Repro Path

Question 1

mature cystic terratoma

Answer 1

from somatic totipotentgerm cell

Most common ovarian tumor of reproductive age group

95% of germ cell tumors are mature teratomas

Tumor differentiation towards all three germ cell layers

Skin is the most common tissue seen

46XX

Rarely malignancy may arise in one of the elements of tumor tissue ( in older women)

Question 2

what age do embryonal tumors peak in children?

Answer 2

befoer age 5 - very rare after that

Question 3

what would be the expected endometrial biopsy with unopposed estrogen?

Answer 3

proliferative endometrium with breakdown

• You have estrogen without progesterone.
• Eventually you will have breakdown of the EM, because normally proliferative EM is not meant to be there forever.
• It’s meant to be opposed by progesterone, and undergo secretory differentiation.
• If you don’t have the progesterone, then the proliferative EM grows to a certain point and then starts to break down.
• Usually what you see, you have proliferative EM with breakdown.

Question 4

Answer 4

serous carcinoma

• Large solid and cystic areas

Necrosis and hemorrhage

Question 5

fibroadenoma vs phyllodes tumors

Answer 5

Question 6

fixation of cells in cytopathology

Answer 6

• When you’re taking specimens for histopathology, you always use formalin, but formalin is not a good fixative for cells because it bursts the cells- makes them swell and then you can’t interpret them.
• Most samples can go to the laboratory “fresh”, which means with no fixative in it- you can just take the sample and bring it on over to us. If it’s going to be delayed, you can refrigerate it, and cells will last overnight in refrigeration.
• In some cases you have to fix the cells, and the fixative that we use is ethyl alcohol. One of the problems that we always have in the beginning of July is that ethyl alcohol is typically not available on the hospital wards and rubbing alcohol is, so people put rubbing alcohol in their solutions and it bursts the cells.
• In some of our clinics, they will actually teach you how to make the slides, because in some areas the clinician is actually doing the fine needle aspiration. So they’ll teach you how to smear the slides and then let them dry by air or fix them by ethanol.

Question 7

stage I ovarian carcinoma

Answer 7

Stage I: Limited to one or both ovaries. Five year survival 90%

Question 8

what is the functional unit of the breast?

Answer 8

the lobule

•The terminal duct and ducules that come out compose the terminal duct lobular unit and that again is where most carcinomas occru

• AT menarchy these ducts proliferate and give rise to some 30 epithelium lined ductules and acini and all those ducules and acini come together to form the lobule
• The breast is divided in to major duct systems that then divide up into lobules
• It’s really lobules that become functional unit of mammary gland
• It’s where you see most of the benign and malignant lesions that occur in the breast.

Question 9

Answer 9

bartholian gland abcess

• The Bartholin glands can get infected and form abscesses.
• Bartholin glands normally are mucinous glands, with a mucinous lining, but with an infection shown here [bottom right], it can undergo a squamous metaplasia.
• Management is with drainage and antibiotics.

Question 10

placental abruption

Answer 10

painful third trimester bleeding

premature separation of plaenta after 20 wks, secondary to rupture of maternal vessels

if marginal - vaginal bleeding

if central - retroplacental hematoma (accumulation of blood - uterus hard and painful, no bleeding!)

higher incidence of toxemia and HTN

Question 11

fetal complications from prematurity

Answer 11

risk inversely related to GA at delivery

respiratory distress syndrome (hyaline membrane disease)

necrotizing enterocolitis

retinopothy

sepsis

neuro issues

Question 12

proliferative fibrocystic change vs proliferative fibrocystic change with atypia

Answer 12

Question 13

what day of the cycle is ovulation

Answer 13

day 14

Question 14

what gene has a bad prognosis for neuroblastoma

Answer 14

N-myc amplification

Question 15

nonprolif fibrocystic change vs proliferative fibrocystic change of the breast

Answer 15

prolif - 1.5-2x increased risk of cancer

Question 16

Rh mechanism

Answer 16

1. Rh negative woman before pregnancy
2. pregnancy occurs, fetus is Rh-positive
3. after deliver, Rh alloimmunization occurs in the mother and she dvelops antibodies for Rh
4. The next positive with an Rh positive fetus - maternal abs can ross the placenta, enter the fetal blood stream, attach to the Rh-positive red cells causing hemolysis

Question 17

what is the leading cause of death in infants without birth defects?

Answer 17

prematurity

Question 18

how do we follow neuroblastoma?

Answer 18

▫Elevated urine metabolites (vanillylmandelic acid [VMA] and homovanillic acid [HVA]). Measuring elevated serum catecholamines is not practical. Typically clinicians measure elevated urine metabolites. Looking at VMA and HVA in terms of whether you have overall catecholamine overexpression. Unlike pheochromocytoma which also produces catecholamines, children with neuroblastoma tend not to present with signs of hypertension. Urine catecholamines are important because they set up a baseline. If a child comes in with high urine catecholamine and then after their tumor is resected they’re still high, it suggests incomplete resection or unknown metastatic disease. If they’re low and subsequently become high several months later, it can suggest recurrence.

Question 19

if twins and embryo splits at second wk of gestation (late)

Answer 19

monochromatic

monoambiotic

only thing that splits is laminar disk!!

Question 20

3 components of Wilms Tumor

Answer 20

• Triphasic tumor
• (1) small round blue cell component-primitive blastema; [blue arrow]
• (2) epithelial component-immature tubules (most often) and glomeruli [black arrow]
• (3) mesenchymal stromal component [green arrow]

Question 21

Answer 21

neuroblastoma

The other aspect that we can see in this tumor, parts of this tumor can have an appearance like this. Rather than having a diffuse round blue cell component, they’ll have Schwannian differentiation. Schwannian differentiation suggests that the tumor has fascicles of eosinophilic spindle cells intermixed with ganglion cells. So these are the ganglion cells that we just talked about (black arrow) and these spindle cells with elongated oval nuclei (blue arrow) and this longer eosinophilic cytoplasm. This is an example of Schwannian stromal differentiation.

Question 22

Answer 22

proliferative fibrocystic change without atypial

1.5-2x risk

Question 23

mild dysplasia

Answer 23

• This is the surface layer [the top layer].
• In the normal maturation process, the cells get bigger and their nuclei get smaller as they go to the surface.
• The very early terms used to describe these lesions were mild dysplasia, moderate dysplasia, severe dysplasia and in situ carcinoma.

In mild dysplasia, up to 1/3 of the epithelium shows immature cells – they do not mature and they become atypical. But above that, you get maturation of cells.

Question 24

serum marker for choriocarcinoma

Answer 24

HCG

Question 25

Anti-D abs

Answer 25

Rh positive or Rh negative

Rhogam protects against developing abs to D

Question 26

type II ovarain cancer pathogenesis

Answer 26

Type II pathogenesis starts with p53 mutations in fallopian tube fimbrial epithelium that gives rise to STIC (serous tubal intraepithelial carcinoma). STIC cells are possibly implanted on the ovulation injury site and grow rapidly to present as high stage ovarian cancers.

Possible precursor of type II ovarian cancer is STIC.

II – p53 mutation in fibrae epitheium

Question 27

Answer 27

Under a microscope, the features of invasion are these cells which have left their boundaries and are starting to grow into surrounding tissue, like here (1).

Question 28

triple test for breast cancer

Answer 28

1. clinical
2. radiologic
3. pathologic

Question 29

chorionic villi - 2nd trimester

Answer 29

Smaller

Stroma more cellular

Increased number of blood vessels

Discontinuous layer of cytotrophoblast

Have more CV that can fit in smaller space! Higher SA (surface area)!!! à more absorption (ie: like when u have microvili in small intestine à increased SA = more nutrients for baby

SA increases in CV as CV get smaller and smaller as requirements for baby’s growth increase.

Question 30

transudate vs exudate

Answer 30

• Transudate is an accumulation of fluid due to increased hydrostatic or osmotic forces, and usually these kind of things happen in a congestive heart failure or pleural fluid in the lungs.
• So you’re looking at this smear [bottom left], you see there’s red blood cells in the background, some lymphocytes [small, solid red balls], and these mesothelial cells. What you’re really trying to notice is that there’s not very many cells, so this is more of a transudate.
• When you look at exudate, you get at an accumulation of fluid usually due to inflammation with increased capillary permeability. That is usually highly cellular.

Question 31

what 3 breast cancers have best prognosis?

Answer 31

1. medullary
2. colloid/mucinous
3. tubular

Question 32

treatment of ovarian surface epithelium carcinoma

Answer 32

Surgery: Debulking and Staging

TAH/BSO, pelvic and peritoneal biopsies, omentectomy, para-aortic and pelvic lymph node dissection for staging

Aspiration of ascites, pelvic wash, biopsies from paracolic gutters, surface of diaphragm for staging

Adjuvant Chemotherapy: Combination of a platinum compound (carboplatin/cisplatin) and a taxane (paclitaxel/docetaxel)

Question 33

pap:

Answer 33

•In contrast, in high grade squamous intra-epithelial lesion, the nuclei are much more enlarged. They almost fill the cells and are much more variable in shape and size. Some are larger and some are smaller.

Question 34

placental accreta

Answer 34

villi attach to myometrium because no intervening decidua

Question 35

maternal compliations in preterm labor/PPSOM

Answer 35

infection related to prolonged cervical dilation or ruptured membranes

chorioamniotiis - bacterial

hemorrhage

morbidity from opeation

Question 36

how do you diagnose if need to give rhogam

Answer 36

determine if fetus is at risk: paternal Rh type/zygosity

fetal testing if father is heterozygous or unknown (amnio > CVS), possible cell free fetal DNA in the future

Question 37

neuroblastoma stage 4S

Answer 37

It has a special stage called 4S where you have either stage I or II primary tumor but you have evidence of remote disease within the liver, the skin, or the bone marrow. In bone marrow it has to be minimal disease with less than 5% of cell population representing the tumor and there has to be no evidence of concomitant boney destruction. In those cases the prognosis is actually very very good

Question 38

serous ovarian tumors

Answer 38

Very commonly bilateral - most common and most lethal

• Serous cystadenoma (60%)
• Borderline serous tumor (15%)
• Serous adenocarcinoma (25%)

Low Grade serous adenocarcinoma (Type I cancer)

High grade serous adenocarcinoma (Type II cancer)

Question 39

what percent of deaths in children from cancer?

Answer 39

11% of deaths

2% of cancers in children

Question 40

endometrial atrophy

Answer 40

• Atrophy is usually a normal physiologic condition in patients who are postmenopausal.
• It is the most common cause of bleeding in postmenopausal women—not cancer, not EM polyps, not leiomyoma, but simply atrophy.
• It’s worth it to remember that.
• The ovaries basically undergo atrophy, and they stop producing the steroid hormones.
• Therefore, the EM lining becomes very thin, the stroma becomes more fibrotic, the glands are less numerous, and some of them are cysticaly dilated.
• The epithelial lining is simple, meaning one single-cell, and is sometimes dilated.
• That’s normal.
• Something you have atrophy also in young patients.
• In those circumstances, you can see this in patients who are on oral contraceptive pills (OCPs.)
• Another cause, which was more frequent in the past, is when you have young patients with cervical carcinoma, especially the patients who do not undergo normal pap smear testing. [Rambles about how she doesn’t know current guidelines.]
• They can develop cervical cancer, young patients, and sometimes it can be advanced.
• Before you can do any surgery, sometimes you have to treat them with radiation therapy to the pelvis.
• If the ovaries are in the field of the radiation, it also can induce atrophy of the ovary, and then therefore you have atrophy of the EM in younger patients.
• Sometimes you have Premature Ovarian Failure.
• In all these conditions, when the ovaries are not producing those steroid hormones, you would expect to see atrophy in the EM.

