Spotter Flashcards
What do the arrows indicate on this image of the villi of a 6w old placenta?
Cytotrophoblast cells (solid cores extend out to form new branches)
What stage of the menstrual cycle is shown here?
Endometrium: onset of mensturation.
What stage of the menstrual cycle is shown here?
Proliferative endometrium with lots of glands forming.
What stage of the menstrual cycle is shown here?
Secretory endometrium. Big cells and glands secreting components for incoming foetus
Label A-E of the pelvis.
A: greater (false) pelvis
B: lesser (true) pelvis
C: pelvic brim/inlet (divides the greater and lesser pelvis)
D: pelvic outlet
E: perineum
Label A-G of the pelvis.
A: iliac crest
B: PSIS
C: ASIS
D: ischial spine
E: ischial tuberosity
F: pubic tubercle
G: superior pubic ramus
Label A and B and state what they form.
A: arcuate line
B: pectineal line
Form the pelvic brim
Label A-E
A: sacrospinous ligament
B: sacrotuberous ligament
C: obturator canal
D: obturator membrane
E: greater and lesser sciatic foramen
Label A-C
A: sacroiliac
B: sacrospinous
C: sacrotuberous
Label A-E
A: anterior sacroiliac ligament
B: sacrospinous
C: sacrotuberous
D: pectineal line
E: pubic symphysis
Label A and B.
What runs from the sacral promontry to the symphysis pubis?
A: pelvic inlet
B: pelvic outlet
Diagonal conjugate.
Label A-C
A: sacroiliac
B: sacrospinous
C: sacrotuberous
Label A-C
A: piriformis (leaves pelvis through greater sciatic foramen)
B: coccygeus (overlying sacrospinous ligament)
C: obturator internus (leaves pelvis through lesser sciatic foramen)
Label A-C.
What does the green line indicate?
A: levator ani
B: coccygeus
C: piriformis
Levator ani muscle attachment
Label A and B
A: obturator nerve
B: pudendal nerve (goes to perineum behind the pelvic floor)
Label A-H of this male pelvic floor.
A: levator prostatae
B: puborectalis
C: pubococcygeus
D: iliococcygeus
E: levator ani
F: coccygeus
G: midline raphe
H: piriformis
Label A-D of this female pelvic floor.
A: puborectalis and pubococcygeus
B: iliococcygeus
C: coccygeus
D: piriformis
Label A-C
A: iliococcygeus
B: pubococcygeus
C: puborectalis
What is this condition?
Widespread purpuric rash - meningococcal septicaemia
What is this condition? (Can be caused by pneumococcus)
Osteomyelitis. Only seen on X ray about 10d after so need MRI instead.
What condition is this?
Molluscum contagiosum in normal host (top 2) and immunocompromised host (bottom 2). In pox virus family. Umbilicated lesions (dome shaped), in moist areas.
Label A-E.
a) placenta
b) myometrium
c) chorionic villi
d) chorion
e) amnion
Label A-G
A) pudendal nerve
B) lesser sciatic foramen
C) inferior anal nerve
D) deep perineal nerve
E) superficial perineal nerve
F) posterior scrotal nerve
G) dorsal nerve of the penis
Label A-E
A) ischiopubic ramus
B) obturator foramen
C) pubic symphysis
D) ischial tuberosity
E) perineal membrane
Label A-E
A) Ischioanal fossa
B) obturator internus
C) levator ani
D) pudendal canal
E) Internal and external anal sphincters
What are the yellow, red, green and blue areas showing?
Yellow: deep perineal pouch
Red: perineal membrane
Green: superficial perineal pouch
Blue: deep perineal fascia
Label A-E
A) levator ani
B) external urinary sphincter
C) in males, Bulbourethral gland (Cowper’s gland) - accessory sexual organ, involved in producing pre-ejaculare
D) perineal membrane
E) deep transverse perineal muscle
Label A-E.
A) Colle’s fascia
B) perineal membrane
C) corpus spongiosum
D) bulb of penis (proximal corpus spongiosum)
E) R and L crura of penis (part of corpus cavernosum)
What are the yellow, red, green and blue parts?
Yellow: perineal body
Red: ischiocavernosus (from ischiopubic rami)
Green: bulbocavernosus
Blue: transverse perineal
Label the muscles of the superficial perineal pouch and waht they cover/compress.
A) bulbiospongiousus, covers bulb and corpus spongiosum, compresses uretha and dorsal vein
B) superficial transverse perineal muscles
C) ischiocavernosus, covers and compresses crura
Help keep blood in corpus cavernosum during erection
Label A-D
A) prepuce of clitoris
B) glans of clitoris
C) opening of greater vestibular (Bartholin’s gland) - secretes mucus into vagina
D) perineal raphe
Label A-F
A) bulbiospongiosus (reduces size of vaginal orifice, compresses dorsal vein of clitoris, fused in middle in male but not in female)
B) ischiocavernosus (assists clitoral erection)
C) superfical transverse perineal (same as in male)
D) Bartholin’s gland
E) bulb of vestibule
F) clitoris
Explain this pathology.
Bartholin’s cyst. Duct from Bartholin’s gland becomes blocked, causes swelling of gland (cyst), can become infected, may need surgical drainage
What are the structures labelled A in the lumina of the seminiferous tubules?
