Pathology - Ovary and uterus Flashcards
What are the 2 layers of the endometrium?
- Functionalis layer (shedded) (outer layer)
- Basalis (regenerative) layer - regenerates functionalis
What is asherman syndrome?
Secondary amenorrhea due to loss of basalis (regenerative) layer and scarring
What can ashermans be due to?
- Overaggressive dilation and curettage (removal of tissue often for diagnosis or as treatment) or abortion
What is a anovulatory cycle?
Cycle with lack of ovulation
What can primary ovarian insufficiency also be called?
Premature ovarian failure
What is primary ovarian insufficiency?
- Premature atresia of ovarian follicles in females of reproductive age (before 40)
What are the common causes of primary ovarian insufficiency?
- Idiopathic (most common)
- Chromosomal anomalies (esp < 30 yrs)
- Autoimmunity
What are the most common causes of anovulation?
- Pregnancy
- PCOS
- Obesity
- HPO axis abnormalities/immaturity
- Premature ovarian failure
- Hyperprolactinemia
- Thyroid disorders
- Eating disorders (low BMI)
- Cushing syndrome
- Adrenal insufficiency
- Chromosomal anomalies (Turner’s)
What is functional hypothalamic amenorrhea due to?
- Calories burned greater than consumed - low BMI or increased stress
- Functional disruption of pulsatile GnRH secretion - decreasing LH, FSH and estrogen
- Pathogenesis includes decreased leptin (due to less fat) and increases cortisol (stress, exercise)
What are the components of the female athlete triad?
- Decreased calorie availability/ excessive exercise
- Decreased bone mineral density
- Menstrual dysfunction
Describe the pathogenesis of PCOS
- Hyperinsulinemia and/or insulin resistance
- This alters the hypothalamic hormonal feedback response, increasing LH to FSH ratio increasing androgens from theca interna cells
- This decreases rate of follicular maturation resulting in unruptured follicles (cysts) + anovulation
What does PCOS present with?
- Decreased fertility
- Amenorrhea/oligomenorrhea
- Hirsutism
- Acne
- Unopposed estrogen from repeated anovulatory cycles
- Obesity
- Acanthosis nigricans
- Enlarged bilateral cystic ovaries
What disease does PCOS increase the risk of?
Endometrial cancer due to unopposed estrogen
How is PCOS treated?
- Cycle regulation via weight reduction (decreased peripheral estrone formation)
- OCPs (prevents endometrial hyperplasia due to unopposed estrogen)
- Clomiphene (ovulation induction)
- Antiandrogen (spironolactone, finasteride, flutamide)
What drug can induce ovulation?
Clomiphene
What is primary dysmenorrhea due to?
Uterine contractions to decrease blood loss -> ischemic pain
- Mediated by prostaglandins
What is primary dysmenorrhea treated with?
NSAIDs
What is a follicular cyst due to?
Unruptured Graafian follicle
What are follicular cysts associated with?
- Hyperestrogenism
- Endometrial hyperplasia
What is the most common ovarian mass in young females?
Follicular cyst
What is a theca lutein cyst also known as?
Hyperreactio luteinalis
What are theca lutein cysts due to?
hCG overstimulation
- Associated with choriocarcinoma and hydatidiform moles
What is the action of estrogen on the endometrium?
Growth p(proliferative phase)
What does hemorrhage into the corpus luteum result in?
Hemorrhagic luteal cyst
What are the 3 areas tumors can arise from in the ovary?
- Epithelium
- Germ cells
- Sex cord stroma
Tumors may also be from metastases
What are the 2 most common surface epithelial tumors?
- Serous cystadenoma
- Mucinous cystadenoma
How can you differentiate benign and malignant epithelial cysts on gross and histological examination? (cystadenoma v cystadenocarcinoma)
- Benign - simple, flat lining (gross) + single layer histologically
- Malignant - Thick shaggy lining (gross)
Who typically gets cystadenomas (benign epithelial)?
Premenopausal
Who typically gets cystadenocarcinomas?
Women 60 -70 yrs old
Do borderline tumors (between malignant and benign) carry metastatic potential?
Yes
What may mucinous cystadenomas cause?
Pseudomyxoma peritonei
- Intraperitoneal accumulation of mucinous material
What does Brenner tumour look like?
Solid pale yellow-tan tumour that appears encapsulated
What does Brenner tumor look like on histology?
“Coffee bean” nuclei on H&E stain
- Contains uroepithelium
What is the most common malignant ovarian neoplasm?
Serous carcinoma
What does serous adenocarcinoma contain on histology?
Psammoma Bodies
Where can a mucinous carcinoma be from?
Metastasis from appendiceal or GI tumours
What may ovarian tumours present with?