Question 41

surface inclusion cysts

Answer 41

Surface inclucision cysts occur due to ovulation injuries – cytoplasm gets stuck, some cysts undergo metaplasia and give rise to serous or mucinous metaplasia

Because surface injury w more ovulation – more injury is a higher risk

Surface inclusion cysts are formed by invagination of surface epithelium during re-epithelialization of ovulation associated surface injury.

They may undergo mucinous or serous metaplasia.

Most women have inclusion cysts in their ovaries

Women with cancer in one ovary have a higher no. of inclusion cysts in the contralateral ovary compared to women in general population

Question 42

if twins and embryo splits early (first 4 days) of gestation

Answer 42

dichroionic diamniotic (fused placentae or own placenta)

1.Since there is a tight space; there will be a common membrane from 2 separate amnions/chorions that fuse in center

Question 43

lymph nodes in cervical carcinoma

Answer 43

pelvic lymph nodes

Question 44

epithelium?

Answer 44

clear cell type

Secretory type glands with cytoplasmic clearing, clearing because cytoplasm contains a lot of glucogen which is lost during provessing

Question 45

LN in vulvar carcinoma

Answer 45

inguinal lymph nodes

Question 46

low risk HPV

Answer 46

6/11

rarely found in cervical carcinoma

Question 47

breast:

Answer 47

invasive lobular carcinoma

Question 48

Why is a biopsy dangerous in Wilm’s Tumor?

Answer 48

in a lot of tumors, a child is diagnosed with a tumor, they go in and do a biopsy in order to figure out what it is and then they dictate treatment and then child has a resection. Dangerous to do in WT. If you biopsy WT you automatically upstage the tumor to stage III because it’s considered intratumoral spillage. Intratumoral spillage also occurs if you do an intraoperative frozen section or if the tumor is transected at the time of initial surgery. Problem is that if you penetrate WT it seeds very easily. They assum eif there’s any defect in the capsule whatsoever then there is tumor within in the abdominal cavity and child is treated according to stage III protocol which is much more aggressive.

Question 49

if twins and embryo splits preimplantation in first wk of gestation

Answer 49

monochorionic

diamniotic

1.If split happens later at stage of blastocyst; when trphoblast has dvlped; tropho will give rise to 1 placental disk + 1 chorion surrounding 2 babies; since amion cav hasn’t dvlpd yet, ea baby will have its own amnion à monochorionic + diamniotic twin gestation

Question 50

fetal phase

Answer 50

10 wks gestation-birth

Question 51

pathophys of HPV and cervical cancer

Answer 51

• These are the events after infection. There is a virion which can stay latent in the host for some time or can progress to HPV infection producing these complete virion particles on the surface cells. That would be considered LGSIL [top right figure].
• If the pt can’t get rid of the infection, it will persist. Under the role of some cofactors such as immune response etc., these cells accumulate genetic abnormalities and progress to HGSIL [bottom right figure] and eventually they acquire the ability to invade underlying tissue and become invasive carcinoma [bottom left figure].
• This progression occurs over many years, not weeks or months.

Question 52

exfoliative cytology

Answer 52

•Urine, CSF

Exfoliative cytology- where the cells just fall off into the fluid that bathes them. So into the urine, the bladder lining cells just fall off and you see them in the urine specimen. In CSF, the same thing; if there’s an abnormality in the lining cells of the meninges, they can fall off into the CSF and you’re looking for that.

Question 53

stage IV ovarian carcinoma

Answer 53

Stage IV: Distant metastasis. Five year survival 15%

Question 54

Answer 54

embryonal rhabdomyocarcoma

rare

childhood

“grape” - cross striations

• You get grape-like vesicles, and this is a muscle-like tumor so you get cross striations on those tumor cells.
• This is a child’s reproductive system removed for this rhabdomyosarcoma.

Question 55

complications of gestational diabetes

Answer 55

spontaneous abortin

congenital malformations (mermaid syndrome, heart disease, neural tube defects)

macrosomia (90th percentile, over 4000 grams) increased delivery compliations

preeclampsia

polyhydraminos

Question 56

epithelium?

Answer 56

endometrial

Proliferative type glands with columnar cells

Question 57

Answer 57

fibroma

Benign

Perimenopausal women

Can be mixed with theca cells (fibrothecoma) and produce estrogen

Basal cell nevus syndrome: Bilateral fibrothecomas, basal cell carcinoma, odontogenic cysts of jaw

Meig’s syndrome: Ovarian fibroma with ascites and pleural effusion

Spindly benign cells, less mitotic activity, just remove

Assocaited w ascites – don’t know why

Basal cell nev – bilateral fibroma

Question 58

chorionic villi in the first trimester

Answer 58

large with double layer of trophoplast (cyto - inner, syncytio - outer)

loose stroma

few blood vessels

CV relatively large ; maternal blood float btwn CV

CV forms a barrier btwn maternal blood + fetal blood that is very thick

CV = large; very little SA

Question 59

non proliferative fibrosis of cystic change

Answer 59

CYSTS RUPTURE WITH RELEASE OF SECRETORY MATERIAL INTO STROMA WITH RESULTING CHRONIC INFLAMMATION AND FIBROSIS

• This is your normal breast tissue [points to first picture, yellow part]. It should really be fatty and looks more yellow.
• But you see white areas are just fibroconnective tissue.

[reads slide]

•And again here [bottom picture] instead of seeing lots of small acini, the fibrous tissue surrounds these acinar tissues and you get an area of fibrosis

Question 60

Chronic Endometritis

Answer 60

• Similarly, we have chronic endometritis.
• You have a chronic inflammatory infiltrate within the EM, which is recognized by these cells with this pink Golgi zone, which are basically plasma cells. [Circle is where she felt the cells displayed this clearly.]
• Most commonly, when you see this in the EM nowadays, it’s actually related to the placement of an intrauterine device (IUD).
• When an IUD is present, it’s a foreign body sitting in the EM cavity, and it irritates the EM so you have a response from the immune system, and you have chronic endometritis in some patients.
• The other thing is that when you have retained products of conception, meaning the placental tissue, you can also have chronic endometritis (in addition to acute) if it stays there for a long time.
• Also, as part of Chronic Pelvic Inflammatory Disease, you can have inflammation along the endometrium, along the fallopian tubes, and sometimes can also involve the ovaries.
• You usually remove the offending cause depending on the circumstances.

Question 61

most common ovarian germ cell tumor?

Answer 61

Germ cell tumors account for 15-20% of ovarian tumors

95% of germ cell tumors are mature cystic teratomas, seen in all age groups

Malignant germ cell tumors are seen mainly in children and young adults (unlike carcinomas which occur mainly in postmenopausal and elderly women)

Malignant germ cell tumors grow rapidly, are usually unilateral, show predilection for lymphatic and hematogenous dissemination

Prognosis in general is good with chemotherapy

Question 62

serum marker for ovarian carcinoma

Answer 62

CA-125

CA-125 is not a good routine screening tool for ovarian cancer because it may be elevated in benign conditions such as endometriosis and may not be elevated in over one third of patients with ovarian cancer

CA-125 can be used for screening in patients with family history of ovarian cancer

CA-125 is routinely used for measuring the response to chemotherapy or to detect recurrence in ovarian cancer patients

Question 63

why is toxemia associated with infarcts?

Answer 63

inadequate maternal vessels remodeling

ischemia of the placenta

Question 64

what is the most common ovarian tumor type?

Answer 64

surface epithelial tumors (70%)

most lethal

Question 65

liquid based pap smear

Answer 65

• Today we use a liquid based cytology, and the two methods that are out there are just two different companies: thin prep, which is the Cytec company, and autocyte, which is the Surepath company.
• What happens is when you take the smear, you actually stick it into a vial of fixative.
• The benefit of this is you can then use the remainder of the fixative to do the HPV, gonorrhea, and chlamydia testing. The patient doesn’t have to come back or have separate swabs taken; you can do it all off of one vial.

Recently they have said that you can do human papilloma virus testing without the pap smear, so instead of having a pap smear every year for your normal checkup, if your HPV is negative you can go every 3 years and not have a pap. And again, this is all evolving; it’s all relatively new in this last decade

• Once this specimen gets to the laboratory, they spin it and all of these cells fall into this fixative and they spin it down into a preparation that allows you to make a smear.
• So years ago, the traditional smear looked like this [right], and today it looks like this [left].
• I think the advantage of it was that a tech has to screen this whole thing, and the likelihood of missing something is much higher when you have to screen this one by one [right] versus screening a much smaller area [left].
• So the cells not only get concentrated together, these techniques also remove a lot of the mucus and the blood that’s there.

Question 66

Krukenberg tumor

Answer 66

Krukenberg tumor is a metastatic adenocarcinoma in the ovary with signet ring morphology

15% of carcinomas presenting in the ovary are metastatic

• Breast, GI, Endometrium

Krukenberg tumor shows mucin filled signet ring cells with eccentric nucleus embedded in fibrous stroma

Most common primary source for Krukenberg tumor is stomach cancer (70%).

Colon, appendix and breast are other common primary sites for Krukenberg tumor

Bilateral mucinous ovarian tumors are likely to be metastatic from other site

Question 67

tubal carcinoma

Answer 67

Primary Tumors: Very rare

Most primary malignancies are serous adenocarcinomas that may present as ovarian masses due to early involvement of Ovary

Metastatic Tumors

Ovary, endometrium, breast, cervix

Question 68

toxemia of pregnancy

Answer 68

• Toxemia of pregnancy is also related to ischemia of placental disc
• Preeclampsia presents w/ triad of symptoms! (HTN + PROTEINURIA + EDEMA – removed as criteria b/c very common in pregnancy)
• Happens in 6% pregnancies
• usually in mom’s 1st preg during last trimester of pregnancy à important b/c in pts w/ HTN, <22wks preg + HTN, need to think about essential hypertension (not related to pregnancy)
• 20% moms w/ complete moles will present w/ HTN in early pregnancy
• hypertension
• proteinuria
• (edema – common in pregnancy) removed as criterion
• Toxemia associated w/ placental abruption + infarction à easy to understand ischemia

•

•Eclampsia – when mom gets convulsions/seizures

• preeclampsia plus convulsions

Question 69

fetal complications of Rh

Answer 69

varying degrees of anemia due to alloimmune hemlytic anemia

severity depends on antibody concentration (expressed as iter)

severe anemia –> high output cardiac failure, hydrops fetalis (abnormal accumulation of fluid in 2 or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin edema), death

Question 70

what is the most common cancer in children?

Answer 70

leukemia - 36%

Question 71

percentage of persistant and high grade dysplasia?

Answer 71

10%

Question 72

failed placental separation

Answer 72

placental accreta - villi attached to myometrium

(also incretia when penetrate myometrium and percreta when perforate serosa)

due to abnormal adherence of placenta to uterine muscle without intervening decidua

associated with placenta previa uterine scar (c-section)

Question 73

leiomyomas

Answer 73

• growth of the myometrium
• They grow big sometimes, and they can outgrow their blood supplies. Therefore, you have ischemic changes.
• In this case [top left], you have ischemia; you have leakage of the fluid from the epithelium because it becomes compromised.
• You have cystic degeneration of these leiomyomas. [green arrow]

This is a hysterectomy specimen that is difficult to even recognize.

