Female Flashcards
what is the acinus?
what the functional unit of the breast, the terminal duct lobular unit, is called during lactation
explain the normal epithelium of the lobules and ducts of the breast (location, shape, and function)
2 layers: inner cuboidal - milk production
outer myoepithelial - contractile function to move milk down duct
what is an important change in the epithelium of the breast that indicates malignancy?
loss of myoepithelial cells in the ducts
define polythelia
accessory nipples - can be anywhere along milk line from axilla to vulva
define polymastia - significance?
accessory breast tissue anywhere along milk line - can have any breast pathology
what is induration of the breast?
hardening
Mother is breast feeding her child and notices a painful lump in her right breast. Diagnosis? Pathogenesis?
Galactocele
cystic dilation of obstructed duct during lactation
32 year old woman presents with a lump in her breast that shows vague nodularity, is bilateral, and gets bigger before mensus. There is no skin change or axillary LN involvement. Diagnosis? Pathogenesis? Relationship to oral contraception?
Fibrocystic change (FCC)
exaggerated response to normal hormones of menstrual cycle
oral contraction REDUCES risk of FCC
42 year old woman presents with cysts of her breast and you see related calcifications on X-ray. On biopsy you find them filled with a bloody, watery substance. Explain her condition. Should you be concerned?
These are blue domed cysts of FCC and are completely benign
35 year old woman presents with lumps that are lined by large polygonal cells with abundant granular, eosinophilic cytoplasm with small, round, deeply chromatic nuclei. You also see lymphomononuclear infiltration. Disease? Name of this histology?
FCC
apocrine metaplasia
How do you tell the difference between simple FCC and proliferative FCC?
Proliferative FCC will have epithelial hyperplasia of ducts and ductules
Proliferative FCC also has nipple discharge
Both hyperplasia and nipple discharge are absent in simple
40 year old woman presents with lump in her breast and nipple discharge. On biopsy you see the lumen of a duct is filled with heterogenous cells of different morphologies. You also see fenestrations around the edges of the duct lumen. What is this condition, specifically. What is the prognosis?
Cribiform pattern of proliferative FCC
ductal hyperplasia carries at 2x increased risk of invasive carcinoma
40 year old woman presents with lump in her breast and nipple discharge. On biopsy you see the lumen a duct is less than 50% filled with monomorphic, hyperplastic cells. What is this condition specifically. What is the prognosis?
Atypical hyperplasia subtype and proliferative FCC
5x increased risk of invasive carcinoma
35 year old woman presents with a hard, rubbery, irregular lump with ill defined borders in the upper outer quadrant of her right breast. On x-ray you see calcifications and on biopsy you find a dense, fibrous stroma with masses of proliferated ducts in a back to back arrangement. Diagnosis? What is an important test to do on this biopsy sample?Prognosis?
Sclerosing adenosis subtype of proliferative FCC
Must stain for myoepithelial cells, if present, not carcinoma!
Sclerosing adenosis only has a 2x increased risk for invasive carcinoma (very small!) so good prognosis, benign condition
27 year old woman nursing her baby suddenly experiences enlargement and pain in her left breast. The entire breast became reddish and the nipple cracked. Diagnosis? Explain how this condition resolves.
Acute mastitis with Strep infection
Strep causes infection of the whole breast and heals WITHOUT scaring
27 year old woman nursing her baby suddenly experiences enlargement and pain in her left breast. You notice a reddish area under her left nipple. Diagnosis? Explain how this condition resolves.
Acute mastitis with Staph infection
Staph infection remains localized, usually under nipple but can heal with indurated scar
65 woman presents with an indurated mass close to her areola, nipple retraction, and green-brown nipple discharge. On histo you see plasma cells, foamy histiocytes, and granulomas. Diagnosis? Pathogenesis? Prognosis?
Duct Ectasia (dilation) obstruction of large duct leading to dilation and rupture benign, but mimics carcinoma (mass in postmenopausal woman usually cancer)
Patient with macromastia presents with a painful mass and shows calcifications on mammography. On histo you see neutrophils, fibrosis, giant cells and cholesterol clefts. Diagnosis? Pathogenesis? Prognosis?
Fat necrosis
Usually traumatic
benign condition - mimics carcinoma but presents with painFUL lump
18 year old presents with a 2cm lump in her right breast that is well delineated and mobile and difficult to palpate. Skin is normal, no LN involvement, no signs of inflammation. Diagnosis? Pathogenesis? Prognosis?
Fibroadenoma - most common benign tumor of breast
Grows with excess estrogen
Benign, no risk of malignancy
24 year old presents with a 4cm lump in her left breast and large, popcorn calcifications on mammography. On biopsy you see loose edematous myxoid fibroblastic stroma containing glandular/duct-like epithelial lined spaces. Diagnosis? Type of tumor? Prognosis?
