Ch 13 Pathoma - Female Genital System and Gestational Pathology Flashcards
<p>Anatomically includes the skin and mucosa of the female genitalia external to the hymen (labia major and minor, mons pubis, and vestibule) and is lined by \_\_\_\_\_ epithelium.</p>
<p>Vulva; squamous</p>
<p>A Bartholin cyst arises from obstruction of the \_\_\_\_\_\_\_\_, (present on each side of the vaginal canal and drains a mucus like fluid in to the lower vestibule). Usually occurs in \_\_\_\_\_\_ and presents as a \_\_\_\_ and \_\_\_\_ cystic lesion.</p>
<p>Bartholin gland; women of reproductive age; unilateral; painful</p>
<p>\_\_\_\_\_ is a warty neoplasm of vulvar skin, most commonly due to \_\_\_\_\_. Histologically characterized by \_\_\_\_\_.</p>
<p>Condyloma; HPV 6 or 11 (less commonly secondary syphilis); koilocytes</p>
<p>\_\_\_\_\_\_ is characterized by thinning of the epidermis and fibrosis of the dermis. Presents as a \_\_\_\_\_\_ with parchment like vulvar skin. Most commonly seen in \_\_\_\_\_ women. Yes/No increased risk for SCC.</p>
<p>Lichen sclerosis; white patch (leukoplakia); postmenopausal; Yes</p>
<p>\_\_\_\_\_\_ is characterized by hyperplasia of the vulvar squamous epithelium. Presents as \_\_\_\_\_\_\_ with thick, leathery vulvar skin. Associated with \_\_\_\_\_\_\_. Yes/No increased risk of SCC.</p>
<p>Lichen simplex chronicus; leukoplakia; chronic irritation/scratching; No</p>
<p>Three potential causes of leukoplakia of the vulva</p>
<p>lichen sclerosis, lichen simplex chronicus, vulvar carcinoma</p>
<p>Vulvar carcinomas presents as \_\_\_\_\_\_. It can be related or not related to \_\_\_\_. When it is related, it arises from \_\_\_\_\_. When it is not related, it arises most often from \_\_\_\_. Age difference</p>
<p>leukoplakia; HPV; VIN (vulvar intraepithelial neoplasia); lichen sclerosis; HPV related seen in women of reproductive age; HPV non related seen in women >70 yrs</p>
<p>\_\_\_\_\_\_ is characterized by malignant epithelial cells in the epidermis of the vulva. Presents as \_\_\_\_, \_\_\_\_\_\_, \_\_\_\_\_\_ vulvar skin. It represents carcinoma in situ usually with no underlying carcinoma (different from \_\_\_\_\_). Must be distinguished from melanoma, done with these three stains.</p>
<p>Extramammary paget disease; erythematous; pruritic; ulcerated; paget disease of the nipple;
~~~
paget = PAS+, keratin+, S100-
melanoma = PAS-, keratin-, S100+</p>
~~~
<p>Adenosis; Increased incidence in females who were exposed to \_\_\_\_\_ in utero</p>
<p>focal persistence of columnar epithelium in upper vagina (lower 1/3 of vag is sq epith derived from urogenital sinus, which during development overtakes the columnar epith of the upper 2/3 derived from Mullerian ducts); diethylstilbestrol (DES)</p>
_______ is a malignant proliferation of glands with clear cytoplasm. It is a rare complication of ___-associated vaginal adenosis
Clear cell adenocarcinoma; DES
Embryonal rhabdomyosarcoma is a malignant ______ proliferation of ______. It presents as ______ and a ____ mass protruding from the vagina or penis of a child (usually
mesenchymal; immature skeletal muscle; bleeding; grape-like; sarcoma botryoides; cross-striations; desmin; myogenin
Vaginal carcinoma’s precursor lesion is ______. When spread to regional lymph nodes occur, cancer from lower 1/3 spreads to _____, and cancer from upper 2/3 goes to _____.
VAIN (vaginal intraepithelial neoplasia); inguinal nodes; iliac nodes
Vulvar intraepithelial neoplasia (VIN), CIN, VAIN are dysplastic precursor lesions characterized by these 4 things.
koilocytic change, disordered cellular maturation, nuclear atypia (high nuclear to cytoplasmic ratio, with hyper chromatic nuclei), and increased mitotic activity
Exocervix is lined by ______ and endocervix is lined by _____. The junction between the two is the ______.
nonkeratinizing stratified squamous epithelium; columnar epithelium; transformation zone
HPV is a sexually transmitted ___ virus that infects the _____, especially the ____.