• This was the cervix [red arrow]
• This was the uterus, the uterine carcass [circle]
• And you have these huge masses that are subserosal [green arrow is one example].
• You can imagine that the symptoms of these patients.
• The uterus is located between the urinary bladder, which is anterior, and the rectum, which is posterior.
• If this mass is sitting right there, it can lead to urinary frequency or constipation.
• They also mimic ovarian masses because they extend laterally.

This whole thing is very painful, and it can interfere with fertility in these patients as well.

Question 74

HPV integration and cancer

Answer 74

• An additional factor that leads to progression of carcinoma or initiation of dysplasia is integration into host genome.
• Normally E6 and E7 proteins are suppressed by E1 and E2.
• But the integration usually occurs in E1 and E2 area, so there is loss of E1 and E2 function after integration into the host genome. Therefore, there is increased expression of E6 and E7 and are able to bind to more retinoblastoma and p53 to cause further proliferation and other abnormality.

Question 75

Answer 75

invasive ductal caricnoma of the breast

70-80%

Question 76

neuroblastoma

Answer 76

• 2nd most common malignancy in childhood
• Median age at diagnosis: 22 months
• Most common site: adrenal gland
• 90% produce catecholamines

▫Elevated serum catecholamines

▫Elevated urine metabolites (vanillylmandelic acid [VMA] and homovanillic acid [HVA])

Question 77

breast stroma

Answer 77

• Majority of the stroma [points to top figure]
• These are your acini [points to purple holes in LLQ of image]
• They come together to form a lobule
• So here would be a lobule [traces circle of a group of acini that share the same patch of whiteish-purplish tissue] here would be a lobule etc [proceeds to circle more groups of acini. I guess if you go by the patches of white as marking a lobule]
• Here is one of the larger ducts [points to big thing that looks like a broken fork on right side]
• And the lobules then become separated by stroma
• The majority of stroma just consists of dense fibroconnective tissue and mixed with some fatty tissue
• But the lobules are imposed by a hormonally responsive stroma so that when some of the neoplasms occur in the breasts and occur in the stroma, it occurs in this stroma that is responsive to hormones [points to stroma around lobules]

Question 78

mucinous type ovarian epiltheila tumor derivation

Answer 78

endocervical epithelium

Question 79

severe dysplasia

Answer 79

•In severe dysplasia, more than 2/3 loss of maturation.

Question 80

mutation in low grade serous type ovarian tumor

Answer 80

kras

braf

Question 81

endometrial stromal sarcoma

Answer 81

• Finally, the other sarcoma that you see most frequently is endometrial stromal sarcoma.
• The tumor cells are similar to the endometrial stroma in the proliferative phase of the EM.
• Although it’s a low grade malignancy, it has a pretty high local recurrence rate: about 40%.
• This is with the caveat that you have to follow up with them for a very long time.
• They can recur even after 20 years.
• The patient is not off the hook, even if she has a hysterectomy.
• They have to be followed up for a long time because the tumor can come back in the pelvis, and it’s pretty high at 40% recurrence.
• The good news is that they express estrogen and progesterone receptors.
• Even patients with gland metastasis can respond to hormonal manipulation, like high doses of progesterone.
• They can shrink sometimes, even in the lungs.

The lung metastasis are still really rare; most of the time it’s a local recurrence within the pelvis

Question 82

endometriod type ovarian epiltheila tumor derivation

Answer 82

endometrial epithelium

Question 83

Answer 83

condyloma (HPV effect)

Question 84

chorionic villi - 3rd trimester

Answer 84

smallest CV 0 increased in number

cytotrophoblast not apparent

syncytiotrophoblastic knots

syncytiovascular membranes

Lots of capillary blood vessels located at periophery of CV;

In some areas, the only barrier btwn maternal blood (present in spaces) + fetal blood = syncitial vascular membrane à composed of basement membrane of endothelial cells + a little syncytiotrophoblast

• very thin = very hi/efficient exchange

Question 85

Answer 85

neuroblastoma

These circles are reminiscent of tubular structures or rosettes. They’re not true rosettes though because they’re not surrounding a definitive lumen. They are instead surrounding a central portion of neuropil. These are called HOMER-WRIGHT psudeorosettes

Question 86

acute salpingitis

Answer 86

Purulent infection: Neisseria gonorrhae, Chlamydia trachomatis, Mycoplasma, E.coli, H. influenzii, grp A streptococci

Young, sexually active patients, mostly under 25

Ascending route of infection through the cervical canal and endometrial cavity

Cornual resection of fallopian tubes or sterilization reduces the risk of salpingi

Question 87

Answer 87

• Here is an example of Herpes on a Pap smear: multi-nucleated cells that have a ground glass appearance to the nuclei [black arrow]. They characteristically have this nuclear molding.
• You can say that this woman has a herpetic infection.
• These nuclei actually mold into one another, meaning that they press up against one another – see here it looks like a moon [green arrow] – they are normally round. The nuclei would just be round if they were not molding – like the ones here [red arrows]. But this one forms the [molding] shape [points to the big cluster of nuclei in the middle] and it’s a characteristic feature of Herpes. They mold together and ground glass is when you can see through it – it’s opaque. You can see how this nucleus [black arrow] looks different from this nucleus [red arrow].

Question 88

what is preterm gestation?

Answer 88

<37 wks

Question 89

staging of breast cancer

Answer 89

0 - DCIS, LCIS

1 - invasive cancer less than 2 cm with negative nodes and no metastasis

2 - invasive cancer 2-5 cm or involved movable axillary nodes

3 - greater than 5 cm with positive nodes or any size with fixed axillary nodes

4 - distant metastese

Question 90

lymph nodes in vaginal carcinoma

Answer 90

• Vaginal cancer from the upper half goes to pelvic, and lower half goes to inguinal
• So these are the lymph nodes that the surgeon will take out, depending on the primary site

Question 91

epithelial hyperplasia of the breast

Answer 91

• This is proliferative epithelial hyperplasia - 1.5-2x increased risk
• The cells are proliferating and you notice that they form slit-like spaces.
• The irregular nature of slit-like spaces that help the pathologist determine between proliferative and atypical hyperplasia

In proliferative the spaces focus more on the outside area rather than the inner area

• And now what you see here [points to bottom picture, left most ductule] are these ductules and how filed they become
• And this is the proliferations of the cells. We’re going to contrast these cells later with atypical epithelial hyperplasia

Question 92

indirect coombs

Answer 92

diagnosis of alloimmunization

incubate maternal serum with known Rh(D) positive RBCs

RBCs then washed and suspended in serum with anti human globulin

RBCs with maternal anti-RhD will be agglutinated

Question 93

gestational hypertension

Answer 93

new onset hypertension in pregnancy without other findings after 20 wks gestation

Question 94

what drug do we give for preterm labor to reduce cerbral palsy

Answer 94

magnesium sulfate

Question 95

Tunica albuginea ovarii

Answer 95

• Ovary is covered by a single layer of surface epithelium derived from the embryonic ceolomic epithelium
• Surface epithelium sits on a layer of dense connective tissue called Tunica albuginea ovarii

Question 96

why is toxemia associated with placental abruption?

Answer 96

incrased placental vasoconstrictors and maternal hypertension

damage of maternal vessels

Question 97

Answer 97

leukoplakia

white patch

finding w dysplasia

Question 98

mucinous tumors of the ovary

Answer 98

Unilateral, endocervical epithelium

Large in size

Multiloculated

• Mucinous cystadenoma (80-85%)
• Borderline Mucinous tumor (5-10%)
• Mucinous Adenocarcinoma (10%)

Question 99

what is normal weight at term?

Answer 99

3300 +/- 600 grams

6.5-8 lbs

Question 100

type I vs type II endometrial carcinoma

Answer 100

•Pathogenetic types –

– Endometrioid Adenocarcinoma (80%)-type I

• Associated with unopposed and prolonged estrogen exposure.
• Obesity, Diabetes, Infertility, Hypertension (positive correlation)
• Low-grade

–Serous Carcinomas – less common, -type II

• Older age group
• High-grade
• Usually it’s a high grade tumor and frequently presents at the highest stage, meaning it has spread more at the time of diagnosis.

Question 101

Answer 101

mild dysplasia

•showing some enlarged nuclei, some overlapping of nuclei, and some loss of maturation [arrow].

Question 102

Answer 102

granulosa cell tumor

Juvenile form: before puberty
Secretes Estrogen and inhibin : Precocious puberty, endometrial hyperplasia/carcinoma
Low Malignant: local spread, recurrence and very rare metastasis
Prognosis better in Juvenile form
Call-exener bodies ( arrow) – aborted follicles – lined by oval cells, pink

coffee bean nuclei

Question 103

serous borderline tumor

Answer 103

cystic with a few solid areas

Question 104

apocrine metaplasia

Answer 104

of benign breast cysts

• The other change is something that’s call apocrine metaplasia
• If you remember metaplasia – one cell type changing to another
• These cells become apocrine
• Apocrine cells have abundant granular cytoplasm
• Prominent nucleoli
• They are characteristic change in cysts
• Secretory products in cysts can calcify and appear on mammogram
• The fluid can appear brown to blue because it can get hemosiderin in it or you can hemorrhage into it and it changes color

Question 105

difference between male and female breast cancer?

Answer 105

scant amt of breast tissue - rapidly infiltrates skin and thoracic wall!

male presents at higher stages

Question 106

types of sex cord stromal tumors

Answer 106

Benign

Thecoma

Fibroma

Malignant

Granulosa cell tumor

Sertoli and Leydig cell tumors

Question 107

Answer 107

koilocytes

• But here, what we’re looking for is not only the accumulation of this halo, but we are also looking at the nuclei. Recall that the nuclei are usually pretty small, but here, look how large the nuclei are getting [red arrow]. But you still have a lot of cytoplasm. Cells that have larger nuclei, abundant cytoplasm are called low-grade SIL.
• When you get to the higher grades, the nuclei keep getting bigger and the cytoplasm shrinks. So they have a much larger nucleus and a much smaller amount of cytoplasm.

Question 108

genetic makeup of complete mole

Answer 108

one sperm with nonviable egg or 2 sperm with nonviable egg

No fetus growth! Only get molar chorionic vili

Can have 2 sperm fertilization à if both YY, baby will die (46YY is non-viable)

Can have 2 haploid sperm fertilization empty egg

Question 109

treatment of benign ovarian surface epithelial tumors

Answer 109

Cystectomy or Unilateral Oophorectomy

Question 110

what is in normal umbilical cord?

Answer 110

1 vein + 2 arteries

Question 111

placental infarct

Answer 111

area if ischemic necrosis due to obsruction of blood supply (thrombus in spiral arteries, outside compression)

peripheral or marginal

if small - no clinical significance

if large and centaral - higher mortality! assoc w diabetes, HTN, lupus

•Infarcted area = pale + pink; corresponds to necrotic vili caused by ischemia

Question 112

proliferative phase

Answer 112

• The proliferative phase is usually the phase that is responsible for the variation in length of the menstrual cycle.
• It can last between 10-20 days.
• It can be different in different women, or even different during the lifetime of the same woman.
• It’s characterized by regeneration of the EM lining after the previous shedding, so therefore you have proliferation of glands and stroma.
• It’s basically regulated by estrogen.
• When you look microscopically at high magnification of the glands, you can easily see mitotic figures [green arrows in top left.] These are the proliferative EM glands.
• You can also see mitoses within the stroma [lower right], quite a few of them.
• Basically this shows you that it’s a regenerating and proliferating.
• You can see more mitotic activity sometimes in normal proliferative EM when you have a low grade cancer.

