13_Female Repro Flashcards
1
Q
Vulva = skin & mucosa external to the _____
A
hymen
2
Q
The vulva is lined by ______ epithelium
A
squamous
3
Q
Bartholin Cyst- basic pathology & typical patient it is seen in?
A
Cystic dilatation of the Bartholin Gland
- It arises due to inflammation & obstruction of the gland or duct
- Usually occurs in women of reproductive age b/c often related to infection / STI
4
Q
Are Bartholin Cysts usually unilateral or bilateral?
A
Unilateral
5
Q
Classic Clinical Presentation of Bartholin Cyst?
A
- Woman of reproductive age
- Unilateral painful, cystic lesion
- Lower vestibule adjacent to vaginal canal
6
Q
Condyloma
A
Warty neoplasm of vulvar skin, often large
- Most commonly due to HPV 6 or 11 (low-risk)
- Characterized by koilocytic change
- Rarely progresses to carcinoma
7
Q
General/classic histologic manifestation of HPV?
A
Koilocytic change (cell looks crinkled, raisin-like)
8
Q
How is the determination made as to whether HPV is High-risk or Low-risk?
(refers to “risk” of developing subsequent carcinoma)
A
DNA sequencing
Low-risk types: 6 & 11 (cause Condylomas)
High-risk types: 16, 18, 31, & 33 (cause Dysplasia)
9
Q
Lichen Sclerosis - basic pathology & presentation?
A
- Thinning of the epidermis & Fibrosis of the dermis
- Leukoplakia w/ “parchment-like” vulvar skin
- Most commonly presents in post-menopausal women
10
Q
Lichen Simplex Chronicus- basic pathology & presentation?
A
- Hyperplasia of vulvar squamous epithelium
- Leukoplakia w/ thick, leathery vulvar skin
- Associated w/ chronic irritation & scratching
11
Q
Vulvar Carcinoma - how common is it?
A
Relatively rare- accounts for only a small percentage of female genital cancers
12
Q
Vulvar Carcinoma- presentation?
A
Presents as Leukoplakia
- Biopsy may be required to distinguish carcinoma from other causes of leukoplakia (Lichen Sclerosis, Lichen Simplex Chronicus)
13
Q
Vulvar Carcinoma- Etiology(ies)?
A
2 Etiologies:
- HPV-related pathway (16, 18)
- – Arises from VIN - Non-HPV-related pathway (6, 8)
- – Arises from longstanding Lichen Sclerosis
14
Q
HPV-related Vulvar Carcinoma:
- Etiology?
- Typical age?
A
- Due to high-risk HPVs (16 & 18)
- Arises from Vulvar Intraepithelial Neoplasia (VIN)
- 40-50 yrs. age
(get HPV @ 20-25, then takes 10-15 to develop neoplasia)
15
Q
Non-HPV-related Vulvar Carcinoma:
- Etiology?
- Typical age?
A
- Arises from Longstanding Lichen Sclerosis
- Chronic inflammation & irritation that eventually leads to carcinoma
- Generally seen in elderly, postmenopausal women (>70 yrs.)
16
Q
Extramammary Paget Disease - basic pathology & presentation?
A
- Malignant epithelial cell in the epidermis of the vulva
- Represents carcinoma in-situ, usually no underlying carcinoma
- Presents as erythematous, pruritic, ulcerated skin
17
Q
Paget cells (carcinoma) vs. Melanoma:
- PAS?
- Keratin?
- S100?
A
Paget cells: PAS +, Keratin +, S100 -
Melanoma: PAS -, Keratin -, S100 +
(PAS not as important as other 2 in distinguishing)
18
Q
Etiology of Paget Disease of the nipple vs. the vulva?
A
Paget Disease of Nipple = means there is a cancer somewhere in the breast
Paget Disease of Vulva = usually NO underlying cancer
19
Q
Lichen Sclerosis- risk of cancer?
A
Benign, however is associated w/ slightly increased risk of Squamous Cell Carcinoma
20
Q
Lichen Simplex Chronicus- risk of cancer?
A
Benign, no increased risk of Squamous Cell Carcinoma
21
Q
The mucosa of the vagina is lined by what type of epithelium?
A
Non-keratinizing Squamous Epithelium
22
Q
Adenosis
A
- Focal persistence of columnar epithelium in upper ⅓ of vagina (from Malarian duct –> normally replaced by squamous epithelium)
23
Q
Adenosis- risk of cancer?
