Pathoma - GU (female) Flashcards
What are some common vulvar issues?
Bartholin cyst Condyloma Lichen sclerosis Lichen simplex chronicus Vulvar carcinoma Extramammary Paget disease
Vulva overview
- skin mucosa external to hyman
- labia majora/minora, vestibule
- squamous epithelium
HPV overview
- infects lower genital canal (vulva, vaginal canal, cervix)
- koilocytic change (raisinoid nuclei)
- some risk of carcinoma
- low risk subtypes: 6,11 => condyloma
- high risk subtypes: 16, 18, 31, 33 => dysplasia => carcinoma (often sq. cell)
- risk determined by DNA sequencing (recall: DNA virus)
patient presents with white, parchment-like skin covering her vulva. What is it? What is the pathophysiology? What population does it affect?
Lichen sclerosis
- thinning of epidermis and fibrosis of dermis
- leukoplakia with parchment-like vulvar skin
- typically in postmenopausal women
- benign
- increased risk for sq cell carcinoma
patient presents with thick, leathery vulvar skin. What is it?
Lichen simplex chronicus
- hyperplasia of vulvar epithelium
- leukoplakia with thick, leathery skin
- assoc with chronic irritation/scratching
- benign
- NO increased risk for sq cell carc
patient presents with leukoplakia on her vulva. How do you differentiate potential causes? What serious condition might this be? What causes the serious condition?
Vulvar carcinoma
- squamous cell carcinoma
- rare
- present with leukoplakia (distinguish from lichen with biopsy)
two types: HPV and non-HPV
- HPV: 16, 18; vulvar intraepithelial neoplasia (VIN); 40-50 y/o
- non-HPV: chronic inflam/irritation; >70 y/o
patient presents with a red, itchy, ulcerated lesion of vulvar skin. What is it? How is it distinguished from other processes?
Extramammary Paget Disease - malignant epithelial cells in epidermis of vulva - erythematous, pruritic, ulcerated skin - carcinoma in situ; no underlying carc - diff dx: carc vs. melanoma keratin + - S100 - + PAS + -
patient presents with a painful mass below and lateral to the vagina. what is it? What causes the condition?
Bartholin cyst
- cyst in Bartholin gland
- inflam/obstruction of gland
- women of repro age
- can form abscess
- unilateral, painful
- lower vestibule adjacent to vag canal
Patient presents with vaginal warts. What are they called and what is the cause? What will it look like on microscopy?
Condyloma
- warty neoplasm of vulvar skin; often large
- HPV 6, 11
- koilocytic change (raisinoid nuclei)
- rare progression to carcinoma
What are some common vaginal issues?
- Adenosis
- Clear cell adenocarcinoma
- Embryonal rhabdomyosarcoma
- Vaginal carcinoma
What is the cellular composition of the vagina epithelium?
non-keratinizing squamous epithelium
What are the characteristics of vaginal embryology?
- upper 1/3 derived from mullerian duct -> columnar epi in fetal life
- lower 2/3 from urogenital sinus -> squamous epi in fetal life
- all epithelium transitions to squamous
patient presents with focal persistence of columnar epithelium in upper 1/3 vaginal canal. What is it, what is the cause and what is an association?
Adenosis
- incr incidence with DES in utero
- incr risk clear cell carcinoma
Clear cell carcinoma of the vagina. What is it and what is the association?
- malignant proliferation of glands with clear cytoplasm
- rare complication of DES-assoc vaginal adenosis
patient presents as a young child with bleeding grape-like mass growing from vagina/penis. What is the condition? What are characteristic microscopic findings?
Embryonal rhabdomyosarcoma
- malignant mesenchymal proliferation of immature skeletal muscle
- rare
- present with bleeding, grape-like mass protruding from vagina or penis of child; < 5 y/o
- rhabdomyoblast:
==> cytoplasmic cross-striations
==> (+) IHC for desmin and myoglobin
patient presents with vaginal carcinoma. What are causes and what lymph nodes will the cancer spread to?
