Gynecologic Pathology Flashcards
Cross section of fallopian tube, pathology?
Acute and chronic salpingitis
Ascending infection of STDs
Cross section of fallopian tube, pathology?
Acute and chronic salpingitis
Ascending infection of STDs
Identify this in context of a cervical biopsy?
What is this commonly associated with?
Follicular cervicitis (subepithelial follicular inflammation with a germinal center)
Chlamydia
Identify this in context of a vulvar biopsy? Etiology?
Describe features…
Gross?
Microscopic?
Is this a premalignant lesion?
Lichen Sclerosus, etiology unknown (autoimmune? Hormonal?)
Irregular white patches (itchy!)
The papillary dermis has marked sclerosis with band-like inflammation underneath (almost like the inflammation is being displaced downward because it can’t infiltrate the dense fibrous tissue)
It itself is not premalignant but can see those lesions in conjunction with it.
Identify this in context of a vulvar biopsy? Etiology?
Describe features…
Gross?
Microscopic?
Lichen Simplex Chronicus. Causes by repeated physical trauma (rubbing/scratching)
Hyperkeratosis and hypergranulosis with psoriasiform hyperplasia (elongation of the rete ridges, suprapapillary thining, spongiosis, fusion of rete). Sparse perivascular chronic inflammation.
Erythematous thickened and scaly papules or plaques
Identify this in context of a vulvar biopsy? Etiology?
Describe features…
Gross?
Microscopic?
Lichen Simplex Chronicus. Causes by repeated physical trauma (rubbing/scratching)
Hyperkeratosis and hypergranulosis with psoriasiform hyperplasia (elongation of the rete ridges, suprapapillary thining, spongiosis, fusion of rete). Sparse perivascular chronic inflammation.
Erythematous thickened and scaly papules or plaques
Identify this perianal lesion?
Describe?
What is the most common site from a gynecological perspective?
Hidradenoma Papilliferum
Complex growth of branching tubules (can have papillae and micropapillae). Often has an outer layer of myoepithelial cells and an inner layer of cuboidal to columnar cells with apocrine secretions.
Labia Major
Identify this lesion on the labia minora?
Describe?
What is the most common site of this lesion (from a gynecological perspective)?
Hidradenoma Papilliferum
Complex growth of branching tubules (can have papillae and micropapillae). Often has an outer layer of myoepithelial cells and an inner layer of cuboidal to columnar cells with apocrine secretions.
Labia Major
How would you diagnose this vulvar lesion?
Etiology?
What lifestyle habit is associated with this? What medical state?
Often multifocal or unifocal?
Relative age of patient?
Vulvar intraepithelial lesion, usual type (VIN 3)
HPV associated
Near full thickness atypia with absent maturation and high mitosis and apoptotic bodies
Smoking, being immunocompromised
Often multifocal
Younger (40-50)
How would you diagnose this vulvar lesion?
Describe?
Etiology?
What percentage progress to SCC?
Relative age of patients?
Vulvar intraepithelial lesion, differentiated type
Subtle, cytologic atypia of the lower layers (nuclear hyperchromasia, premature keratinization, prominent parakaratosis, elongation and anastomosis of the rete ridges)
This is associated with vulvar inflammatory disease (lichen sclerosis), but lichen sclerosis itself is not considered a premalignant lesion. Has p53 mutations (strong, basal staining).
90% (much much higher then the usual type, also faster)
Older (70-80 years)
- Diagnose this labial lesion?
Describe common features?
What subtype of HPV is associated with this?
What is the common age of presentation?
Prognosis?
Bowenoid Papulosis
Squamous atypia that can extend the entire layer of the epthelium. Can have koilocytic changes. It may appear microscopically identical to VIN, but grossly it looks more indolent (benign looking papules and macuoles).
HPV 16
This lesion presents in a slightly younger age group then VIN. This lesion is 20-40s, VIN is 40s-50s.
This lesion often regresses spontaneously, despite the terrible look under the microscope. Clinical correlation is key here. A minority of lesions can progress, especially in the older or immunocompromised patients.
Diagnose this labial lesion?
Describe common features?
What subtype of HPV is associated with this?
What is the common age of presentation?
Prognosis?
Bowenoid Papulosis
Squamous atypia that can extend the entire layer of the epthelium. Can have koilocytic changes. It may appear microscopically identical to VIN, but grossly it looks more indolent (benign looking papules and macuoles).
HPV 16
This lesion presents in a slightly younger age group then VIN. This lesion is 20-40s, VIN is 40s-50s.