Spermatozoa
Higher magnification of a seminiferous tubule in the testis. Identify the following structures A-D.
A) spermatogonia
B) spermatocytes
C) spermatids
D) spermatozoa
What are A and B?
A) Epididimis
B) Testis
What type of epithelium is A?
What do the ducts contain, labelled B?
A) pseudostratified columnar epithelium
B) spermatozoa
Identify the following structures:
A) smooth muscle
B) pseudostratified columnar epithelium
C) lumen of the ductus vas deferens
What is this?
Seminal vesicle, a ductile organ, has a fibromuscular wall and mucosa with many folds
What is this structure?
What kind of cell lines the prostatic urethra?
High power view of prostate gland.
The coumpound tubuloacinar glands (g) are surrounded by the stroma made of connective tissue (ct) and smooth muscle (SM). They produce a watery secretion that is thought to aid motility of the sperm in the ejaculate. Contraction of the smooth muscle by sympathetic stimulation expels stored secretions from the lumina of the glands.
Urothelium
What are CCP and CCU?
The penis has three columns of erectile tissue in its centre that contain many vascular spaces.
The two columns located dorsally are the corpora cavernosa of the penis (ccp).
The ventral column surrounds the penile urethra and is called the corpus spongiosum (ccu).
What structures are labelled A?
Primordial follicle
Identify A-C of the growing follicle.
A) zona pellucida
B) oocyte
C) granulosa cells
Identify A-F of the graafian follicle
A) fluid filled antrum
B) cumulus layer of granulosa cells
C) theca layer
D) oocyte
E) zona pellucida
F) peripheral granulosa cells
What is the structure labelled A in the ovary?
Corpus albicans
Identify the parts of the fallopian tube labelled A and B?
A) smooth muscle
B) folded mucous membrane
Identify the following stuctures in the endometrium in proliferative phase of cycle.
A) Developing glands
B) Endometrium
C) Myometrium
Identify a cell undergoing mitosis in the endometrial gland.
Black line
Endometrium in secretory phase: what is happening to the glands?
The glands are coiled, mature, active, and secreting thick, glycogen and glycoprotein rich material
What layer of the uterus is this and what is it composed of?
- myometrium
- smooth muscle with a network of arteries and veins supported by dense collagenous tissue
Identify A-C of the vaginal mucosa.
A) stratified squamous epithelium
B) subepithelial tissue/submucosa
C) blood vessels
This photomicrograph shows the junction between ectocervical and endocervical mucosa (often called the transitional zone).
- Which is the endocervical and which is the ectocervical mucosa?
- Why is this site important in pathological terms?
A: endocervical mucosa (glandular epithelium), B: ectocervical mucosa (squamous cell epithelium)
This is the site of origin of most cervical carcinomas.
What is A in the epididymis?
Spermatozoa
Identidy A-G in the testes
A) primary spermatocyte
B) spermatogonia
C) Spermatid (late)
D) myeloid cell (myofibroblast)
E) spermatid (early)
F) Sertoli cell
G) Leydig cell
Identify A-F in the testes
A) sertoli cell
B) Leydig cell
C) spermatocyte (primary)
D) spermatogonia
E) myeloid cell (fibroblast)
F) spermatid (early)
The tissue indicated in the epididymis is?
What sort of epithelium is found in the vas deferens?
Smooth muscle
pseudostratified columnar
What are A-C of the prostate gland?
A) glands
B) fibromuscular stroma
C) epithelium of urethra
Identify the follicles and other structures in the female.
A) primary follicle
B) Graafian follicle
C) theca interna
Label A-G
A) antrum
B) corona radiata
C) theca externa
D) oocyte
E) zona pellucida
F) zona granulosa
G) theca interna
Which phase of the menstural cycle is this endometrium?
What are the 2 layers seen here?
Proliferative
Endometrium (top)
Myometrium (bottom)
Two different states of endometrial lining are shown here - which ones?
A: Proliferative endometrium: stright glands have mitotic profiles
B: Secretory endometrium: glands coiled and cells bunched up secreting glycogen rich mucus visible in lumen that provides nutrition for fertilised ovum
What layer covers the oviduct (1)? What is layer 2?
1) serosa
2) smooth muscle
Label A-F (at 5-6 weeks)
A) mesonephros
B) gonadal ridges
C) metanephros (kidney)
D) Wolffian duct (mesonephric)
E) Mullerian duct (paramesonephric)
F) Cloaca
Label A-G
A) prostate
B) pubic symphysis
C) external urinary sphincter
D) rectovesical pouch
E) seminal vesicle
F) common ejaculatory duct
G) Cowper’s gland
Label A-C
A) ovarian ligament
B) round ligament
C) broad ligament (hangs down either side = fold of peritoneum)
Label the 2 peritoneal pouches
A) vesicouterine pouch
B) rectouterine pouch (Douglas pouch), can accumulate pus/blood, can be drained through anterior wall of vagina
Label A-G
A) fallopian tube
B) suspensory ligament - contains ovarian vessels
C) ureter
D) ovary
E) cervix
F) bladder
G) round ligament
Label A-G in this posterior view of the uterus.
A) suspensory ligament (vessels)
B) ovarian/round ligament
C) broad ligament (mesometrium)
D) isthmus
E) ampulla
F) infundibulum
G) fimbriae
What is this condition?