Vaginal carcinoma
- from squamous epithelium of vaginal mucosa
- usually related to high risk HPV (16, 18, 31, 33)
- precursor is VAIN (vaginal intraepithelial neoplasm)
- lymph spread:
==> upper 1/3 vag -> iliac nodes
==> lower 2/3 vag -> inguinal nodes
Female genital cancer by age
== Pre-menopause:
- Vulvar carcinoma (caused by HPV 16/18, 40-50 y/o)
- Cervical carcinoma (HPV; 40-50 y/o)
- Leiomyoma
- Ovarian cystadenoma (30-40 y/o)
- Ovarian germ cell tumors (15-30 y/o; cystic teratoma, embryonal carcinoma, yolk sac tumor, dysgerminoma, choriocarcinoma)
== Post-menopause:
- Vulvar carcinoma (following lichen sclerosus)
- Endometrial carcinoma (from hyperplasia: unopposed estrogen; ~50 y/o; endometroid)
- Endometrial carcinoma (sporadic p53 mutation from atrophic endometrium; >70 y/o; serous)
- Leiomyosarcoma
- Ovarian cystadenocarcinoma (60-70 y/o)
== Child:
- embryonal rhabdomyosarcoma (<5y/o)
- endodermal sinus tumor (mimic yolk sac)
== Other:
- extramammary Paget disease
- Clear cell adenocarcinoma assoc with adenosis
- vaginal carcinoma
- granulosa-theca tumor (any age, estrogen prod)
- sertoli-leydig tumor
- fibroma (sex cord-stroma)
- Krukenburg
- Pseudomyxoma peritonei
Woman comes in with vaginal bleed, what’s the differential?
- if post-menopause: most commonly atrophic endometrium, also consider tumors of post-menopause
- if young: consider precocious puberty
- if child-bearing age: consider pregnancy, endometrial hyperplasia, cervical cancer
What are patients with a BRCA1 mutation at increased risk for?
- breast cancer
- serous carcinoma of ovary and fallopian tubes
Tissue sample microscopically shows Reinke crystals, what is it?
think: Sertoli-leydig tumor
a mass protruding from a child’s genitalia is positive on IHC for some markers. What is the mass? What are the markers?
think: embryonal rhabdomyosarcoma
- desmin from intermediate filaments of muscle cells
- myoglobin from muscle
- cells will show cytoplasmic cross striations
tissue sample comes back keratin (+) and S100 (-), what is it?
squamous cell carcinoma
- will also be PAS (+)
- these stains distinguish carcinoma from melanoma
tissue sample comes back keratin (-) and S100 (+), what is it?
melanoma
- S100 characteristic
- stains distinguish it from carcinoma
Where is the transformation zone of the cervix?
Encompasses the region from the squamocolumnar junction to any squamous metaplasia
What are some issues of the cervix?
- Cervical carcinoma
Patient presents with vaginal bleeding. What are risk factors for cervical carcinoma? What is the most common age group? What are the subtypes and their prevalence? What are complications?
- Risk factors:
- HPV (hi risk: 16, 18, 31, 33, 45)
- smoking
- immunodeficiency
- Age group: 40-50 y/o
- Subtypes: both HPV assoc
- squamous cell carcinoma (most common)
- adenocarcinoma
- grows local with late mets
- complications
- Hydronephrosis: invades ant uterine wall into bladder -> post renal failure
What is the best way to screen for cervical cancer? What test is used to confirm positive screening results? What are the limitations?
Pap test
- confirm with colposcopy and biopsy
- limitations:
- must be done at transformation zone
- cannot detect adenocarcinoma well
What does the immunization against HPV cover? Are pap tests still needed?
- effective against HPV 6, 11, 16, 18
- still need pap tests because of other types of HPV
- immunization lasts 5 years
What are some issues of endometrium and myometrium?
- Asherman syndrome
- Anovulatory cycle
- Acute endometritis
- Chronic endometritis
- Endometrial polyp
- Endometriosis
- Endometrial hyperplasia
- Endometrial carcinoma
- Leiomyoma
- Leiomyosarcoma
