Gynae-Gao Flashcards
1
Q
Adult granulosa cell tumors- uni or bilateral
A
Unilateral
2
Q
Mutation characteristic of adult granulosa cell tumors
A
FOXL2
3
Q
IHC to distinguish between granulosa cell tumors and thecomas
A
reticulin
4
Q
How do low grade serous and high grade serous differ?
A
- Mitotic rate higher in HGSC
2. Total absence of p53 IHC seen in HGSC rather than LGSC
5
Q
IUD removed, endometrial bx shows lymphoid follicles with increased plasma cells… what is true?
A
acute salpingitis often a/w this condition
6
Q
Examining hysterectomy labeled as “fibroid uterus”, single lesion found in myometrium. Dx of PECOMA made…. PECOMAS
A
- PECOMA is morpho/IHC similar to epithelioid AML, lymphangioleiomyoma, clear cell “ sugar tumors”
- Patchy HMB-45 positivity
- Can be positive for SMA and desmin
- NOT all PEComas are malignant
7
Q
Serous carcinoma vs. mesothelioma IHC
A
PAX8 (positive in serous, neg meso),
ER (positive in serous, neg meso),
Calretinin (positive in mesothelioma, neg serous);
WT-1 positive in both
8
Q
What can you NOT diagnose on endometrial curettage….
A
endometrial stromal nodule
9
Q
germline mutations in gynae tumors…
A
BRCA1- HGSC
SMARCA4- ovarian small cell carcinoma, hypercalcemic type
DICER1- sertoli leydig cell tumor
[FOXL2 is NOT germline]
10
Q
Ddx of elevated serum hCG
A
Choriocarcinoma
Molar pregnancy
Germ cell tumor
11
Q
Gynae tumors a/w Peutz-Jeghers
A
Endocervical gastric type adenocarcinoma
Adnexal mucinous neoplasms
Sex cord tumor with annular tubules
12
Q
Features of uterine adenosarcoma
A
- Leaflike architecture
- Sarcomatous overgrowth
- Rhabdomyoblastic differentiation
13
Q
LSIL a.w HPV
A
6 +11
14
Q
Can LSIL be a/w HPV 16/18?
A
YES….weird…..
15
Q
Feature to distinguish low grade endometrial stromal sarcoma from endometrial stromal nodule
A
INFILTRATIVE BORDER
16
Q
P53 and dVIN
A
P53 abnormal in dVIN, however it is difficult to interpret as a diagnostic IHC marker
17
Q
dVIN or uVIN more likely to progress to invasive carcinoma?
A
DIFFERENTIATED VIN
18
Q
Can benign leiomyomas have tumor cell necrosis?
A
NO.
19
Q
Is infiltrative border required for dx of leiomyosarcoma
A
NO.
20
Q
Can CD10 and desmin reliably distinguish smooth muscle tumor from endometrial stromal neoplasm?
A
NO.
21
Q
Gross characteristics of ovarian polycystic disease
A
rounded and slightly enlarged ovaries; bilateral disease usually
multiple small subcortical follicles, typically similar in size
22
Q
Micro features of PCOS
A
Fibrous and thick ovarian capsule
Hyperplastic ovarian stroma (+/- luteinized)
No stigmata of prior ovulation
23
Q
List nonneoplastic cysts found in the ovary
A
- Epithelial inclusion cyst
- Follicular cyst
- Corpus luteum cyst
- Endometriotic cyst
- PCOS
- Hyperreatico luteinalis
24
Q
Micro-epithelial inclusion cyst
A
single layer with flat to cuboidal to columnar lining (+/- ciliated)
< 1 cm (if >1cm serous cystadenoma)
25
Micro-follicular cyst
2.5- 10 cm
Uniloculated with an inner layer made of granulosa cells and outer theca cells
NOTE: large solitary luteinized follicular cyst of pregnancy and puerperium may show nuclear pleomorphism and hyperchromasia
26
Micro-corpus luteum cyst
lined by luteinized granulosa cells with an outer layer of luteinized theca cells
27
Micro-endometriotic cyst
Endometrial glandular epithelium lining the cyst, often denuded in areas
Underlying endometrial stroma and/or hemosiderin laden macrophages
28
Micro-hyperreactio luteinalis
Multiple follicular cysts with luteinized theca and granulosa layers
Edema within the stroma and theca layer
Luteinized stroma
29
When should the term "mixed carcinoma" of the ovary be used?
When 2 or more distinctive subtypes of surface ep carcinoma are identified
When each distinctive subtype represents >10% of the tumor
When the relative proportions should be specified
When this may have prognostic significance
30
Why NB to carefully examine the ovarian surface?
Important to stage tumors limited to the ovary, as surface involvement may influenze treatment
Patients with a fam hx of ovarian and/or breast cancer may have small carcinomas centered at the ovarian surface that are potentially lethal
31
Why is it important to know the integrity of the ovary, and whether there is a rupture?