Anencephaly - some defects are not compatible with life.
What is this condition?
Hypospadias - opening of the urethra is on the underside of the penis. Classified as major defect but rarely life threatening.
What is this condition?
Cryptorchidism - undescended testis, 1-4% male live births, most spontaneously correct within 3 months. Can affect developing sperm and lead to testicular malignancy later in life, so need to operate on and if >1 year may remove it entirely.
What is this condition? What causes it?
Holoprosencephaly - varies from mild (L) to severe (R) and causes can be genetic or environmental (alcohol consumption). Due to loss of midline structures.
What is this condition?
Congenital diaphragmatic hernia: diaphragm (seperates thorax from abdomen) doesn’t close properly allowing GI system to enter thorax. Loops of intestines enter the chest and prevent proper lung development. Defect usually on L side of diaphragm. Treating depends on defect size - if small stictch up, if bigger - synthetic patch. Can have in utero repair.
What are A and B in the picture of a terminal branch of villus from a full-term placenta?
A) endothelial cells
B) syncytiotrophoblast
The synciyiotrophoblasts are always the cells in contact with the maternal blood in the lacunae
A syncytial knot is a characteristic of the term placenta. Which letter represents it?
4
Syncytiotrophoblast nuclei cluster together leaving zones of thin cytoplasm between them, reducing the diffusion barrier in these intervening areas.
Is this the maternal or foetal side of the placenta?
Maternal
Bumpy and has the shape of the villus masses. The foetal side is smooth and the umbilical cord projects from it.
The image shows the endometrium in two different phases. Identify the phases and the letters S and I.
L = secretory phase (pre implantation)
R = endometrium during early pregnancy
Stromal cells take up most of the space in the R and they are smaller on the L
S = syncytiotrophoblasts
I = cytotrophoblasts
What type of chorionic villus is this (primary, secondary or tertiary)?
Secondary
Primary = only syncytiotrophoblasts, tertiary = would contain BV
What is the developing embryonic structure?
Blastocyst
Label A-D of this early villous component.
A) mesenchyme
B) extravillous cytotrophoblasts forming a branch villus/invading
C) villous cytotrophoblasts
D) syncytiotrophoblasts
Label A-G of the breast.
A) areolar glands
B) fat tissue
C) alveoli
D) lactiferous ducts
E) lobule (contains alveoli)
F) lactiferous sinuses
G) areola
What are the following congenital defects and what are they caused by?
L = spina bifida**: failure of closure of posterior neural pore. **R = anencephaly: failure of closure of anterior neural pore = skull doesn’t close fully.
Determine the following 3 outflow defects?
L: transposition of great vessels - pulmonary trunk coming out of L vein. Hypertrophy of R ventricle.
Middle: persistant truncus arteriosus - mixing O2 and unO2 blood, acyanotic
R: tetralogy of fallot, aorta 3x size it should be and pulmonary trunk v small, R sided hypertrophy of walls, cyanosis becuase 2 parallel systems of O2 and unO2 blood
What are the following kidney defects?
L: horseshoe kidney
Middle: pelvic kidney
R: bifid ureter
What is this gut defect? Explain it.
Omphalocele/exomphalos: failure of umbilicus to close completely combined with failure of mid-gut to herniate back into abdominal cavity fully.
What are these gut defects? Explain them.
Top 2: vitelline duct abnormalities. 2-4% have small portion of vitelline duct forming outpocketing of ileum. Can become blocked and lead to trapped food and appendicitis but usually no symptoms.
Bottom 3: gastroschisis, usually to R of umbilical cord. Body wall muscle doesn’t form - lateral mesoderm doesn’t close properly. Gut not protected. More prone to infections and dehydrated. Covered with plastic silo.
What does this x-ray of a newborn show?
Duodenal atresia: see double bubbles: gastric bubble (black arrow) and big swollen duodenum with bubble (white arrow). If blockage in duodenum, presents with vomiting but takes longer than if oesophageal atresia.
What does this x-ray of a newborn show?
Diaphragmatic hernia. Baby has bowel in chest. As it developed, diaphragm had hole in it and bowel slipped up into pleural cavity so lung on R not developed. Baby: blue, tachycardia.
What is this condition?
Gastroschisis. Don’t want to put in back in right away or else baby can’t breathe b/c lungs and diaphragm splinted by pressure from reintroduced bowel, so have to do it slowly day by day.
What is this condition?
Omphalocele
Label the following cell types in the small intestine.
A) Goblet cell
B) Absorptive cell
C) Crypt cell
D) Paneth cell
What is this condition?
Chicken pox
What is this condition?
Shingles: reactivation of VZV later in life, usually in one dermatome only b/c VZV forms latent infection in one of the dorsal root ganglia. R = opthalmis VZV, serious.
What is this condition?
Neonatal HSV
What is this condition?
Syphilis.
L = primary syphilis - ulcer.
Top R = secondary syphillis, blistering rash usually on hands and feet
Bottom R = tertiary syphillus = erosions of nasal bone and cartilage, don’t see anymore.
What is this condition?
Chlamydia.
Top L: discharge clear and watery. Top R: cervix down speculum
Bottom L: arthritis. Bottom R: advanced PID - massive ovarian abcess on L, lifethreatening.