Fibroadenoma
tumor of stroma cells
Benign, no malignant potential
Name 2 benign stromal tumors of the breast. How can they be differentiated?
Fibroadenoma: teens and 20s
Phylloides tumor: 40s-50s (much less common)
45 year old woman presents with firm, palpable, 12 cm mass that is growing quickly. On histo you see mild atypia of stromal cells and hypercellular projections with slits and clefts. Diagnosis? Prognosis? Should you be concerned about the axillary lymph nodes? why or why not
Phylloides tumor (stromal tumor) usually benign (15% malignant) invasion is usually only local, but if it does metastasize, it does so via blood, so no need to remove axillary LNs
45 year old woman presents with firm, palpable, 12 cm mass that is growing quickly. On histo you see hypercellularity, atypical stromal cells, stromal overgrowth, mitosis, and infiltrative borders. Diagnosis? Prognosis?
Phylloides tumor (malignant - usually only 15%)
Malignant, usually only invades locally, can spread via BLOOD
“leaf like projections”
Phylloides tumor
29 year old female presents with serous, bloody discharge from her right nipple which is retracted. No signs of inflammation but a 1cm subareolar lump is palpable. Diagnosis? Prognosis?
Intraductal papilloma
benign condition
29 year old female presents with serous, bloody discharge from her right nipple which is retracted. No signs of inflammation but several 1cm subareolar lumps are palpable. Diagnosis? Prognosis? Treatment?
Intraductal papilloma
benign condition, but multiple lumps carry a higher risk of malignancy
Excise the whole duct system
35 year old woman presents for her biannual mammogram. You find a small area of calcification but can palpate no mass. Should you be concerned?
Further testing is needed, could be malignant or benign. Important: not all cancers present with a lump!!!!
name 4 commons sites of metastasis of breast cancer
lungs, bone, liver, adrenals
Woman presents with thick nipple discharge that can be squeezed out with gentle pressure. Histo shows necrosis and dystrophic calcifications in center of ducts. Diagnosis? Prognosis?
DCIS comedo type
60% become invasive carcinomas
Name the 4 subtypes of invasive ductal carcinoma of the breast
Tubular
Mucinous (colloid)
Medullary
Inflammatory
70 year old woman presents with soft, gelatinous mass in her right breast. Biopsy stains PAS+. Diagnosis? Prognosis?
Mucinous (colloid) carcinoma
subtype of invasive ductal carcinoma
study hint: tumor cells “stuck” in mucus, can’t spread -> good prognosis
Female presents with well-circumscribed mass in her right breast. Histo shows large sheets of large oval cells and little stroma with lymphocytic infiltration. Diagnosis? Pathogenesis? Prognosis? Important differential?
Medullary carcinoma
subtype of invasive ductal carcinoma
increased incidence in BRCA1 carriers
good prognosis
commonly mistaken for fibroadenoma
Pregnant woman in her last trimester presents with an inflamed, swollen, red breast. You see stippling of the skin over the affected area but cannot palpate a mass. Diagnosis? Pathogenesis? Treatment? Prognosis?
Inflammatory carcinoma (common in pregnancy) subtype of invasive ductal carcinoma
carcinoma in dermal lymphatics
commonly mistaken for acute mastitis, treat with antibiotics, if they don’t work -> carcinoma
bad prognosis (already in lymph)
which type of breast carcinoma is more common? How often can carcinomas present bilaterally?
ductual 90% lobular 10%
both can present bilaterally 10-20%
This tumor is usually multifocal and bilateral and is characterized by loss of E-cadherin adhesion proteins. Usually does not produce a mass or calcifications.
Lobular carcinoma in situ (LCIS)
Patient presents with a hard, fibrous mass in their left breast. On histo you see well-differentiated tubules and nests of cells with small monomorphic nuclei that are invading the surrounding stroma. This tumor is characterized by a desmoplastic response. Diagnosis? Prognosis? What is a desmoplastic response?
Infiltrating Ductal Carcinoma NOS
worst prognosis and most invasive
desmoplastic response is growth of stroma surrounding tumor that leads to fibrosis (why it appears hard)
single file line of cells is characteristic of what? why are they in a line?
Invasive lobular carcinoma
cannot form ductal structures due to lack of E-cadherins
This breast tumor is estrogen receptor + and shows tumor cells surrounding normal acini and ducts. Diagnosis? Name the buzzword for this description and give 2 other common findings on microscopy.
Invasive lobular carcinoma
“bull’s eye pattern”
also see indian file pattern and signet ring morphology
Patient presents with eczema, hyperemia, edema and fissuring of the nipple with no palpable mass. On biopsy you see cells with large hyperchromatic nuclei with a clearing around them. Diagnosis? Prognosis? How will these cells stain?