This lesion often regresses spontaneously, despite the terrible look under the microscope. Clinical correlation is key here. A minority of lesions can progress, especially in the older or immunocompromised patients.
- Diagnose this vulvar lesion?
What condition can this be associated with?
Describe histological features?
Verrucous carcinoma
Can be associated with lichen sclerosus (just like VIN, differentiated variant)
This mix of unusual histological features includes very well differentiated squamous cells with thick acanthotic papillae and think fibrovascular cores. The papillae are superated by keratin filled “craters” with prominent orange keratin. One key feature is pushing, club-shaped/bulbous borders. As you can see in the closer up picture, the squamous cells are bland (prominent nucleoli and vesicular nuclei look more reactive then anything.
Diagnose this vulvar lesion?
What condition can this be associated with?
Describe histological features?
Verrucous carcinoma
Can be associated with lichen sclerosus (just like VIN, differentiated variant)
This mix of unusual histological features includes very well differentiated squamous cells with thick acanthotic papillae and think fibrovascular cores. The papillae are superated by keratin filled “craters” with prominent orange keratin. One key feature is pushing, club-shaped/bulbous borders. As you can see in the closer up picture, the squamous cells are bland (prominent nucleoli and vesicular nuclei look more reactive then anything.
- Identify this vulvar lesion?
Describe the histology?
What stains can you use to confirm? (4) What stains could you do to evaluate for your 2 most common differentials?
Extramammary Paget Disease
You have small nests or single cells confined to the basal and parabasal layers (may have extension higher), can have pale cytoplasm and vesicular nuclei.
For primary extramammary paget you would have CK7, GCDFP-15, MUC1, and MUC5 positive.
For insitu and invasive SCC with intradermal spread you would have CK5/6 and p63
For superficial spreading melanoma and melanoma in situ you would have lots of choices (MART-1, Melan-A, HMB-45)
- What is the second most common malignant neoplasm of the vulva?
Melanoma.
How would you diagnose this vulvar lesion?
Describe?
Mucosal melanocytic macule
Often an illdefined lesion. Microscopic examination shows increased pigment but not increased melanocytes. You can have some melanocytic hyperplasia in rare cases (see picture and arrows) but should not have atypia.
Identify this vulvar lesion?
What 3 stains could help your diagnosis?
Malignant melanoma.
S100, MART-1/Melan-A, HMB45,
Irregular nests and cords of tumor cells deeply infiltrating the dermis with associated pigment. You can see the intraepidermal component at the top.
- Identify this vulvar mass lesion biopsy?
Describe the typical feature?
What immunostain(s) could help you?
How would you differentiate this from other similar lesion(s)?
Angiomyofibroblastoma
This is a stromal tumor (benign) composed of numerous capillaries and myofibroblasts. There are hyper and hypo cellular zones, with the stromal cells tending to cluster around vessels.
Desmin positive, often ER and PR positive
Aggressive angiomyxoma: Stromal cells can be desmin positive, larger and thicker blood vessels, infiltrative
Superficial angiomyxoma: Desmin negative, smaller and thin-walled vessels, multinodular but well demarcated
Angiofibroblastoma: Desmin positive, thin walled vessels, well demarcated
- Identify this vulvar mass lesion biopsy?
Describe the typical feature?
What immunostain(s) could help you?
How would you differentiate this from other similar lesion(s)?
Angiomyofibroblastoma
This is a stromal tumor (benign) composed of numerous capillaries and myofibroblasts. There are hyper and hypo cellular zones, with the stromal cells tending to cluster around vessels.
Desmin positive, often ER and PR positive
Aggressive angiomyxoma: Stromal cells can be desmin positive, larger and thicker blood vessels, infiltrative
Superficial angiomyxoma: Desmin negative, smaller and thin-walled vessels, multinodular but well demarcated
Angiofibroblastoma: Desmin positive, thin walled vessels, well demarcated
Identify this vulvar mass?
Describe?
What stain(s) may help in your diagnosis?
What is the prognosis?
(Deep) Aggressive Angiomyxoma
An infiltrative hypocellular tumor with a myxoid matrix containing bland, spindle cells and medium to large sized vessels with thin and thick walls. It can also have collections of smooth muscle “myoid bundles”
In contrast to the superficial angiomyxoma, this tumor involves deep soft tissues and has an infiltrative pattern with large and medium sized vessels. The superficial angiomyxoma has lobulated growth with well-demarcated borders and smaller blood vessels.