What is this condition?
Genital warts (HPV)
Top 2: warts
Bottom L: laryngeal infection, oropharyngeal HPV, warts on folds
Bottom R: cervix neck
What is this condition?
Neisseria gonorrhoea.
Top L: thick purulent discharge from urethra
Bottom R: disseminated gonorrhoea - arthritis
What is this condition?
Far L: HSV1 - oral herpes (cold sore).
Middle and far R: HSV2 - genital herpes (ulcers and blisters).
What is this condition?
Top 2: primary syphilis (single ulcer (chancre) and dark ground +ve)
Bottom 2: secondary syphilis (condyloma lata and lesions of palms and soles)
What causes this condition?
HIV
What condition does this CT scan of the right lung show? (Normal on the L, pathology on the R).
Bronchiectasis: enlarged airway. Arrow = cignet ring sign.
Baby X was born at 27 weeks’ gestation (by dates) and weighed 510 g. Apgar scores were 6, 7 and 8. She was transferred immediately to neonatal ITU, given 3 doses of surfactant, and ventilated. She was hypotensive and a chest X-ray on day 4 showed ‘solid’ lungs. She became profoundly hypoxic with refractory metabolic acidosis and died on day 9. Photomicrograph A is lung tissue acquired at the post-mortem examination and photomicrograph B is normal lung tissue taken at a different post-mortem from a baby that died at 25 weeks gestation from a different cause.
- What are the diagnosis as seen in photomicrograph A?
- What are the causes of prematurity?
- What are the major causes of death in pre-term babies?
- What factors determine survival rates in premature babies?
- What useful information can the autopsy provide?
1) Hyaline membrane disease: Formation of membranes in the peripheral airways (fibrin & cellular debris). Architectural & functional immaturity of lungs, surfactant deficiency. In uncomplicated cases reparative changes begin within 3-4 days.
2) PROM (premature rupture of membranes) 30-40%. Intrauterine infection 25%. Uterine anomalies (fibroids, bicornuate). Cervical incompetence. Placental problems (abruption, pl. praevia). Multiple gestation. IOL for maternal or fetal disease.
3) Hyaline membrane disease (HMD). Intraventricular haemorrhage (IVH). Necrotizing enterocolitis (NEC)[Pic]. Neonatal sepsis.
4) Gestational age (>35/40). Size (BW >2500g). Antenatally: corticosteroids. Exogenous surfactant at delivery. Postnatally: management - treating the underlying disease.
5) Confirm clinical diagnosis. Additional pathologies. Congenital malformations. Infection. Assess intrauterine growth restriction (IUGR).
What condition is this?
Pneumopericardium.
What else is wrong with baby X? What are some possible causes?
SGA: Birth weight <10th centile - at term <2500g. Causes: constitutional (genetic), IUGR (small, dysmature).
IUGR: Symmetric: proportional underdevelopment, early onset, chromosomal abnormality, chronic infection. Asymmetric: disproportional underdevelopment (“brain sparing” effect), late onset >25/40, causes incl. chronic placental disease and chronic cord problem.
What are the following conditions A-D?
A) Hypercoiled umbilical cord
B) Cord stricture
C) Thrombus in a chorionic vessel
D) Thrombi in stem vessels
Describe the following images A-D.
A) Recent thrombus in a chorionic vessel
B) Old thrombus in a chorionic vessel
C) Recent event: haemorrhagic endovasculosis
D) Remote event: avascular villi
Six-month-old baby Y was found dead in his cot, by his mother, on Sunday morning. He had been well since birth, but his mother thought he had been irritable on Saturday. The autopsy did not reveal any significant abnormality, and the cause of death was recorded as SIDS. The mother has another child, and is worried that the same thing will happen again. [Pic: normal alveoli]
- How should ‘cot deaths’ such as this be investigated?
- What is the differential diagnosis?
- Is there an increased risk for subsequent children?
- What can the mother do to minimise the risk?
1) Contact the coroner - natural death, accident or non-accidental injury? Blood & urine tests in A&E. Complete autopsy. Examination of the death scene. Review of clinical history.
2) Infection. Undiagnosed congenital abnormality. Undiagnosed tumour. Undiagnosed genetic or metabolic defect. Accident. Non accidental injury (NAI).
3) SIDS risk 1-2 per 1000 live births. Risk of recurrence 1 : 8000 due to other diseases or inherited conditions, and same risk factors may be repeated in subsequent pregnancies.
4) Baby on the back. Stable surface. Safe bedding. No co-sleeping. No hyperthermia. No smoking in the baby’s room.
* Sudden unexpected death in infancy (SUDI) - death <24h. SIDS - death <1 year old occuring during sleep, remains unexplained, typical findings: serosal petechiae, focal lung haemorrhage, acute stress in thymus, extramedullary haemopoiesis, mild URTI.*
A 9 month old baby girl develops a temperature, goes off her food and cries continuously for 4 hours. Her mother takes her
to the local A&E department where she is found to have a generalised rash. In addition, she appears to become drowsy and unresponsive. After appropriate investigation, treatment is given, but unfortunately she fails to respond and dies 24 hours later. An autopsy is performed.
- How would you describe the rash?
- What abnormality do you see in the brain?