If the tumor has ruptured, malignant cels may have spilled into the abdominal cavity
In tumors that have an admixture of benign, borderline, and/or malignant areas, it may also be NB to know which area is ruptured
32
Why is it important to classify epithelial tumors of the ovary based on histology?
Dif histo present at dif stages
Require dif tx/adjuvant tx
May have dif responses to CTX
Are different in prognosis and survival rate
33
CAP Ovarian tumors
```
Specimen
Procedure
LN sampling
specimen integrity
Primary tumor site
Ovarian surface involvement
tumor size
histo type
histo grade
implants
Extent of involvement of other tissues/organs
Peritoneal ascitic fluid
Pleural fluid
optional:
- LVI
- Tx effect
- additional path findings
- ancillary studies
- clinical history
```
34
How to gross omentum?
If tumor grossly identifiable, representative sections are enough.
For borderline tumors or immature teratoma with grossly apparent implants, multiple sections of the implants should be taken
Take 5-10 sections of grossly normal omentum
35
What is the important of LVI in ovarian epithelial carcinomas?
Presence or absence of LVI does NOT impact tumor staging
Prognostic significance has NOT been demonstrated
In some cases, such as otherwise well-differentiatedd mucinous carcinoma, the presence of LVI should raise suspicious for METASTATIC disease to the ovary
36
What is the most common histologic type of familial ovarian carcinoma?
High grade serous carcinoma
37
What is the mutation a/w HGSC
BRCA1/2
38
How should the ovaries and tubes be submitted in patients with BRCA mutations or with suspected increased risk of hereditary breast or ovarian cancer?
All ovarian and tubal tissue should be serially sections and submitted in toto-- ovaries are sectioned at 2-3 mm
SEE-FIM tubes:
- amputate distal fimbriated ends (2cm) and section parallel to long axis of fallopian tube to maximize the amount of tubal epithelium available available for histo exam
- remainder of the ft is submitted as serial cross sections as 2-3mm intervals
39
List the types of serous neoplasms of the ovary
1. Serous cystadenoma/ cystadenofibroma
2. Serous borderline tumors
3. SBT, micropapillary variant
4. LGSC
5. HGSC
40
Micro- serous cystadenoma
Cystic or papillary with broad papillae
| Single layer of ciliated cuboidal to columnar lining cells (similar to ft)
41
Micro-serous borderline tumors
Papillary branches with increased epithelial complexity
Stratified epithelial lining with tufting
Mild to moderate cytological atypia
Microinvasion: <5 mm based on WHO [others say <3mm or <10mm^2]
42
Micro-SBT micropapillary variant
```
Long, nonbranching, nonhierarchical papillae with very little stromal core
Cribiform pattern (may be present)
```
43
Micro- LGSC
Papillary or micropapillary, with stromal invasion
Psamomma bodies (may be present)
Low mitotic rate
No significant nuclear pleomorphism
44
Micro- HGSC
Heterogeneous patterns: complex papillary, solid, glandular
Significant cytological atypia, with bizarre nuclei
Markedly increased mitotic rate
45
Mgmt serous cystadenoma
Unilateral oophorectomy, no further tx
46
Mgmt borderline SBT
With or without noninvasive implants requires no further treatment; those with invasive implants require further staging/treatment
47
Mgmt serous carcinoma
Full staging
Postop chemotherapy
(sometimes neoadjuvant chemo)
48
Prognosis serous cystadenoma
100% survival
49
Prognosis SBT
Mixed prognosis; noninvasive implants (good prognosis), invasive implants (same prognosis as LGSC)
50
Prognosis LGSC
poor, tend to recur within a longer time period
51
Prognosis HGSC
poor, progress more rapidly
52
Significance of finding SBT in lymph nodes
Occurs in 1/3 of patients with SBT who had lymphadenectomy
Requires EXCLUSION of all of the following:
- endosalpingiosis involving lymph nodes
- psamommatous calcifications without epithelial cells
- nodal mesothelial hyperplasia
- metastatic LGSC involving lymph nodes
Definitive SBT in a lymph node is a/w more frequent invasive or noninvasive implants, but is NOT an independent prognostic fact
53
What are the two types of peritoneal implants a/w SBTs...
1. Noninvasive (including epithelial and desmoplastic)
| 2. Invasive implants
54
Significance of peritoneal implants in SBTs
Current literature suggests that the survival rate is nearly 100% for SBTs with noninvasive implants
SBTs with invasive implants have increased recurrence rates and are a/w worse prognosis, much like LGSC
55
Classification of endometrioid neoplasms of the ovary
Benign: endometrioid cystadenoma or cystadenofibroma
Borderline: endometrioid borderline tumor
Malignant: endometrioid adenocarcinoma
56
Name 1 benign finding a/w endometrioid neoplasms..