DNA; lower genital tract; cervix (transformation zone)
High risk HPV types are _____. Low risk HPV types are _____. High risk HPV produces ___ and ___, which result in destruction of ____ and ____ respectively
16, 18, 31, 33
6 and 11
E6 and E7
p53 and Rb
p53 recruits ___, which inactivates ____, which normally stabilizes the mitochondrial membrane, so ____ can escape and cause apoptosis
BAX; bcl2; cytochrome c
Rb holds ____, which is needed to progress to the cell cycle.
E2F (transcription factor)
CIN I involves ___ of the thickness of the epithelium (also answer CIN II and CIN III, and CIS)
Cervical carcinoma is invasive carcinoma that arises in the cervical epithelium most commonly in _____ women, and presents as _____ or _____. Key risk factor is ____; 2ndary risk factors include ___ and ____. 80% of cases are ____ and 15% are ____.
middle aged; vaginal bleeding (especially post coital) or cervical discharge; HPV; smoking and immunodeficiency (AIDS defining illness); squamos cell carcinoma; adenocarcinoma
In advanced stages of cervical carcinoma, tumors often invade through the ____ into the _____ and blocking the _____. Common cause of death is _____ due to _____.
anterior uterine wall; bladder; ureters; postrenal failure; hydronephrosis
The goal of the pap smear is to catch ____ before it develops in to ____. An abnormal pap is followed by ______ and _____. There is limited efficacy in screening for _____.
dysplasia (CIN); carcinoma; confirmatory colposcopy; biopsy; adenocarcinoma
The quadrivalent vaccine is effective in preventing HPV types _____.
6, 11, 16, and 18
Endometrium
mucosal lining of the uterine cavity (it is hormonally sensitive)
______ is the smooth muscle wall underlying the endometrium
myometrium
Growth of endometrium is ____ driven (proliferative phase), preparation for implantation is ____ driven (secretory phase), and shedding occurs with loss of _____ support (menstrual phase)
estrogen; progesterone; progesterone
_______ is secondary amenorrhea due to loss of the basalis (basal endometrial layer) and scarring. It is a result of overaggressive _____.
Asherman syndrome; dilation and curettage (D&C)
________ is the lack of ovulation resulting in an estrogen driven proliferative phase without a _______ phase. Results in dysfunctional ______, especially during menarche and menopause
Anovulatory cycle; progesterone driven secretory phase; uterine bleeding
Acute endometritis is a _____ infection of the endometrium, usually due to _____, which presents with these three symptoms.
bacterial; retained products of conception (after delivery/miscarriage); fever, abnormal uterine bleeding, and pelvic pain
Chronic endometritis is chronic _____ of the endometrium characterized by the presence of ____ and most importantly _____, and presents with these three symptoms.
inflammation; lymphocytes; plasma cells (lymphocytes are normally found in endometrium); abnormal uterine bleeding, pain, and infertility
Name four causes of chronic endometritis.
retained products of conception (same as in acute), chronic PID (e.g. chlamydia); IUD; TB (would also see granulomas)
______ is a hyperplastic protrusion of endometrium, which presents as _____. Can arise as a side effect of ______, a drug with anti-estrogenic effects of the breast, but weak pro-estrogenic effects on the endometrium
endometrial polyp; abnormal uterine bleeding; tamoxifen
Endometriosis is when ______ and _____ are found outside of the uterine endometrial lining, most likely due to ______. It presents as _____ and _____ and may cause ____.
endometrial glands and stroma; retrograde menstruation; dysmenorrhea (pain during menstruation); pelvic pain; infertility
The most common site of involvement of endometriosis is the _____, which results in formation of a _______.
ovary; chocolate cyst
Aside from the ovary, name the 5 other sites of endometriosis and how they present.
These implants typically appear as _____ nodules.