- What abnormality do you see in the adrenal glands?
- What is the diagnosis?
- What is the cause of the disease?
- What would the symptoms have been if the presentation had been in an adult?
1) Haemorrhagic, purpuric, petechial
2) Oedema
3) Bilateral haemorrhagic infarct (Waterhouse-Friderichsen syndrome)
4) Meningococcus septicaemia: shock, bilateral adrenal haemorrhage, widespread purpura, meningitis. Underlying pathology: deranged clotting / Disseminated Intravascular Coagulation (DIC).
5) An overwhelming bacterial infection caused by: Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas sp., Staphylococcus sp.
6) Meningeal irritation: headache, photophobia, neck stiffness, vomiting. Clouding of consciousness.
What can you see in this adrenal gland?
Haemorrhage and necrosis
What can you see in this lung?
Intravascular thrombus
A 32-year-old mother has a miscarriage at 21 weeks’ gestation. Photographs A-C show the baby.
- What morphological abnormalities does the baby show?
- What diagnosis would you consider?
- What further investigations would you perform?
- What would you look for at autopsy?
1) Dysmorphic features: hypertelorism, low-set ears, small chin, short neck, broad thorax, polydactyly, rocker-bottom feet.
2) Chromosomal abnormality Trisomy 18: Edwards syndrome - karyotype 47,XX,+18 or 47,XY,+18, 1:8000 births, advanced maternal age.
3) Antenatally: chorionic villous sampling CVS, amniocentesis. Postnatally or at PM: blood, skin, sternum.
4) Congenital heart defects: septal defects, aortic/pulmonary valve stenosis. Renal anomalies: horse-shoe kidney, polycystic kidney disease. Exomphalos. CNS anomalies: hydrocephaly, meningomyelocoele.
What foetal conditions are these?
A) omphalocoele
B) Diaphragmatic hernia
C) Univentricular heart
D) spina bifida
What condition is this?
Turner syndrome, monosomy 45, X0 at 18 weeks. Female is partly/completely missing an X chromosome.
What condition is this?
Meckel-Gruber syndrome (autosomal recessive) at 42w. Characterized by renal cystic dysplasia, central nervous system malformations (occipital encephalocele), polydactyly (post axial), hepatic developmental defects, and pulmonary hypoplasia due to oligohydramnios
What condition is this?
Sirenomielia
A 35 year old woman had a routine cervical smear at the Family Planning Clinic. On the basis of the cytology report, a cervical biopsy was carried out.
- How do the cells in C and D differ?
- How does the epithelium in A and B differ?
- What is the diagnosis?
- What is known about the aetiology, pathogenesis and natural history of this lesion?
1) C shows a normal cervical smear: squamous cells have a low nuclear:cytoplasmic ratio and no nuclear pleomorphism. D shows many cells with a high nuclear:cytoplasmic ratio, show nuclear pleomorphism and hyperchromasia.
2) A shows normal cervical epithelium with maturation towards the surface, the cells becoming progressively more flattened as they reach the surface. B shows lack of maturation of epithelium - no flattening of cells as they reach the surface. The nuclei are hyperchromatic and pleomorphic.
3) CIN 3 (Cervical Intraepithelial Neoplasia Grade 3).
4) CIN: refers to the spectrum of epithelial changes that take place in the squamous epithelium as the precursors of invasive squamous carcinoma. Lesion severity is assessed subjectively as Grade 1, 2, and 3 according to the level in the epithelium at which cytoplasmic maturation is taking place. Any grade of CIN is potentially invasive, although the risk of invasion becomes greater as the severity of the lesion increases.
Squamous neoplasia of the cervix is associated with: sexual activity, early age at first intercourse, frequency of intercourse, number of sexual partners, cigarette smoking, sexual behaviour of male partner, family history of cervical neoplasia, wives of men with carcinoma of the penis, urban areas.
HPV is the main aetiological factor. 60 subtypes of HPV. HPV 6, 11 are associated with genital warts and are not usually implicated in malignant transformation. HPV 16, 18, 31, 33 have been isolated from carcinoma.
Mechanism: Papillomavirus DNA is incorporated into host genome. Produces proteins (E6, E7) which form complexes with anti-oncogenes such as p53, thereby inactivating the normal cellular response to DNA damage. This results in accumulation of genetic abnormalities. HPV is also implicated in vulval and vaginal intraepithelial neoplasia. CIN may progress to invasive carcinoma or regress. The higher the grade of CIN, the less likely the lesion is to spontaneously regress.
A 28 year old woman comes to her GP with a lump in her breast. She is referred to the Breast One-Stop clinic at Barts for investigations.
- What investigations do you think should be carried out?
- Broadly how do benign masses differ in their appearance from malignant ones?
- What are different types of benign and malignant tumours?
- Is this tumour likely to be benign or malignant?
- What is the name of this lesion?
1) 4 investigations: mammogram, ultrasound, fine needle aspiration cytology +/- core biopsy.
2) Benign: slow growth rate, rounded/ovoid, smooth edge, pushing growth - easy to shell out, close resemblance to normal, no atypia/necrosis or invasion, never metastasises. Malignant: rapid growth, irregular shape, infiltrative edge, tethered to surrounding structures, variable resemblance to normal, atypia, necrosis, high mitotic activity, invasion, frequent metastasis.
