endometrium with no evident precursor lesion - histology shows papillary structures with psammoma bodies - p53 mutation is common

Endometrioid carcinoma is related to precursor (blank). It is graded by (blank). Associated with mutations in (blank) and (blank)

hyperplasia; FIGO; PTEN and DNA mismatch repair gene

This type of endometrial carcinoma is not related to endometrial hyperplasia; it occurs in the fallopian tube & ovary; occurs in postmenopausal women usu; associated with p53 gene mutations

serous carcinoma | sporadic - papillary pathway

Benign neoplastic proliferation of smooth muscle arising from myometrium Most common tumor in females Gross exam shows multiple, well-defined, white whorled masses

leiomyoma (fibroids)

Leiomyomas are related to (blank) exposure

estrogen **premenopausal women, enlarged during pregnancy

How does leiomyoma present?

usu asymptomatic; | when present, symptoms include abnormal uterine bleeding, infertility, & a pelvic mass

Malignant proliferation of smooth muscle arising from the myometrium Arises de novo, NOT from leiomyoma Gross exam often shows a single lesion with areas of necrosis & hemorrhage

leiomyosarcoma

Do leiomyosarcomas come from leiomyomas?

nooo! they arise de novo

What things can cause salpingitis?

**gonorrhea chlamydia pelvic inflammatory disease

Implantation of fertilized ovum at a site other than the uterine wall

ectopic pregnancy

Where is the most common site of ectopic pregnancy implantation? What is the key risk factor for ectopic pregnancy?

lumen of fallopian tube; | key risk factor is scarring

How does an ectopic pregnancy present?

lower quadrant abdominal pain after a missed period **surgical emergency

The functional unit of the ovary is the (blank)

follicle

Discuss the contents of an ovarian follicle

consists of an oocyte surrounded by granulosa (inside) & theca cells (outside)

(blank) acts on the theca cells to induce androgen production (blank) stimulates granulosa cells to convert androgen to estradiol (blank) surge induces an LH surge, which leads to ovulation

LH; FSH; estradiol

After ovulation, what happens to the residual follicle?

it becomes the corpus luteum - which secretes progesterone to prepare the endometrium for a possible pregnancy

Degeneration of follicles | Small number are common in women & have no clinical significance

follicular cysts

What is a luteal cyst?

hemorrhage into the corpus luteum - this can occur especially during pregnancy

Multiple ovarian follicular cysts due to hormone imbalance Increased LH causes increased androgen production - hirsutism Androgen is converted to estrone in adipose tissue, which decreases FSH via negative feedback --> results in cystic degeneration of follicles

PCOS

What is the classic presentation of PCOS?

obese young woman with infertility, oligomenorrhea, and hirsutism

What are the 3 cell types of the ovary that can lead to tumors?

surface (germinal) epithelium germ cells sex cord stroma

Most common ovarian tumor | Derived from coelomic epithelium that lines the ovary

surface epithelial tumors

What are the two most common subtypes of surface epithelial tumors?

serous - full of watery fluid | mucinous - full of mucus-like fluid

Mucinous and serous epithelial tumors of the ovary can be benign, borderline, or malignant. How are these different?

benign - composed of a single cyst with simple flat lining - most commonly arise in premenopausal women malignant - composed of complex cysts with a thick, shaggy lining - most commonly in postmenopausal women borderline - features in between benign & malignant, some malignant potential

Less common subtype of epithelial tumor of the ovary Composed of bladder-like epithelium Usu benign

Brenner tumors

A multilocular, usually benign, tumor produced by ovarian epithelial cells and having mucin-filled cavities.

mucinous cystadenoma

Abnormal conception characterized by swollen & edematous villi with proliferation of trophoblasts Uterus expands as if a normal pregnancy is present, but the uterus is larger, b-HcG is higher, no heart sounds, and snowstorm appearance on ultrasound

hydatidiform mole

What are the differences between a complete mole & a partial mole in the following realms? ``` Genetics Fetal tissue villous edema trophoblast proliferation risk for choriocarcinoma ```

genetics: complete mole is when an empty ovum is fertilized by two sperm (46 chromosomes), while a partial mole is a normal ovum fertilized by two sperm (69 chromosomes) fetal tissue: absent in complete mole, while present in partial mole villous edema: most villi are hydropic in complete mole, while only some villi are hydropic in partial diffuse trophoblastic proliferation around hydropic villi in complete mole, focal proliferation of trophoblasts in partial mole minimal risk for choriocarcinoma in partial, increased risk for complete

How does a mole present?

second trimester | passage of grape-like masses thru the vaginal canal

Malignant tuumor composed of cytotrophoblasts & syncytiotrophoblasts Mimics placental tissue, but no villi Small, hemorrhagic tumor w/ early hematogenous spread High b-hCG

choriocarcinoma

Neoplastic proliferation of granulosa & theca cells Often produces estrogen, presents with signs of estrogen excess Malignant, but minimal risk for mets

Granulosa-theca cell tumor

Who is Gardasil recommended for? | Who is Cervarix recommended for?

Gardasil: females & males - protects against types 6, 11, 16, & 18 Cervarix: females only, protects against types 16 & 18

Fung: Gyn Pathology Flashcards

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