OBGYN PATH Flashcards
What cell does HPV infect for cervical cancer
HPV infects basal cells of squamous epithelium of cervix.
HPV 16 – 60%
HPV 18 - 10%
Only a small proportion of HPV infections progress to cancer.
Low grade squamous intraepithelial lesion (LSIL):
- affects which part of cervix ?
- Prognosis
- Mild dysplasia in lower third only
- Most regress, 10% will become HSIL but does not progress to cancer (not pre-malignant lesion)
High grade squamous intraepithelial lesion (HSIL):
- affects what thickness of cervix ?
- prognosis ?
- Moderate to severe dysplasia 2/3 or more of the epithelial thickness
- Pre-malignant lesion - 10% progress to cancare
- Takes several years to a decade usually
Cervical cancer nodal spread pattern ?
- Tends to spread locally.
- Lymphatic spread to pelvic then para-aortic nodes.
Stage 3 cervical cancer defined as:
Stage 3:
- Carcinoma to pelvic sidewall or lower 1/3rd of vagina.
- Hydronephrosis
Stage 4:
- Beyond true pelvis. Into bladder or rectum.
- Distant mets.
Prognosis of Cervical cancer
- Most die of local complications like hydronephrosis, pyelonephritis or uraemia.
Ectopic pregnancy consists of what % of total pregnancy ?
2%
Most common site for ectopic pregnancy
Ampulla
Ectopic pregnancy RFs
Top 3:
- IUD
- Peritubal Scars (appendicitis, diverticulitis, surgery)
- PID
Microscopic finding of Ectopic pregnancy
Micro: chorionic villi and trophoblast invade the tubal wall.
Death rate of Ectopic pregnancy ?
Accounts for 5-10% (Robbins) of all pregnancy related deaths.
When is medical therapy viable for ectopic pregnancy
< 3 cm in size, beta-HCG < 3000, not live and not ruptured.
Most common female genital tract cancer
Endometrial cancer most common
Type 1 vs Type 2 endometrial cancers
Type 1 (more common)
- 80%
- due to hyperplasia
- can show squamous differentiation
- mimic proliferative endometrial glands
- PTEN mutation
- DIRECT INVASION with late nodal and hematogeneous mets
Type 2
- 20%
- due to atrophy
- includes Serous, Clear cell, Carcinosarcoma and Mixed mullerian tumor*
- poorly differentiated
- p53 mutation
- TRANS-TUBAL SPREAD to peritoneum and lymphatics
Endometrial cancer RFs
Type 1 risk factors mostly related to Hyperestrogenism:
- Obesity, Infertility, Unpposed estrogen, Nulliparity, late menopause, PCOS, Tamoxifen
- Diabetes and Hypertension***
- HNPCC and Cowden
Most common site of Endometriosis
Ovary
Micro and macro of Adenomyosis
Macro:
- Focal or diffuse. More often in posterior wall when asymmetrical.
- Enlarged globular uterus.
- Cut surface : blood filled cystic spaces may be seen.
Micro:
- Nests of endometrial tissue in the myometrium with surrounding smooth muscle hypertrophy.
- At least 3 mm separated from the basalis
Adenomyosis epi
- seen in reproductive women
- rare in post menopause, often regresses
- seen microscopically in 5-70% of hysterectomy specimens
Adenomyosis vs Enddometriosis histology difference
- Adenomyosis mostly made of basal layers of cells while endometriosis is mostly made of the functional
layers. - They are closely related but slightly different conditions.
Classification of Gestational Trophoblastic Disease
Molar pregnancy
- Complete mole (Diploid)
- Partial mole (Triploid)
- Invasive mole (Penetrates uterine wall)
Choriocarcinoma
- Neoplasm of trophoblasts without villi
Placental site trophoblastic tumour (PSTT)
Molar pregnancy Epi
- Two ends of reproductive life (teenager or 40s)
Clinical presentation of Molar pregnancy
- Spontaneous miscarriage
- Enlarged uterus
- Abnormal bleeding
Complete mole features
- Fertilisation of empty ovum by 1 or 2 sperm (all paternal genetic material)
- 90% are 46XX from one sperm
- 10% when fertilized by two sperm can be 46XX or 46XY (heterogeneous complete mole)
- can become invasive mole
- Small risk of Choriocarcinoma
Partial mole features
- Fertilisation by two sperm
- Triploid 69XXX, XXY or XYY
- can become invasive mole
- NO increased risk of choriocarcinoma*
Invasive mole features
- Arise more commonly from complete mole
- Invasion of myometrium by hydropic villi and trophoblastic tissue
- The hydropic villi may embolise to distant sites but do
not grow and eventually regress. - Good response to chemotherapy.
Complete mole morphlogy?