3) [Pic]
4) Commonest benign tumour of the breast, common before 30, in a breast lobule, presents as a mobile mass often described as a breast ‘mouse’. Multiple in 20% cases.
5) Fibroadenoma
A 54 year old woman presented with a 2 month history of ascites, anorexia and weight loss. At laparotomy, a left-side knobbly ovarian mass was removed.
- What type of tumour is this? What is its natural history likely to be?
- What are the 2 functions of the ovary? What are the cell types found in the ovary that carry out these functions? Apart from the tumour in the above case, what other tumour types might arise in the ovaries?
- What type of tumour is in photograph C? What is its natural history?
1) Ovary is enlarged into a multicystic mass with protrusions over the inner and outer surface producing a cauliflower-like appearance. The tumour is formed by glands arranged back-to-back with marked cytological atypia. This is an ovarian adenocarcinoma.
Adenocarcinomas constitute 90% of all ovarian malignancies. Arise from surface epithelium of ovary. Account for a disproportionate number of fatal malignancies - commonly asymptomatic until they have reached a large size. Prognosis is very poor - overall 5-year survival of about 25%.
2) Functions: produce female gametes/ova - develop from oocytes present in the ovary from birth. Produce female sex hormones, oestrogen and progesterone - development of female sexual characteristics, support development of the embryo in early pregnancy. These are produced by specialised stromal cells of ovary.
Ovarian tumours are classified into three major types according to their cell of origin, the remainder being mixtures of these tumours metastatic to the ovaries. The 3 categories are:
- *a. Epithelial tumours** - arising from the surface epithelium, as the one here. These may be benign or malignant and are of several subtypes: serous, mucinous, endometriod, and Brenner tumour.
- *b. Germ cell tumours** - eg. teratoma, yolk sac tumour, dysgermonoma, embryonal carcinoma, choriocarcinoma.
- *c. Sex cord-stromal tumours** - eg. granulosa cell tumour, thecoma-fibroma and Sertoli-Leydig cell tumour.
3) Cystic tumour containing hair and sticky sebaceous material. Sometimes these tumours may have teeth, cartilage and bone. The diagnosis is mature cystic teratoma.
* The vast majority are completely begnign and do not recur when removed surgically.*
What do the astrix and arrow show on this breast mirograph?
Asterix: interlobular stroma (dense fibrocollagenous tissue mixed with adipose tissue)
Arrow: intralobular stroma (looser fibrocollagenous tissue containing hormonally-responsive breast-specific fibroblasts imp in mammary gland remodelling)
What is the tissue at the top of the photomicrograph?
Dense (irregular) fibrocollagenous tissue: interlobular stroma
Identify the cell types in this photomicrograph of the ovary.
A) oocyte
B) surface ovarian epithilium/germinal epithelium
C) stromal cell
D) granulosa cell
E) thecal cell
There is neural tissue labelled in this germ cell tumour of the ovary. What is indicated by the arrow?
Epidermis of skin.
What kind of sex-cord stromal tumour is shown?
Thecoma: characteristic foamy cytoplasm due to large numbers of lipid droplets.
Label A-E of the female reproductive tract.
A) uterine artery
B) ovarian artery
C) vaginal artery
D) spiral arteries
E) suspensory ligament
Label A-F
A) ureter
B) ligament of ovary
C) round ligament of uterus
D) ovarian artery and vein
E) suspensory ligament of ovary
F) broad ligament of uterus
Label 1-7 in this laproscopic view of the uterus.
1) uterus
2) round ligament
3) ovarian ligament
4) uterosacral ligament
5) ovary
6) suspensory ligament of the ovary
7) ureter
* 6 accompanied by 7*
Label A-D
A) uterine artery
B) inferior gluteal artery
C) vaginal artery
D) internal pudendal artery
Label A-F on the posterior view of the uterus.
A) suspensory ligament
B) ovarian/round ligament
C) broad ligament
D) isthmus
E) ampulla
F) infundibulum
Label A-D.
A) piriformis
B) ischial spine
C) coccygeus
D) levator ani
Label A-C.
A) lumbosacral trunk
B) obturator nerve
C) pudendal nerve
PSN: pelvic cplanchnic nerves (cut), parasympathetic to inferior hypogastric plexus
Label A-E of this female pelvic floor.
A and B) puborectalis, pubococcyygeus
C) Iliococcygeus
D) Coccygeus
E) piriformis
Label the following.
1) superficial pouch (erectile tissue + associated muscles)
2) deep pouch (deep perineal muscles and EUS (and Cowper’s glands in male))
A) levator ani
B) Colles’ fascia
C) round ligament
D) perineal membrane
E) urogenital diaphragm
F) obturator internus
Label A-E. What do A and B do?
A) bulbospongiosus - reduces size of vaginal orifice, compresses dorsal vein of clitoris
B) ischiocavernosis - assists in clitoral erection
C) superficial transverse perineal
D) Bartholin’s gland
E) bulb of vestibule
What would you deduce about this baby from its foetal growth chart?
Head growing along 50th centile = good. But abdo circumference has increased above 95th centile b/c baby is well nourished = typical of diabetic baby, lots of glycogen stored in liver so abdo larger and may get stuck in delivery. Normal baby = head should be largest bit.