Paget’s disease of the breast
ALWAYS associated with an underlying ductal carcinoma - find it! Prognosis is based on the tumor you find
Paget cells are PAS+
explain how obesity can be a risk factor for breast cancer
Adipose cells take up androgens and convert it to estrogen. High estrogen levels are associated with many breast carcinomas
What is the most important factor when giving prognosis for breast cancer? What is the most useful? Why?
Most important is metastasis, but most people present before metastasis so axillary lymph node involvement is more useful.
How long can breast tissue sit out before being placed in fixative? How long should it be fixed for?
1 hour or less
fixed for at least 6 hours but no longer than 72
how does tomoxifen work?
it is an antiestrogenic agent - many cancers are associated with excess estrogen
how does trastuzumab work?
aka Herceptin
It is a designer antibody targeted to the HER2 growth factor receptor leading to decreased growth of the tumor
what % of breast cancers express estrogen receptor? why is this important?
60% - can treat with anti-estrogens like Tomoxifen
explain the treatment and outcome of ER+/PR+ vs ER-/PR- tumors
ER+/PR+ tumors respond well to endocrine treatment with anti-estrogens (tomoxifen)
tumors without these receptors have a very low response to this kind of treatment and need to be treated preferentially with chemo
explain the significance of 17q21
loci for the HER2/neu oncogene
How does the prognosis of ER+/PR+ tumors different from HER2/neu tumors?
ER+/PR+ tumors have a better prognosis and respond well to treatment. HER2/neu tumors metastasize quickly
Explain the downside of herceptin
herceptin works well for treatment of tumors with HER2/neu, but it cannot cross the BBB so if there is metastasis there, the therapy won’t work
high cathepsin D is found in a tumor - how does this affect the prognosis and what does it do?
Cathepsin D degrades basement membrane and connective tissue - indicates metastatic potential -> poor prognosis
What group of women has higher incidence of BRCA1 and BRCA2 mutations? What is significant about these mutations (2 things)?
Ashkenazi Jews
- higher risk of breast AND ovarian cancer
- breast cancer appears 15-20 years earlier than sporadic cancers
ER/PR/HER2 receptor analysis is important in what stage tumor?
Important in stage 1
which mutation carries the higher risk of ovarian cancer?
BRCA1
which mutation increases the chance of breast cancer in a male?
BRCA2
Male with Klinefelter’s syndrome is at higher risk for what disease?
Breast cancer
what type of breast carcinoma is more common in males? why?
invasive ductal carcinoma - male breast develops very few lobules
Name the functional unit of the ovary and describe the basic histology
functional unit: follicle
a follicle is an oocyte surrounded by granulosa and theca cells
What acts on theca cells to induce them to do what?
LH acts on theca to produce androgens
What acts on granulosa cells to induce them to do what?
FSH acts on granulosa cells to convert androgen to estradiol
What marks the beginning of the secretory phase of the menstrual cycle? What hormonal changes precede its beginning?
ovulation marks beginning of secretory phase
estrogen induces an LH surge which leads to ovulation
what is the corpus luteum and what does it produce and for how long?
residual follicle - produces progesterone until menstruation or for the 1st trimester if pregnancy occurs
how do ovarian diseases commonly present?
usually silent for a long time until they get big enough to cause mass effect -> pressure, pelvic discomfort, frequent micturition
what is the relationship between oral contraception and ovarian cancer?
oral contraception is usually protective against ovarian cancer
you find a thin walled cyst filled with clear fluid in an ovary. Diagnosis? What is the etiology? common symptoms?
follicular cyst
ovulation doesnt occur, egg is not released, follicle grows until it becomes a cyst
sharp, one-sided pain usually during ovulation
you find a mass on an ovary filled with a dark fluid. Histology shows lipid accumulation in the theca cells. Diagnosis? Etiology? Complication?
corpus luteum cyst
hemorrhage into persistent corpus luteum
can undergo torsion -> rupture -> internal bleeding
on inspection of the ovaries you find multiple, bilateral, yellow/hemorrhagic cysts that show hyperplasia of theca interna cells. Diagnosis? Pathogenesis? List 2 associated disease
Theca lutein cyst
excess stimulation of theca interna cells due to high circulating hCG
associated with choriocarcinoma and moles (both increase hCG - also pregnancy)
On inspection of an ovary, you find a cyst filled with a dark fluid. Biopsy shows normal glands, stroma, RBCs and hemosiderin. Diagnosis? Etiology? Important association?
