Sept7 M1,2-Gynecological Pathology Flashcards
ecto vs endocervix
endocervix = columnar mucinous epithelium ectocervix = squamous epithelium
TZ def
junction of ecto and endo cervix
where cervical cancer can be
TZ (most likely so pap smear done there)
ecto or endocervix
steps of cervical cancer dev
- oncogenic HPV infection
- persistence of infection
- progression to precancer (asx, above BM, detected by screening)
- dev of invasive CA (below BM, can metastasize, may be sx)
pap smear looks at what
dysplastic changes in cells of TZ
colposcopy is done when + bx what
specific cases if pap test +. bx lesions if see any + bx TZ + bit of endo and exocervix
3 precursor lesions of cervical cancer (all above BM)
- low grade squamous intraeptih lesion (LSIL) (CIN1 and CIN2. cervical intraepith neoplasm)
- high grade squamous intraepith lesion (HSIL) (CIN3)
(imp?) how HPV infection is detected in LSIL
see specific cell type called koilocytes
- cytoplasmic vacuole
- large and dark nucleus
- coiled nuclear membrane
CIN1 vs CIN2 vs CIN3
CIN1: = koilocytes in bottom, near BM CIN2 = koilocytes going up, in middle but still the top cells are mature and pink CIN3 = koilocytes all the way
specific changes in CIN3
high NC ratio, big nuclei, more cells (increased cellularity), more mitotic figures
cervical adenocarcinoma in situ (AIS) def + grading
see glandular lesions (glands) = AIS present.
no grading**
AIS charact
- glandular
- high NC ratio
- mtiotic figures
- crowding
- stratification
end point of cervical AIS
invasive adenoCA
low risk HPV types (leading to external genitalia lesions)
6, 11, etc.
high risk HPV types (LSIL and HSIL)
16, 18, etc.
tx of LSIL
conservative (regresses often)
tx of HSIL and AIS
surgical excision (LEEP)
sx of invasive CA of the cervix
- early = asx
- late = abnormal vaginal bleeding (typically postcoital) and abnormal vaginal discharge
RFs for invasive cervical CA
- many partners
- high risk partners
- early age intercourse
- other STDs
- immunosuppression
- smoking
- high parity
- low SES
macroscopic lesion charact of invasive squamous CA
red exophytic lesion irregular
what’s below the BM of cervix, where do cervical invasive CA cells invade
stroma. get an inflammatory desmoplastic response in the stroma
how to define invasive adenoCA of the cervix
- glands fused and formed a clear architecture
- high NC ratio, high cellularity, mitotic figures, crowding, stratification
- NOT based on BM bc hard to tell if went below BM or not*
tx of cervical invasive CA early vs late
- early = radical hysterectomy or chemo radiation
- advanced = radiation and chemo
classif of vulva pathologies
- HPV related lesions (same morpho as cervix and now caled VIN for vulvar)
- non HPV related
- note: vulva = squamous epith
VIN3 charact on histo
- red
- slightly raised
- dysplastic cells
- mitotic figures
non HPV related lesions in vulva + charact
- lichen simplex chronicus
- lichen sclerosus
- chronic inflam
- setup for squamous cell CA (SCC)
- especially older pts
(important) what to do when see vulvar lesion
biopsy (bc can’t guess if dysplastic)
paths of the endo
- endo hyperplasia with or without atypia
- endo CA
benign paths of the myometrium
- leiomyoma (fibroids)
- adenomyosis
malignant paths of the myometrium
leiomyosarcoma (malignant counterpart of fibroids. DOESN’T arise from fibroid)
endo hyperplasia def and cause
overgrowth of endo caused by persistent stim by estrogens
common cause of endo hyperplasia
granulosa cell tumor
RFs for endo hyperplasia and CA
- obesity
- diabetes
- htn
- infertility
- estrogen secreting ovarian tumor (like GC tumor)
- tamoxifen use
sx of endo hyperplasia
