path of vagina vulva and uterus

Question 1

Describe lymphatic drainage of vulvar, cervical and uterine lesions

Answer 1

VULVAR lesions: drains to inguinal, pelvic, periaortic nodes. Cervical lesions: pelvic (internal/external iliac) and periaortic nodes. Uterine lesions: pelvic (external iliac/ lumbar) and periaortic nodes

Question 2

Define endophytic, exophytic and pagetoid

Answer 2

enDophytic =growing DOWN into the tissue. exOphytic =growing OUT from the surface. Pagetoid = Single cells/clusters PERCOLATING through the epithelium

Question 3

Ddx for vulvar pruritis and papules

Answer 3

HSV, molluscum contagiosum, HPV

Question 4

HSV pathology/ Sx

Answer 4

eosinophilic intranuclear inclusions. Painful red lesions 3-7 days after exposure (red papules > vesicle > coalescent ulcer)

Question 5

Molluscum contagiosum pathology/ Sx

Answer 5

Flesh colored, pearly skin lesions. Genital in adults, extremities in children (sharing towels). Path: Endophytic growth with eosinophilic inclusion bodies

Question 6

Condyloma acuminatum pathology

Answer 6

branching treelike cores of stroma covered by squamous epithelium with viral cytopathic change (koilocytic atypia- perninuclear clearing). Hyperparakeratosis: thickened stratum corneum with ghost nuclei. Elongated rete ridges and hypergranulosis

Question 7

Trichomonas infection Sx and pathology

Answer 7

flagellated protozoan; frothy yellow d/c, dysuria, dyspareunia; “strawberry cervix” on colposcopy

Question 8

Actinomyces

Answer 8

“sulfur granule” with clublike projections; non-copper IUD, non-pathogenic

Question 9

Vulvar intraepithelial neoplasia pathology

Answer 9

Nuclear atypia (koilocytes with perinuclear clearing) and lack of maturation

Question 10

VIN III/ squamous cell carcinoma in situ pathology

Answer 10

Grossly: Discrete white hyperkeratotic raised lesions. Increased mitoses, full thickness dysmaturity (cells at the surface look the same as those near the base)

Question 11

HPV associated squamous cell carcinoma pathology

Answer 11

Infiltrating irregular nests of malignant squamous cell eliciting a desmoplastic stromal response (tissue with low cellularity, hyalinization, myxoid or sclerotic stroma and disorganized blood vessel infiltration). Basaloid (poorly differentiated) small dark cells infltrating in cords and nests

Question 12

Inflammatory associated squamous cell carcinoma path

Answer 12

Prominent keratin “pearls” in well-differentiated carcinoma. Increased mitoses, pink cytoplasm

Question 13

Lichen sclerosus

Answer 13

Itching, fissures/bleeding/pain, dyspareunia. Increased risk (not specified) for developing SCC. Possibly autoimmune related: activated T cells in subepithelial inflammatory infiltrate and increased frequency of autoimmune disorders.

Question 14

Lichen sclerosus pathology

Answer 14

Smooth white plaques/papules, resembles parchment. Dermal fibrosis (top, solid pink) w/ perivascular mononuclear infiltrate . Thinned epidermis w loss of rete pegs, hydropic degeneration of basal cells & superficial hyperkeratosis.

Question 15

Extramammary Paget disease pathology

Answer 15

Form of adenocarcinoma. Red, crusted sharply demarcated map like area on vulva. Marked hyperkeratosis and “pale” basal epidermis. Tumor cells with halo in epidermis, occasional gland formation

Question 16

Malignant melanoma of vulva

Answer 16

rapid vertical growth.

Question 17

List conditions associated with in utero DES exposure

Answer 17

DES is diethylsilbestrol, a synthetic estrogen prescribed to prevent miscarriage until 1971. Can cause adenosis, clear cell carcinoma

Question 18

embryonal rhabdomyosarcoma pathology

Answer 18

Gross: Polypoid, rounded, bulky masses which fills and protrude from vagina, resembling grape-like clusters (sarcoma botryoides). Histology: Cambium layer: Dense zone of rhabdomyoblast present beneath the surface epithelium. Small spindle-shaped cells with abundant mitoses. Elongated spindle cells have striations with eosinophilic cytoplasm (rhabdomyogenic differentiation)

Question 19

Adenosis pathology

Answer 19

Glandular tissue in vagina, mucinous epithelium. Red granular spots and patches. Can have overlying squamous metaplasia as healing phenomenon.