Chocolate cyst
caused by endometriosis (hence endometrial glands)
associated with infertility
explain how hyperinulinemia can lead to high levels of LH
- Hyperinsulinemia -> inc GnRH -> inc LH relative to FSH (see below)
- persistently high LH stimulates theca cells in ovary to produce excess androgens leading to anovulation
- excess androgens are converted to estrogen by adipose tissue. Excess estrogen inhibits release of FSH, but stimulates release of GnRH
- GnRH acts on pituitary to release LH (and FSH but FSH is inhibited by estrogen)
An obese 26 year old woman with hirsutism and oligomenorrhea presents complaining of infertility. Diagnosis? Cause of infertility and explain
Polycystic ovarian disease
infertility caused by anovulation due to persistently high LH levels but no spike to induce release of oocyte
Ovary shows thickened capsule with multiple large cysts inside. Surface of ovary is uniform. Diagnosis? long term complication?
polycystic ovarian disease
insulin resistance leading to type 2 diabetes
name the 3 cell types of the ovary
surface epithelium
germ cells (eggs)
sex cord-stroma
sex cord stromal tumors of the ovary can arise from what cells?
granulosa, theca, or fibroblasts
what is the clinical significance of cystic ovarian tumors vs solid ovarian tumors?
cystic tumors are generally benign whereas malignant tumors are generally solid
name the 4 subtypes of surface epithelial tumors of the ovary and the type of epithelium of each and where else that epithelium is found
serous: ciliated columnar (fallopian tube)
mucinous: tall mucin secreting cells (endocervix)
endometrioid: non-ciliated columnar (endometrium)
brenner: transitional (bladder)
What are the 3 possible designations that can be given to an ovarian surface epithelial tumor? What is important to remember about these designations?
Benign, borderline, malignant
NOT a continuum (one doesnt necessarily lead to the next)
Increased CA125 is indicative of what? what can it be used for?
ovarian tumor
used to monitor response to therapy and recurrence… diagnostic aid is debatable
Name the 4 types of germ cell tumors of the ovary and what tissues they produce
teratoma (fetal tissue)
dysgerminoma (oocytes)
endodermal sinus tumor (yolk sac)
choriocarcinoma (placental tissue)
you find bilateral ovarian cysts lined by tall columnar ciliated cells filled with watery fluid. What type of tumor is this? How likely is it to be malignant and what is this called? benign and what is this called?
serous surface epithelial tumor
2/3rds of malignant serous tumors are bilateral (cystadenocarcinoma)
only 20% of benign serous tumors are bilateral (cystadenoma)
papillae, polyps, psammoma bodies are found in what type of tumor? malignant or benign?
serous surface epithelial tumors of the ovary
seen in both benign and malignant (malignant has more papilla/polyps and solid nodules)
what is important about the presence of a fibrovascular core?
means its not malignant
On histo of a fluid filled ovarian tumor you see finger-like papillae with a fibrovascular core, Multilayering, moderate mitosis, nuclear atypia - diagnosis? prognosis?
borderline serous surface epithelial tumor
10 year survival 75%
BRCA1 mutation increases a female’s risk for what type of ovarian cancer?
serous carcinoma
psammoma bodies are more likely to be seen in benign or malignant serous epithelial tumors?
malignant
you find a glistening tumor of the ovary that shows tall columnar cells with basal nuceli and graffian follicles in the stroma - diagnosis? How likely is it found bilaterally if it is malignant? benign?
mucinous surface epithelial tumor
only 15% of malignant mucous tumors are bilateral (unlike serous where 2/3rds were)
only 5% of benign mucous tumors are bilateral
Patient presents with abdominal distension, digestive difficulties, and weight changes. On biopsy of the patients ovaries, you find mucinous material bilaterally. Describe the possible pathogenesis of this condition
mucinous tumors are rarely bilateral and digestive problems and wt. changes suggests pseudomyxoma peritonei which is due to a primary carcinoma of the appendix which seeded the peritoneum and metastasized to the ovaries
Mass in the ovary appears cystic, small, has papillae and a velvety surface. Micro shows non-ciliated columnar cells. Diagnosis? Pathogenesis? Prognosis? Clinical significance?
Endometroid surface epithelial tumor
caused by endometriosis
usually malignant
15% are associated with an independent endometrial carcinoma
what cancer has the worst prognosis of the female genital tract cancers?
surface epithelial carcinomas
concentric laminated calcified concretions describe what histological feature?
psammoma bodies
A solid tumor of the ovary shows multiple small nodules made of dense fibrous tissue. The cells appear to be stratified with domed surfaces. Diagnosis? Prognosis?
Brenner's surface epithelial tumor usually benign (even though its solid with nodules) and clinically silent
coffee bean nuclei can be found in what 3 pathologies?
brenner’s tumor
adult granulosa cell tumor
thyroid papillary carcinoma
how likely is a germ cell tumor of the ovary likely to be malignant? in what age group?
95% are benign
5% of malignant ones are in kids and young adults
15 year old girl presents with a mass in her right ovary that contains neuroepithelium. Possible diagnosis? Prognosis?