Question 113

cryosurgery

Answer 113

for cervical dysplasia

•Cryosurgery is used for low grade lesions. You freeze the lesion and it’ll die off, and hopefully that’ll be the end of that.

Question 114

Answer 114

immature terratoma from totipotent cell

Rare

Most patients under 20 yrs of age.

Mature and immature elements from three germinal layers.

Immature neural tissue common. Grows rapidly, can rupture in peritoneal cavity or metastasize to lymph nodes, lung, liver. Treatment: Surgery + chemotherapy.

Question 115

endometrial polyps

Answer 115

• Another condition which is a cause for bleeding from the EM are EM polyps.
• You have the polyp here [giant ball shown by navy arrow]. You have cystically dilated glands. You can see them on low power [green circle although they’re everywhere in the polyp].
• On high power [lower right picture], you normally see the thick-walled blood vessel [square], which you can sometimes see on imaging.
• Later on you will have a lab session, and some of the OB/Gyn colleagues will sometimes see on US the feeding blood vessel into the EM polyps.
• We can have a good idea sometimes on imaging that the patients might have EM polyps in the EM cavity.
• Then you also have a fibrotic stroma [lower middle picture] and this sort of disorderly glands, cystically dilated.
• They are not neatly arranged like you would see in the normal proliferative or secretory phase of EM.

Question 116

stage II ovarian carcinoma

Answer 116

Stage II: Involvement of pelvic tissues. Five year survival 60%

Question 117

serous type ovarian epiltheila tumor derivation

Answer 117

fallopian tube epithelium

Question 118

aspiration cytology

Answer 118

breast, lymph nodes

•Aspiration cytology- taking a thin little needle, sticking it into a lump and bump. We do a lot of this in breast, lymph nodes, and thyroid

Question 119

moderate dysplasia

Answer 119

•In moderate dysplasia, there is 1/3 to 2/3 loss of maturation.

cells atypical in the bottom

Question 120

embryonic phase

Answer 120

<10 wks

Question 121

woman’s lifetime risk of developing ovarian cancer?

Answer 121

1 in 72

Question 122

Ewing Sarcoma/PNET

Answer 122

• 2nd most common bone cancer in adolescents after osteosarcoma
• M:F 1.3:1
• Rare in Africans and African-Americans
• Typically occurs in diaphysis of long bones, pelvis, ribs

small blue cells - Small round blue cell tumor. Characteristic picture of pediatric tumors. Solid growth pattern. Intervening fibrous septa with a high degree intratumoral vascularization.

Question 123

non-proliferative fibrocystic change of the breast

Answer 123

alteration present in most women

lumpy bumpy changes on exam

20-40 years of age, peaks premenopause

NO RISK of breast cancer

Question 124

endometrial carcinosarcoma

Answer 124

• Another condition that is very rare is carcinosarcoma.
• It’s composed of both malignant epithelial and malignant mesenchymal components, as the name indicates: carcino-sarcoma.
• The sarcomatous component in these tumors can look like malignant smooth muscle when it’s homologous.
• Sometimes the malignant sarcomatous component can have differentiation towards cartilage, bone, skeletal muscle, so it’s something that you normally don’t see in the uterus. Therefore, this type is called heterologous.

Question 125

Answer 125

•Severe dysplasia: more than 2/3 loss of maturation.

Question 126

host factors for progression of HPV?

Answer 126

• Host factors include smoking, which reduces local immune response in the cervix by loss of dendritic cells.
• Anti-oxidants are helpful in preventing infections of various types.
• During pregnancy, immune response is suppressed, and therefore infection can progress more rapidly.
• Other things that lead to reduced immune status such as HIV infection will also lead to more rapid progression of HPV infection.
• The role of oral contraceptives and other concurrent infection is controversial.

Question 127

Answer 127

chronic salpingitis

Pyosalpinx: Pus in the lumen, thinning of wall

Hydrosalpinx: Very thinned wall with loss of smooth muscle and plicae, non-ciliated epithelium, no inflammation

Fibrosis – don’t see neutrophils as much

Plicae fuse together and block lumen

Question 128

choriocarcinoma and mole

Answer 128

preceded by mole in 50%

rapidly invasive, widely metastatic

sheets of malignant cells recapitualiting primitive cyto-syncitiotrophoblast

no villi formation

high hCG

extremely responsive to chemo

Question 129

Answer 129

neuroblastoma

The other thing to keep in mind with this tumor is that you may have areas with further differentiation. So you have a small round blue cell here (upper red arrow) and adjacent to it you have a much larger cell (black arrow) with an eccentric nucleus, prominent nucleolus and abundant eosinophilic cytoplasm. Right next to that you have a cell that also has a very large nucleus (green arrow) but you can see that it has more cytoplasm compared to this (blue arrow). This is showing maturation toward ganglion cell differentiation. This is another key feature.

Question 130

Answer 130

cervical adenocarcinoma

Question 131

clear type ovarian epiltheila tumor derivation

Answer 131

secretory endometrial epithelum

Question 132

Answer 132

Ovarian counterpart of testicular seminoma - from undifferentiated germ cell

Most common malignant germ cell tumor of ovary

Patients in 20s and 30s

Undifferentiated germ cells

May produce hCG leading to elevated serum hCG levels

Radiosensitive, excellent prognosis

Sheets of germ cells interspersed by fibrotic septa – with some lymphocytes

Malignant, very radiosensitive, very good prognosis

Question 133

difference between high grade and low grade>

Answer 133

Morphologically the main difference between low grade and high grade serous carcinoma is the degree of nuclear atypia ( mild in low grade, severe in high grade)

Low grade serous carcinoma is often seen in association with borderline serous tumors, shows KRAS and BRAF mutations and is relatively chemoresistant

High grade serous carcinoma is often seen in association with fallopian tube STIC lesions, shows p53 mutation and is relatively chemosensitive

High – shows ugly pleomorphic nuclei w mitotic figures

Low – less mitotic

Question 134

comedocarcinoma of the breast

Answer 134

high grade malignant cells with central necrosis

necrosis calficies and is noted

Question 135

Answer 135

lymphoma

• The important thing about cytology is you can use immunohistochemistry to help you define what it is. Immunohistochemistry is another stain that we use – we have a bunch of immunohistochemical markers that are helpful. This is for leukocyte common antigen [bottom right image] – see all the cells that are stained brown. That helps you to say it is lymphoid.
• We can do the smears in conjunction with a bunch of stains to help us determine what the tumor is.
• This is important b/c if this were a metastatic lesion from somewhere else you would want to know from where. Lymphomas are very differently treated than carcinomas.

Question 136

Answer 136

Botryoid rhabdomyosarcoma occurs along the mucosal membrane of hollow organs (bladder, vagina, nasal cavity). This histologic appearance is classic. One you should remember and know.

You have your squamous mucosal surface (black arrow). Squamous mucosa lines vaginal canal. Immediately under that you have condensed hypercellular layer of cells. This layer of cells is an undifferentiated small round blue cell proliferation called the cambium layer. Supposed to be reminiscent of the cambium layer from which tree roots start to grow. So very condensed cell layer of cell growth. Underneath that you have this very pauci(?) cellular loose mixoid type of tumor growth. Botryoid rhabdomyosarcoma has an extraordinarily good prognosis.

Question 137

cervical intraepithelial neoplasia categorization

Answer 137

• everything under that category can invade.
• Grade 1 has a lower chance of invasion than grade 3. Grades 1-3 correspond to mild, moderate and severe dysplasia.
• The most recent terminology is in cytology which classifies HPV infections and mild dysplasia as low grade and moderate and severe dysplasia as high grade squamous intraepithelial lesion.
• If you have low grade SIL, the pt can be managed conservatively. If you have high grade SIL, the management is more aggressive, with cone biopsy for the most part.

Question 138

pap smear

Answer 138

• You use a spatula or brush to scrape the cervix in the area where squamous epithelium joins columnar epithelium.
• This is the body of the uterus [1] and this is the vaginal opening [2].

Question 139

preeclampsia

Answer 139

new onset of hypertension AND proteinuira OR end-organ dysfunction, occuring after 20 wks of gestation in a previously normotensive woman

multisystem, progressive

ranges from mild-severe

progression may be gradual or rapid

Question 140

Rhogam

Answer 140

16% of Rh negative wmen become sensitized after 2 deliveries of Rh positive infants

give postpartum anti-D immunoglobulin - reduces risk to 2%

give postpartum and antepartum - reduces risk to .1%

pooled plasma source - derived from hman plasma

give at 28wks if fetus is Rh [ositive

Question 141

fibroadenoma of the breast

Answer 141

benign

• Has two components – fibrous = stroma,
• adenoma = glandular

This is characteristic look of fibroadenoma – longer than it is wide

• Why is that important?
• Things that are benign spread along the fascial plane and why this extends side to side and not up and down
• Cancers in the breast go through the fascial planes.

When I show you cancer, they are characteristically wider than they are long

• This contrasts to the cyst which looked all black because this is made up of fibrous and glandular tissue. This will have speckled normal-looking breast tissue within here.
• If you trace it along edges, it looks well-circumscribed.

Question 142

how to differentiate bleeding from placental previa and plancental abruption?

Answer 142

placental abruption is painful bleeding, placenta previa is painless

Question 143

pathogenesis of preeclampsia

Answer 143

not entirely understood but both maternal and placental

maternal vascular insufficiency, increase placental mass without correspondingly increasing placental blood flow (increase prevalence at high altitudes)

abnormal placental development (impaired trophoblast differentiation and invasion, abnormal remodeling of the spiral arteries)

immuno factors (exposure to paternal/fetal antigens appears to be protective)

increased sensitivity to angiotensin II

Question 144

schiller test

Answer 144

•, the application of iodine to the squamous epithelium, which normally contains glycogen and is a brown color, but with dysplasia there’s a loss of glycogen and those areas look white. So you can biopsy those areas if you don’t see anything that you can see with your eyes. You can use vinegar and it’ll do the same thing.

Question 145

mutation in mucinous type ovarian tumor

Answer 145

kras

Question 146

most important prognostic factor in breast cancer?

Answer 146

lymph node metastasis

Question 147

Answer 147

borderline mucinous tumor

Epithelial stratification

Mild nuclear atypia

NO stromal invasion

finger like layers lined w mult layers

Question 148

Answer 148

mucinous cystadenoma

Complicated epithelial architecture: cribriform/solid patterns

Nuclear atypia

Stromal Invasion

Differential diagnosis for mucinous ovarian tumors should always include metastatic mucinous tumors from gastrointestinal tract. Appendix and colon are the most common primary sites for metastatic mucinous tumor in ovary.

glands back to back, stroma has been infiltrated

Question 149

choriocarcinoma

Answer 149

Choriocarcinoma differentiates towards extraembryonic tissue (placental). It secretes beta hCG. Responsive to chemotherapy

totipotent - diff toward placental

Question 150

Answer 150

psammoma bodies

serous carcinoma

Question 151

pathogenesis of wilm’s tumor

Answer 151

Malignant neoplasm derived from nephrogenic blastema

If you were to look at fetal kidney up until the 37th week of gestation immediately under the capsule is your nephrogenic (? Cant understand what she says) which shows the primitive cells that lead to nephrogenesis and these cells are the origin of the Wilms tumor. The Wilms Tumor histology tries to recapitulate normal nephrogenesis.

