Female Genital System Flashcards by Denisse Tiangco

Thinned epidermis
Hydropic degeneration at basal layer
Sclerotic stroma
Dermal inflammation
Dermal fibrosis
Atrophic epithelium

Lichen sclerosus

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Thickened epidermis (acanthosis)
Hyperkeratosis
Dermal inflammation

Lichen simplex chronicus

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Carries a slightly increased risk for development of SCC

Lichen sclerosus

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Flat, moist, minimally elevated in secondary syphilis

Condyloma lata

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Papillary, distinctivelt elevated or flat and rugose
Anywhere on anogenital surface
Strongly associated with HPV

Condyloma acuminata

6 & 11 (low risk of malignant transformation)

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Characteristic cellular feature of HPV
Perinuclear cytoplasmic vacuolization
Wrinkled nuclear contours

Koilocytosis

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Less common 
Related to HPV:
Middle aged women
Cigarette smokers 
Preceded by precancerous changes termed VIN (valvular intraepithelial neoplasia)
Progresses to greater degree of atypia
Immunodeficiency

HPV related VULVAR SCC

16 and 18

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Older women with reactive epithelial changes like lichen sclerosus
Lacks cytologic changes of VIN
but with atypia of basal layer and keratinization
Invasive is well differentiated and keratinizing

Non HPV related VULVAR SCC

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Leukoplakia -> exophytic or ulcerative endophytic tumors -> HPV + are multifocal -> poorly diff SCC whereas negative are unifocal and manifest as well differentiated keratinizing SCC

SCC of Vulva

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Red scaly plaque caused by prolif of malignant epithelial cells within epidermis
No underlying carcinoma unlike that of nipple

Paget disease of the vulva

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This differentiates Paget disease cells from melanoma

Positive staining PAS lacks mucin

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Watery copious discharge gray green in which parasites are identified with microscopy

Trichomonas vaginalis vaginitis

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Uncommon, older than 60 yrs
Similar risk factors as in vulvar CA
Precursor lesion is vaginal IN assoc with HPV

SCC of Vagina

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Very rare tumor

Identified in young women whose mothers took diethylstilbestrol to prevent threatened abortion

Clear cell Adenocarcinoma of VAGINA

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Agent associated with elevated risk of cancer when exposed

1/3 will present with small glandular or microcystic inclusions appearing in mucosa

Red, granular appearing foci lined by mucus-secreting ciliated columnar cells called
where clear cell adenocarcinoma arises

Diethylstilbestrol

Vaginal adenosis

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Rare form of primary vaginal cancer manifesting as soft polypoid masses
Infants and children <5
Also in bladder and bile duct

Sarcoma botryoides

Embryonal rhabdomyosarcoma

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Most common infection of cervix 40%

C trachomatis cervicitis

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Acute form of cervicitis is usually in women

postpartum

staph or strep

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Cervicits comes to attention because of

leukorrhea

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During puberty, SC junction of cervix undergoes eversion causing columnar epithelium visibility in exocervix called

transformation zone

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HPV has tropism for this site on cervix

immature squamous cells of transformation zone

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Rf for cervical ca

HPV exposure
Early coitarche
Multiple sexual partners
Male with multiple sexual partners
Persistent infection of HPV

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HPV infected squamous cells do not usually replicate but expression of two potent oncogenes encoded in HPV genome enable this

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E6 and E7 genomes bind and INactivate two critical TSG namely

that promote growth and inc susceptibility to additional mutations leading to carcinogenesis

E6 - p53

E7 - Rb

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Most important risk factor for development of CIN and carcinoma

HIGH RISK HPV 16 and 18 70% Also 31, 33

Serine threonine kinase phosphorylating and activating AMPK, a metab sensor AMPK regulates cell growth through mTOR Somatic mutations in this protein (loss) is related to cervical ca, Peutz Jhegers and inactivated lung CA

LKBI

Episomal infection

HPV 6 and 11

Viral integration

HPV 16 and 18

Two tiered grading system for CIN

``` LSIL previously (CIN I) HSIL previously (CIN II and III) ```

Rationale for Pap smear Most successful cancer screening test ever developed

Early detection of DYSPLASTIC changes

Dysplastic changes in lower third of squamous epithelium and koilocytic change in superficial layers of epithelium

CIN I

Dysplasia extending to middle third of epithelium Delayed keratinocyte maturation Assoc with variation in nuclear and cell size Heterogeneity of chromatin Presence of mitoses above basal layer

CIN II HSIL

``` Complete loss of maturation with greater variation in cell and nuclear size Chromatin hererogeneity Disorderly orientation of cell Normal/abnormal mitoses Affects ALL layers of epithelium ABSENT koilocytic change ```

CIN III HSIL

Abnormal pap smear -> colposcopy with acetic acid test LSIL positive: HSIL:

Observation Cone biopsy

HPVs can cause these types of cervical ca

SCC 75% Adeno Adeno squamous 20% Small cell neuroendocrine 5%

Invasive carcinomas of cervix develop in

transformation zone

Tumors encircling cervix and penetrate underlying stroma produce

barrel cervix

Growth of basal layer of endometrium down to myometrium inducing reactive hypertrophy (enlarged, globular uterus with thickened uterine wall) No bleeding bec infiltrative glands come crom basalis