Immature teratomas have immature tissues (usually neural), common in children and young women, and are malignant
30 year old woman presents with a mass in her right ovary and complains of sterility. On biopsy of the mass, you find various embryological tissues. Diagnosis? Rare but important complication?
Mature teratoma
1% of the time, the fetal skin tissue inside the teratoma can develop squamous cell carcinoma
patient presents with heat intolerance, weight loss, agitation, and tremor. There are no abnormal neck masses. What could be a possible explanation of her condition? How would this appear grossly?
Stuma ovarii: teratoma with mature, hyperfunctional thyroid tissue
small, unilateral, brown ovarian masses
dermoid cyst is another name for what?
mature ovarian teratoma that only has ectodermal tissue
Patient presents with flushing, diarrhea, abdominal cramps, wheezing, salivation, nausea and vomiting. These are symptoms of what? Caused by what? Found in what disease?
carcinoid syndrome (flushing!)
serotonin
can be related to a mature teratoma
layers of epithelial cells around blood vessels resembling glomeruli describes what histological finding? This is seen in what pathology?
Schiller Duval bodies
Endodermal sinus tumor (yolk sac) germ cell tumor of the ovary
A 6 year old female presents with a mass in her ovary that contains cytoplasmic pink inclusions. Diagnosis? What are the inclusions? Prognosis?
Endodermal sinus tumor (yolk sac) germ cell tumor of the ovary
inclusions: alpha feto protein
malignant and aggressive
What two blood tests should you order for a woman with an endodermal sinus tumor? What is the origin of this tumor?
AFP and alpha 1- AT
germ cell tumor
you find a malignant germ cell tumor in the ovary, what is it most likely to be?
dysgerminoma (most common malignant tumor of the ovary)
Patient presents with a unilateral solid tumor of the ovary. It is a soft, fleshy tumor that shows lymphocytic infiltration. Serum LDH levels are noted to be high. Diagnosis? What is the origin of this tumor? Prognosis?
Dysgerminoma
germ cell tumor
good prognosis, all malignant but only 1/3 aggressive, most respond to radiotherapy
30 year old patient presents with unilateral solid tumor in her ovary. On microscopy you see large, uniform, round cells with clear cytoplasm and central regular nuclei and little stroma. Diagnosis? Origin of the tumor? Where else is this histology seen (2 places)
Dysgerminoma
germ cell tumor
testicular seminoma and medullary carcinoma of the breast
24 year old woman has a small, hemorrhagic tumor in her ovary. You see areas of necrosis, pleomorphism, multi nucleation, and giant cells. Levels of beta-HCG and CGT are high but she says she has not had sex recently. Diagnosis? Prognosis?
nongestational choriocarcinoma
very bad prognosis, early and widespread metastasis - resistant to therapy
A 25 year old woman presents with cachexia, wt loss, and a cough. On chest X-ray you see multiple nodules in her lungs. On biopsy you see trophoblasts, but no villi. Diagnosis? How does it spread? Prognosis?
nongestational choriocarcinoma that has metastasized to the lung
EXCEPTION: it is a carcinoma that spreads hematogenously
prognosis is very bad
A 25 year old woman who is short in stature, has swelling of her hands and feet and a webbed neck presents with abdominal pain, vaginal bleeding, and a palpable abdominal mass. Diagnosis?
Dysgerminoma - associated with gonadal dysgenesis like the streak ovaries associated with Turner’s syndrome
“Gland/follicle-like structures formed by the tumour cells aligning themselves around a central space that is filled with acidopilic material” describes what histological structure? where do you find it?
Call-Exner bodies
Granulosa cell tumor - ovary
this ovarian tumor presents with polygonal cells with pale, uniform nuclei that contain grooves, commonly post-menopausal
Granulosa cell tumor (with coffee bean nuclei - grooves)
65 year old woman presents with uterine bleeding and signs of endometrial hyperplasia. You find a mass in her ovary - diagnosis? risk of metastasis? why is she bleeding?
granulosa cell tumor
malignant but minimal risk of metastasis
tumor is producing estrogen which causes the endometrial hyperplasia which sheds as it outgrows its blood supply
ovarian tumor biopsy stains (+) for inhibin - diagnosis? complication in adolescents? increased risk of what? why?
granulosa cell tumor
precocious puberty/irregular menses
inc. risk of breast cancer due to inc estrogen
what is important to note about the theca cells in a granulosa-theca cell tumor?
only the granulosa cells can become malignant, not the theca cells
this ovarian tumor stains positive for red oil O
fibrothecoma of ovary
Unilateral ovarian tumor shows intersecting bundles of polygonal cells and spindle cells producing collagen - diagnosis? risk of metastasis?
fibrothecoma of ovary
none - almost always benign
woman presents with fluid in her abdomen and right sided rales. There is no sign of liver damage. diagnosis? what is the name of this condition?
