GYNAE

Question 1

Features of vulval intraepithelial neoplasia: uVIN vs dVIN

Answer 1

• Premalignant intraepithelial squamous proliferation.
• uVIN 4th, 5th decades and HPV related; dVIN 7th, 8th decades and non-HPV related.
• uVIN micro & stains:
• Atypical parakeratosis with koilocytosis.
• Full or near full epithelial involvement.
• Squamous dysmaturation and crowding of cells.
• Small cells (basaloid variant) or large cells (warty variant). Pagetoid spread can occur.
• Nuclear enlargement, hyperchromasia and brisk mitotic activity/apoptosis.
• p16 + (strong, diffuse), ki67 + (upper layers). p53 wild type.
• DD: Condyloma (papillary, no p16 block+), vulvar SqCC, sebaceous ca (vacuolated cytoplasm, AR +), Paget’s (pale cytoplasm, GCDFP, CEA and CK7+) .
• dVIN micro & stains:
• Prominent parakeratosis and acanthosis; elongation and anastomosis of the rete ridges.
• Enlarged, hypereosinophilic keratinocytes with prominent intercellular bridges.
• Premature keratinization with keratin pearls.
• Prominent cytologic atypia of the basal layer.
• p53: continuous positivity in the basal layer. p16 -.
• DD: Lichen simplex chronicus, Lichen sclerosus, Hypertrophic Lichen Planus.

Question 2

Features of chronic endometritis

Answer 2

• Plasma cells required, often adjacent to lymphoid aggregates.
• Spindled stromal cells +/- stromal breakdown, +/- oedema.
• Weakly proliferative or out of phase/mixed pattern endometrium.
• Endometrial metaplasias: squamous or eosinophilic.
  Note:
  Plasma cells maybe patchy and they can be seen in endometrial polyps and endometrium overlying a leiomyoma. Clues: Difficulty dating endometrium (inflamed endometrium does not respond normally to hormones), streaming of stromal cells, clusters of Lo and Eo,

Question 3

List the mixed epithelial/mesenchymal tumours if the uterus

Answer 3

• Carcinosarcoma/MMMT.
• (Mullerian) Adenosarcoma.
• Carcinofibroma.
• Adenofibroma.
• Adenomyoma.

Question 4

Features of (Mullerian) Adenosarcoma

Answer 4

• Biphasic low-grade tumour composed of benign mullerian glands (rarely CIS) and low grade malignant stroma.
• Peri or post-menopausal. Hx of estrogen use of prior radiation therapy.
• Micro:
• Periglandular cuffing of low grade malignant stroma resembling endometrial or fibroblastic stroma often forming intraluminal polypoid projections.
• Glands with phylloides architecture, cystically dilated or less commonly small.
• Proliferative-type endometrial epithelium (most common) with variable cytologic atypia.
• Diagnostic criteria: >2 mitosis/10HPF with cuffing or cytologic atypia of stroma.
• Sarcomatous overgrowth: >25% of tumour composed of only neoplastic stroma, typically high grade.
• Ancillary tests: Stroma is ER, PR, CD10, WT1 +.
• DD: Cellular endometrial polyp, Endometrial stromal sarcoma with glands, embryonal rhabdomyosarcoma.

Question 5

Features of endometrioid adenocarcinoma

Answer 5

• Etiology: Unopposed estrogen stimulation or genetic susceptibility (Lynch syndrome or Cowden syndrome).
• Micro:
• Typically resembles proliferative endometrium with larger/irregular glands, back to back arrangement. May be cribiform or papillary.
• Variants: With squamous/mucinous/tubal differentiation, with secretory change, villoglandular (papillary), sertoliform, dediff.
• Grading based on the extent of solid growth (excluding squamous differentiation). <5%= FIGO Grade 1, 6-50%= FIGO Grade 2, >50%= FIGO Grade 3. Conspicuous cytologic atypia (at 10x) may upgrade by one grade.
• Often associated with EIN/atypical hyperplasia.
• Different patterns of myoinvasion: single gland, broad front, MELF, adenomyosis-like, adenoma malignum-like.
• IHC:
  ER/PR +, p53 and p16 - or patchy.
  PAX8, Vimentin, WT1 (variable) +.
  Napsin A -.