abnormal vaginal bleeding (usually postmenopausal)
endo hyperplasia without atypia def
- no clonal growth, not neoplstic yet, no cytological atypia*
- glandular crowding (meaning glands cover >50% of surface)
- irregular shape of glands
when to tx endo hyperplasia wo atypia and how
ALWAYS if dx
-progesterone
atypical endo hyperplasia other name
endometrial intraepithelial neoplasia (EIN)
EIN charact
- glandular crowding (meaning glands cover >50% of surface)
- cyto atypia and alteration
most common invasive tumor of the female genital tract
CA of the endometrium
clinical pres of CA of endo
abnormal vaginal bleeding (PMB = premenopausal bleeding, menometrorrhagia)
2 types of endo CA
type 1: estrogen dependent (endometrioid CA and variants)
type 2: unrelated to sustained E stim. (serous CA or clear cell CA)
Lynch syndrome pt: screen for what gyn paths
endometrial CA
type 1 vs type 2 endo CA
- type 1 assoc with endometrial hyperplasia. type 2 with atrophy
- type 1 low grade. type 2 high grade
- type 1 good prognosis. type 2 bad prognosis.
type 1 endo CA grading
- gade 1 = normal glands, normal endo
- grade 2 between 1 and 3
- grade 3 = no glands, undiff. only solid sheaths of cells
type II endo CA serous
- high NC ratio, no cyto
- shed cells in lumen that travel in tube to get spread
- more likely lymphovascular spread
type II endo CA clear cell
- clear cytoplasm
- high grade atypical nuclear features and architecture
T1a endo CA def (in TNM staging)
- confined to endo
- NO myometrium invasion
- tumor is a raised growth
T1b endo CA def (in TNM staging)
- invasion deep in myometrium
- almost reached serosa
- invaded into the outer half of the myometrium
fibroids content
benign tumor from smooth muscle, no atypia, spindle cells,, no mitotic figures
fibroids sx
- often asx
- abnormal uterine bleeding
pedunculated fibroid def
= out of external os
parasitic fibroid def
free floating in pelvic cavity
leiomyosarcoma macro charact
- large
- solitary
- hemorrhagic
- necrosis
- variegated color
leiomyosarcoma origin
arises de novo from SM
when to suspect a leiomyosarcoma
see a leiomyoma (fibroid) growing a lot after menopause as a single lesion (not supp to happen)
leiomyosarcoma charact
- malignant
- sarcoma
- not arising from fibroid
- SM origin
- grows fast
leiomyosarcoma on histo
- spindly like SM
- atypica cells
- mitotic figures
adenomyosis def
abnormal localisation of endometrial stroma and glands within deep myometrium
sx of adenomyosis
menorrhagia, pelvic pain
consequence of adenomyosis
- bleeding in myometrium
- causes pain + myometrial reaction (hyperplasia)
- forms tumor like mass
adenomyosis on macro
- thick
- trabeculated
adenomyosis on micro
- SM
- stroma
- endometrial glands
types of ovary paths
- non neoplastic lesions
- borderline lesions (atypical proliferative with potential malignancy)
- neoplastic lesions
non neoplastic lesions of ovaries
- benign cysts
- endometriosis
neoplastic lesions of ovaries
- primary (surface epithelial origin which can be benign, borderline or malignant, germ cell tumor or sex-cord stromal tumor)
- metastatic
benign cysts of ovary characteristic progression
- transient
- physiologic
- spontaneous regression
- common in young pts
- may look like ovarian neoplasm
2 types of benign ovarian cysts
- follicular cyst
- corpus luteum cyst
benign cysts of ovary charact
- smooth wall
- unolocular
- no papillary excresence
- no solid component
when to worry about an ovarian lesion
- liquid
- solid
- cystic
- multicomponent
endometriosis and myometriosis def
endometrial glands and stroma (or myometrium for myometriosis) present outside endometrial cavity
clinical pres of endometriosis
- pelvic pain
