Vulva/Vagina/Cervix/Uterus/Endometrium Path Flashcards
Embryological Derivatives Mullerian Duct (4) Urogenital Sinus, Mesonephric Duct
Unfused Mullerian: Fallopian tubes
Fused Lower Mullerian: Uterus, Cervix, Upper vagina
Urogenital sinus becomes Lower Vagina
Mesonephric duct regresses
Bartholin Gland Cyst
Etiologies (2) and Clinical Features (2)
Obstruction of gland via infectious inflammation
Neisseria gonorrhoeae
3-5 cm cyst on vulva
Local pain
Lichen Sclerosis
Pathogenesis, Morphology (4) and Clinical Features (3)
Likely autoimmune etiology
Smooth white plaques on vulva
Thinning of epidermis
Hyperkeratosis
Band-like T cell infiltrate (lymphocytosis)
Postmenopausal women
Not premalignant
Associated with autoimmune conditions
Vulvar Squamous Hyperplasia
Etiology, Morphology (2), Clinical Features (2)
Caused by scratching skin to relieve pruritis
Thickened epidermis (acanthosis) Hyperkeratosis
Presents as leukoplakia
Not premalignant
Condyloma Latum
Etiology and Morphology
Syphillis (Treponema pallidum)
Benign raised skin lesion
Condyloma Accuminatum
Etiology (2), Morphology (3) and Clinical Features (2)
HPV 6 and 11
Koilocytic atypia of surface epithelium
Papillary exophytic tree like cores of stroma
Thickened epithelium
Not premalignant
Multifocal genital warts involving vulva, perineum, perianal region
Classic Vulvar Intraepithelial Neoplasia
Population (2), CVIN Morphology (2)
Complications with Morphology (2)
Younger patients with HPV 16 infection
White hyperkeratotic lesion or
Slightly raised pigmented lesion
Basaloid Carcinoma Precursor:
Nests and cords of small tightly packed cells resembling normal basal layer
Warty Carcinoma Precursor:
Exophytic, papillary, koilocytic atypia
Differentiated Vulvar Intraepithelial Neoplasia
Population (3), DVIN Morphology
Complication with Morphology
Older patients with long standing lichen slerosis or squamous hyperplasia
Basal layer atypia with normal superficial layers
Invasive Keratinizing Squamous Cell Carcinoma
Central keratin pearls
Extramammary Paget Disease
Staining (3), Morphology (3) and Clinical Features (2)
PAS, Alcian blue, Mucicarcmine
Pruritc, red, crusted area on labia majora
Not associated with underlying cancer
Malignant process but unlikely to invade (poor prognosis if it does)
Papillary Hidradenoma
Morphology (4)
Sharply circumscribed nodule on labia majora or interlabial folds
Papillary projections covered in two layers:
Columnar secretory cells
Flat myoepithelial cells
Vaginal Developmental Anomalies
Examples with Descriptions (3)
Uterus didelphys: Double uterus, associated with septate (double) vagina
Vaginal Adenosis: Persistence of glandular columnar, endocervical-type epithelium, from DES exposure
Gartner Duct Cyst: Persistence of mesonephric duct
Embryonal Rhabdomyosarcoma
Presentation, Morphology (4) and Prognosis
Infants and children < 5 years old
Polypoid, grapelike mass
Small cells with oval nuclei with small protrusions
Tumor cells found in cambium layer
(+) for Desmin intermediate filaments
Malignant tumors that require excision and chemotherapy
Cervix
Histological Regions (3)
Transformation Zone Significance (2)
Ectocervix is squamous epithelium and ends at external os
Endocervix is columnar epithelium
Meeting point between endo/ecto is squamocolumnar junction (transformation zone)
Squamocolumnar Junction is most susceptible to HPV infection
Cervical precursor lesions develop at junction
Endocervical Polyps
Morphology and Significance
Loose fibromyxomatous stroma covered by glands
Source of irregular vaginal spotting or bleeding
Cervical Intraepithelial Neoplasia
Pathogenesis (3), Morphology (5)
Persistent infection with high risk HPV strains (mostly 16)
E6 protein blocks p53
E7 protein breaks up Rb
Nuclear Atypia: Nuclear enlargement, Hyperchromasia, Chromatin granules
Koilocytic atypia
p16 overexpression
Cervical Intraepithelial Neoplasia
Classifications (2) with Associated Natural Histories and Morphology (1/2)
Low Grade Squamous Intraepithelial Lesion (LSIL)
CIN I
60% regress, 30% persist and 10% progress to HSIL