Question 152

placenta previa

Answer 152

low lying placenta

marginal, partial, complete

painless 3rd trimester bleeding

associated w placenta accreta (inability to do labor at the end)

• When the placenta is so low (in placenta previa), it can cover internal cervical oss partially/completely; requires C section for delivery of baby
• Pt had placenta previa associated w/ placenta accreta (very thin decidua); if u have placenta previa, u have higher risk of also having placenta acretaà this pt had both accreta + previa à caused massive hemorrhage

Question 153

pap:

Answer 153

•] Shown here is the effect of the HPV infection: the nuclei get larger; the cells acquire a perinuclear clearing – this empty space around the nuclei known as koilocytic change. These are all changes of HPV infection, also in cytology they are called part of low grade squamous intra-epithelial lesion.

Question 154

in situ ductal carcinoma of the breast

Answer 154

15-30% of breast cancer - helped by mammography

cannot invatde through BM of ducts –> can’t metastasize!

can spread through the ductal system and involve large segments!!

Question 155

Answer 155

polycystic ovary disease

LEFT: Have thick, pearly capsule outside because ovulation has not been occurring so the capsule is very thick.

RIGHT: In the superficial cortex there are multiple cysts with a thin wall and prominent theca cell layers.

Question 156

Answer 156

•The Pap smear shows cells with very hyperchromatic nuclei [bottom left image]. Much larger nuclei. Also see the orange cytoplasm typical of squamous cell carcinoma. Once you see this, you know what the pt has.

Squamous cell carcinomas are also spindled – see the shapes of the nuclei here, the oval spindled cells [red oval]. This is a keratinizing squamous cell carcinoma

Question 157

atypical ductal hyperplasia of the breast

Answer 157

4-5x risk

architectural and cytological atypia - more rounded spaces and monomorphism of cells

cells fail to entirely fill the lumen

usually assciated w calcification

• The spaces, rather than irregular, become more uniform and rounded.
• Even cells themselves, start to become larger and more pleimorphic.
• Differences in size and shape – although there is some monotony and start to look very similar to one another

[reads second point]

• meaning there are still these spaces but again within these spaces can have calcification because there is proteinaceous material
• Lead to calcifications on mammogram that may be subject to biopsy

Question 158

why is plaenta previa more frequently associated with placental accreta?

Answer 158

deficiency of decidua

Question 159

Acute Endometritis

Answer 159

• Acute endometritis is uncommon.
• It can cause discharge from the vagina, infertility, and uterine tenderness, like any inflammation.
• In some patients it can be asymptomatic.
• Most of the time it’s related to retained placental tissue.
• This is composed of chorionic villi.
• It can be either post-abortion or post-partum after normal delivery when some of the placental tissue was left behind and can lead to infection.
• Usually when you have an infection, it’s polymicrobrial and caused by an ascending infection from the normal flora of the vagina.
• The treatment would be, if you have retained tissue, to remove it.
• If you have an infection of bacterial origin, you would treat it with antibiotics.

Question 160

partial hydatidiform mole

Answer 160

mix of edematous villi and normal sized villi

In contrast, a partial mole occurs when a haploid egg is fertilized by two sperm or by one sperm which reduplicates itself yielding the genotypes of 69,XXY (triploid) or 92,XXXY (tetraploid).[4]

Irregular villous outline (trophoblastic inclusions)

Fetal parts à can have development of an abnml baby

Persistent GTD is low, 0.4%-4%

Very rare reported cases of choriocarcinoma; can become cancerous

Question 161

type II ovarian cancer

Answer 161

Type II ovarian cancers are rapidly growing and present at stage III or IV. Histologically they are not seen associated with possible precursors such as an adenoma or borderline ovarian tumor. They show p53 mutations. Most patients with BRCA mutations get type II ovarian cancer.

High grade serous, High grade endometrioid and undifferentiated carcinoma are type II ovarian cancers

High grade Serous

High grade Endometrioid

MMMT ( carcinosarcoma)

Undifferentiated carcinoma

Most type II ovarian tumors are supposed to be arising in the fimbrial end of fallopian tube as a result of p53 mutation occurring in the fimbrial epithelium.

Question 162

pap smear shows LGSIL?

Answer 162

• If the Pap smear shows a LGSIL, these women are tested for HPV.
• If high risk HPV is detected, these pt undergo colposcopy and biopsy.
• If the high risk HPV is negative, these pt are followed with Pap smears.

Question 163

how do we differentiate neuroblastoma?

Answer 163

In order to define a neuroblastoma you have to have a shwannian core tumor. The area that I showed you before, the shwannian stroma, that has to make up less than 50% of the tumor in order to classify it as a neuroblastoma.

. Further going on to indicate whether or not you’re dealing with an undifferentiated, poorly differentiated or a dedifferentiating subtype that’s where the preseence fo those ganglion cells comes into play. A tumor with no ganglion cell

Poorly differentiated subtypes have less than 5% ganglion cell differentiation or evidence of neuropil and maturation. Differentiating subtypes have greater than 5%. So that’s the next stage in terms of whether or not you’re dealing with a favorable or unfavorable prognosis.differentiation and little or no neuropil is called an undifferentiated subtypes.

Question 164

mechanism of toxemia in pregnancy

Answer 164

•3 key events in toxemia happen

1. Decreased maternal perfusion (aka ischemic placenta)
2. Placenta makes more vasoconstrictive substances + less vasodilator production à set up for HTN in mom
3. Damage from injury of the endothelium à can activate coagulation in maternal blood vessels (aka disseminated intravascular coagulation)

à if happens in kidney, mom gets proteinuria b/c won’t have normal filtration in the kidney

à if happens in CNS, mom gets convulsions

à if happens in liver, get abnml LFTs b/c of necrosis of hepatocytes

•

•Bascially inflammation/abnml remodeling of mom’s blood vessels during 2nd wk of 1st trimester + remodeling of blood vessels present in superficial SM (smooth muscle) layer à won’t perfuse placenta adequatelyà can lead to ischemia

Question 165

treatment for malignant germ cell tumors

Answer 165

Mature cystic Teratoma: Cystectomy or unilateral oophorectomy

Malignant: Unilateral salpingo-oophorectomy plus chemotherapy

Malignant germ cell tumors are usually treated with unilateral salpingo-oophorectomy and chemotherapy since bilaterality is not very high and most patients are young so preservation of fertility is important.

Most malignant germ cell tumors respond to chemotherapy well and 5 year survival rate is close to 100% even when tumor has spread beyond the ovary.

Question 166

Answer 166

mucinous cystadenoma

Multilocular

Smooth cyst walls

Lined by a single layer of mucinous epithelium with basally located small nuclei

cysts mutli loculated – no solid in their, thin 1 layer of epithelium, papillary/finger like projeections, all w single layers

Question 167

organic vs dysfunctional uterine bleeding

Answer 167

dysfunctional: anovulatory (hormonal) is most common cause

excessive estrogen without progesterone

• DUB is generally ascribed to poorly understood derangement in functional effects of hormones on the EM.
• Dx of exclusion after other known causes of abnormal bleeding are ruled out.
• Anovulatory cycle is the most common case of DUB in the reproductive age group.

DUB due to anovulatory cycles typically occurs at menarche and at menopause, but can occur at any time during the reproductive years

Question 168

change in chorionic villi over pregnancy

Answer 168

become smaller and increase in number to increase surface area with a thin barrier

Question 169

Answer 169

plasmacytoid

• These large cells are in an arrangement called plasmacytoid- the nuclei shifts all the way to one side of the cell and there’s a lot of cytoplasm.
• That’s a typical arrangement of what happens in a breast cancer.

Plasmacytoid means resembling the cytoplasm of plasma cells; normal plasma cells have their nuclei shifted towards one side.

Question 170

hormonal influences of breast cancer

Answer 170

sporadic related to hormone exposure

increased exposure to estrogen unopposed by progesterone - may be that estrogens stim growth facotrs!

Question 171

eclampsia

Answer 171

new onset grand mal seizures in a woman with preeclampsia that cannot be attributed to another cause

may occur during or right after labor - give magnesium sulfate for labor of preeclampsia

Question 172

Leiomyosarcoma

Answer 172

• malignant sarcoma with a smooth muscle differentiation.
• As pathologic criteria, like any malignancy, you have cellular atypia, necrosis, and high mitotic counts in these tumors.
• Leiomyosarcomas are bad news.
• You have only a 50% five year survival, about 50% recurrence rate, and 78% chance of having distant metastasis, usually to the lungs.
• Sarcomas usually use the veins to metastasize. That’s why you should always check the lungs when you have leiomyosarcoma.
• You don’t have very good chemo for leiomyosarcoma. You don’t have much to offer to these patients.

Question 173

complete hydatidiform mole

Answer 173

Molar pregnancy is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus and will fail to come to term. A molar pregnancy is a gestational trophoblastic disease[1] which grows into a mass in the uterus that has swollen chorionic villi. These villi grow in clusters that resemble grapes.[2] A molar pregnancy can develop when a fertilized egg does not contain an original maternal nucleus. The products of conception may or may not contain fetal tissue. A complete mole is caused by a single (incidence is about 90%) or two (incidence is about 10%) sperm combining with an egg which has lost its DNA (the sperm then reduplicates forming a “complete” 46 chromosome set) [4] Thegenotype is typically 46,XX (diploid) due to subsequent mitosis of the fertilizing sperm, but can also be 46,XY (diploid).[4] 46,YY (diploid) is not observed.

Associated w/ Trophoblastic proliferation

• No dvlpmt of baby; No fetal parts
• Prognosis

80-90% benign

10% invasive mole

2.5% choriocarcinoma

Mom only needs to be followed + no pregnancy in future b/c not sure if increased HCG is caused by this or by new pregnancy

Small percent of moms w/ complete moles can become choriocarcinoma

Question 174

Alveolar rhabdomyosarcoma

Answer 174

Tends to occur, in contrast to embryonal and botryoid, in older children so early teens to mid-adolescence. It tends to occur in deep muscles of the extremities as well as axial skeletal and perineum

Alveolar rhabdomyosarcoma is characterized by an alveolar or lepidic pattern of growth. It’s supposed to look like alveolar septa of lung. Have this discohesive component of cells that sort of falls into the middle (black arrow). These tumors will typically have anaplasia, high mitotic activity and may have intratumoral necrosis.

Question 175

presentation of polycystic ovary disease

Answer 175

Most common complaint is difficulty to conceive, or infertility.

There is a wide presentation of symptoms.

A lot of patients are asymptomatic until they can’t conceive.

A big chunk of patients have symptoms: amenorrhea, acne, hirsuitism, and they come to clinicians for that.

The basic syndrome: characterized by secondary amenorrhea, or irregular menstrual cycles. They may be infertile. Hirsutism, acne.

A lot of patients are obese.

On ultrasound both ovaries will have multiple cortical cysts.