Adenomyosis of endometrium

Ectopic endometrial glands and stroma

Endometriosis

3 hypotheses for endometriosis

1 regurgitant theory (menstrual backflow through fallopian tubes) 2 metaplastic theory (endomentrial differentiation of coelomic epithelium) 3 vascular or lymphatic dissemination (extrapelvic or intranodal implant)

Ectopic endometrial glands are abnormal bec of

Inc inflammatory mediators (PGE2) Inc estrogen production due to aromatase enhancing persistence of endometrial tissue in foreign locations

Endometriosis contains this type of endothelium Grossly red brown implants coalescing to form large masses In ovaries, they are called

functional hence bleed Chocolate cyst

Hx diagnosis of endometriosis involves

2/3 structures Endometrial glands Endometrial stroma Hemosiderin pigment

AUB due to precocious puberty (hypothalamic, pituitary, ovarian)

Prepuberty

AUB in anovulatory cycle

Adolescence

AUB in complications of pregnancy (abortion, tropho, ectopic) Proliferation (leiyomyoma, adenomyosis) Anovulatory cycle Ovulatory dysfunctional bleeding inadequate luteal phase

Reproductive age

AUB due to anovulatory cycle Irregular shedding Proliferation

Perimenopause

AUB due to proliferation | Endometrial atrophy

Postmenopause

Induces exaggerated endometrial proliferation or hyperplasia and risk for carcinoma

Prolonged excess estrogen relative to progesterone

Estrogen excess rf

1 ovulatory failure 2 exogenous estrogen without progestin 3 PCOS or estrogen producing tumor like granulosa theca cell of ovary 4 obesity

Hyperplasia of endometrium is classified based on

1 architectural crowding (simple vs complex) | 2 cytologic atypia (normal vs atypical) -related to risk of carcinoma

Endometrial Hyperplasia progression to carcinoma is related to inactivating mutation of which acts as brake on PI-3kinase/AKT pathway

PTEN tumor supressor gene

Most frequent cancer occuring in genital tract

Endometrial CA

Arise in setting of endometrial hyperplasia and estrogen excess in perimenopausal 80% Mutations in PTEN May be mucinous, tubal, squamous or adenosquamous Infiltrates myometrium in cribriform pattern

Endometriod cancer

Arises fr endometrial atrophy in postmenopausal Forms small tufts and papillae not glands with greater atypia Aggressive IHC demonstrates hig levels of mutant

Serous endometrial CA | p53

Endometriod CA rf

``` Obesity DM HTN Infertility Exposure to unopposed e ```

Women with germline mutations in PTEN are known as | and have inc risk for endometrioid CA

Cowden syndrome

15% of endometrial tumors | All have mutations to:

Serous endometrial CA TP53

Most common benign tumor in women Sharply circumscribed Whorled cut surface

Leiomyoma | Fibroid

Leiomyosarcomas arise from and not from Solitary on postmenopausal Soft hemorrhagic necrotic masses Tumor necrosis, atypia and mitotic activity Recurrence and mets are common typically:

De novo mesenchymal cells leiomyosarcoma Lung

Most common disorder of fallopian tube

Salphingitis from PID

Primary adenoCa of fallopian tubes may be:

Serous | Endometrioid

Serous adenoca of fallopian tube are related with mutations of AdenoCa of FP occur in

BRCA fimbriae

Multiple cystic follicles in ovaries producing excess androgen and estrogen with high LH and low FSH (Pituitary inhibition through hypothalamus)

Polycystic ovarian disease | Stein-Leventhal Syndrome

Three cell types in ovary:

Multipotent coelomic epithelium Totipotent germ cells Sex cord stromal cells

``` 65-70% Malignant ovarian proportion: 90% Age group: 20+ years Types: Serous, Mucinous, Endometrioid, Clear cell, Brenner, Cystadenofibroma ```

Surface epithelial stromal cell tumors of ovary

``` 15-20% Proportion of malig: 3-5% Age group: 0-25+ years Types: Teratoma, dysgerminoma, endoderm sinus tumor, choriocarcinoma ```

Germ cell tumors of ovary

``` 5-10% Malignancy proportion: 2-3% Onset: all ages Types: Fibroma, Granulosa-theca cell, Sertoli-leydig cell ```

Sex cord-stroma tumors of ovary

5% Malignancy proportion: 5% Onset: variable age

Metastases to ovary

Most common form of ovarian epithelial tumor | Borderline and malignant: 60%

Serous carcinoma of | Ovary

Arise from borderline lesions | Assoc with KRAS, BRAF or ERBB2 mutation

Low grade serous of ovary

Develop rapidly from TUBAL intraepithelial carcinoma with mutations in TP53 and FOXM1

High grade serous of ovary

25% of serous carcinoma of ovary are

bilateral

Tall columnar epithelial cells with cilia Psamomma bodies in tips of papillae If carcinoma, anaplasia and stromal invasion with complex papilla and multilayered nests of undiff malignant cells In between: less atypia with little or no stromal invasion but seeds peritoneum