Desmin +, also typically positive for SMA, ER, and PR
Favorable, but can be locally devastating with reoccurrence and destruction if not completely excised.
Identify this vulvar mass?
Describe?
What stain(s) may help in your diagnosis?
What is the prognosis?
(Deep) Aggressive Angiomyxoma
An infiltrative hypocellular tumor with a myxoid matrix containing bland, spindle cells and medium to large sized vessels with thin and thick walls. It can also have collections of smooth muscle “myoid bundles”
In contrast to the superficial angiomyxoma, this tumor involves deep soft tissues and has an infiltrative pattern with large and medium sized vessels. The superficial angiomyxoma has lobulated growth with well-demarcated borders and smaller blood vessels.
Desmin +, also typically positive for SMA, ER, and PR
Favorable, but can be locally devastating with reoccurrence and destruction if not completely excised.
Identify this vaginal lesion….
Describe?
Mullerian cyst
Single layer of columnar epithelium (can be endocervical, ciliated, or endometrioid type)
- Identify this vaginal lesion….
Describe?
What are these often associated with?
Squamous cyst
Lined by stratified squamous cells with bland morphology
Prior surgery
Identify this vaginal lesion….
Describe?
Where are they located? What do they arise from?
Gartner cyst
Single layer of cuboidal to columnar epithelium
Typically located in the lateral vaginal wall, these are mesonephric duct remnants
Identify this vaginal lesion?
Describe?
What is a risk factor for this?
- What areas does this typically effect?
What is the natural history of this lesion?
Vaginal adenosis
Typically at the surface or superficial LP, simple or cystic glands
DES exposure in utero (can happen sporadically, but most have DES exposure)
Upper 1/3 and anterior wall of vagina
Can be associated with clear cell carcinoma, increased risk for VAIN.
Identify this vaginal lesion
What is a common risk factor?
Describe typical features…
Clear cell adenocarcinoma of the vagina
Prior DES treatment is a common risk factor
Variable patterns, most commonly tubulocystic . Can also be papillary (second pic). Clearing of the cytoplasm, hobnailing, atypical nuclei with prominent nucleoli.
Identifiy this vaginal lesion in a 3 year old girl..
Embryonal rhabdomyosarcoma
(Sarcoma botryoides)
Identifiy this vaginal lesion in a 3 year old girl..
What type of IHC stains help with this diagnosis?
Describe the histology
Embryonal rhabdomyosarcoma
(Sarcoma botryoides)
Skelatal muscle markers
Multiple polypoid projections of malignant mesenchymal cells, these mesenchymal cells are usually more cellular/condensed around the surface epithelium. These cells can also have cross-straiations, in keeping with their muscle origin.
What viral protein expression causes koilocytosis?
What viral protein interacts with p53? Rb?
What HPV subtypes are associated with LGSIL?
What are high risk HPV subtypes (2)?
E4
p53-E6
Rb-E7
Remember that “p” comes before “r” in the alphabet like 6 comes before 7.
HPV 6, 11
HPV 16, 18
Identify this lesion?
What is this commonly associated with?
Decribe common features?
Microglandular hyperplasia- Benign, nonneoplastic endocervical glandular hyperplasis
Often associated with hormone exposure or high hormone states (pregnancy, OCPs, hormone replacement)
Tightly packed glands with intervening stroma containing variable amounts of acute and chronic inflammation
Identify this lesion?
What is this commonly associated with?
Decribe common features?
Microglandular hyperplasia- Benign, nonneoplastic endocervical glandular hyperplasis
Often associated with hormone exposure or high hormone states (pregnancy, OCPs, hormone replacement)
Tightly packed glands with intervening stroma containing variable amounts of acute and chronic inflammation
What HPV subtypes are typically associated with AIS?
HPV 16 and 18.
What effect does estrogen alone have on the endometrium?
OCPs and Progesterone?
Hyperplasia and eventually carcinoma
Stromal decidualization and small atrophic glands
What is the FIGO grading scale with endometrial adenocarcinoma?
How does cytology fit into this system?
Grade 1: 5% or less solid growth
Grade 2: 6-50% solid growth
Grade 3: Greater then 50% solid growth
Notable nuclear atypia can raise it one grade level
Identifiy this lower uterine segment mass?
Define
Atypical polypoid adenoma
A biphasic millerian tumur composed of endometrioid glands and fibromuscular stroma.
The glands can become neoplastic but the stroma is benign.
Define this lesion?
What are the common features?
How does this stain IHC wise?