- infertility
- can mimic a tumor mass (‘‘endometrioma’’)
consequences of endometriosis and why have symptoms
- cycles and bleeds in ectopic location
- can cause adhesion and twisting of uterine tube (Fall)
endometrioma def
endometriosis that formed a tumor mass with bleeding and fibrosis
endometriosis macro
- raised, red to brown, can deposit anywhere (skin to lung)
- can deposit on ovaries (cyst dilated ovary)
most common area of endometriosis
serosa of pelvic area
diff names for endometriotic cyst
- cystic endometriosis
- chocolate cyst (one with old hemorrhage)
chocolate cyst def
benign lesion that can develop endometrioid lesions (atypical hyperplasia and adenoCA are possible in endometriosis)
how age helps for ovarian tumor prognosis
- young = likely benign
- older = likely malignant
4 categories of ovarian neoplasms
- surface epithelial or stromal cells
- germ cells
- sex-cord stroma
- metastasis to ovaries
most common ovarian neoplasm
surface epithelial tumors
important thing to know about germ cell tumors of ovaries
- develop in young patients (under 25). pelvic mass or ovarian mass.
- important ddx
- serum markers help to dx
3 types of surface epithelial tumors of ovaries
- serous (tubal)
- mucinous (endocervical)
- endometrioid (endometrial type)
most common ovarian neoplasm
high grade serous surface epithelial CA
3 classifications that each epithelial tumor type of ovary can have depending on prognosis
- benign
- atypical, borderline
- malignant
diff categories of benign epithelial tumors of ovaries
- cystadenoma
- cystadenofibroma
- adenofibroma
- name depending on if see lot of fibroid, cystic component
diff categories of malignant epithelial tumors of ovaries
-adenoCA
-cystadenoCA
(not really imp if cyst present or not tho..)
dx features of epithelial tumors of ovaries
- cell prolif
- nuclear atypia
- stromal invasion
2 most common gynecologic malignant tumors
#1 endometrial CA #2 ovarian carcinoma
leading cause of death in gyn cancers
ovarian cancer
sx of ovarian CA
- often asx until spread
- non specific, vague sx = urinary symptoms, GI, etc.
causes classif for ovarian CA
- sporadic (de novo) (90%): no precursor lesion.
- hereditary (10%): BRCA1, BRCA2, HNPCC (Lynch)
2 things protective against ovarian CA
- high parity
- use of OCP
diff types of serous tumors of ovary
- serous cystadenoma
- serous cystadenofibroma
- serous borderline tumor
- low grade serous CA (uncommon)
- high grade serous CA (more common)
how do you grade a serous tumor of ovary found in the uterine tube
high grade by def
steps of pathophgy of low grade serous CA of ovary
- tubal type of epith
- get serous cystadenoma
- Kras and BRAF mutation = epith prolif
- serous borderline tumor is the result
- stromal invasion (mutations)
- LGSC is the result
steps of pathophgy of HGSC
- tubal type epith
- p53 mutation
- result = HGSC
theory (almost accepted) regarding origin of HGSC
- originates in end of fall tube as serous tubal intraepithelial CA (STIC)
- goes to ovaries
(important) precursor lesion that causes most high grade serous CA of ovaries
serous tubal intraepithelial CA of the Fallopian tube
serous cystadenoma histo
-single layer of tubal epith. smooth wall. genign
serous borderline ovarian CA histo
- epithelial prolif
- grape like growth in the lumen, tree like branches, papillary projections with epith cells
LGSC of ovaries on histo
stromal invasion
HGSC of ovaries on histo
- big nucleoli
- papillary growth pattern
diff types of mucinous tumors of ovaries
- benign mucinous cystadenoma
- mucinous borderline tumor
- invasive mucinous CA
mucinous cystadenoma histo
- smooth wall
- cystic
- looks like cervix