Below are 2 CTG traces. Name and breifly describe the condition the foetal heart trace is showing.
Trace A: tachycardia - foetal HR consistantly above the normal 120-160bpm.
Trace B: type II dips - foetal HR returns to baseline only after contraction ends.
What condition is this and what are the features?
HMD. Collapsed air spaces, distal airways lined by necrotic material later by eosinophilic hyaline membranes, dilation of septal lymphatics, oedema and focal haemorrhage, capillary thrombi.
What condition is this?
Necrotising enterocolitis.
Dilation of involved segments, dusky serosal surface, deeply congested mucosa, patchy/diffuse ulceration, perforations often multiple.
What is this condition?
Intraventricular haemorrhage.
Usually 20 to bleeding in the germinal matrix. Haemorrhage can occur at one/several sites. Blood may fill entire ventricle system. When ventricles overdistended, blood dissects into parenchyma.
What condition is this?
Periventricular leucomalacia.
Oedema and lack of grey and white matter differentiation.
What is this condition?
Acute myocarditis - can see lots of neutrophils.
What can you see on this thymus?
Petechiae - small (1–2 mm) red or purple spot on the skin, caused by a minor bleed from broken capillary blood vessels
What is this condtion?
Waterhouse-Friderichsen - bilateral necrosis of adrenals. Commonly caused by severe bacterial infection.
What are these 2 lung conditions?
L: bronchiolitis, R: haemorrhage
What is this lung condition?
Oedema
What is this kidney condition?
DIC (disseminated intravascular coagulation): blood constantly clotted and fibrolysed so lots of haemorrhages and clots at the same time; clots hard to find (destroyed fast) but haemorrhages stay.
What is this condition?
Meckel-Gruber syndrome (autosomal recessive) at 42w. Characterised by triad of occipital encephalocele, large polycystic kidneys, and postaxial polydactyly
What are these 2 conditions?
L: hypercoiling. R: stricture in cord. Both compromis blood flow to foetus. Group B.
What is this condition?
Placental abruption. Group C.
What are these 2 conditions? (L is chorion/amnion and R is the umbilical cord).
L: acute chorioamnionitis: membranes inflamed, lots of inflammatory cells present. R: funisitis: cord vessels inflamed, clot within cord vessels -> hypoxic insult to foetus.
What condition does this baby have and what could have caused it?
Macrosomia and all visceral organs quite big, maternal diabetes/gestational diabetes.
Label A-F.
a) bladder
b) prostate (middle lobe)
c) prostate (isthmus)(anterior lobe)
d) EUS
e) seminal gland
f) prostate (inferoposterior lobe)
Label A-F.
a) bladder
b) peritoneum
c) levator ani
d) membranous urethra
e) prostatic urethra
f) obturator internus
Label A-G. What is the yellow triangle and how is it related to hernias?
a) inferior epigastric artery
b) deep inguinal ring
c) rectus abdominus muscle
d) superficial inguinal ring
e) inguinal ligament
f) exernal iliac vessels
g) ductus deferens
Traingle: Hesselbach’s triangle - direct inguinal hernias leave abdomen through this triangle. (Hernia medial to epigastric vessels).
What is this condition and how is it treated?
Direct inguinal hernial. Tx: truss if reducable (can push hernia back with finger), otherwise surgery.
What is this conditon? What causes it?
Indirect inguinal hernia. Failure of inguinal canal to close properly after passage of testes in utero. 60% to R b/c R testes takes longer to get into scrotum. Loops of intestine can go through processus vaginalis if not closed, go through deep and inguinal ring. Always need surgery, done laproscopically.
What condition is this?
Variocele.
A 70 year old man presented to his GP with urinary frequency and urgency. A serum PSA test revealed a level of 50ng/dl. He underwent a trans-rectal biopsy of the prostate.
- What is a PSA test?
- How do the tissues differ in the patient from the normal?
- What is the diagnosis?
- What is known about the aetiology, pathogenesis and natural history of this disease?
- How may it be treated?
- PSA is secreted by the prostate, but more is secreted in cancer than normal, and it is used by some as a screening test.
- The normal shows well organised glands within fibrous stroma. The patient’s tissue shows fibrous tissue with infiltration by cells with irregular hyperchromatic nuclei and almost total lack of organisation. Some vacuolation of cells is seen.
- Prostate cancer - adenocarcinoma.
- Very common, increases in frequency in elderly, v common in African-Americans, unusual geographic incidence; common in West but rare in China, causes are unknown, but diet is thought to play a factor.
Most diagnosed by PSA test. Some men present with urinary symptoms. Later they may present with metastatic disease.
Cancers used to present late, as the tumours arise in the gland periphery and only cause symptoms after they have spread. However the PSA test means many cancers present much earlier. The disease is very common and most cases do not spread when diagnosed early. Most men die WITH their prostate cancer rather than FROM it. The tumour may spread locally to the bladder, urethra, seminal vesicles, pelvic wall and rectum, but will usually metastasize before this. The tumour shows a preference for bones, and gives rise to sclerotic metastases.
The grading of the tumour is very important. The Gleason grading system is used. The Gleason grade of this tumour is 5 (on a scale of 1-5). Implications for prognosis and management.