High grade endometrial stromal sarcoma
Highly cellular tumor (blue appearence) with a high grade component consistenting of epithelioid cells with eosinophillic cytoplasm and nuclear atypia, often highly actively mitotic. Often has a prominant delicate capillary network
Will stain for cyclin D1 diffusely and strongly
Often CD117 positive
Negative for CD10, ER, PR
The low grade ESS is the opposite, with positivty for CD10, ER, PR and negativity for CD117 and cyclin D1 (only patchy positive)
Define this lesion?
What are the common features?
How does this stain IHC wise?
Low grade endometrial stromal sarcoma
Unlike the high grade version, the low grade is composed of uniform small blue cells without much cytoplasm (the high grade has epitheliod cells with more cytoplasm), Often displays arterioles as well.
Positve for CD10, ER, PR
Negative for CD117 and Cyclin D1 (unlike high grade ESS)
What are some of the key differentiating features of leiomyosarcoma?
Coagulative tumor necrosis (can still make out cell borders and ghost cells, unlike hyalinizing necrosis)
Infiltrative borders (sometimes not as well circumscribed
Cellular
Nuiclear atypia,
Mitotic activity (>10/10 HPF)
Identify this uterine lesion?
Leiomyosarcoma
Describe this endometrial lesion…
Classic features?
Endometrioid adenocarcinoma with villoglandular features
Elongated, slender papillae with pseudostratified epithelium
What could the following lesion represent?
How would this appear under the microscope?
Ovarian torsion, notice the dusky dark red discoloration
Only blood and inflammatory cells, a nonspecific finding, see picture below
What would the appearance of the ovaraies be in Turners syndrome? Contrasted with normal ovaries?
These ovaries would have fibrous “streaks” instead of follicles
What is this?
Define?
What stain could help you to identiify? (Especially in mets
What are the two most common areas of mets?
Choriocarcinoma
A dimorphic tumor composed of cytotrophblasts and syncytiotrophoblasts
B-HCG will stain the syncytiotropoblasts strongly, with weak staining of the cytotrophoblasts
Vagina (50% of cases)
Lungs (75% of cases)
These can be found in both molar and regular (term) pregnancies, more common in molar
What is the most common ovarian tumor? Second most common? Third most?
1st: Surface epithelial tumors
2nd: Germ cell tumors
3rd: Sex cord-stromal tumors
Identifiy this ovarian tumor
What type?
Serous borderline tumor
Hierarchical branching of papillae with detached cell clusters (arrow)
Identify?
What type?
Serous boderline tumor
Micropapillary type (long, delicate papillae, LONGER THEN WIDE)
In fact, this pattern can look very much like a low grade tumor with those delicate micropapillae, the low grade will have prominant nucleoli.
Diagnose this ovarian tumor
Features
What key stain is used to help diagnose these?
Clear cell carcinoma
Here you can see the hobnail cells (there are also multinucleated giant cells in this one, but that’s pretty rare for clear cell carcinoma)
Can have variable growth patterns including tubulocystic, papillary, and solid.
Napsin A
Diagnose this ovarian tumor
Brenner tumor
These are infiltrating sheets of cells with streaming nuclei with lots of nuclear grooves. The vast majority are benign. Often an incidental finding.
Diagnose this tumor?
What are some characteristic features as far are architecture and cytology?
What stain(s) can be helpful?
Granulosa cell tumor
Mixture of patterns, most common is diffuse, followed by trabecular. The Call-Exner bodies are the characteristic feature rounded spaces filled with a proteinacious fluid. Nuclear grooves are often present (see picture)
Inhibin, calretinin, FOXL2
What is the diagnosis (Ovarian tumor)
Juvenile Granulosa Cell Tumor
Variably shaped follicles filled with basophillic material.
This differs from the adult version as the granulosa cells tends to lack nuclear grooves, and the theca cells tend to be more spindled then the granulosa cells. Also usually more mitotically active
Diagnosis?
What does this stain for? What other tumor of the ovary has this pattern?
Thecoma. A stromal tumor composed of cells resembeling thecal cells from an ovarian follicle.
Granulosa cell tumor
Can also be luteinized (picture below)
What is the diagnosis of this ovarian tumor? Describe?
What other tumors does this stain like from the ovary?
A sex-cord stromal tumor with sertoli and leydig cells. The Sertoli cells typically line hollow tubules and there are clusters of leydig cells. The background is often fibrotic.