Fibrothecoma of ovary
Meig’s syndrome
18 year old patient has just had her 3rd skin carcinoma removed in the past 5 years. On examination you notice bifid ribs and jaw abnormalities. What is the name of this condition? What is it associated with?
Nevus/Gorlin syndrome
fibroma of the ovary
which cells over-proliferate in a fibroma of the ovary?
fibroblasts
A 13 year old girl presents with excess facial hair and a hypertrophied clitoris. Diagnosis? should you be concerned?
Sertoli Leydig cell tumor of the ovary
usually benign
12 year old girl presents with a unilateral mass in her ovary. On histo you see Reinke crystals - diagnosis?
Sertoli Leydig cell tumor of the ovary
you find signs of tumor metastasis to the ovary. Name the 3 most common sites of origin
intestine, appendix, stomach
what % of bilateral tumors of metastatic?
10% - low
you find a multi-nodular solid metastatic tumor in an ovary - name 2 possible sites of origin
breast
stomach
you find a cystic/solid metastatic tumor in an ovary - name a possible site of origin
intestine
you find a cystic metastatic tumor in an ovary - name a possible site of origin
pancreas/biliary tract
you find a metastatic tumor in an ovary containing signet ring cells - diagnosis? give 2 specific tumors of origin and which is most common?
Krukenberg tumor
gastric carcinoma (most common 70%) lobular carcinoma of breast
you find a tumor of the ovary with signet ring cells - what is the most important factor for correct diagnosis? why?
whether it is bi or unilateral
krukenberg is bilateral and primary mucinous carcinoma is unilateral
sertoli leydig cell tumor has another name, what is it?
androblastoma
what is the breakdown product of serotonin? When would you see this in ovarian tumors?
5-HT
carcinoid syndrom from dermoid cyst aka mature teratoma
during which phase does the endometrium have coiled glands? conspicuous arterioles? cuboidal cells? which hormones drive which part of the cycle?
secretory
secretory
proliferative
estrogen: proliferative (1-14)
progesterone: secretory (15-28)
Menorrhagia - definition and common cause
Excessive amount of regular (cyclical) bleeding
Cause: Submucosal Leiomyoma
Metrorrhagia - definition
irregular noncyclical bleeding
Menometrorrhagia - definition and 2 causes
excessive AND noncyclical bleeding
Causes: cervical polyps, cervical/endometrial carcinoma
Oligomenorrhoea - definition and 2 causes
Infrequent (greater than 35 days) bleeding
Causes: polycystic ovarian syndrome, low body weight
Dysmenorrhoea - definition and association
painful menses - high levels of prostaglandin F
what is the luteal phase?
another name for secretory phase
patient presents with early menses and increased bleeding. what hormonal changes are responsible for this?
inadequate corpus luteum - low progesterone, FSH, LH
patient presents with excessive bleeding and prolonged periods (10+ days) - what hormonal changes are responsible for this?
persistent luteal phase - due to continued low level production of corpus luteum after onset of menstruation
what causes the onset of menstruation?
abrupt cessation of progesterone secretion by corpus luteum
patient presents with pelvic pain and dysmenorrhea. on examination you find blood-filled cysts in her ovary and histo shows large amounts of hemosiderin - diagnosis? this is associated with an increased risk of what?
endometriosis ovarian carcinoma (or carcinoma at site of endometriosis)
on examination of a uterus you see diffuse deposition of endometrial tissue in the myometrium - 2 names for this condition?
endometriosis - adenomyoma
define pyometrum - what can it lead to?
obstruction of cervical os by neoplasm or fibrosis
endometritis (infection of endometrium)
patient presents with pain on defecation and lower back pain. she also notes bleeding - diagnosis?
endometriosis in the rectovaginal pouch (pouch of Douglas)
most common site of endometriosis? what is this called? what do you see on histo?
ovary - chocolate cyst
endometrial glands and stroma and blood clots
on examination of a uterus you see a focal deposition of endometrial tissue in the myometrium - 2 names for this condition?
endometriosis - adenomyosis
on examination of the endometrium you see an increased gland to stroma ratio - what is this called? what causes it? what is most important when looking for high risk factors? what can high risk factors predict?
endometrial hyperplasia
high estrogen
cellular atypia -> carcinoma
55 year old woman presents with metrorrhagia and on exam you find a 2cm protrusion of the endometrium of her uterus - diagnosis? cause? should you be concerned?
endometrial polyp
extreme response to hyperplasia (from increases estrogen)
malignant transformation is very rare
57 year old woman presents with vaginal bleeding despite having been through menopause several years earlier. On exam of her uterus you find a protruding mass and asymmetric enlargement of her uterus. Diagnosis? Cause? list 3 risk factors?