A
Increases risk of developing Clear Cell Adenocarcinoma
24
Q
Clear Cell Adenocarcinoma
A
- Malignant proliferation of glands w/ clear cell cytoplasm
- Rare complication of DES-associated vaginal adenosis
(discovery of this & other complications led to cessation of DES usage)
25
a) Where is the upper ⅓ of the vagina derived from?
b) What about the lower ⅔ of the vagina?
c) What type of epithelium lines each part?
a) Upper ⅓ = Mullerian Duct
b) Lower ⅔ = Urogenital Sinus (UGS)
c) Both are lined by non-keratinizing Squamous Epithelium. The upper ⅓ is originally Columnar, however during development is replaced by squamous epithelium (EXCEPT in the case of Adenosis, where there is focal persistence of columnar epithelium in the upper ⅓)
26
There is an increased incidence of Adenosis in females exposed to _____ in-utero
DES
27
Embryonal Rhabdomyosarcoma - basic pathology?
Malignant mesenchymal proliferation of immature skeletal muscle
(very rare)
28
Embryonal Rhabdomyosarcoma- presentation?
- Bleeding, grape-like mass protruding from the vagina or penis of a child
- Usually <5 yrs. old
29
2 important characteristics of Rhabdomyoblast (malignant cell of Embryonal Rhabdomyosarcoma)
- Cytoplasmic cross-striations
| - Positive IHC staining for Desmin (muscle cell IF) & Myoglobin
30
Vaginal Carcinoma - basic pathology?
- Carcinoma arising from squamous epithelium lining the vaginal mucosa
- Usually related to high-risk HPV (16, 18, 31, 33)
- Precursor lesion is vaginal intraepithelial neoplasia (VAIN)
31
What is the precursor lesion for Vaginal Carcinoma?
Vaginal Intraepithelial Neoplasia (VAIN)
32
Where are the typical locations for regional lymph node spread of vaginal tumors?
Cancer from upper ⅓ of vagina --> Regional Iliac Nodes
Cancer from lower ⅔ of vagina --> Inguinal Nodes
33
The Exocervix is lined by __a__ epithelium.
The Endocervix is lined by __b__ epithelium
a) squamous
| b) columnar
34
What is the "Transformation Zone" in the Lower Genital Tract (LGT)?
Why is this important pathologically?
It is where the squamous epithelium of the exocervix meets the columnar epithelium of the endocervix.
This is one of the most common sites of HPV infection in the LGT (persistent infection leads to risk for CIN)
35
What 2 proteins do "high-risk HPVs" make that make them high-risk?
High-risk HPVs make 2 proteins:
1. E6: increases destruction of p53 (HPV16)
2. E7: increases destruction of Rb (HPV18)
36
General difference between dysplasia (CIN 1-3) & carcinoma in-situ?
CIN 1-3 (cervical intraepithelial neoplasia) involves increasing amounts of the epithelium from the basal layer.
Once the entire epithelial layer is included, it is considered carcinoma in-situ.
- Carcinoma in-situ is IRReversible
- CIN 1-3 are all reversible (1>2>3)
37
How do you distinguish invasive carcinoma vs. carcinoma in-situ (CIS)?
Invasive carcinoma goes through the basement membrane
38
Classic presentation of invasive cervical carcinoma?
Presents as vaginal bleeding, typically in a 40-50 yr old woman
(also post-coital bleeding or bleeding after intercourse is classic)
39
Primary & secondary risk factors for invasive cervical carcinoma?
Primary -- high risk HPV infection (16, 18)
Secondary -- Smoking, immunodeficiency
40
What types of cancers does smoking tend to cause?
1. Organs it has direct contact w/ upon smoking -- Oropharynx, Esophagus, Lungs
2. Anything urine touches b/c kidney filters carcinogens from blood → Kidneys, ureters, bladder
3. 2 randoms to remember -- Cervix & Pancreas
41
T or F?
| Cervical carcinoma is an AIDS-defining illness in a HIV+ patient.
True
42
Most common subtypes of cervical carcinoma?
Which are ass'd w/ HPV?
Squamous CC - Exocervix - much more common
Adeocarcinoma - Endocervix
BOTH subtypes are ass'd w/ HPV
43
Classic finding in an advanced cervical tumor?
