Pathology of the Female Reproductive Tract Part 2 Flashcards
Clinical Features
insert diagram
What are the main risk factors for endometroid-type adenocarcinoma of the uterus?
- unopposed oestrogen exposure = cause
- EIN (endometrial intraepithelial neoplasia)
- endometrial hyperplasia
- PCOS, high BMI, nulliparity
- younger women, perimenopausal
What are the main risk factors for non-endometroid type adenocarcinoma of the uterus?
- aetiology = unsure
- metaplastic/neoplastic change in atrophic
endometrium - associated with p53 mutations
- post-menopausal women
What are the main risk factors for Endometrial stromal Sarcomas?
- aetiology = unsure
- specific endometrial stromal (not
glandular) invasion - rare
- peri/post-menopausal women
What are the main risk factors for endometrial carcionsarcomas?
- aetiology = unsure
- progress quickly, can fill uterine cavity
- poor prognosis
- elderly
Overall risk factors for endometrial cancer:
- obesity
- nulliparity
- late menopause
- early menarche
- tamoxifen
^all related to prolonged, unopposed
oestrogen exposure
Clinical Presentation of Endometrial Cancer:
- abnormal vaginal bleeding
- especially around menopause/post-
menopause (5-10% = cancer)
- especially around menopause/post-
- abnormal vaginal discharge is rare
- pain unusual till invasion and metastases
are present
Which of the following are pre-invasive ovarian lesions?
- non-neoplastic lesions/cysts
- PCOS
- epithelial neoplasm
- ovarian hyperstimulation
- ovarian hyperplasia/lutenisation
- endometriosis
all but epithelial neoplasm
Ovarian Cysts:
- common or rare?
- non-neoplastic cysts include:
- related to menstrual cycle
- related to —–
- presents with
- common
- non-neoplastic cysts include: mesothelial
lined, epithelial inclusion, follicular, corpus
luteum and endometriotic - follicular is common + linked to menstrual
cycle - endometriotic cysts = chocolate cysts (dark
blood) - present with pain due to inflammation
Why is PCOS a cause of ovarian adenocarcinoma in young woman, albeit rare?
ovarian hyperstimulation and hyperoestrogenism provide unopposed oestrogenic environment for metaplastic or neoplastic changes in the endometrium and ovaries
What is ovarian hyperstimulation syndrome?
- serious side effect of fertility treatment
and excess gonadotrophin - characterised by multiple follicular cysts
and bilateral ovarian enlargement
Stromal hyperplasia and lutenised cells are seen in?
- peri/post-menopausal women
- reflects ovarian stromal proliferation
- causes hyperandrogenic effects
- hormonally-mediated association between
endometrial hyperplasia and carcinomas
Endometriosis link to endometroid tumours of the ovary and adenocarcinoma?
endometriod tissue outside of the uterus
What are the four categories of ovarian neoplasms?
- epithelial: serous, mucinous, clear cell,
endometriod, transitional cell - germ cell: dysgermimoma, teratoma,
extraembryonic, mixed germ cell - sex-cord stroma: theocoma granulosa cell,
Sertoli-Leydig - metastatic: both genital and extragenital
metastases to the ovary, but genital
metastasis more likely
Ovarian Neoplasms: Epithelial Tumours:
- arise from the mesothelial layer of the
peritoneum covering the ovary - due to mesothelial origin, they are
inherently metaplastic - serous tumours originate from tubal
mucosae - mucinous tumors originate from
endocervical mucosa - endometriod tumours originate from
endometroid tissues outside uterus and
ovary - clear cell tumours are a distinct
histological type of epithelial ovarian
cancer, characterised by HOBNAIL CLEAR
CELLS - transitional cells are found in the bladder,
hence strange but tumours still found
Ovarian Epithelial Neoplasms: Clear Cell Tumours:
- common or rare?
- young or old?
- associated with?
- recurrence?
- rare, aggressive tumours
- young people
- association with endometriosis
- high risk of recurrence
- caught early strong survival rate, caught
late survival is low as 30%
What are the characteristics of benign mucinous, serous and transitional cell tumours
- smooth walled and cystic
- transitional cell tumours are solid but may
show cystic areas
Mucinous ovarian tumours and the relations to the intestine.
- often have intestinal type cells as part of
their makeup - often represent intestinal metastases
- intestinal metastases can secrete a lot of
mucous and cause intestinal obstruction
Ovarian Neoplasms: Germ Cells: Dysgermimoma:
- analogous to
- arise from which cell types
- associated with?
- common or rare?
- younger or older people?