ENDOMETRIOSIS
57
Micro cystadenofibroma
Branching angular glands and cysts, usually resembling those of proliferative or minimally hyperplastic endometrium
+ fibrous stroma
58
Micro borderline endometrioid tumor
Spectrum of epithelial proliferation, glandular crowding, cytological atypica, resembling hyperplastic endometrium with or without atypia
Areas of microinvasion (<5mm) or intraepithelial carcinoma (possible)
59
Micro endometrioid adenocarcinoma
Morphologically resembles endometrioid adenocarcinoma of the endometrium
Has 2 main patterns of invasion:
1. Confluent or expansile growth pattern shows extensive glandular branching, budding, cribiform architecture and/or complex papillary proliferation
2. Destructive invasion
60
How to grade endometrioid adenocarcinoma of the ovary?
Numerous grading systems....
1. Silverberg grading system: based on architecture patterns, nuclear grade, mitotic activity
2. FIGO grading system: similar to endometrioid adenocarcinoma of endometrium
3. Binary nuclear grading system
61
Molecular alterations in endometrioid adenocarcinoma of ovary
AIRD1A, PTEN, PIK3CA, MMR, CTTNB1, TP53
62
CTTNB1 molecular alteration of endometrioid adenocarcinoma of ovary a/w....
Low grade tumor, often with squamous differentiation
63
TP53 molecular alteration of endometrioid adenocarcinoma of ovary a/w.....
High grade tumors
64
Prognosis of benign endometrioid tumors of ovary
EXCELLENT
65
Prognosis of borderline endometrioid tumors of ovary
EXCELLENT
66
Prognosis of malignant endometrioid adenocarcinoma of ovary
Better prognosis vs. serous carcinoma
A high proportion of endometrioid adenocarcinoma presents as stage I disease
The higher the FIGO stage, the worse the prognosis
5 year survival rate for patients with stage I tumors is >75%, compared to <10% for patients with stage IV tumors
67
What is the clinical significance of synchronous ovarian and endometrial primary endometrioid adenocarcinoma vs. metastatic endometrial adenocarcinoma to the ovary
Synchronous primary tumors are a/w excellent prognosis when the tumor is limited to the endometrium and ovary
68
Distinguishing metastatic endometrial endometrioid adenocarcinoma of the ovary from synchronous ovarian and endometrial primary adenocarcinomas....SYNCHRONOUS:
Myometrial invasion: superficial
LVI: absent
Endometriosis: present (+/- atypia)
Ovarian involvement: parenchymal location, solitary, unilateral
Spread of tumor to other locations: absent
69
Distinguishing metastatic endometrial endometrioid adenocarcinoma of the ovary from synchronous ovarian and endometrial primary adenocarcinomas.....METASTATIC:
Myometrial invasion: deep
LVI: present
Endometriosis: absent
Ovarian involvement: surface, small tumor, multinodular, bilateral
Spread of tumor to other locations: present
70
List the different types of clear cell neoplasms of the ovary:
Benign: clear cell cystadenoma or cystadenofibroma
Borderline: borderline clear cell tumor (rare)
Malignant: clear cell carcinoma
71
Name 1 associated benign finding for clear cell neoplasms of ovary
ENDOMETRIOSIS
72
Micro clear cell carcinoma of ovary
Patterns: solid, tubulocystic, mixed
Hobnailed cells with relatively uniform hyperchromatic nuclei, prominent nucleoli
Clear OR eosinophilic cytoplasm, with relatively low mitotic activity
Presence of hyaline globules or psamomma bodies (possible)
Hyalinized stroma
73
Ddx clear cell carcinoma of ovary
Serous carcinoma
Endometrioid carcinoma with clear cell changes
Yolk sac tumor
Dysgerminoma
Metastatic clear cell carcinoma from an extraovarian site
Steroid cell tumors
74
How to handle a cystic, mucinous ovarian mass at time of frozen section
- weigh and measure
- inspect capsule for intactness, record any surface lesions or rupture
- ink the outer surface
- cut and open as many cystic components as possible, if multiloculated
- examine for solid/papillary areas and submit more than 1 block for FS, if needed
75
How to handle a cystic, mucinous ovarian mass- GROSSING
- sample 1 block per cm of tumors greatest dimension, and any suspicious areas (solid, papillary, necrosis) more sections may be requires
- sample fallopian tubes
- assess any other tissue sent with ovarian mass and sample appropriately:
omentum/ uterus/cervix (endomyometrium with serosa)/ opposite ovary +/- ft, appendix and/or other tissue
76
Morphology of ovarian mucinous borderline tumor
- no invasive component or only microinvasion
- complex and stratified mucinous lining (seromucinous or intestinal types)
- papillary protrusions (possible)
- mild to moderate atypia
77
Top ddx of ovarian mucinous borderline tumor
Adenocarcinoma - primary or secondary