- Completely filled with Hydropic Villi
- Looks like cluster of grapes
- NO fetal parts
- Theca lutein cysts in ovaries
Partial mole morphology ?
- Less trophoblastic hyperplasia than complete mole
- Only partly grape-like
- HAVE fetal parts
Complications and prognosis of Complete mole
Complete mole: 15% risk of invasive mole, 2.5% risk of choriocarcinoma
Complications and prognosis of Partial mole
increased risk of invasive mole, but less than with complete moles.
No increased risk of choriocarcinoma.
Invasive mole Complication and prognosis
Good response to chemotherapy.
Rarely requires hysterectomy if uterus ruptures.
How long should b-HCG be monitored for after molar pregnancy removed
Beta-HCG monitored for 1 year after molar pregnancy removed.
What can Choriocarcinoma arise from ?
- Molar pregnancy (most common)
- Normal pregnancy
- Prior abortion
- Ectopic pregnancy
malignant neoplasm of trophoblastic cells
Choriocarcinoma clinical presentation and b-HCG level compared to Molar pregnancy
- PV bleeding and very high beta-HCG levels, even more than molar pregnancies.
- Often metastatic at diagnosis but gestational choriocarcinoma is highly chemosensitive with excellent survival.
Placental Site Trophoblastic Tumour Epi
- Rare neoplasms, less than 2% of GTD.
- Often follow a normal pregnancy. The rest are after spontaneous miscarriage or molar pregnancies
(Ddue to proliferation of extravillous (intermediate) trophoblasts)
Placental Site Trophoblastic Tumour b-HCG level and prognosis ?
- Produce human placental lactogen, with only moderate beta-HCG elevation.
- Overall good prognosis but 10-15% mortality from metastases.
Leiomyoma epi
- found in 75% of older women
- gets smaller with menopause as its hormonally responsive
Which placental accreta spectrum disorder most common ?
- Placental accreta (most common)
- Placental percreta (most rare and severe)
Placenta accreta spectrum disorders RF ?
Prior C-section (also same RF for placental previa)
Cyst within a cyst appearance in a normal fetus pelvis, Diagnosis ?
- Ovarian cyst
Twin-to-twin transfusion syndrome (TTTS) only occurs in what ?
- Monochorionic (either MCDA or MCMA) twin pregnancy.
When evaluating fetal head size with biparietal diameter (BPD) and head circumference (HC), what is diagnostic of idiopathic dolicocephaly?
Small BPD and normal HC
- Idiopathic dolichocephaly is a narrow head which is otherwise normal (small BPD and normal HC).
- If the HC is also small, then microcephaly may be present and is considered abnormal.
- A wide head (large BPD) is brachycephaly and is probably normal if the HC is normal.
Radial ray malformation classically associated with ?
Trisomy 18
Features of Cervical Insufficiency
- Bulging of fetal membrane into a widened internal os (most reliable sign) “hour glass appearance if complete bulging”
- Cervical canal shortening: <3 cm
- Risk for pre-term delivery
- A large intraplacental mass with abundant vascular flow near the umbilical cord insertion site.
- Cardiomegaly.
Diagnosis ?
Diagnostic for a placental chorioangioma.
In addition, the extra finding of cardiomegaly in the fetus reflects the associated high output heart failure and hydrops, which can be seen with large chorioangiomas.
most likely cause of oligohydramnios developing in the 3rd trimester?
Placental insufficiency
- Oligohydramnios associated with placental insufficiency is common and is associated with late-onset fetal growth restriction.
Bladder outlet obstruction: cause oligohydramnios presents much earlier.
Gestational diabetes is associated with polyhydramnios.
Placental abruption is associated with bleeding and preterm labor.
Classic features:
Choroid plexus cyst
Atrioventricular septal defect
Holoprosencephaly
Cystic hygroma
Turners: Cystic hygroma, often with hydrops (monosomy X)
Trisomy 21: Atrioventricular septal defect
Trisomy 18: Choroid plexus cysts, Clenched fist
Trisomy 13: Holoprosencephaly, polydactyly, omphalocele
What does placental abruption look like ?
- Acutely thickened placenta
- Heterogeneous mass like appearance
Endocardial fibroelastosis
- appearance and association ?
- Brightly echogenic appearance of the left ventricular lining seen in association with hypoplastic left heart syndrome.
Rhabdomyoma
- appearance ?
- discrete, homogenous, echogenic mass in the myocardium at the apex of the right ventricle
Is Cell-free DNA testing, also known as noninvasive prenatal testing (NIPT) used for ?
Cell-free DNA testing, also known as noninvasive prenatal testing (NIPT) is a screening test for common aneuploidies.
It is not a diagnostic test. Amniocentesis and chorionic villus testing is diagnostic and invasive.
Lemon shaped head, diagnosis ?