- analogous to seminomas
- tumours arise from undifferentiated
female germ cells - associated histological appearance of
germ cells mixed with lymphocytes - rare, malignant
- affect younger people
Ovarian Neoplasms: Germ Cell: Teratoma:
- arise from?
- histological elements?
- features
- young or old
- subtypes
- tumours arising from the process of
differentiation - have histological elements of all germ cells
layers (ecto,endo and mesoderm) - contain hair, sebaceous material and teeth
- most commonly seen in younger people
- immature teratomas, mature cystic
teratomas, monodermal teratomas
What is the most common ovarian tumour?
- mature cystic teratomas
- benign
- in older people malignancy is possible
Germ Cell Ovarian Neoplasms: Mature Cystic Teratomas:
- mature cystic teratomas
- originate from an oocyte that has
completed the first meiotic division - more commonly seen in young people
Germ Cell Ovarian Neoplasms: Immature Teratomas:
- immature tissues similar to those seen in a
growing embryo - these include neural tissue
- amount of neural tissue is directly related
to malignant potential - tumours metastasise to the peritoneum
Germ Cell Ovarian Neoplasms: Monodermal Teratomas:
- derive from one germ cell layer = ONLY
ONE - significant malignant potential including
thyroid-type and carcinoid tumours
Germ Cell Ovarian Neoplasms: Extraembryonic Germ Cell Teratomas:
- arrive from non-embryonic parts of the
overy eg primitive yolk sac, trophoblast - malignant
- histologically mixed
- histologically, presents with Duval-Schiller
bodies which are central vesseled tumours
with rosette tumour cells surrounding
them - alpha fetoprotein is a serum marker for
the condition
*choriocarcinomas of the ovary are more commonly of germ cell origin but can present as mixed
Ovarian Neoplasms: Sex-Cord Stromal Tumours:
- arise from
- arise the cell cords that grow down the
surface epithelium of the ovary from the
4th month of fetal life, and frequently
produce steroid hormones
Ovarian Neoplasms: Sex-Cord Stromal Tumours: Thecoma:
- common or rare?
- features?
- presents?
- benign or malignant?
- most common sex cord tumour
- cellular, spindle-celled tumour with lipid
- produces oestrogen and presents during
reproductive years - benign
Ovarian Neoplasms: Sex-Cord Stromal Tumours: Granulosa Cell Tumour: Presentation/Features:
- malignant
- unilateral
-multicystic - bleeding and necrosis is common
Ovarian Neoplasms: Sex-Cord Stromal Tumours: Granulosa Cell Tumour:
- histological features
- serum markers?
- young or old?
- nests and cords of granulosa ccells with
characterstically ggrooved nuclei - central space around eosinophilic hyaline
material = Call-Exner Body - produces oestrogen and inhibin = serum
marker - occur at any age with late recurrence
common
Ovarian Neoplasms: Sex-Cord Stromal Tumours: Sertoli-Leydig Cell Tumours:
- common or rare?
- histological features (2)
- rare
- histologically include Reinke crystals within
the cytoplasm of tumour cells - mix of cell types related to testis related
anatomy, hence present androgenic
features
Ovarian Neoplasms: Sex-Cord Stromal Tumours: Gonadoblastomas:
- common or rare?
- affects?
- histological features?
- malignant?
- rare
- arise in individuals with phenotypic
features of female, but carry Y
chromosome - primitive germ cells, sex-stromal
derivatives - undergo malignant changes
Ovarian Neoplasms: Sex-Cord Stromal Tumours: Steroid Cell Tumours:
- benign or malignant?
- common or rare?
- unilateral or bilateral?
- histological features
- benign
- rare
- unilateral
- histologically, tumour cells include adrenal
cortical cells and produce androgens
Ovarian Neoplasms: Sex-Cord Stromal Tumours: Metastatic Tumours:
- most likely
- both genital and extragential tumours
metastasise to the ovary - most likely extragenital tumours to
metastasise to ovary is L. intestine,
stomach and breast adenocarcinomas
A 40 year old patient presents to their GP with abdominal bloating and rapid, unintentional weight loss of 1 stone over the last 8 weeks. The patient has a history of polycystic ovarian syndrome with significant amenorrhoea as a consequence of this condition. The patient is nulliparous.
Differential diagnosis?
- ovarian cancer esp genetic due to age
- most likely is ovarian cancer or metastatic
spread from endometrial cancer
What is the link between ovarian cancer and PCOS?