Question 176

Answer 176

sertoli-leydig cell tumor

Very rare ( 1% of all ovarian tumors)

All ages but common in child bearing years

Low malignant potential/ may metastasize

Resemble embryonic testis

Reinke crystals ( arrow) in Leydig cells

Secretes weak androgens : Virilization with large tumors

Resembles primitive tubules – arrange in tubule shapes

Look like leidig cells

Question 177

hydrops placenta

Answer 177

common end-stage pway of variable etiology

cardiac failure

tissue hypoxia and edema in the fetus and placenta

Question 178

ovarian carcinoma

Answer 178

Florid cellular proliferation giving rise to solid areas

Nuclear atypia

High mitotic activity

Areas of necrosis

Stromal infiltration = Metastatic potential

Borderline tumor grows proliferally – solid areas – access to blood vessels in the stroma

Question 179

secretory phase

Answer 179

• For example, on Day 17, you have a lot of clearing beneath the nucleus in the cells of the EM glands. [Gestures around a gland.]
• These are the subnuclear secretory vacuoles. The whole cell looks like a piano key.
• This is morphologic proof that ovulation took place.
• Later on, these vacuoles are moved into the apical portion of the cytoplasm and secreted into the lumen on Day 19.
• From Day 20 on, the changes within the stroma, rather than the EM glands, are important for dating the EM.
• On Day 22, you see these pale areas all over the place. This is edema fluid, which is accumulating there.
• On Day 22, you have implantation of the fertilized ovum.
• If you don’t have it, then you have these secretory changes [Day 25] which are in the form of decidualized stroma.
• These pink areas that you see between the glands, these are decidualized stroma, and it’s diffuse on Day 25.

Question 180

epithelum?

Answer 180

serous (fallopian tube derivation)

Cuboidal to columnar cells with central nucleus and cilia

Question 181

exposure to HPV?

Answer 181

75%

Question 182

Answer 182

• You can get HPV infections in this area.
• This tends to be a low risk HPV infection that gives you raised lesions- these are called condylomas.
• These are low-risk so they don’t go on to cancer, but they can present a clinical problem.

Question 183

Answer 183

mosaic vessels

•Mosaic refers to pattern of blood vessels with a mosaic pattern

finding w dysplasia

Question 184

wat is considered large for gesational age?

Answer 184

>4000 gms

macrosomia

Question 185

borderline tumor

Answer 185

Proliferation of epithelial lining of inclusion cyst gives rise to some solid areas

Mild nuclear atypia is seen

Can shed epithelial cells from its surface and cause implants on peritoneal surfaces or on other organs

No stromal infiltration

Can not metastasize

Recurs

5 year survival up to 90% even with peritoneal involvement

Death due to non-malignant complications of disease such as bowel obstruction

Benign can start undergoing some proliferation, start forming areas of stratification w mult layers, epithelial tufts can get pushed off and lay if fluid, can be shed into peritoneum

mixed./borderline – not single layer, more prolific growith – has not invaded ovarian stroma yet! Has not accessed blood vessels – no metastatic potential

Question 186

invasive mole

Answer 186

molar tissue penetrates or perforates myometrium

hCG emains elevated

need to treat with chemo and hysterectomy

Question 187

lichen sclerosus et atrophicus.

Answer 187

• A lesion that occurs in older women, and for an etiology for which we don’t know, is lichen sclerosus et atrophicus.
• The skin becomes thin, with a patchy white appearance and itchy skin.
• This is a gross appearance [left]
• This is a microscopic picture [right] with a lot of keratin. But the epithelium itself is thin, and then there’s hyalized collagen below that.

Question 188

what two cancers are associated with endometriosis?

Answer 188

endometriod adenocarcinoma

clear cell carcinoma

Both are seen associated with endometriosis in up to 50% of cases

They resemble the endometrial cancers of same morphology

Squamous morules (arrow) are often seen in endometrioid carcinoma just like in the endometrioid carcinoma of endometrium

Endometriod – looks like in uterus

Clear cell – clear cytoplasm

Question 189

how is pediatric cancer different from adult cancer?

Answer 189

• Lower incidence
• Different tumor types - Carcinoma is rare!
• Overall better prognosis
• Special predispositions

–Chromosomal and genetic syndromes

–Congenital immunodeficiency syndromes

•Increased significance of late effects of therapy

Question 190

what is cut off for Low birth weight

Answer 190

<2500 grams

small for gestational age (<10%ile)

preterm

Question 191

congenital cytomegalovirus infection

Answer 191

most common hematogenous infection of the fetus

most mothers are asymptomatic

most infants are asymptomatic

risks: primary and recurrent maternal infection

Question 192

Answer 192

moderate dysplasia

•slightly more than 50% loss of maturation.

Question 193

what is term gestation?

Answer 193

37-42 wks

Question 194

pelvic inflammatory disease

Answer 194

PID ( pelvic inflammatory disease ) = chronic salpingitis with involvement of surrounding structures including ovary and parametrium

PID is characterized by exacerbations of acute episodes

IUD usage is associated with Actinomyces infection which is rare otherwise: Risk of infection is related to the length of IUD usage, 85% cases occurring after 3 or more years of IUD usage

Question 195

management of patient at increased risk of preterm delivery <34 wks

Answer 195

corticosteroids to reduce risk/severity of RDS

abx

tocolysis to delay delivery for 48 hours

Question 196

what are the 2 layers of trophoblast cells?

Answer 196

inner - cytotrophoblast

outer - syncytiotrophtrophoblast

• We focus on cytotrophobast (white à has fingerlike projections; very proliferative, but no production of substances/hormones)
• Gray cells w/ nuclei = SYNCYTIOTROPHOBLAST (terminally differentiated; circled in blue)
• SYNCITIOTROPHOBLAST MAKES HCG (human chorionic gonadotrophin)
• During second week, embryo + everything formed by conception is embedded in endometrium when the process of implantation is complete
• White = trophoblast à 1’ chorionic vili; composed of trophoblast

Question 197

adenomyosis

Answer 197

• The uterine smooth muscle wall is markedly thickened because….you see these little red dots? [navy arrow for one example]
• These dots correspond microscopically [right side] to the present of EM glands and stroma within the smooth muscle.
• You can see the two pinks stripes of smooth muscle on either side of the purple stroma and glandular EM tissue in the center.
• When this is present within the smooth muscle wall, they induce smooth muscle hyperplasia.
• Therefore the uterine wall is thickened, but it’s not forming any well-circumscribed masses. It’s a diffuse process.
• Contrast this to slide 41, where you have well-circumscribed masses.
• With adenomyosis, you don’t have these. Just diffuse thickening of the uterine wall.
• It’s a very painful condition, because these EM glands and stroma are present within the smooth muscle, but they slough like they would in the EM cavity without a way to get out.
• This induces a lot of inflammatory response in those areas.
• You have cytokines, which leads to quite a lot of pain.

•

Question 198

treatment of polycystic ovary disease

Answer 198

TREATMENT: lifestyle changes – lose weight.

Metformin itself can cause ovulation, used to treat the hyperinsulinemia.

If you don’t want to get pregnant – want to regularize menstrual cycle through the use of oral contraceptives.

Androgenic symptoms are treated with anti-androgens.

Patients who want to conceive can be treated with clomiphene.

Question 199

high risk HPV

Answer 199

HPV 16/18

risk of progression to high grade dysplasia around 20%

Question 200

type I ovarian cancer pathogenesis

Answer 200

Type I pathogenesis starts with the formation of cortical inclusion cysts that undergo mullerian metaplasia ( serous/mucinous/endometrioid). It follows a stepwise progression from adenoma to carcinoma through borderline tumors. K-ras mutations are most commonly seen in mucinous carcinoma, B-raf in low grade serous carcinoma and PTEN in endometrioid carcinoma of ovary.

Question 201

Answer 201

brenner tumor

Rare

Benign

Transitional epithelium nests separated by fibrous stroma

Sharp cytoplasmic borders, clear cytoplasm, Nuclear grooves

Borderline and malignant forms (Atypical Proliferative Brenner Tumor and Transitional cell carcinoma) are very rare

brenner – rarely seen, benign, solid/firm, cystic, nests of transitional epithleium

Oval nuclei w grooves

Question 202

Answer 202

keratin pearls

squamous cell carcinoma of the vulva

•Microscopically, these well differentiated lesions have these keratin pearls (1), a feature of squamous cells in a well-differentiated carcinoma.

These epithelial pearls are invading underlying stroma, so it’s an invasive cancer

Question 203

breast ductule lining

Answer 203

• The ductules are lined by 2 layers [points to bottom figure]: inner layer of epithelial cells, outer layer of myoepithelial cells
• Things that make something be benign
• Lose these when something becomes malignant
• Ducts are lined by a basement membrane
• What will become important will be tumors that don’t break through the basement membrane and don’t have the ability to spread anymore

Question 204

TORCHES infection

Answer 204

Tosoplasmosis

Other (parvovirus B19, varicella zoster, listeria)

Rubella

Cytomegalovirus

HErpes virus

Syphilis

A vertically transmitted infection (or mother-to-child transmission) is an infection caused by bacteria, viruses, or in rare cases, parasitestransmitted directly from the mother to an embryo, fetus, or baby during pregnancy or childbirth. It can occur when the mother gets an infection as anintercurrent disease in pregnancy. Nutritional deficiencies may exacerbate the risks of perinatal infection.

Question 205

Answer 205

mature teratoma - from totipotent cell tending toward somatic

Most common ovarian tumor of reproductive age group

95% of germ cell tumors are mature teratomas

Tumor differentiation towards all three germ cell layers

Skin is the most common tissue seen

46XX

Rarely malignancy may arise in one of the elements of tumor tissue ( in older women)

Squamous carcinoma is the most common type of carcinoma arising in dermoid cyst

Post meiotic reduplication of germ cell

Occasionally can develop metaplasia and ca

Question 206

common membrane in dichorionic diamniotic twins?

Answer 206

can be monozygotic or dizygotic

opaque

four layers: 2 amnion, 2 chorion (fused)

Question 207

transitional type ovarian epiltheila tumor derivation

Answer 207

urinary epithelum

Question 208

endometriosis

Answer 208

• This time, you have the presence of EM glands and stroma but it’s outside of the uterus.
• In adenomyosis, you have EM glands and stroma within the smooth muscle wall of the uterus, which is also abnormal.
• It should be just in the EM cavity.
• In this condition, it’s completely outside.
• It’s also in young patients, usually in the reproductive age group.

It can also lead to infertility and to pain: to pelvic pain and to painful intercourse

Question 209

epithelum

Answer 209

Columnar cells with basal nuclei and pale blue cytoplasm, mucin vacules, nuclei are small and on basophil

endocervical derivation

Question 210

cone biopsy

Answer 210

done for high grade dysplasia. So basically, you remove a cone-shaped piece of cervix and I’ll show you how that looks like. Sometimes the cone biopsy margins come out positive with dysplasia.

Question 211

Gene mutation in Ewing/PNET

Answer 211

11;22 which is the EWS/FLI-1 translocation.

Now use dual fusion break apart probe and fluorescent in situ hybridization. Take EWS and label each side of it. Side is dependent on where you put the break point. Breakpoint is usually at 22q. So you label each side. So in a normal chromosome they should be right next to each other.