Hydronephrosis w/ post-renal failure
Tumor invades bladder & blocks ureters
(cervical cancers tend not to metastasize outside of local area until very, very late )
44
What is the confirmatory test for an abnormal pap smear?
Colposcopy w/ biopsy
(introduce a magnifying glass into vaginal canal to view cervix, can apply acid to visualize abnormal areas & collect BIOPSY)
45
2 major limitations of pap smear?
- Inadequate sampling of transition zone may not pick up area w/ cancer -- false negative
- Does not detect Adenocarcinoma as well (incidence of adenocarcinoma has not dec'd significantly since use of pap smear)
46
Which strains of HPV are prevented by the Quadrivalent vaccine & for how long is this effective?
Are pap smears still necessary if you've had the vaccine?
HPV 6, 11, 16, & 18
Protection lasts about 5 years
Pap smears are still necessary to cover the other HPV subtypes
(or to pick up non-HPV ass'd neoplasias)
47
Asherman Syndrome - Cause & Pathology?
Secondary amenorrhea due to loss of basalis (stem cell layer of endometrium) & scarring
This is a result of overaggressive dilation & curettage (D & C)
48
Dx?
| Secondary amenorrhea due to loss of basalis & scarring w/ a Hx of overaggressive dilation & curettage.
Asherman Syndrome
49
Acute Endometritis - Cause & pathology?
Bacterial infection of endometrium
Usually due to retained products of conception
50
Acute Endometritis - Classic presentation?
- Fever
- Abnormal uterine bleeding
- Pelvic pain
51
Chronic Endometritis - characterized by what type of cells?
```
Plasma cells
(these must be seen in endometrium in order for it to be called chronic endometritis)
```
52
Chronic Endometritis - Common causes?
- Retained products of conception
- Chronic PID (chlamydia)
- IUD
- TB (granulomas present)
53
Chronic Endometritis - Classic presentation?
- Abnormal uterine bleeding
- Pelvic pain
- Infertility
54
Endometrial Polyp - Classic presentation?
Abnormal uterine bleeding
55
Endometrial polyps may arise as an adverse effect what drug?
Tamoxifen
| b/c of its pro-estrogenic effects on endometrium
56
Endometriosis - pathology?
Abnormal placement of both endometrial glands & stroma outside of the uterus/endometrial lining
- Non-neoplastic
- Characterized by cyclic bleeding (menstrual type) from ectopic endometrial tissue, resulting in blood-filled "chocolate cysts)
- In ovary or on peritoneum
57
Endometriosis - Classic presentation?
- Severe menstrual-related pain (dysmenorrhea)
- Painful intercourse (dyspareunia)
- Infertility
- Menorrhagia (cyclic, menstrual-type bleeding from ectopic endometrial tissue)
Uterus is normal sized (as opposed to Adenomyosis)
58
Endometriosis - Causes?
Retrograde menstrual flow
59
Endometritis - Tx?
Gentamycin + Clindamycin
--- w/ or w/out Ampicillin
60
What specific cell type are you always looking for on a pap smear?
Koilocytes, to indicate dysplasia
| wrinkled, "raisinoid" nuclei, some of which have clearing or a perinuclear halo
61
Endometriosis - Tx?
Oral contraceptives, NSAIDs, Leuprolide, Danazol
62
Name the anatomical site of involvement of the following symptom seen in a patient w/ Endometriosis:
- Chocolate cyst
Ovaries
63
Name the anatomical site of involvement of the following symptom seen in a patient w/ Endometriosis:
- Pelvic pain
Uterine Ligaments
64
Name the anatomical site of involvement of the following symptom seen in a patient w/ Endometriosis:
- Pain w/ urination
Bladder wall
65
Name the anatomical site of involvement of the following symptom seen in a patient w/ Endometriosis:
- Pain w/ defecation
Pouch of Douglas
66
Name the anatomical site of involvement of the following symptom seen in a patient w/ Endometriosis:
- Abdominal pain & adhesions
Bowel serosa
67
Name the anatomical site of involvement of the following symptom seen in a patient w/ Endometriosis:
- Scarring
Fallopian tube mucosa
68
Pathogenesis of Chocolate Cyst?
Endometriosis implants inside an ovary & goes through cycles of growing & shedding, building up more & more blood inside the cyst
69
Adenomyosis - Pathology?