-uterine ligaments (pelvic pain);
-pouch of Douglas (pain with defecation);
-bladder wall (pain with urination);
-bowel serosa (abd pain and adhesions);
-fallopian tube mucosa (scarring –> ectopic)
yellow-brown/gun powder
_____ is endometriosis with involvement of the uterine myometrium
adenomyosis
Yes/No to an increased risk of carcinoma at the site of endometriosis
Yes - especially in the ovary
Endometrial hyperplasia is hyperplasia of endometrial ____ relative to _____. Occurs as a consequence of unopposed _____ (obesity, PCOD, replacement) and classically presents as ______. Histologically, the growth pattern can be ____ or _____ with the presence or absence of _____.
glands; stroma; estrogen; postmenopausal uterine bleeding; simple or complex; cellular atypia
Cellular atypia is the most important predictor of progression to carcinoma
Endometrial carcinoma is a malignant proliferation of endometrial _____. It presents as ______. It can arise from two distinct pathways: _____ and _____
glands; postmenopausal bleeding; hyperplasia (75%) and sporadic (25%)
What is the most common invasive carcinoma of the female genital tract?
endometrial carcinoma
In the hyperplasia pathway of endometrial carcinoma, it arises from ______ (due to unopposed estrogen). Average age of presentation is ____. Histology is _____. Risk factors are related to ____ exposure.
endometrial hyperplasia; 60; endometrioid; estrogen (early menarche/late menopause, nulliparity, infertility with anovulatory cycles, obesity)
In the _____ pathway of endometrial carcinoma, it arises in an _____ endometrium with no evident precursor lesions. Avg age of onset is ____, and histology is usually ____ and characterized by ____ with ____ formation
sporadic; atrophic; 70; serous; papillary structures; psammoma body formation
Which pathway of endometrial carcinoma (hyperplasia/sporadic) is associated with a p53 mutation and aggressive tumor behavior?
sporadic
Name the four types of cancers with which you see psammoma bodies
- papillary carcinoma of the thyroid
- meningioma
- papillary serous carcinoma
- mesothelioma
_____ are concentric lamellated calcified structures seen in certain types of cancer.
Psammoma body
______ are benign neoplastic proliferation of smooth muscle arising from myometrium. They are related to ____ exposure. Gross exam shows ____, ______, _____, _____ masses. Usually asymptomatic, but symptoms include these three.
Leiomyoma; estrogen; multiple, well defined, white, whorled; abnormal uterine bleeding, infertility, pelvic mass
common in premenopausal women
What is the most common tumor in females?
Leiomyoma
Leiomyoma/Leiomyosarcoma - which one presents as single/multiple, white/whorrly vs hemorrhagic/necrotic, premenopausal/postmenopausal
leiomyoma: multiple, white/whorrly, premenopausal
leiomyosarcoma: single, hem/nec, post
______ is a malignant proliferation of smooth muscle from the myometrium; on gross exam shows a single lesion with _____ and _____. Histological features include ____, _____, _____.
leiomyosarcoma; areas of necrosis and hemorrhage; necrosis, mitotic activity, cellular atypia
True/False: leiomyosarcomas arise from leiomyomas
False - they always arise de novo
_____ is the functional unit of the ovary and consists of an oocyte surrounded by ___ and ___ cells.
follicle; granulosa; theca
____ acts on theca cells to induce ____ production; ____ acts on granulosa cells to convert _____ to _____. A ____ surge induces a ____ surge, which leads to ovulation.
LH; androgen; FSH; androgen; estradiol; estradiol; LH
After ovulation, the residual follicle becomes a _____, which secretes _____. Hemorrhage in to it results in a ______, especially during early pregnancy. Degeneration of follicles results in ____.
corpus luteum; progesterone; hemorrhagic corpus luteal cyst; follicular cysts (which are common and have no clinical significance)
Polycystic ovarian disease (PCOD) is characterized by increased ____ and low ____.
LH; FSH (LH:FSH>2)
In this disease, increased LH induces excess androgen causing _____. Androgen can be converted to estrone in ____ tissue, causing feedback and subsequent decrease of ____, resulting in cystic degeneration of follicles
Polycystic ovarian disease (PCOD); hirsutism; adipose; FSH
PCOD increases/does not effect/decreases the risk for endometrial carcinoma
increases
Which disease classically presents as an obese young woman with infertility, oligomenorrhea, and hirsutism; and is often associated with insulin resistance.