Question 20

Clear cell carcinoma pathology

Answer 20

Affects anterior upper 1/3 of vagina, with discontinuous areas (kissing lesion). Occurs in women under 30. Tubulocystic pattern of growth with dense hyaline stroma; clear cytoplasm with bland nuclei

Question 21

Endocervical polyps pathology and treatment

Answer 21

Polyp inside the OS of cervix. Loose fibromyxomatous stroma w dilated, mucus-secreting glands and inflammation. Eosinophilic stroma. Curettage is curative

Question 22

Most common form of cervical cancer and the most common cause

Answer 22

squamous cell carcinoma- HPV. Adenocarcinoma is 15% of cervical cancer cases and is also caused by HPV

Question 23

Squamous cell carcinoma pathology

Answer 23

Increased mitoses, full thickness dysmaturity. Infiltrating irregular nests of malignant squamous cells, eliciting a desmoplastic stromal response

Question 24

Adenocarcinoma in situ pathology

Answer 24

Hyperchromasia, mucin depletion, luminal mitoses, high N: C ratio

Question 25

Describe histology of proliferative phase of menstrual cycle

Answer 25

straight tubular glands, mitoses, nuclear stratification

Question 26

Describe histology of secretory phase of menstrual cycle

Answer 26

“S-shaped” tortuous, coiling glands, secretory activity. Subnuclear vacuoles (piano keys)

Question 27

Describe histology of menstrual phase of menstrual cycle

Answer 27

stromal/glandular breakdown, inflammation, intravascular fibrin

Question 28

describe the histological effects of exogenous hormones on the uterine lining

Answer 28

Hypersecretory glands (short term), decidualized stromal cells, inactive glands (chronic) and incomplete response

Question 29

Endometrial histology during pregnancy

Answer 29

stromal decidualization, Arias-Stella Reaction: hypersecretory glands with nuclear enlargement, no mitoses

Question 30

endometrial histology during menopause

Answer 30

Thin endometrium w/o mitoses. Decreased Cervical mucous and glycogenation. Cystic atrophy

Question 31

Causes of menometrorrhagia

Answer 31

aka heavy, irregular periods. Polyps, endometritis, mesenchymal neoplasm (adenomyosis, leiomyoma, leiomyosarcoma)

Question 32

endometrial polyps pathology

Answer 32

Dense pink stroma, haphazardly arranged glands. Cystic dilatation, hormonally unresponsive.

Question 33

Endometritis path and Sx

Answer 33

Sx: PID, infertility if chronic. Acute: increased PMNs in stroma and glands. Chronic: plasma cells.

Question 34

adenomyosis vs endometriosis

Answer 34

adenomyosis: endometrial glands and stroma in uterine wall. Endometriosis: endometrial glands and stroma in abnormal exrauterine location. Both cause infertility and dysmenorrhea

Question 35

Leiomyoma path

Answer 35

Can have single or multiple. Spherical, firm, white, whorled, well circumscribed masses of smooth muscle. Central ischemic necrosis or calcification common. Cigar shaped nuclei

Question 36

Most common uterine tumor

Answer 36

leiomyoma

Question 37

Leiomyoma Sx, treatment

Answer 37

Menometrorrhagia, infertility, mass. Treatment: surgery, embolization, GnRH agonist, nothing

Question 38

Leiomyosarcoma path

Answer 38

Malignant smooth muscle tumor. Infiltrating polypoid mass. Hemorrhage, necrosis. Hypercellular, pleomorphic nuclei, mitoses

Question 39

Leiomyosarcoma behavior

Answer 39

rapid increase in size, mets to lungs, low survival if high grade (15%)

Question 40

Risk factors for endometrial cancer

Answer 40

unopposed estrogen supplements, later menopause, low parity, PCOS, obesity, ovarian lesions

Question 41

simple endometrial hyperplasia pathology and progression and treatment

Answer 41

rarely progesses to cancer. Increased gland to stroma ratio- crowded hyperchromatic glands. Thickened, fluffy endometrium. Treated with progestins

Question 42

Complex endometrial hyperplasia pathology, progression

Answer 42

nuclear atypia, glandular crowding and architectural complexity. Diffuse involvement of endometrial cavity. 5-30% progress to cancer

Question 43

endometriod adenocarcinoma grade 1 path

Answer 43

Exophytic (protruding) mass of tightly packed glands without intervening stroma. Squamous metaplasia

Question 44

endometriod adenocarcinoma grade 2-3 path

Answer 44

solid pattern of growth. Severe nuclear atypia and mitoses

Question 45

Endometrod adenocarcinoma prognosis

Answer 45

Stage1: 96% survival at 5 years. Stage III: 23%

Question 46

Serous carcinoma path

Answer 46

type II adenocarcinoma cancer. Papillary growth (fibrovascular stromal cores), atypia, disseminated at presentation.

Question 47

Malignant Mixed Müllerian Tumor (Carcinosarcoma)

Answer 47

biphasic tumor. Can be Homologous = cell types of tissue normally found in the uterus (smooth muscle, fibroblasts) OR Heterologous = cell types of tissue NOT normally found in the uterus (cartilage, fat, bone, skeletal muscle)

Question 48

compare type I vs type II endometrial cancers

Answer 48

Both are adenocarcinomas. Type I endometrial cancers occur in younger women and are estrogen-dependent with a generally good prognosis, while Type II endometrial cancers occur in older women, have higher grade histology and poorer prognosis Both are adenocarcinomas. Type I endometrial cancers occur in younger women and are estrogen-dependent with a generally good prognosis, while Type II endometrial cancers occur in older women, have higher grade histology and poorer prognosis

Question 49

genes involved in type I endometrial cancer

Answer 49

mutations in PTEN > MLH1 > KRAS > beta catenin

Question 50

genes involved in type II endometrial cancer

Answer 50

p53 aneuploidy