PCOS increases the amount of unoppossed oestrogen a person is exposed to and there is also ovarian hyperstimulation
can lead to increased risk of ovarian cancer
rare but common in younger women -»>adenocarcinoma
An 80 year old patient presents to their GP with whitening of their vulval skin, thinning and bleeding of the vulva and itching. Recently they have also noted an ulcer on their vulva. They want to know what is causing the problem.
Differential diagnoses?
- squamous carcinoma of the vulva
secondary to differentiated vulval
intraepithelial neoplasms associated with
lichen sclerosis
A 65 year old woman presents to her GP with postmenopausal bleeding for 6 months, pain and bloating of her abdominal region. She said that the bleeding started as only a few drops but is now getting heavier and this is why she is attending today.
What pathology is extremely important to investigate as a priority?
Endometrial carcinoma
A 65 year old woman presents to her GP with postmenopausal bleeding for 6 months, pain and bloating of her abdominal region. She said that the bleeding started as only a few drops but is now getting heavier and this is why she is attending today.
- endometrial carcinoma
Which endometrial cell change is associated with this condition?
Endometrial hyperplasia with atypia, which is an important, pre-invasive condition associated with endometrial carcinoma
A 65 year old woman presents to her GP with postmenopausal bleeding for 6 months, pain and bloating of her abdominal region. She said that the bleeding started as only a few drops but is now getting heavier and this is why she is attending today.
Endometrial carcinoma
What hormonal aetiology is associated with this pathology?
unopposed oestrogen exposure
A 30 year old patient who has never had a smear test presents to their GP with unexplained weight loss and bleeding with sexual intercourse. The patient smokes 20 cigarettes a day but has no other past medical or surgical history of note.
What important pathology would you want to investigate?
Squamous neoplasia of the cervix
A 30 year old patient who has never had a smear test presents to their GP with unexplained weight loss and bleeding with sexual intercourse. The patient smokes 20 cigarettes a day but has no other past medical or surgical history of note.
- squamous neoplasia of the cervix
What pre-invasive risk factor is most commonly associated with this pathology?
The presence of HPV causing cervical intraepithelial neoplasia (CIN)
A 30 year old patient who has never had a smear test presents to their GP with unexplained weight loss and bleeding with sexual intercourse. The patient smokes 20 cigarettes a day but has no other past medical or surgical history of note.
- squamous neoplasia of the cervix
- presenc of HPV causing CIN
How does this pre-invasive risk factor enact its effect on the cervix?
The virus can integrate itself into the host DNA, as well as episomal (extrachromosomal methods)
increases the likelihood of neoplastic changes
Yes I am concerned the rapid increase in size twinned with the change in appearance and the patient’s PMH of endometriosis makes this more likely to be a neoplastic pathology.
Endometriosis connection and the cystic nature of the pathology makes it more likely to be a subtype related to endometroid-type ovarian cancers or clear cell carcinomas of the ovary.
Metastatic spread, local invasion from lymph nodes, endometrial origin through endometriosis.
Ovarian Cancer: Subtypes and Discrete Biological Features:
- epithelial
- germ cell
- sex-cord stroma
- Epithelial: serous, mucinous (subtypes),
clear cell, endometroid, transitional cell - Germ Cell: Dysgermimoma, teratoma
(subtypes), extraembryonic, mixed germ
cell. - Sex-cord Stroma: Thecoma, granulosa cell,
Sertoli-Leydig cell, gonadoblastomas,
steroid cell
Vulva Cancer: Subtypes and Discrete Biological Features:
- squamous carcinoma
- Paget’s disease
- Basal cell carcinoma
- squamous carcinoma of the vulva is an
epithelial vulval cancer associated with
differentiated VIN and lichen sclerosis and
with this hyperkeratosis of uncertain
aetiology - Paget’s disease of the vulva incolves
mucin-containing adenocarcinoma cells in
the squamous epithelium of the vulva - Basal cell carcinoma and malignant
melanomas are also seen in the vulva
Vagina Cancer: Subtypes and Discrete Biological Features:
- squamous carcinoma of the vagina
- similar histologically to cervical squamous
carcinoma - BUT invades locally and radical surgery
often indicated
Uterus Cancer: Subtypes and Discrete Biological Features:
- majority arise from the endometrium
- consists of both glandular and supporting
(stromal) elements - to undergo malignant changes
- adenocarcinomas arising from the
endometrial glands
Sarcomas of the muscle of the uterus, myometrium or the stromal tissues of the endometrium are rare
Cervix Cancer: Subtypes and Discrete Biological Features:
- squamous neoplasia is the most common
- associated with HPV and CIN
- metastases to cervix are common
- embryological origins of these cancers
mean that there is a lot of interconnected
elements