Question 212

management of preeclampsia

Answer 212

definitive treatment is delivery (at >37 wks it’s recommended, even without severe features)

expectant management if no severe features (daily BP monitoring, lab testing/wk, corticosteroids)

Mg sulfate for labor to reduce seizure risk

anti hyptertensives avoided if BP below 160/110 (don’t change disease process)

termination is offered <24 wks (bad prognosis)

Question 213

dysgerminoma

Answer 213

from undifferentiated germ cell

Sheets of germ cells interspersed by fibrotic septa – with some lymphocytes

Malignant, very radiosensitive, very good prognosis

Question 214

invasive ductal carcinoma of the breast

Answer 214

70-80% of carcinomas

irregular spiculate masses

stony hard to cut section

malignant cells in cords, solid cell nests, tubules

Question 215

staging of cervical carcinoma

Answer 215

• The prognosis of cervical cancer depends on the stage of disease.
• The earlier the stage, the better the prognosis; so much so that if the disease is less than 5mm invasive, called Stage IA, survival is 98%. That’s pretty amazing, you can pick up cancer early and you’ll get close to 100% survival.
• If it’s greater than 5mm invasion, prognosis falls down to 80%.
• If there’s involvement of vagina or parametrium with Stage II, 70%.
• With pelvic sidewall, there’s a considerably worse prognosis, with 35% survival.
• And Stage IV would be mucosal involvement of bladder or rectum, with only 10% survival.

Question 216

treatment of borderline ovarian surface epithelial tumors

Answer 216

Young patient: Cystectomy/ unilateral Oophorectomy

Older patient: Bilateral salpingo-oophorectomy with hysterectomy and staging

Question 217

velamentous umbilical cord

Answer 217

1. Velamentous – umbilical cord inserted into fetal membrane at edge of the placenta; rare; what’s important is that the blood vessels are now crossing internal cervical oss; if baby trying to push into cervical canal (where the velamentous insertion of the umbilical cord is located à THE BABY TRYING TO PUSH THROUGH THE CERVICAL CANAL WILL SQUISH AND CAUSE RUPTURE OF THE BLOOD VESSELS à THIS CONDITION IS CALLED VASA PREVIA
   - BABY NEEDS TO GET C SECTION TO AVOID RISK OF HEMMORRHAGE
   - ALSO PRONE TO MECHANICAL INJURIES B/C NO CUSION (usually connective tissue will form a cushion around the umbilical blood vessels; in velamentous insertion, the blood vessels are OUTSIDE of the umbilical cord à don’t have the protective connective tissue cushion à VERY PRONE TO MECHANICAL INJURY!!)

Question 218

Answer 218

serous borderline tumor

• epithelial stratification (4-5 cell layers)

tufting of epithelium

• mild nuclear atypia - Psammoma bodies (arrow)
• No stromal invasion

Question 219

ER/PR +

Answer 219

better prognosis!

can be treated with tamoxifen (anti estrogen that blocks ER) or arimidex (aromatase inhibitor)

Question 220

management of patient at increased risk of preterm labor <32 wks

Answer 220

corticosteroids (reduce risk/severity of RDS)

magnesium sulfate to reduce risk of cerebral palsy

abx to prevent vertical transmission of GBS

tocolysis - delay delivery for 48hrs

Question 221

primary, secondary, tertiary chorionic villi

Answer 221

Primary CV (trophoblast ONLY), day 12 - 14 (end of 2nd week)

Secondary CV (tropho then acquires mesenchymal core) @3rd wk , day 16

Tertiary CV (blood vessels form end of 3rd wk; can see on H&E section ) , day 21 (3rd - 5th week) à building block of placenta

Question 222

ovarian cystadenoma

Answer 222

Lining epithelium of the inclusion cyst undergoes metaplasia to become serous or mucinous

Single layer of epithelium lines the cyst cavity

Tumors can become massive, usually filled with serous or mucinous fluid depending on the type of lining epithelium or with blood in case of endometrioma

5 year survival: 100%

All women have inclusion cysts – some get a lot bigger and accumulate fluid because cells become metaplastic into serous or mucinous, lined by SINGLE layer of epihtlium – means there isn’t much epithelial proliferation so it a benign cystadenoma

Question 223

decidua

Answer 223

Compare w/ img B (end of 3rd trimester) à CV + separated from SM via layer of decidua à THIS IS NORMAL!!

• important b/c if decidual is smaller (ie: b/c of leiomyoma/scar tissue) à CV can grow thru and attach to SM (smooth muscle)à aka placenta atreta à important b/c at delivery of baby, placenta delivered w/ baby (dissection usually along decidual layer; usually smoothly delivered)
• if CV growing into SM, PLACENTA CAN’T BE DELIVERED à can cause hemorrhage!!! Can be deadly!! à pt will need hysterectomy!

Question 224

how does invasive cervical carcinoma present?

Answer 224

• Spotting or bleeding
• Post coital bleeding
• Abnormal pap smear; this would typically be in a patient who has never had a pap smear in her entire lifetime
• Advanced cases of cancer may present as uremia because cervical cancer tends to grow locally and close off the ureters on the sides, therefore causing uremia.

Question 225

endometrial hyperplasia with atypia vs without atypia

Answer 225

• On the left, you have glands that are haphazardly arranged.
• They are crowded.
• There is a reduced amount of stroma between the glands, but
• you can delineate every individual gland.
• You can have a nice stroma.
• There is no cytologic atypical in the EM epithelial lining of those glands.
• This is simple hyperplasia without atypia.
• On the other hand, when you look at the right, these glands are very crowded.
• There is hardly any stroma separating these glandular structures from each other.
• We start to have these little outpouching. [The glands look branched instead of round in cross-section.]
• At higher magnification, you have nucleoli where the chromatin is cramped.
• This is an example of complex hyperplasia with atypia, or atypical complex hyperplasia.
• This is the one that is associated with high risk of developing of developing endometrioid adenocarcinoma.

Question 226

Oncoproteins of HPV?

Answer 226

E6, E7 - bind to tumor suppressor genes in cells

• It was discovered in 1989 that papillomavirus E7 protein is able to bind to retinoblastoma gene.
• Retinoblastoma is a tumor suppressor gene. Once cells lose tumor suppressors, they have increased ability to divide and go on to become tumors.
• One year later, it was found that E6 protein binds to p53, which is important for maintaining normal cells.

Question 227

what predicts response to treatment and prognosis for wilm’s tumor?

Answer 227

presence/absence of anaplasia

Anaplasia in Wilms Tumor has a specific diagnosis. It is defined by two criteria and BOTH MUST BE PRESENT:

(1) Abnormal polypoid or tetraploid mitotic figures (black arrow)
(2) marked nuclear enlargement [green arrow] and hyperchromasia [blue arrow]. Nuclear enlargement must be at least 3X larger than non-anaplastic adjacent cells

Again it’s very important to distinguish between multifocal and diffuse. In the lab we will take a photomicrograph of tumor section and map out exactly where each section comes from. So we have a diagram that tells us which part of the tumor we’ve taken the section from and if we see anaplasia on that slide we can see how much of the tumor is anaplastic.

Question 228

Answer 228

serous cystadenoma

30-60% bilateral. Unilocular, smooth walled, filled with serous/clear fluid

Bilat huge cyst – with clear fluid, clear and glistening, benign

Question 229

breast:

Answer 229

fibroadenoma

cellular fibroblastic stroma enclosing glandular and cystic spaces lined by epithelium

n- FIBROADENOMA EPITHELIUM IS HORMONALLY RESPONSIVE

n- SLIGHT INCREASE IN SIZE AT END OF MENSTRUAL CYCLE OR DURING PREGNANCY

n- REGRESSION OCCURS POSTMENOPAUSALLY LEADING TO HYALINIZATION AND CALCIFICATION

Question 230

leukoplakia of the vulva

Answer 230

old age

thickened keratotic vulvar skin

biopsy to rule out dysplasia

Question 231

Answer 231

• Intense vulvar itching and white cheesy discharge are typical of candidal infection.
• You do a Pap smear and you can see the spores and the pseudohyphae. The long elongated structures in the image are the hyphae. You can make the diagnosis of candida.
• The patient will get treated and cured.

Question 232

what cells give rise to the placenta?

Answer 232

trophoblast cells

During the 2nd wk the trophoblast proliferates rapidly and gradually differentiates into: 1) an inner cytotrophoblast, and 2) an outer syncytiotrophoblast. The erosive trophoblast invades the maternal endometrium (decidua) and blood vessels. This leads to remodeling of the vessels with leakage of maternal blood into trophoblastic spaces (lacunae). The fusion of the adjacent lacunae results in formation of lacunar network where exchange of nutrients and gasses takes place between maternal blood and the developing embryo.

Question 233

molecular cytopathology

Answer 233

• As we move into the more molecular age, there are things in cytology that use molecular detection. One of these is Urovysion, used to aid in the diagnosis of bladder cancer in pts with hematuria (blood in urine) and to monitor tumor recurrence in pts who already have a hx.
• They just take a urine sample that looks abnormal and do FISH on it and see if they can detect aneuploidy (change in the number of chromosomes).
• They look for certain chromosomes – loss of a particular chromosome that is associated with pts having bladder cancer. Those pts with those abnormalities will probably have to get cystoscopy where they look in with a scope. Most of these pts are just monitored through urine samples, so it adds to understanding that these pts might be at a greater risk and leading to another procedure.

Question 234

Answer 234

breast cyst

• And most of the time, the breast tissue is this blackish white tissue
• The whiter parts are normal glandular tissue
• The blacker areas are fat because majority of breast is actually composed of fatty tissue
• And this is lesion here [circles oval] and what we see here is this very darkened lesion
• If you look at edges of it, you see that it is very circumscribed, edges are quite smooth. This is characteristic of a cyst.
• It looks black because of greater transmission through fluid

Question 235

Answer 235

struma ovarii

Monodermal teratoma

More than 50% of the tumor tissue should be thyroid tissue to be classified as Struma ovarii

5-10% patients may have hyperthyroidism clinically

20-30% patients may have thyroid cancer arising in struma ovarii ( commonly Papillary type, occasionally follicular type)

Peritoneal strumosis: Seeding of peritoneum by benign strumal tumor: Rare

Thyroid tissue! More than 50%

Question 236

neonatal phase

Answer 236

first 28days of life

Question 237

neuropil

Answer 237

neuroblastoma

As you look at the fibro-stromal background you’ll note that you have thicker pieces of actual fibrous tissue [black arrow] and attached to that you have this more fine fibrillary eosinophlic matrix [green arrow]. This is a very important histologic image for you to remember. The presence of this material which is called neuropil [black circle] is a key diagnostic feature for this tumor. The remainder of this tumor is a typical small round blue cell appearance. You have a very small cell. It’s very dark blue. It’s hyperchromatic. It has sort of inconspicuous nucleoli but it has lots of clumpy or vesicular chromatin.

Question 238

phyllodes tumors

Answer 238

lobulated and irregular on ultrasound

solid and cystic

leaf-like pattern with stromal hypercellularity

biphasic: neoplastic stromal cells and epithelial lined glands

most are benign but can be malignant (associated w increased stromal cellularity, mitotic figures, rapid increase in size)

Question 239

Answer 239

thecoma

sex cord derived tumor

Benign

Unilateral

Occur in postmenopausal women

Appears yellow grossly

Produce estrogen: Abnormal uterine bleeding, breast enlargement, endometrial hyperplasia or carcinoma

Post-menopausal – benign, well circumscribed, YELLOW bc fat has cytoplasm

Plump oval shapped cells – can mae estrogen (irregular/post men bleeding

Question 240

“suspicious” in cytopathology

Answer 240

•If we call something “suspicious”, it means we do see abnormal cells that we think are cancer, but we’re not 100% sure because there’s not enough to definitely make that clear. When we call it “positive”, we want to be right.