> 55 years old
- Abdo distension
- Bowel obstruction
- Pleural effusion
How is the response of an ovarian tumor to therapy usually measured/
CA 125 levels
- Once removed should be zero
What can increase the risk of ovarian tumours?
- Advanced age
- Infertility
- Endometriosis
- PCOS
- Genetic predisposition (BRCA, Lynch, strong FH)
What can decrease the risk of ovarian tumours?
- Pregnancy
- Breastfeeding
- OCPs
- Tubal ligation
What are malignant epithelial endometrioid carcinomas related to?
Endometriosis
What are the different types of epithelial tumors of the ovary?
- Serous cystadenoma
- Serous carcinoma
- Mucinous cystadenoma
- Mucinous carcinoma
- Brenner tumour
- Endometrioid tumour
What are some of the symptoms of epithelial ovarian tumours?
- Present late (poor prognosis)
- Vague abdo symptoms (pain, fullness)
- Signs of compression (urinary frequency)
Where may epithelial tumors of the ovary spreafd?
Locally - peritoneum
What percentage of ovarian tumours are germ cell tumors?
15% - 2nd most common
Who are affected by germ cell tumours?
Young women - repro age
What are the different types of germ cell tumors?
- Mature cystic teratoma
- Immature teratoma
- Dysgerminoma (most common)
- Yolk sac tumor
- Embryonal carcinoma
What is the most common ovarian tumour in young females?
Mature cystic teratoma
What percentage of cystic teratomas are bilateral?
~ 10%
What may be contained in mature cystic teratomas?
All 3 germ layers
- Teeth, hair, thyroid, gut, sebum
What can mature cystic teratomas turn into (rare)?
Squamous cell carcinoma
A monodermal form of mature cystic teratoma with thyroid tissue and thus hyperthyroidism is called what?
Struma ovarii
What can mature cystic teratomas cause which may elicit pain?
- Ovarian enlargement and possibly torsion
What type of teratoma has malignant potential?
Immature
What type of tissue is contained in an immature teratoma?
Fetal tissue
- Neuroectoderm -> immature/embryonic like neural tissue
What is the most common malignant germ cell tumor?
Dysgerminoma
What do dysgerminoma contain on histology?
Large cells with clear cytoplasm and central nuclei
- Sheets of uniform ‘fried egg’ cells
What is the testicular counterpart of a dysgerminoma?
Seminoma
What may be elevated in a dysgerminoma?
hCG and LDH
What is the most common germ cell tumor in children?
Endodermal sinus tumor (yolk sac tumor)
What does a yolk sac (endodermal sinus) tumor look like?
- Yellow, friable (hemorrhagic) mass
- Schiller- Duval bodies (like glomeruli on histology) in 50% of cases
What is the tumor marker for yolk sac (endodermal sinus) tumor?
alpha fetoprotein
What type of germ cell has large primitive cells and is aggressive? (may metastasise)
Embryonal carcinoma
What are the different types of sex cord stromal tumors of the ovary?
- Fibroma
- Thecoma
- Sertoli-Leydig cell tumor
- Granulosa cell tumor
Who may be affected by Granulosa cell tumors?
- Predominantly women in 50s although can affect any age
What are the signs/symptoms of granulosa cell tumors?
Estrogen excess related signs:
- Postmenopausal bleeding
- Endometrial hyperplasia
- Sexual precocity (preadolescents)
- Breast tenderness
What is the tumor marker for Granulosa cell tumors?
Tumor marker: Increased Inhibin
What may histology show for a granulosa cell tumor?
Call-Exner bodies
- Granulosa cells arranged haphazardly around collections of eosinophilic fluid, resembling primordial follicles
What may Sertoli-Leydig cell tumor in females look like?
- Small grey to yellow-brown mass
- Histology shows tubules/cords lined with pink sertoli cells
- Leydig cells contain Reinke crystals
What may Sertoli-Leydig cell tumor in females present?
Virilization (hirsutism, male pattern baldness, clit enlargement)
What is a fibroma?
Benign sex cord stromal tumor
- Bundle of spindle-shaped fibroblasts
What is Thecoma?
Benign neoplastic proliferation of Theca cells
- May produce estrogen
- Presents usually with abnormal uterine bleeding
What is Meigs syndrome?
Ovarian fibroma with symptoms of:
- Ascites
- Pleural effusion
- “Pulling” sensation in groin
What cancers may spread to ovary?
- Kruckenberg tumor -> mucous tumour (usually from gastric carcinoma), also breast, colon
- Pseudomyxoma peritonei -> mucus in peritoneum (jelly belly) primary source from appendix usually
How can you differentiate between a primary mucinous tumor of the ovary and a metastasized tumour?
Bilateral usually indicates metastasis