Chiari II
- Posterior fossa compression is key finding
- Ventriculomegaly (common and progressive)
- Frontal bone concavity (lemon sign)
- Associated findings in 40%
- Can be diagnosed in 1st trimester
Mature teratoma variant ?
Struma Ovarii (Monodermal subtype of teratoma)
- more than 50% of the tumour should be composed of thyroid tissue
- ALWAYS unilateral
- Hyperthyroidism
*the other monodermal teratoma is carcinoid
Mature teratoma complications
- Ovarian torsion
- Rupture with peritonitis
- Malignant degeneration (1%)
- Limbic encephalitis
- Gliomatosis peritoneii
Immature teratomas mean age ?
18
Immature teratoma prognosis
- Mets at time of diagnosis
- Good prognosis however with no recurrence
Name the malignant OVARIAN germ cell tumors
- Dysgerminoma
- Choriocarcinoma
- Embryonal cell tumor
- Yolk sac tumor
Dysgerminoma mean age ? Prognosis ?
- 20-40 (equivalent to male seminoma)
- Chemosensitive so survival >80%
Dysgerminoma risk factor ?
- Gonadal dysgenesis
Yolk sac micro and macro appearance ?
- Heterogeneous
- Schiller-Duval bodies
Choriocarcinoma germ cell Histology ?
- Trophoblasts*
Choriocarcinoma prognosis ?
- Mostly FATAL
- not responsive to chemotherapy
- Ovarian choriocarcinoma much more resistant to Placental counterpart*
Embryonal cell carcinoma mean age ?
- 15
- bHCG high
- AFP sometimes high
- Highly malignant
Sex cord stromal tumors ?
- Granulosa cell tumor
- Fibroma/Thecoma/Fibrothecoma
- Sertoli Leydig cell tumor
Granulosa cell tumor epi
- more common after menopause
- 95% adults
Granulosa cell tumor secrets ?
- Estrogen high (precocious puberty, proliferative breast disease, endometrial hyperplasia and ca)
- Inhibin high
- Androgen (rarely)
Granulosa cell tumor prognosis
- Usually indolent
- 10 year survival rate is 85%.
Granulosa cell tumor micro appearance ?
- look like immature follicles are seen (Call-Exner bodies).
Fibroma/Thecoma/Fibrothecoma
- Micro ?
Contain mixed amounts of fibroblasts (fibroma) or spindle cells (thecoma).
Fibroma/Thecoma/Fibrothecoma
- associations ?
- Meigs syndrome (ascites, right hydrothorax)
- Associated with Basal Naevus Syndrome
Sertoli-Leydig Cell Tumours secrets ?
- Mostly androgens = Masculinization
- Rarely secrets estrogen
Sertoli cell usually hormonally silent
Sertoli-Leydig Cell Tumours looks like what other tumor ?
- Looks like granulosa cell tumor, golden yellow
- Unilateral
Ovarian surface epithelium stromal tumors
- Serous
- Mucinous
- Endometroid
Most common Ovarian epithelial stromal tumor ?
- Serous cystadenoma/adenocarcinoma
Serous ovarian tumor mostly benign or malignant ?
- Benign (70%) mostly
What does high grade ovarian serous tumor arise from ?
- pre-cursor leasion called STIC lesion (serous TUBAL intra-epithelial carcinoma)
- Arises in fallopian tube or arise in Ovarian cysts
- May become another entity called Primary Peritoneal Serous Carcinoma*
Serous ovarian tumor unilateral or bilateral
- Bilateral (malignant tumor more likely bilateral)
Serous ovarian tumor RFs vs Mucinous ovarian tumor ?
SEROUS
- Nulliparity or low parity (more ovulations damages surface epithelium more).
- BRCA1, BRCA2
- HRT
MUCINOUS
- Smoking and BMI only***
Mucinous ovarian tumor special histology ?
Most demonstrate gastric or intestinal
differentiation.
Macro appearance of Serous vs Mucinous ovarian tumor ?
Serous
- Unilocular
- Psamomma bodies
- Papillary projections
Mucinous
- Multilocular
- Large
- Lining of columnar epithelial cells with apical mucin vacuoles
- intestinal differentiation
Endometroid tumor bilateral or unilateral
- Bilateral (40%)
Which ovarian tumor are solid ?
Transitional cell (Brenner)
- Homogeneous*
- Cells resemble Urothelium*
Malignant Mixed Mullerian Tumour (MMMT)
- Heterogeneous
- sarcomatous elements. Often has cartilage.
- Worst prognosis
Which tumors associated with endometriosis and endometrial carcinoma ?
- Endometroid tumor
- Clear cell tumor
Testicular germ cell tumor RFs?