Endometriosis that involves the myometrium
- increased risk of carcinoma
70
Adenomyosis - Classic presentation?
- Menorrhagia
- Dysmenorrhea
- Pelvic pain
Uterus is enlarged (as opposed to endometriosis that doesn't involve the myometrium)
71
Adenomyosis - Tx?
Hysterectomy
72
Endometrial Hyperplasia - pathology?
Hyperlasia of endometrial glands relative to the stroma
| consequence of unopposed estrogen
73
Endometrial Hyperplasia - Causes?
Unopposed estrogen
| postmenopausal - estrogen lowers but progesterone is absent, so the limited estrogen that's left is unopposed
74
Endometrial Hyperplasia - Clinical presentation?
Postmenopausal uterine bleeding
75
What is the most important predictor for progression to carcinoma?
Cellular Atypia
76
Endometrial Carcinoma is a malignant proliferation of _________
endometrial glands
77
Endometrial Carcinoma - Clinical presentation?
Postmenopausal bleeding
78
2 distinct pathways leading to Endometrial Carcinoma?
1. Hyperplastic pathway
- Carcinoma arises from Hyperplasia
- Risk factors: Estrogen exposure
- Avg. age = 50-60 yrs
- Histology = Endometrioid
2. Sporadic pathway
- Carcinoma arises in atrophic endometrium
- No evident precursor lesion
- Avg. age = 70 yrs.
- Histology is usually serous (papillary)
- p53-driven (aggressive)
79
Which of the 2 endometrial carcinoma pathways is driven by p53 mutations?
Sporadic
80
Which pathway of endometrial carcinoma is more likely to have psammoma bodies on histology?
Sporadic
| papillary, finger-like growths become calcified, leading to psammoma bodies -- concentrically arranged calcifications
81
Leiomyoma - pathology?
Benign proliferation of smooth muscle arising from myometrium
82
Leiomyoma - Causes?
Related to estrogen exposure
83
Leiomyoma - gross appearance?
Multiple, well-defined white whorled masses
| important for differentiation w/ leiomyosarcoma
84
Dx?
| Tumor of myometrium that has multiple, well-define white whorled masses.
Leiomyoma
85
Leiomyoma - Clinical presentation?
- Premenopausal women
- Usually asymptomatic
- -- IF they have symptoms, they would be abnormal uterine bleeding, infertility, &/or pelvic mass
- Enlarge during pregnancy
- Shrink after menopause
86
Leiomyosarcoma - Clinical presentation
- Postmenopausal women (>70-80 yrs.)
- Single mass/lesion w/ necrosis or hemorrhage in center
- Necrosis, mitotic activity, & cellular atypia
87
T or F?
| Leiomyomas run the risk of turning into a Leiomyosarcoma.
FALSE
Leiomyosarcomas develop de novo & do NOT arise from leiomyomas!
88
What is the residual follicle called just after ovulation?
| What is its primary secretion?
Corpus Luteum
Primarily secretes Progesterone
89
2 key distinctions in gross appearance of Leiomyoma vs. Leiomyosarcoma?
1. Leiomyoma = usually multiple.
Leiomyosarcoma = usually singular.
2. Leiomyoma = White, whorly regular masses
Leiomyosarcoma = Necrosis or hemorrhage in center of mass
90
Leiomyosrcoma - pathology?
- Malignant proliferation of smooth muscle arising from the myometrium
- Arises de novo (NOT from leiomyoma)
- Single lesion w/ necrosis & hemorrhage
91
BRCA1 gene mutation carriers have an increased risk of both breast cancer & what else?
Serous Carcinoma of the Ovary & Fallopian Tube
92
Dx?
| Ovarian tumor that contains cells that resemble Urothelium.
```
Brenner tumor
(surface epithelial carcinoma of the ovaries)
```
93
Dx?
| Ovarian tumor ass'd w/ Endometriosis.
```
Endometrioid tumor
(surface epithelial carcinoma of the ovaries)
```
94
15% of patients w/ Endometrioid Carcinoma of the ovaries will also have a separate Endometrioid Carcinoma in the ______.
Endometrium
95
General types of Ovarian Tumors most common in each age group:
- 15-30 yrs.
- 35-40 yrs.
- 60-70 yrs.
15-30 yrs. = Germ cell tumor (reproductive age)
35-40 = Benign Surface Epithelial tumor
60-70 = Malignant Surface Epithelial tumor