Endometrial carcinoma
unopposed estrogen and is preceded by hyperplasia
obesity, type II diabetes, nulliparous
on biopsy of a mass from a uterus you find a tumor with 50% glands and 50% solid mass - diagnosis and stage. List identifying factors of the other stages
endometrial carcinoma - stage II
stage I: all glands “back to back”
stage III: mostly solid, few glands
list 3 conditions where you see psammoma bodies
papillary carcinoma of the thyroid
endometrial carcinoma
ovarian carcinoma
70 year old woman with an atrophic endometrium has a tumor in her uterus. Histo is mostly serous with papillary structures and psammoma bodies - diagnosis? how common? associated mutation?
endometrial carcinoma
25% are sporadic (as opposed to 75% that are linked to hyperplasia and present 10 years earlier, 60)
p53
on biopsy of 58 year old uterus you find a large, fleshy mass with hemorrhage and necrosis. you find evidence of epithelial growth as well as some muscle tissue - diagnosis? why is it named this? prognosis?
mixed mullerian (mesodermal) tumor
has both epithelial and mesenchymal tissues
poorly differentiated tumor with poor prognosis
long term use of IUD can lead to what condition?
chronic endometritis
how do you differentiate between acute and chronic endometritis? give 2 causes of each
acute has PMNs and chronic has plasma cells
acute: postpartum sepsis, gonococcal infection
chronic: IUD and TB
to make a diagnosis of leiomyoscarcoma what 3 factors must be present?
nuclear atypia
tumor necrosis
mitotic index > 10
a 30 year old woman pregnant with her 3rd child experiences sudden acute, severe pain and has to be treated with strong pain killers - diagnosis? name of this condition and what is it?
leiomyoma
red degeneration: rapidly growing fibroid (due to increased estrogen from pregnancy) outgrows blood supply and necrosis
on exam of uterus you find multiple unencapsulated growths that are white and whorled - diagnosis? what tissue is involved? should you be concerned?
leiomyoma
myometrium
no, NO malignant potential does NOT lead to leiomyosarcoma!!!!!
best way to differentiated between leiomyoma and leiomyosarcoma? second best?
leiomyomas are multiple and leiomyosarcomas are singular
age of onset: myomas premenopausal and go away after menopause
sarcomas usually in postmenopausal women
name 3 conditions that can lead to uterine bleeding
endometriosis, endometrial carcinoma, leiomyoma
epithelium of the ectocervix?
non-keratinized stratified squamous
epithelium of the endocervix?
simple columnar
where is the normal squamo-columnar junction in the cervix?
external cervical os
patient presents with several firm, mucous filled cysts on her cervix. diagnosis? how does it occur?
retention (Nabothian) cyst
squamous cells grow over cervical crypts and lead to retention of the secretions
on examination you notice that the squamo-columnar junction of your patient has moved closer to the inner cervical os. Should you be concerned? what is this called?
no, no malignant potential and reversible
squamous metaplasia
you notice several polyps on your patient’s endocervix. should you be concerned?
no, no malignant potential
increased nuclear to cytoplasmic ratio on a pap smear is indicative of what?
dysplasia
explain the Schiller test
paint the cervix with iodine and look for unstained pale patches (these areas don’t have glycogen which is what the iodine stains) which can indicate cervical dysplasia or inflammation, not specific but shows areas to be biopsied
(keep in mind this is not Schilling’s test for B12 absorption)
most common cause of acute cervicitis?
chlamydia
perinuclear halo, large hyperchromatic nuclei - in what cells is this seen? in what disease?
koilocytes
HPV infection
what site can get metastasis from all other cancers of the female genital tract?
vagina
on routine vaginal exam you find small asymptomatic cysts on the lateral wall of the vagina - diagnosis? how are they formed?
gartner’s duct cyst
remnants of mesonephric ducts
on vaginal exam of a preteen girl you find areas of columnar epithelium in the upper 1/3 of the vagina. Her mother tells you that she took diethyl stilbesterol (DES) while pregnant to prevent abortion - diagnosis? should you be worried?
vaginal adenosis
its a benign condition but 10-35 years later, many develop clear cell adenocarcinoma
on a vaginal biopsy you see proliferation of glands with non-staining cytoplasm - history of DES use in pt.’s mother - diagnosis? prognosis?
clear cell adenocarcinoma
malignant, poor prognosis
4 year old child presents with vaginal bleeding and large, nodular mass protruding from vagina - diagnosis? what type of tissue is involved? prognosis?
embryonal rhabdomyosarcoma (sarcoma botryoides (grapes))
immature skeletal muscle
highly malignant and aggressive
these glands are located on either side of the vaginal canal and drains into the lower vestibule - name? complication?
bartholin
inflammation and unilateral cyst formation
these glands are located around the urethral opening
Skene’s glands
60 year old woman presents with white patch on her vulva. On exam you find scaly plaques with thinning of the epidermis - diagnosis? should you be concerned?