mucinous borderline histo
- solid growth
- prolif of epith
mucinous CA histo
- obvious solid component
- stroma
- neoplastic epith in the stroma
important thing about INVASIVE mucinous tumors of ovary (mucinous CA)
80% are metastatic and come from another source particularly GIT
imp thing to do if suspect mucinous CA of ovaries
G scope and C scope to rule out GI cancer
endometrioid CAs assoc with what conditions
- ovarian or pelvic endometriosis (makes sense bc can then become neoplastic)
- endometrioid CA of the endometrium (sometimes can’t tell which is metastasis of the other)
how to dx ovarian cancer
at time of laparotomy (for staging), bc late detection. by bx of omentum or peritoneum
tumor marker of ovarian CA
C25
screening tests for ovarian CA
none
2 categories of germ cell tumors of ovaries
- benign dermoid cyst (97%)
- malignant (3%): dysgerminoma and non dysgerminoma
4 types of non dysgerminoma germ cell tumors of ovaries
- endodermal sinus (yolk sac tumor)
- immature teratoma
- embryonal carcinoma
- choriocarcinoma
sx of malignant germ cell tumors of ovaries
- young people
- abd pain, pelvic mass, rapidly enlarging
- highly aggressive
- highly chemosensitive
tumor markers of dysgerminoma germ cell tumors of ovaries
- LDH
- EST
- alpha FP
- chorio:hCG
dermoid cyst germ cell tumors of ovaries other name
mature cystic teratoma (dermoid cyst)
mature cystic teratoma histo
- sebaceous glands
- cartilage
- neural tissue
- from endo, meso or ecto derm embryonically
most common ovarian tumor
dermoid cyst (mature cystic teratoma)
sex cord stromal tumors of ovaries composition
- sex cord derivatives (GCs and Sertoli cells)
- stromal derivatives (theca and Leydig cells)
most common sex cord stromal tumors of ovaries
- fibroma
- thecoma
- granulosa cell tumor
how to determine the type of sex cord stromal tumors of ovaries a patient has
- the tumor may be functioning or not, meaning secreting estrogen or androgen or not)
- if secreting estrogen, see feminization so know it’s thecoma
- if secreting androgens, see masculinization so know it’s Sertoli cell tumor (Sertoli-Leydig cell)
what to worry about in estrogen producing sex cord stromal tumors of ovaries like thecomas
high estrogen so have to check if endometrium is fine
general features of metastatic tumors of the ovaries
- bilateral
- surface deposit
- multinodular
- lymphovascular invasion (more commonly)
- IHC help dx
how definite dx of metastatic tumor of ovaries is done
IHC
3 most common metastatic tumor of ovaries
- Colorectal ca
- breast ca
- Krukenberg ca
krukenberg ca def
- signet ring cell CA from GIT
- most often gastric stromal CA
- SIGNET RING CELLS*
most common breast cancer to metastasize to ovaries
invasive lobular CA (bc tends to invade abdominal and pelvic cavities)
paths of the fall tube
- PID (inflammatory disorder of upper GIT most often secondary to bacterial infection)
- tumor (STIC): precursor of lot of peritoneal, pelvic, high grade CA
complications of PID
- hydrosalpinx (infalmmation overtime, reactive changes, adhesions, fibrosis. twisted, tender, lumen blocked, cystic lesion like.
- prob of higher incidence of ectopic pregnancy + INFERTILITY
- tubo-ovarian abscess. (can get misdx as a tumor), is painful
what’s the prophylactic tx for ovarian cancer in BRCA carriers
removal of fallopian tubes
diagnostic features of STIC when see it when bx it from removed fallopian tubes in BRCA carrier
- significant atypia
- p53 mutation
- increased Ki67 prolif mix
tubal intraepith CA (TIC) often assoc with what
invasive serous CA in the tube
pelvic HGSC different theories for organ of origin
- ovarian
- tubal
- tubo-ovarian
- peritoneal