Epithelial atypia in lower 1/3
High Grade Squamous Intraepithelial Lesion (HSIL)
CIN II and CIN III
30% regress, 60% persist and 10% progress to carcinoma
Full thickness epithelial atypia
Ki67 (+) staining
Mestrual Cycle Tissue Changes Menstrual Phase (2) Proliferative Phase (3) Secretory Phase (4)
Menstrual Phase
Decreased progesterone
Stratum functionalis shedding
Proliferative Phase
Increased estrogen causes:
Straight tubular glands
Stromal cell proliferation and mitotic figures present
Secretory Phase Increased progesterone causes: Sawtooth shaped glands Subnuclear vacuoles progress to supranuclear vacuoles Prominent arterioles present
Abnormal Uterine Bleeding Differential By Age Group
Prepuberty (1) Adolescence (2) Reproductive Age (4) Perimenopausal (2) Postmenopausal (2)
Precocious puberty
Anovulatory cycle, Coagulation disorders
Pregnancy complications, Lesions, Anovulatory cycle, Ovulatory dysfunctional bleeding
Anovulatory cycle, Lesions
Endometrial atrophy, Lesions
Dysfunctional Uterine Bleeding
Most Common Cause and Differential Diagnosis(3)
Anovulatory Cycles
Differential:
Endocrine Disorders
Ovarian Lesions
Metabolic Disturbances
Endometritis Etiologies and Features
Acute (1/2) and Chronic (4/2)
Acute:
Bacterial infection after delivery or miscarriage
Stromal inflammation
Treat with antibiotics and gestational material removal
Chronic: Chronic PID Retained gestational material IUD use Tuberculosis
Diagnosed via plasma cells in stroma
Treat with antibiotics
Endometriosis Common Sites (8), Pathogenesis
Ovaries Uterine Ligaments Rectovaginal septum Cul de sac Pelvic peritoneum Large/Small bowel and Appendix Mucosa of cervix, vagina, fallopian tubes Laparotomy scars
Regurgitation Theory:
Endometrial tissue travels through fallopian tube and out into abdominal cavity
Endometriosis
Molecular Abnormality, Morphology (3) Presentation (5)
Increased aromatase which increases estrogen levels
Red/blue or yellow brown nodules on mucosa/serosa
Fibrous adhesions
Chocolate cysts in ovaries (endometriomas)
Menometrorrhagia Severe dysmenorrhea Dyspareunia Pelvic pain Small bowel obstruction (if adhesions present)
Adenomyosis
Definition, Morphology and Presentation (4)
Presence of endometrial tissue in uterine wall
Nests of endometrial stroma within myometrium
Menometrorrhagia
Severe dysmenorrhea
Dyspareunia
Pelvic pain
Endometrial Hyperplasia
Etiologies (4), Genetics (2)
Classifications (2) with Characteristic Features (2/3)
Prolonged Estrogen exposure from: Anovulation Obesity Menopause Estrogen only therapy for Menopause
PTEN inactivation (Cowden syndrome) Causes overactivation of PI3K/AKT pathway
Non-Atypical: Increased gland to stroma ratio
Rarely progresses to cancer
Atypical: Conspicuous nucleoli
Back to back glands with little stroma
More often associated with cancer
Type I Endometrial Adenocarcinoma
Precursor, Presentation (5) Mutations (6) and Morphology (2)
Precursor is endometrial hyperplasia
Ages 55-65 Unopposed estrogen Type 2 Diabetes HTN Obesity
PTEN* Microsatellite instability (Lynch syndrome) ARID1A KRAS FGF2 CTNNB1
Well differentiated
Mimic endometrial glands (endometrioid carcinoma)
Type II Endometrial Adenocarcinoma
Precursor, Presentation (2) Mutations (6) and Subtypes (3)
Serous endometrial intraepithelial carcinoma
Ages 65-75
Endometrial atrophy
Thin physique
TP53* Aneuploidy PI3K FBXW7 CHD4 PP2A
Serous carcinoma*
Clear cell tumors
Mixed Mullerian tumors
Carcinosarcoma
Description, Presentation, Prognosis
Malignant adenocarcinoma with mixed mesenchymal components
Present with postmenopausal bleeding
Prognosis bad if mesenchymal component is heterologous
Leiomyoma
Morphology (3) and Clinical Features (4)
Whorled Pattern of smooth muscle bundles
Found in myometrium of the corpus
Sharply circumscribed firm grey-white masses
Often multiple masses
Benign, not mitotically active
Abnormal bleeding
Urinary frequency
Leimyosarcoma
Morphology (3), Clinical Features (2) and Mutation
Mitotic figures*
Nuclear atypia
Zonal necrosis
Most metastasize before presentation
40-60 years old peak age
MED12 mutations