Benign cystadenomas Cystadenocarcinoma Tumors of low malig potential

Similar to serous but epithelium consists of mucin 80% benign Larger, multicystic Serosal penetration and solid areas of growth suggestive of malig Less likely bilat

Mucinous tumor of ovary

BILATERAL | Mucinous adenocarcinoma tumor of GI metastasizing to ovary

Krukenberg tumor

Implantation of mucinous tumor in peritoneum producing mucin Usually from appendix

Pseudomyxoma peritonei

Solid or cystic sometimes assoc endometriosis Tubular glands within lining of cyst Usually malignant Bilateral and with concomitant endometrial CA Mutations in:

Endometrioid carcinoma of ovary | PTEN

Uncommon, solid unilateral with abdundant stroma with nests of transitional type endothelium resembling URINARY TRACT Most are benign

Brenner tumors

15-20% of ovarian tumors Common in first two decades of life The younger the greater risk of malignancy 90% benign

Teratoma

Hallmark of benign mature cystic teratomas | 90% uni, Right side

Presence of MATURE tissues from all 3 GERM CELL LAYERS (ecto, endo, meso)

Cysts lined by epidermis replete with adnexal appendage

dermoid cyst

Complication of benign mature cystic teratoma

torsion

Rare paraneoplastic complication benign mature cystic teratomas With mature neural tissue and remits with tumor resection

Limbic encephalitis

Bulky, solid punctuated areas of necrosis Cystic foci with sebaceous secretion, hair and other similar to mature IMMATURE ELEMENTS (minimally diff cartilage, bone, muscle, nerve) Neuroepithelial diff

Immature malignant teratoma

Rare subtype of teratoma Specialized tissue Most common eg: Struma ovarii

Specialized teratoma

Mature thyroid tissue producing hyperthyroidism in ovary | Small solid brown unilateral

Struma ovarii teratoma

Marker of ovarian ca Elevated in 75-90% of ovarian ca Greatest value is of determinance to therapy response

CA 125

``` 2nd-3rd decade Gonadal dysgenesis Unilateral 80-90% Counterpart of testicular SEMINOMA Solid large to small gray Sheets or cords of large cells separated by scant fibrous strands Contain lymphocyte and granuloma All malignant but 1/3 are aggressive and spread All radiosensitive, 80% cure rate ```

Dysgerminoma | Germ cell

``` First 3 decades Unilateral Identical to placental tumor Small, hemorrhagic focus with two types: cytotrophoblast and syncio Mets early, widely Ovarian primies resistant to therapy ```

Choriocarcinoma | Germ cell

``` Postmenop but sometimes any Unilateral Tiny, large gray cystic space Cuboidal granulosa in cords, sheets or strands or spindles or plump lipid laden theca cell Elements may recapitulate ovarian follicle as Call-Exner bodies Large amounts of ESTROGEN from theca Promotes endometrial or breast ca Granulosa malignant 5-25% ```

Granulosa-theca cell | Sex-cord tumor

``` Any age Unilateral Solid gray fibrous cell to yellow lipid laden plump theca cell Hormonally INactive Ascites and hydrothorax 40% Rarely malignant ```

Thecoma-fibroma | Sex-cord tumor

``` All ages Unilateral Small, gray to yellow brown, solid Recapitulates testes with tubules or cords and plump pink Sertoli cell Masculinizing or defeminizing Rarely malig ```

Sertoli-Leydig Cell | Sex-cord tumor

Older age Mostly bilateral Solid gray white mass large Anaplastic tumor cells, cords, glands, dispersed through fibrous background Signet ring or mucin-secreting Primaries of GI aka Krukenberg, breast, lung

Metastases to ovary

Hallmark of granulosa theca cell carcinoma | Recapitulate ovarian follicles

Call-Exner bodies

``` 46XX, XY All villi edematous Diffuse circumferential trophoblast prolif Elevated HCG ++++ Tissue HCG Choriocarci risk: 2% All chromosomes paternal No fetal tissue ```

Complete mole

``` Triplod karyotype Some villi are edematous Focal slighr trophoblast prolif Less elevated HCG + Tissue HCG Rare subsequent choriocarcinoma Two sets of paternal chromosomes With fetal tissue ```

Partial H mole

Highly invasive freq metastatic tumor responsive to chemotherapy and curable

Gestational choriocarcinoma Vs ovarian germ cell

Indolent immediate trophoblasts that produce HPL and doesn’t respond well to chemotherapy

Placental site trophoblastic tumor

Insufficient maternal blood flow to placenta secondary to inadequate remodelling of spiral arteries

Preeclampsia (toxemia of pregnancy)

Placental abnormality in preeclampsia:

Infarcts Retroplacental hemorrhage Premature maturation of placental villi with villous edema, hypovascularity, inc production of syncytial epithelial knots Fibrinoid necrosis

Preeclampsia clinical features

Edema Proteinuria HTN Seizure - eclampsia with multi organ damage