Question 241

epithelium of endocervix and exocervix

Answer 241

endocervix - columnar lining

exocervix - stratified squamous lining

•Shown here is an actual cervical slide, showing the outer part of cervix [red circle], the endocervix [yellow circle] and the squamo-columnar junction [blue circle].

Question 242

stage III ovarian carcinoma

Answer 242

Stage III: Involvement of lymph nodes or extra-pelvic peritoneum. Five year survival 25%

Question 243

pap smear recommendations

Answer 243

•It is recommended that women in reproductive age groups have Pap smears every 3 years. Yearly Pap smears used to be the recommendation, but people realized that these lesions don’t progress so fast, so you can still pick them up if you do a smear every 3 years.

Question 244

Rh positive

Answer 244

his term strictly refers only to the most immunogenic D antigen of the Rh blood group system, or the Rh− blood group system. The status is usually indicated by Rh positive (Rh+ does have the D antigen) or Rh negative

Question 245

what is post term gestation

Answer 245

>42 wks

Question 246

Answer 246

chocolate cyst

Called a chocolate cyst because the clotted blood collected very menstrual cycle looks like chocolate

Endometriotic cysts contain clotted blood

Cyst wall is formed by endometrial epithelium and stroma

Endometriotic cysts are considered precursors of endometrioid and clear cell types of ovarian cancer

Question 247

squamous cell carcinoma of the vulva

Answer 247

• Squamous cell carcinoma: the vulva can present with ulcer, mass, or nonspecific itching.
• Older women
• The lesions are usually well differentiated. In the cervix, lesions are typically poorly differentiated, but in the vulva they’re typically well differentiated.

Question 248

where in the ovary are the germ cells?

Answer 248

• Outer portion is the cortex that contains the germ cells (primordial follicles) embedded in specialized stromal cells
• Inner portion is the medulla that contains the rich vascular network

Question 249

extrachorial placenta

Answer 249

Peripheral rim of the placenta is not covered by the membranes. May be associated with vaginal bleeding and leakage of amniotic fluid.

Question 250

tubular carcinoma of the rbeast

Answer 250

well formed tubules with absent myoepithelial layer and apocrine snouts

axillary metastases uncommon - excelllent prognosis!

Question 251

pap smear shows HGSIL?

Answer 251

• If the Pap smear shows a HGSIL, these women undergo colposcopy and biopsy.
• Colposcopy is direct visualization of the cervix. So you can sample the most abnormal looking areas.

Question 252

acute chorioamniotis

Answer 252

• 10% ifx = ascending ifx; usually followed by premature rupture of the maternal membrane
• caused by bacteria growing in mom’s vagina (could be Group B strep)
• Associated w/ increased perinatal mortality
• In asc ifx, when bacteria coming into amniotic fluid, mom’s immune system will respond to the infectionà can see lots of neutrophils that come from maternal decidua à can see lots of neutrophils that come in to fight ifx
• Baby can also get ifx; baby can respond to ifx à will see inflammation in vessels of the umbilical cord umbilical cord

•

•Can see lots of neutrophils in umbilical cord à means baby is also ifx’d L

Question 253

most common cause of spontaneous abortion?

Answer 253

karyotype abnormalities

Question 254

Embryonal Rhabdomyosarcoma

Answer 254

•Children ages 3-10 years

▫nasal and oral cavities, orbit, middle ear, prostate, paratesticular region

Question 255

“atypical” in cytopathology

Answer 255

•Atypical” is sort of a wishy-washy category where we see something that we think is abnormal but aren’t sure.

Question 256

abrasive cytology

Answer 256

gastring brushings

•Sometimes you have to use more of an abrasive method, and this is mainly in the gastrointestinal tract, where you have to scrape it off or brush it off. When you go through the endoscopy clinic and you’re with one of the gastroenterologists, when they put the tube down to take a biopsy, they have these little brushes that come out from the endoscopy tube and you can swirl it around a little, the cells get stuck to that brush, they put them in a fixative, and we make slides out of those cells to see whether its benign or malignant.

Question 257

adenocarcinoma of the cervix

Answer 257

• So adenocarcinomas are much less frequent; only about 10% of cervical carcinomas are adenocarcinomas.
• The incidence may be increasing; there’s some evidence for that
• And HPV 18 is frequently detected, as opposed to HPV 16 in squamous cancers.

Question 258

2 components of the endometrium?

Answer 258

• The lower 1/3 [below the white line], which is the regenerative layer, responds to steroid hormones in a minimal fashion.
• The upper 2/3, whih is the functional layer, sheds at the end of the menstrual cycle, proliferates, and the one which undergoes sexretory differentiation later.
• I wanted to point out to you that it’s very orderly arranged.
• This is the surface of the EM [green arrow]
• The glands are more or less perpendicular to it, and they are parallel to each other. [She gestures vaguely at the circles everywhere.]
• They are evenly spaced.
• It has a very organized look to it, which is important.

Question 259

cytopathology

Answer 259

cytopathology is different from histopathology (where you’re looking at actual tissue). This is where you’re just looking at cells.

Question 260

colloid carcinoma of the breast

Answer 260

older women, grows more slowly

well circumscribed, soft due to gelatinous mucinous material

small enoplastic cells float in lakes of mucin

excellent prognosis, low incidence of ln metastais

Question 261

medullary carcinoma of the breast

Answer 261

younger women

well circumscribed

slightly better prognosis

• One is syncytial nests of very large pleomorphic cells with prominent nucleoli and frequent mitoses [mouses over pale pink part on top image]
• The other is that it is surrounded by this lymphoplasmacytic infiltrate
• So there are lymphocytes and plasmacytes surrounding it [mouses to part around the syncytial nest with lots of nuclei]

solid sheets of large cells pleomorphic nuclei with prominent muceloli and requent mitosis

lymphoplasmacytic infiltrate surrounding

**pushing borders

Question 262

what if umbilical cord is too long or too short?

Answer 262

•Length, mean 60 cm

–Long

•knots, prolapse, strangulation

–Short

• abruption, uterine inversion, umbilical hernia
• psychomotor impairment

Question 263

three patterns of non-proliferative fibrocystic change of the breast

Answer 263

• Have cysts – the black things
• Fibrosis – the white part on the top picture
• Adenosis – just an increase in the number of acini within a lobule

Question 264

acute atheros

Answer 264

in toxemia of pregnancy

•Name of the pathologic changes in toxemia = ACUTE ATHEROSIS

•

•When maternal blood vessels in decidual is destroyed + replaced by fibrin (aka fibrinoid tumor) à lots of foamy histiocytes + cells around it

•

• In Toxemia à correlation btwn morphology + clinic presentation ISN’T VERY GOOD!
• Pt can have really bad clinical presentation, but no changes in blood vessels!

Question 265

chronic salpingitis

Answer 265

Chronic Salpingitis: Chronic inflammation, fibrosis and fusion of plicae, scarring leading to:Tubo-ovarian adhesions, Tubo-ovarian abscess, Pyosalpinx, Hydrosalpinx, Ectopic Pregnancy, Infertility

PID ( pelvic inflammatory disease ) = chronic salpingitis with involvement of surrounding structures including ovary and parametrium

PID is characterized by exacerbations of acute episodes

IUD usage is associated with Actinomyces infection which is rare otherwise: Risk of infection is related to the length of IUD usage, 85% cases occurring after 3 or more years of IUD usage

Question 266

succenturiate placental lobe

Answer 266

• Usually see succenturiate aka accessory lobe
• usually not a problem; will have an irregular piece of placental tissue
• just check to make sure the vessels in the accessory placenta are intact in case they break b/c they’re not protected by placental parenchyma/membrane surrounding the normal placenta

Question 267

Treatment of ductal carcinoma in situ

Answer 267

segemntal excision wth radiation

mastectomy if extensive

doesn’t metastasize - no need for LN dissection

Question 268

type I ovarian cancer

Answer 268

— Indolent and Present as stage I

—Develop from well established precursors such as

• Borderline tumors
• Endometriosis

Type I ovarian tumors follow the traditional model of pathogenesis i.e. they start as surface inclusion cysts, undergo metaplasia to form benign tumors and then dysplasia to form first borderline and then malignant tumors.

Common mutations seen in type I tumors are KRAS, BRAF

Mucinous adenocarcinoma, Clear cell carcinoma and low grade serous and endometrioid carcinoma are type I ovarian cancers

Question 269

presentation of hydatidiform mole

Answer 269

vaginal bleeding in 1st trimester

uterus larger than expected

HTN in first trimester

elevated HCG

Question 270

Answer 270

atypical ductal hyperplasia - 4-5x risk

Question 271

risk factors for breast cancer

Answer 271

n- H/O PROLIFERATIVE BREAST DISEASE (1.5-2X) (4-5X FOR ATYPICAL DUCTAL HYPERPLASIA)

n- GEOGRAPHIC INFLUENCE: US AND NORTHERN EUROPE HAVE HIGHEST RATE

n- LENGTH OF REPRODUCTIVE LIFE: INCREASES WITH EARLY MENARCHE AND LATE MENOPAUSE

n- PARITY: MORE FREQUENT IN NULLIPAROUS

n

n- AGE AT FIRST CHILD: RISK INCREASED IN WOMEN OLDER THAN 30

n- POSTMENOPAUSAL HORMONE REPLACEMENT THERAPY SLIGHTLY INCREASES RISK

Question 272

invasive lobular carcinoma of the breast

Answer 272

5-10%

strands of infiltrative tumor cells in a single file pattern

no formation of tubules

lacks e-cadherin

Question 273

amnion nodosum

Answer 273

assoc w oligohydraminos and fetal urinary tract abnormalities must be excluded

• Surface of placenta should be smooth and glistening; but this placenta is sick à bumpy usually b/c of oligohydramos (not enough amniotic fluid à amniotic fluid produced by kidneys of fetus
• Should check for kidney/urinary problems in the fetus

Question 274

meconium staining of fetal membrane

Answer 274

Green discoloration of membranes due to staining by the colonic contents, normally seen in association with fetal distress. There may be hyperplastic changes in the amnion layer with pigment-laden macrophages beneath.

Can also see meconium staining (greenish staining on fetal plate) à when baby in distress, it will pass meconium that stains fetal membranes à meconium = chemical irritant; can lead to inflammation; black brown spots = meconium eaten by macrophages

Question 275

embryonal carcinoma

Answer 275

Embryonal carcinoma is comprised by undifferentiated totipotential cells. Responds well to chemotherapy.

totipotent cell without further differentiation

Question 276

genetic makeup of partial mole

Answer 276

• TRIPLOID à 1 nml egg fert by 2 sperms à 69 chromosones

Complete + partial mole = 2 sets of DNA from dad

Complete = 2 sets of DNA from dad + no DNA from mom

Question 277

pathogenesis of polycystic ovary disease

Answer 277

The basic central pathogenesis is supposed to be increased production of androgens from ovaries. The theca cells are producing a lot of androgens, so there is increased serum androgens, which are being converted into estrogen by granulosa cells, and a lot of patients are obese, so they have their adipose tissue converting it into estrogen.

We saw on the last side that when there is increased serum estrogen, there is increased LH because estrogen stimulates the productive of LH. When there is a lot of LH and estrogen, FSH production goes down.

àààHave high androgens (like testosterone or DHEAS), so high estrogen, and high LH and decreased FSH.

LH/FSH ratio is supposed to be 2-3:1

Because there is a high level of estrogen, and low progesterone because there is no ovulation taking place (no corpus luteum creation), there is increased risk of endometrial carcinoma.