- Crytorchidism
- Hypospadias
- FHx
- NOT Klinefelters (although they have a 50x increased risk of mediastinal germ cell tumours).
What’s the precursor lesion of most Testicular germ cell tumor ?
Most testicular germ cell neoplasms arising from a precursor lesion called intratubular germ cell neoplasia, with the exception of paediatric yolk sac tumours, teratomas and spermatocytic. Believed to arise in utero and stay dormant until puberty.
Which stage do Seminomas mostly present as
Stage 1:
- Contained in testis, epididymis or spermatic cord only (surgery is cure)
Extra stuff:
Stage 2:
- Distant spread to retroperitoneal nodes below diaphragm only (cure rate also 95%)
Which testicular carcinoma has worst prognosis
Choriocarcinoma
Spermatocytic Seminoma Prognosis ?
- It is a rare slow growing tumour affecting older men (65+) which rarely metastasises and has excellent
prognosis
Do Seminomas often go through Tunica Albuginea ?
- No (c.f. Embryonal Carcinoma: Smaller than seminoma and often go through tunica albuginea. Cut surface appears as a variegated haemorrhagic mass with necrosis and poorly defined margins)
Seminoma stains + for what ?
- KIT + (c.f. Embryonal carcinoma is KIT -)
Most common pure GCT in infants and young children, up to around age 3 ? Prognosis ?
Yolk Sac Tumor
Good prognosis in this age group. Mixed in adults.
Testicular Embryonal Carcinoma bHCG andd AFP levels ?
- Can express both beta-HCG and AFP.
Yolk Sac Tumour (Endodermal sinus tumour) Micro and Macro /
- Homogeneous
- Keyword: Schiller-Duval bodies which are structures resembling endodermal sinuses.
Testicular choriocarcinoma MACRO and MICRO
- No testicular enlargement, Small nodule <5cm
- 2 cell types: syncytiotrophoblasts and cytotrophoblasts
Complication of Testicular teratoma
- Can degenerate into malignant non-germ cell tumours. Most often these are SCC, adenocarcinoma
or sarcoma. These secondary tumours are often resistant to chemo and require excision.
Which sex cord stromal tumor most likely hormonally active ?
Leydic cell tumor (benign, same as Sertoli)
- secrets androgen, estrogen or even corticosteroids
- gynaecomastia or precocious puberty
most common testicular tumour in men aged > 60 ?
NHL
- Clinically mimics other tumours with a painless mass. May have systemic involvement.
- Diffuse large B cell > Burkitt > NK/T cell lymphoma.
- Testicular lymphomas have increased propensity for CNS involvement
IUGR Ultrasound findings
reduced abdominal circumference (AC) and/or EFW
- AC and/or EFW <3rd percentile
- AC and/or EFW <10th percentile with deranged Doppler parameters
Umbilical artery Doppler assessment
- increased PI above 95th percentile
- absent/reversed diastolic flow
Umbilical venous Doppler assessment
- presence of pulsatility
Uterine arterial Doppler assessment
- increased mean uterine artery PI above 95th percentile
CP ratio
- reduced below 5th percentile
AFI <5 cm is considered to be oligohydramnios
AFI >25 cm is considered to be polyhydramnios
Fetal MCA assessment for ?
MCA PI: 1.2 (<5th centile)
- Fetal anemia
Physiologic bowel herniation is normal before when ?
12 week
Spontaneous miscarriage defined before how many week ?
20 weeks of gestation
Endometrial polyp associations
- Esotrgen
- Endometriosis
- Multiparity
Gestational Choriocarcinoma response to chemo ?
- Very good response to chemo
Placental Accreta defined by ?
Chorionic villi and/or cytotrophoblasts directly attach to the myometrium with LITTLE or NO intervening decidua.
Which tumour arises from extraembryonic origin:
Yolk sac
Salpingitis Isthmica Nodosa associations
- Infertility
- Ectopic pregnancy
Which ovarian tumours are commonly bilateral?
Serous cystadenomas/cystadenocarcinomas (0.5 marks)
Endometrioid carcinomas (0.5 marks)
Clear cell carcinomas (0.5 marks)
Metastases (0.5 marks)
Lymphoma (0.5 marks)
Describe the vascular anomaly and perfusion pattern seen in twin reversed arterial perfusion.
One twin lacks a well-formed heart (acardiac twin) (1 mark)
There is a superficial artery-to-artery placental anastomosis (1 mark)
The anastomosis provides perfusion of the acardiac twin by the donor (pump) twin (1 mark)
What are 2 established safety considerations when performing fetal MRI?
No imaging in the first trimester due to fetal risks from tissue heating (1 mark)
No gadolinium due to potential fetal risk (1 mark)
Also accept minimising acoustic damage to the fetus and using a low field strength (1.5 T) however this is more controversial (0.5 marks each)