- Very early prostate cancer may not be treated, especially if the patient is elderly or unwell. Cancers in younger men which have not spread may be treated by surgery (Radical prostatectomy) or radiotherapy. Cancers which have spread are given anti androgenic hormonal therapy which often controls the disease.
This specimen is from a 15 year old boy. It is an interoperative specimen, the day after the boy participated in a football match.
- What is the organ shown here?
- What are the abnormal findings?
- What is the cause of these appearances?
- What is the natural history, presentation and treatment of this disease?
- testis - intraoperative and post surgical specimens.
- grossly swollen, dusky black on the external surface, black internally, necrotic with early cystic degeneration, necrosis appears to extend into the cord.
- testicular torsion.
- Testicular torsion is a urologic emergency. Delay in diagnosis and management can lead to testicle loss. Most commonly occurs in adolescents and is the most frequent cause of testicle loss in that population.
Normally testicle covered by tunica vaginalis which attaches to the posterolateral surface of the testicle and allows for little mobility of the testicle within the scrotum. In men who have an inappropriately high attachment of the tunica vaginalis, the testicle can rotate freely on the spermatic cord within the tunica vaginalis (intravaginal testicular torsion). This congenital anomaly, called the bell clapper deformity, can result in the long axis of the testicle being oriented transversely.
Presentation: sudden onset of severe unilateral scrotal pain. Onset of pain can occur more slowly, but this is an uncommon presentation of torsion. Torsion can occur with activity, can be related to trauma in 4-8% of cases or can develop during sleep. Relief of torsion can be performed manually but in most cases surgical exploration is necessary and excision if the tissue is necrotic. Later diagnosis means an orchidectomy is necessary.
A 24 year old man presented to his GP complaining of a lump in the right testis. The patient was referred to his local urology department and underwent a right orchidectomy.
- Describe the macroscopic appearances.
- Describe the microscopic appearances.
- What is the diagnosis?
- What other tumours may arise in the testis?
- What are the risk factors for developing a germ cell tumour?
- What is the treatment for seminoma and how do they respond?
- Testis is entirely replaced by a firm white mass (often described as looking like a cut potato) with some central cystic degeneration and necrosis.
- Testis is replaced by sheets of pleomorphic cells with some prominent nucleoli and clear cytoplasm with well defined cell boundaries. On the left there are lymphocytes and fibrous tissue.
- Classical seminoma.
- Seminomas are a type of germ cell tumour. Other testicular tumours are usually nonseminomatous germ cell tumours and can be a mixture of different tissues including: teratoma, yolk sac tumour, choriocarcinoma.
- Maldescended or undescended testis. Rare genetic conditions. Geographical variation in incidence: high in Europe and in Maoris, low in Africa. Generally very rare.
- Primary excision for localised tumours, radiotherapy to the paraaortic nodes for aggressive, vascular invasive tumours, a single dose of a chemotherapy agent, carboplatin, may be equally effective with fewer side effects. V. responsive to treatment: 5 year survival of > 98%. Non-seminomas may be treated by more intensive chemotherapy - slightly worse prognosis.
Label A-G.
a) urethra
b) ureter
c) seminal vesicle
d) ejaculatory duct
e) prostate gland
f) vas deferens
g) epididymis
Label the zones of the prostate.
A) transitional
B) periurethral (A and B around prostatic urethra)
C) central (around ejaculatory ducts)
D) peripheral
What are the 2 prostate conditions shown?
A) BPH - retains glandular structure of tissue, usually nodular.
B) adenocarcinoma of the prostate - (*) = small crowded gland has cells with enlarged nuclei, darker cytoplasmic staining, and prominent nucleoli. Basal layer is absent in adenocarcinoma
What is indicated by the arrow?
Gubernaculum
Label A-D of the seminiferous tubules.
A) spermatids (late)
B) spermatids (early)
C) spermatocyte
D) spermatogonia
What are the cells A and B in the seminiferous tubules?
A) sertoli cell - elongated nucleus and cytoplasm, supports and nourishes, forms blood-testis barrier, regulates hormone production and function, secretion of tubular fluid, phagocytosis of spermatid cytoplasm.
B) leydig cell - looks foamy, makes androgenic steroids.
The testicular tumour shown in the photomicrograph is a…?
Teratoma: consists of foetal type tissues like cartilage C, poorly differentiated epithelial structures E, and primitive mesenchyme M. They tend to behave in a malignant fashion.
Two orchidectomy pathology specimens are shown - what is the one on the right?
Seminoma - lobulated, pale mass usually devoid of necrosis and haemorrhage. It is more homogenous compared to the mixed germ cell tumor (L) which is cystic and haemorrhagic. Necrosis and haemorrhage often reflect choriocarcinoma and/or embryonal carcinoma admixtures with different tissue components of teratoma found in 45% of germ cell tumours.
What is this condition and the clinical phenotype?
Turner syndrome: a female is partly or completely missing an X chromosome.
Phenotype: short stature, SHOX haplo-insufficiency, gonadal dysgenesis, webbed neck, shield chest, widely spaced nipples, cubitus valgus, lymphodema of hands, shortening of 4th/5th metacarpal, knock-knees.
What GI condition is this in the oesophagus?
Eosinophillic Oesophagitis.
What is this condition?
Crohn’s disease.
What are these in the rectum?
Polyps.