Polycystic ovarian disease (PCOD)
Ovary is composed of these three cell types, and tumors can arise from any of them
surface epithelium (70%), germ cells (15%), sex-cord stroma
Name the four subtypes of surface epithelial ovarian tumors
serous and mucinous (most common 2), endometrioid, Brenner tumor
Cystadenomas are benign/malignant tumors composed of a ____ cyst with a ___, ___ lining and most commonly arise in ____ women.
benign; single; simple, flat; pre menopausal (30-40)
these are mucinous or serous surface epithelial ovarian tumors
Cystadenocarcinomas are benign/malignant tumors composed of _____ cysts with a ___, ___ lining and most commonly arise in ____ women.
malignant; complex; thick, shaggy; postmenopausal (60-70)
these are mucinous or serous surface epithelial ovarian tumors
BRCA1 mutation carriers have an increased risk for ____ of the ovary and fallopian tube
serous carcinoma
Endometrioid tumors are usually benign/malignant; brenner tumors are usually benign/malignant, and are composed of ____ epithelium
malignant; benign; bladder-like
True or False: 5% of endometrioid carcinomas of the ovary are associated with an independent endometrial carcinoma (endometrioid type)`
False - 15% are
Surface tumors (ovary) clinically present early/late with _____ symptoms or signs of _____.
late; vague abdominal (pain/fullness); compression (urinary frequency)
How cancers typically like to spread:
Carcinomas –>
Sarcomas –>
Ovary –>
lymphatics
hematogenously
locally to peritoneum
Which type of cancer has the worst prognosis of female genital tract cancers?
Surface epithelial carcinoma (ovary)
Germ cell tumors usually occur in ______. Name the four tumor subtypes and the name of the tumor
WOCBP; (1) fetal tissue (cystic teratoma and embryonal carcinoma); (2) oocytes (dysgerminoma); (3) yolk sac (endodermal sinus tumor); (4) placental tissue (choriocarcinoma)
Cystic teratoma is a cystic tumor composed of ____ derived from ____. It is benign, though the presence of ___ or ____ indicates malignant potential. ____ is a teratoma composed of thyroid tissue
fetal tissue; 2 or 3 embryologic layers (skin, hair, bone, cartilage, gut, thyroid); immature tissue (usually neural); somatic malignancy (usually sq cell carcinoma of the skin); Struma ovarii
Dysgerminoma is a tumor composed of ____ cells, with ____ cytoplasm, and ____ nuclei (resemble oocytes). It is the most common malignant germ cell tumor; it’s testicular counterpart is called _____. It has a good/poor prognosis and serum ___ may be elevated
large; clear; central; seminoma; good (responds to radiotherapy); LDH
______ is a malignant tumor that mimics the yolk sac. It is the most common germ cell tumor in children. Serum ___ is often elevated, and ______ are classically seen on histology.
Endodermal sinus tumor; AFP; Schiller-Duval bodies (glomerulus like structures)
Choriocarcinoma is a malignant tumor composed of _____ and ______; it mimics placental tissue but ____ are absent. It is a small, hemorrhagic tumor with ____ spread. High ____ is characteristic. And it may cause ___ in the ovary
cytotrophoblasts and syncytiotrophoblasts; villi; hematogenous; B-hCG; thecal cysts
Poor response to chemo
Embryonal carcinoma is a malignant tumor composed of large ____ cells. It is aggressive with early mets
primitive; not surprising it’s aggressive as primitive embryo cells have the ability to grow/spread
Name the three types of sex cord-stromal tumors (ovary)
Granulosa-theca cell tumor; Sertoli-Leydig cell tumor; Fibroma
Granulose-Theca cell tumors presents with signs of _____. Name these symptoms in a pt prior to puberty, in reproductive age, and postmenopausal, and which one is most common. They are malignant but with minimal risk for mets
estrogen excess; precocious puberty; menorrhagia (heavy bleeding) or metrorrhagia (abn bleeding from uterus); endometrial hyperplasia with postmenopausal bleeding; post menopausal
Sertoli Leydig cell tumor is composed of sertoli cells that form tubules and leydig cells (btwn tubules) with characteristic ____. May produce ____ and associated ___ and ___
Reinke crystals; androgen; hirsutism and virilization
Meig’s syndrome is a triad of a _____, ____ and ____
ovarian tumor; pleural effusions and ascites
____ is a benign tumor of fibroblasts often associated with Meig’s syndrome
fibroma
Name two metastatic tumors you see in the ovary
Krukenberg tumor and Pseudomyxoma peritonei
Krukenberg tumor is a metastatic ____ tumor that invovles BOTH ovaries; most commonly due to metastatic ____.