Like thecomas and granulosa cell tumors, stains with inhibitin and calretinin. FOXL2 may have positivity in all these tumors.
What is this ovarian tumor?
What syndrome is it associated with?
Sex cord stromal tumor composed of sertoli cells with rare to absent leydig cells (sertoli cells make little tubules, groups of them often form a nodular pattern with thin fibroconnective septa.
Peutz-Jeghers
What is this ovarian tumor?
What clinical symptoms can patients experience with this?
Leydig cell tumor
Polygional cells in sheets, nodules (also cords and nests). Will see the characteristic intracytoplasmic Reinke crystals.
Elevated serum testosterone and androgenic symptoms
What is this tumor of the ovary?
What are some stains that will help?
Dysgerminoma
Nests of tumor cells seperated by fibrous septae (lymphocytes in the fibrous septae)
OCT4 (membranous), SALL4 (nucelar), CD117 (membranous), PLAP
What is this ovarian tumor?
What is in classification?
Network of irregular reticular channel expanding to form cysts. Can have papillary structures with central blood vessels (Schiller-duval bodies) buit these are only in about 1/3 of these tumors.
Germ cell tumor of the ovary
What is this ovarian tumor?
What stains can help?
Embryonal carcinoma
A germ cell tumor composed of undifferentiated epithelial cells with marked atypia and a variety of growth patterns.
Cytokeratins, PLAP, OCT3/4, CD30, Sall4, SOX2
What is this ovarian tumor?
Describe?
Stains?
Nongestational choriocarcinoma
Mixture of cyto and syntiotrophoblast cells, also dilated vasculature and “blood lakes” as seen in the picture.
Both the syntio and cytotrophoblasts wiill stain with CD10 and pan keratin. The Syntio will stain with HCG too.
What is this ovarian mass>
Cystic teratoma
Diagnosis this ovarian tumor?
Struma ovarii
Monodermal teratoma (most common) Can be malignant but still has an excellent prognosis.
What is this ovarian tumor?
Immature teratoma, note the immature, primitive neural components
What is this ovarian tumor?
Gonadoblastoma
A mixed germ cell-stromal tumor. Often variably sized nests of primitive germ cells and sex cord cells in a fribotic stroma.
What is this ovarian tumor?
What syndrome is this often associated with?
What stains can help with this?
Small cell carcinoma of the ovary, hypercalcemic type
Undifferentiaed ovarian carcinoma with small blut cells, can also form a tightly nested pattern (picture below)
Paraneoplastic hypercalcemia
CAM 5.2, patchy pankeratin
What is this ovarian tumor? (also seen in cervix, corpus)
High grade sarcoma and carcinoma components that are admixed.
p16 and p53 often positive in both components Many other stains can be positive depending on the differentiation of the tumor.
What is this placental pathology?
Meconium-stained placenta
Feces, meconium laden macrophages and/or globular pigment. The amnion may have columnar reactive changes with loss of nuclear basophilia.
What is this placenta pathology?
What important risk factor increases the chance of this?
Villi and basal fibrin adhere to myometrium without a decidual layer.
Note that there is not decidualized endometrium and myometrium is not thined.
C sections
What is placental increta?
Invasion of the myometrium by placental villi
What is this placental pathology?
Placenta percreta, notice that that there is not myometrium anymore, the only thing between the placenta and the pelvix cavity is fat (serosa).
What is the differences between a complete and partial hydatidiform mole?
Partial: Evidence of fetus, 2 villous populations, a small minority have central cisterns
Complete: No evidence of fetus, one enlarged population, practically all villi have cisterns
Tips to remember
COMPLETELY NO FETUS, COMPLETELY LARGE VILLI, COMPLETELY CISTERNS
What type of hydatiform mole is this? (Evidence of fetus was present)
Partial mole, notice the mixed villi, only one of which has a cistern (practically all will with a complete mole)
Partial: Evidence of fetus, 2 villous populations, a small minority have central cisterns
Complete: No evidence of fetus, one enlarged population, practically all villi have cisterns
Tips to remember
COMPLETELY NO FETUS, COMPLETELY LARGE VILLI, COMPLETELY CISTERNS
What type of hydatiform mole is this? (No evidence of fetus)
Complete mole, only one type of villi,they all have cisterns
Partial: Evidence of fetus, 2 villous populations, a small minority have central cisterns
Complete: No evidence of fetus, one enlarged population, practically all villi have cisterns
Tips to remember
COMPLETELY NO FETUS, COMPLETELY LARGE VILLI, COMPLETELY CISTERNS
