Female Repro Pathology I Flashcards
Uterus, Vulva, Vagina
State some common congenital abnormalities occurring in the uterus.
- uterus unicornis - degeneration of one half of the mullerian duct, only half of uterus present
- uterus didelphys - non-fusion of the mullerian duct, uterus splits and each has own cervix
State types vaginal infection and their corresponding discharge colour.
- Bacteria
- BV - grey-white
- Other bacterias - yellowish purulent - Virus (herpes)
- vesicles - Protozoa (trichomonas)
- bubbly frothy - Fungus (candida)
- whitish exudate
State the conditions of the vulva.
- Lichen sclerosus
- Lichen simplex chronicus
- Paget’s disease
- Vulvar malignancy (invasive and non-invasive)
- Bartholin cyst
State the histological features of Lichen sclerosus.
- very thinned epidermis
- hydropic degeneration of basal layer
- sclerotic stroma
- dermal inflammation
State everything you know about Lichen sclerosus.
- non-neoplastic epithelial disorder (potential to become neoplastic)
- autoimmune
- gross: whitish plaques (leukoplakia)
State the histological features of Lichen simplex chronicus.
- thickened epidermis (acanthosis)
- Hyperkeratosis
- Dermal inflammation
State everything you know about Lichen simplex chronicus.
- non-neoplastic epithelial disorder (potential to become neoplastic)
- secondary to pruritus
State the histological features of Vulva Paget’s disease.
- Presence of neoplastic glandular cells
State everything you know about Vulva Paget’s disease.
- positive CK7 immunohistochemistry stain that picks up glandular cells
- originates from primitive epithelial progenitor cells
- in situ glandular neoplasm that arises from stratified squamous epithelium
- presents as red lesions on weeping skin
- premalignant condition
State the histological features of vulvar cancer.
- irregular islands of invasive SCC
- kerratin pearls
- intercellular junctions
State the common vaginal diseases. (3)
- VAIN
- clear cell adenocarcinoma
- embryonal rhabdomyosarcoma
State everything you know about VAIN (vaginal intraepithelial neoplasia)
- associated with HPV 16 and HPV 18
- premalignant condition
State the histological features of clear cell adenocarcinoma.
- clear cytoplasm clusters
- stratified squamous epithelium with formation of glands
State everything you know about clear cell adenocarcinoma.
- common in young women
- due to in-utero exposure to DES (diethylstilbestrol) in mothers treated with DES during pregnancy
- possibly preceded by vagina adenosis (presence of metaplastic cervical or endometrial epithelium within vaginal wall)
State the histological features of embryonal rhabdomyosarcoma
- normal stratified squamous epithelium of vagina
condition affects external genitalia, less impact on internal
State everything you know about embryonal rhabdomyosarcoma.
SARCOMA BOTRYOIDES
- common in infants and children
- gross: grape like clusters projecting into vaginal lumen
- treat: resection surgery (vaginectomy) and chemotherapy
State the common cervix diseases. (2)
- Cervical intraepithelial neoplasia
- Cervical Carcinoma
State the common histological features associated with cervical intraepithelial neoplasia.
- high N:C ratio
- nuclear irregularity
- increased mitotic rate
- dysplastic change
- CIN I - koilocytosis
State everything you know about cervical intraepithelial neoplasia (exclude risk factors).
TARGETS THE SQUAMOCOLUMNAR JUNCTION BETWEEN ECTOCERVIX AND ENDOCERVIX
- ectocervix = non-keratinised stratified squamous epithelium
- endocervix = simple columnar epithelium
Staging of cervical intraepithelial neoplasia:
- mild dysplasia (lower 1/3) - CIN I - low grade SIL
- moderate dysplasia (lower 2/3) - CIN II - high grade SIL
- severe dysplasia (full length) - CIN III - high grade SIL
State the risk factors for cervical intraepithelial neoplasia.
- many sex partners
- early age at first intercourse
- increase parity (number of births)
- male partner with multiple previous sex partners
- cancer associated HPV 16 and 18 (MOST IMPORTANT!!! usually located within transitional zone)
- certain HLA and other subtypes
- oral contraceptives and nicotine
- genital infections (chlamydia)
How does HPV lead to cervical cancer?
95% OF CANCERS SHOW HPV DNA
Pathogenesis:
HPV 16 is associated with amplification of 3q -> cell cycle regulation disrupted by viral oncogenes E6 and E7 (p53 and Rb respectively)
(most HPV infections regress and do not progress into cervical cancer)
Integrated vs episomal viral DNA
- integrated -> link to cervical cancer
- episomal -> low grade cervical cancer
Treat: vaccines
Tests:
1. HPV immunohistochemistry
2. PAP smear (once every 3 years from 25-69 if sexually active)
3. HPV DNA test
State the histological features of HPV.
- perinuclear haloes
- multinucleation
- crinkled nuclei
State the histological features of cervical carcinoma
SCC:
- large cell non-keratinising
- large cell keratinising
- small cell
or
- adenocarcinoma
- adenosquamous
- undifferentiated
State everything you know about cervical carcinoma.