mucinous; gastric garcinoma (diffuse type)
_____ is massive amounts of mucus in the peritoneum due to a mutinous tumor of the _____. “Jelly Belly”
pseudomyxoma peritonei; appendix
_____ is implantation of the placenta in the lower uterine segment where it overlies the ______. It presents as ______ and often requires delivery of fetus by c-section
Placenta previa; cervical os; 3rd trimester bleeding
____ is separation of placenta from the decidua (uterine wall) prior to delivery of the fetus. It is a common cause of _____, and presents with _____ and _____.
Placental abruption; still birth; 3rd trimester bleeding and fetal insufficiency
_____ is improper implantation of the placenta (can be in the myometrium) with little or no intervening decidua. It presents with _____ and _____. Often requires ____
Placenta accreta; difficult delivery of the placenta and postpartum bleeding; hysterectomy
(increta = in the myometrium)
Preeclampsia is pregnancy induced ____, ____, and ____ usually in 3rd trimester (seen in 5% of pregnancies). Due to abnormality of the _____ in the placenta. Eclampsia is preeclampsia + _____.
HTN (can cause headaches and visual abnormalities), proteinuria, edema; maternal-fetal vascular interface; seizures
HELLP is preeclampsia with _____ involving the ____. It stands for:
It warrants immediate delivery (as dose eclampsia)
thrombotic microangiopathy; liver
Hemolysis, Elevated Liver enzymes, Low Platelets
Sudden Infant Death Syndrome is when healthy infant age _____ dies without obvious cause (usually during ____). Name three risk factors
1 month to 1 year; sleep; sleeping on stomach, exposure to cigarette smoke, prematurity
_____ is an abnormal conception characterized by swollen and edematous villi with proliferation of trophoblasts
Hydatidiform mole
With a hydatidiform mole, the uterus is larger/smaller than in normal pregnancy and the B-hCG is higher/lower. It classically presents in the ____ trimester as passage of ____ through the vaginal canal. On US, fetal heart sounds are absent and a ____ appearance is seen. Tx is ____.
larger; higher; 2nd; grape-like masses; snowstorm; suction curettage (also need to monitor B-hCG to ensure adequate removal and to screen for development of choriocarcinoma)
can be complete or partial
Choriocarcinoma may arise as a _____ (spontaneous abortion, normal pregnancy, hydatidiform mole) or as a _____. Which one responds well to chemo?
complication of gestation; spontaneous germ cell tumor
gestational pathway
_____ mole has an empty ovum fertilized by two sperm (46 chromosomes), absent fetal tissue, edematous villi, proliferation of trophoblasts around all vili, and a 2-3% risk for choriocarcinoma
Complete mole
Partial has 69 chromosomes (ovum fertilized by 2 sperm or one sperm that duplicates chromosomes) - has fetal tissue; some of everything else (instead of all); minimal risk
Name the teratogen effect: alcohol, thalidomide, cocaine, cigarette smoke
most common cause of mental retardation, also facial abnormalities and microcephaly; limb defects; intrauterine growth retardation and placental abruption; intrauterine growth retardation
Name the teratogen: spontaneous abortion, hearing and visual impairment; discolored teeth; fetal bleeding; digit hypoplasia and cleft lip/palate
isotretinoin; tetracycline; warfarin; phenytoin
Spontaneous abortion (before 20 weeks) presents with these 3 symptoms.
vaginal bleeding, cramp-like pain, passage of fetal tissue
Spontaneous abortion is most often due to these 4 causes
chromosomal anomalies (esp trisomy 16); hyper coagulable states (antiphospholipid syndrome seen in lupus); congenital infxn; exposure to teratogens (esp during first two weeks)
Effect of teratogen based on time of exposure
First 2 weeks –>
weeks 3-8 –>
months 3-9 –>
spontaneous abortion
organ malformation
organ hyoplasia
____ is a polypoid inflammatory lesion near the female urethral meatus which elicits pain and bleeding - occurs in women, most frequently after menopause.
Caruncle
presents as an exophytic, often ulcerated polypoid mass of 1-2 cm diameter