Lichen sclerosus (Kraurosis vulvae)
very low malignant potential but can be associated with squamous cell carcinoma (another cause thats not HPV!!!)
buzz phrase: “parchment like” vulva
63 year old woman presents with severe itching in the vaginal area and has a thickened, leathery vulva - diagnosis? should you be concerned?
Lichen simplex chronicus
no malignant potential
patient presents with reddish brown plaque on vulva - diagnosis? should you be concerned?
Bowen’s disease (VIN III) (carcinoma in situ)
yes, needs to be excised, can lead to squamous cell carcinoma
40 year old patient presents with flat, gray-white papule on vulva. she smokes and had a kidney transplant 3 years prior - diagnosis?how to treat? should you be worried? pathogenesis?
vulval intraepithelial neoplasia (VIN)
treat with resection - but often multifocal, many recur
even after treatment, can progress to carcinoma
associated with high risk HPV (16, 18, 31, 33)
If something stains PAS+ what cell type must it be?
only epithelial cells make mucin
If something stains positive for keratin, what cell type must it be?
only epithelial cells produce keratin
25 weeks of gestation, you see nucleated RBCs in the embryonic vessels of the placenta, should you be concerned?
Yes, nucleated red cells should disappear after 20 weeks of gestation, if they persist suggests ischemic disease of the fetus
name the inner and outer cells of the placenta
inner: cytotrophoblasts
outer: syncitiotrophoblasts
pelvic inflammatory disease is associated with increased risk of what? why?
tubal pregnancy
fibrosis blocks the passage of fertilized ovum
female patient presents with acute onset, RLQ abdominal pain. Two differentials
acute appendicitis
ruptured ectopic pregnancy
cowdry bodies are found in what pathology? what stain do you use?
Herpes
Tzanck
biopsy of the uterus shows hypersecretory glands but no chorionic villi - diagnosis? name of this condition?
ectopic pregnancy - can’t be spontaneous abortion because that would show chorionic villi
arias stella reaction
when does an embryo become considered a fetus and when does a fetus become a premature baby?
embryo: up to 8 weeks
fetus: up to 20 weeks
premature: 20-40 weeks
pregnant woman presents with vaginal bleeding in her third trimester - diagnosis? etiology? how to treat?
placenta previa
placenta implants in lower uterine segment and overlies cervical os
caesarian section is necessary
a woman in her 3rd trimester presents with vaginal bleeding, premature labor, and shock. No fetal heart beat can be auscultated - diagnosis? cause? complication?
abruptio placenta
sudden, incomplete separation of placenta from implantation site prior to delivery of fetus
still birth
after delivery of her newborn, mother experiences severe postpartum bleeding and difficulty delivering the placenta - diagnosis? cause? how to treat?
placenta accreta
no decidua, villi directly invade the myometrium
requires hysterectomy (removal of uterus)
a pregnant woman in her third trimester presents with edema, proteinuria and headaches - diagnosis? what causes the headaches? etiology?
preeclampsia
headaches causes by severe HTN
ischemic placenta
30 year old Asian woman presents with highly elevated BetaHCG and a greatly expanded uterus as compared to normal in second trimester. Diagnosis? what do you see on histo? ultrasound?
hydatiform mole
histo: proliferation of trophoblasts
ultrasound: “snowstorm”
give the genotypes of both a complete and partial mole. which one has fetal parts? Someone with this condition has an increased risk of developing what?
complete: 46XX (two sperm)
partial: 69XXY (fetal parts seen)
choriocarcinoma
patient presents with positive pregnancy test, amenorrhea, excessive symptoms of morning sickness and vaginal bleeding at 3 months gestation - diagnosis?
partial mole
salpingitis is another name for what?
pelvic inflammatory disease
after giving birth, patient presents with friable, hemorrhagic mass in their uterus found after complaining of bloody discharge from the vagina. No chorionic villi are seen on histo, but beta-HCG levels are elevated - diagnosis? what cells are involved? prognosis?
gestational choriocarcinoma
malignant cyto and syncitiotrophoblasts
good prognosis with chemo (better than non-gestational type)
following pregnancy, patient presents with mass in uterus but shows no fetal parts and low levels of beta-HCG. Cells are positive for placental lactogen - diagnosis? prognosis? why is beta-HCG low?
placental type trophoblastic tumor
prognosis good if confined to uterus (cured by curettage), bad if it spreads
its a tumor of cytotrophoblasts only, and syncitiotrophoblasts produce beta-HCG
common sites of metastasis for gestational choriocarcinoma? how does this affect prognosis?
lungs and vagina
even with metastasis, still good prognosis, very responsive to chemo
What disease does the following histo describe? Cystic swelling of chorionic villi, large edematous vascular villi, degeneration of stroma, proliferation of chorionic epithelial trophoblasts (all kinds)
hydatidiform mole