75-90% IS SCC, 10-25% IS ADENOCARCINOMA
- gross: fungating, ulcerating, infiltrative, cauliflower erosion
- presentation: intermenstrual blood, post-coital blood (post-intercourse), postmenopausal blood, dyspareunia (pain during intercourse)
- spreads by local invasion into uterus&vagina&bladder&rectum, lymphatics, haematogenous (lung, liver, bone, brain)
Staging:
I - 90% 5 year - cervix only
II - 75% 5 year - upper vagina, paraimetrium (fat and connective tissue around uterus)
III - 30% 5 year - lower vagina, pelvic wall
IV - 10% 5 year - rectum/bladder, extrapelvic
State the common uterine diseases and their constituent locations.
ENDOMETRIUM (majorly)
1. endometrial hyperplasia
2. endometrial carcinoma
3. endometrial stroma neoplasms
4. endometriosis
MYOMETRIUM
1. leiomyoma
2. leiomyosarcoma
3. adenomyosis
MIXED MULLERIAN TUMOUR
1. carcinosarcoma
State the histological features of the 2 types of endometrial hyperplasias.
- SIMPLE (cystic) HYPERPLASIA
- irregularly dilated glands similar to proliferative stage
- uncommonly progresses to adenocarcinoma (<5%) - COMPLEX HYPERPLASIA
- glandular crowding and irregular shape
- epithelial stratification (increased mitosis)
- loss of PTEN tumour suppressor gene (check with PTEN IHC)
- more commonly progresses to cancer
State everything you know about endometrial hyperplasia.
- defined as an increase in number of glands relative to the stroma, appreciated as crowded glands with abnormal architecture
- commonly due to unopposed estrogen stimulation
- important cause of vagina bleeding
- 2 types of hyperplasia: simple hyperplasia + complex hyperplasia
- PTEN tumour suppressor gene mutated in ~20% of endometrial hyperplasias
State the histological features of endometrial carcinoma.
- crowded glands
- squamous nodule formation of stratified squamous epithelium
- tumour cells invade into underlying myometrium
State everything you know about endometrial carcinoma.
- common in postmenopausal women
- presents as postmenopausal bleeding
Types of endometrial sarcoma:
1. PROLONGED ESTROGEN SECRETION
- endometrial hyperplasia
- ovarian estrogen secreting tumour
- estrogen replacement therapy
- NO ASSOCIATION WITH ESTROGEN
- no pre-existing hyperplasia
- P53 tumour suppressor gene mutation
- poorly differentiated serous type
-poor prognosis
STAGING:
I - 80% - corpus - 75% survival
II - 5% - corupus and cervix - 52% survival
III - 5% - invasion into pelvis - 30% survival
IV - 10% - outside pelvix - 10% survival
State everything you know about endometriosis.
PRESENCE OF ENDOMETRIAL GLANDS AND STROMA IN ABNORMAL LOCATIONS OUTSIDE THE UTERUS
- ectopic tissue can undergo cyclic bleeding
- presentation: pain, dysmenorrhea, infertility
- possibly precursor to carcinoma (endometrial or clear cell carcinoma)
State the histological features of leiomyoma.
- palasades of smooth muscles arranged in interlacing islands
- well-circumscribed
- homogenous
- resembles surrounding smooth muscle tissue
- tan whorling mass
State everything you know about leiomyoma.
- common in middle aged women
- most common uterine neoplasm
- regresses after menopause
- increases in size with nuclear estrogen receptor
- multiple tumours seen in 2/3 with neoplasms
- progestins and pregnancy cause increase in size + haemorrhagic degeneration
SYMPTOMS:
- bleeding
- bladder compression
- sudden pain
- infertility
- spontaneous abortion
GROSS:
- beefy red appearance due to rapid growth and infarction
State the histological features of leiomyosarcoma.
1.nuclear atypia
2. necrosis
3. increased mitosis
4. haemorrhagic necrosis
5. well circumscribed
6. some invasion
7. homogenous
8. tan whorling mass
State everything you know about leiomyosarcoma.
- metastatises to brain/lungs
- 5 year survival is 40%
State the histological features of adenomyosis.
- Presence of endometrial tissue, glands and stroma within smooth muscle cells
State everything you know about adenomyosis.
ECTOPIC ENDOMETRIAL DEPOSITS IN MYOMETRIUM
- with accompanying overgrowth of muscle and connective tissue
TYPES:
1. Diffuse - deposits confined to inner part of myometrium
- foci of endometrium brownish in colour
2. Localised - resembling fibroid with brownish foci
State 5 causes of dysfunctional uterine bleeding
- uterine lesions (polyps, fibroids, cancer)
- pelvic inflammatory disease
- adenomyosis
- ectopic pregnancy
- hydatiform mole
- uterine leiomyoma
- endometritis
- trauma and sexual abuse
- medications
- foreign bodies
