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98 Cards in this Set
- Front
- Back
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Describe the vulva anatomically/histologically.
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Includes skin and mucosa of female genitalia external to the hymen (labia majora, labia minora, mons pubis, vestibule) and is lined by squamous epithelium
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There is a dilation of the gland located at the lower vestibule adjacent to the vaginal canal. It usually occurs in women of reproductive age and presents as a unilateral, painful lesion. What is this caused by?
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Inflammation and obstruction of Bartholin gland
(Bartholin cyst) |
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Condyloma in the vulva is most commonly due to HPV 6 or 11 (condyloma acuminatum), but what is a less common cause, which is also sexually transmitted?
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Syphilis (condyloma latum)
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What is the histological hallmark of HPV-infected cells?
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Koilocytes (crinkled/raisin-looking nucleus)
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Leukoplakia + parchment-like (thin, papery) vulvar skin + postmenopausal = what dx?
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Lichen Sclerosis
may be autoimmune -> has thinning of the epidermis and fibrosis (sclerosis) of the dermis |
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Leukoplakia + thick, leathery vulvar skin = what dx?
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Lichen Simplex Chronicus
hyperplasia a/w chronic irritation and scratching |
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Leukoplakia on vulva + reproductive age + multiple partners/early first intercourse = what dx if confirmed by biopsy?
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HPV-related Vulvar Carcinoma (d/t 16 or 18)
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Koilocytic change, disordered cell maturation, nuclear atypia, and increased mitotic activity are histological characteristics of what in the vulva?
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VIN (vulvar intraepithelial neoplasia)
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Leukoplakia on vulva + elderly woman (avg >70) + carcinoma confirmed by biopsy. What usually causes this?
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Long-standing lichen sclerosis (Non-HPV related vulvar carcinoma)
Lichen sclerosis, although benign, has a slightly increased risk for squamous cell carcinoma. Lichen simplex chronicus, also benign, has no associated risk. |
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Paget disease is characterized by malignant epithelial cells in the _______.
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Epidermis
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Erythematous, pruritic, ulcerated vulvar skin is biopsied and tested for markers. It is PAS+, keratin+, S100-. What is the dx?
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Extramammary Paget Disease
This represents carcinoma in situ and is usually NOT a/w underlying carcinoma. Paget dz of the nipple usually IS! PAS marks mucous and keratin marks intermediate filament in epithelial cells. Therefore, this ID's epithelial cells. |
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Erythematous, pruritic, ulcerated vulvar skin is biopsied and tested for markers. It is PAS-, keratin-, S100+. What is the dx?
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Melanoma
S100 is indicative of melanoma. Melanoma is not derived from epithelial cells. |
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Focal persistence of the columnar epithelium in the upper 1/3 of the vagina is called ______ and has a higher incidence in what females?
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Adenosis
DES (diethylstilbestrol) exposure in utero |
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The upper 1/3 of the vagina is derived from what?
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Mullerian ducts - therefore it is columnar epithelium during fetal development and the squamous epithelium from the lower 2/3 (urogenital tract-derived) grows to replace it during development (so later, the whole vagina is lined by non-keratinized squamous epithelium except in adenosis)
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A female who was exposed in utero to a certain drug develops a mass in the vagina. The patient also has an abnormally-shaped uterus. This malignancy is likely a malignant proliferation of _____ with ____ cytoplasm.
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Glands; clear
This is likely clear cell adenocarcinoma, a rare complication of DES-associated vaginal adenosis. |
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A grape-like mass from the vagina of a 4 yo female (<5 yo) is biopsied and found to have immature cells with cytoplasmic cross-striations. What immunohistochemical stains would you expect to be positive in this patient?
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Desmin and myoglobin, because this is Embryonal Rhabdomyosarcoma - a malignant, mesenchymal proliferation of immature skeletal muscle.
The pt may have bleeding, and it may also occur in males. It is also known as sarcoma botyroides. |
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A mass is biopsied from the upper 1/3 of the vagina and is found to be a/w a high-risk HPV strain. What lymph nodes should be evaluated to determine if the cancer has spread?
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This is vaginal carcinoma, and the regional iliac nodes should be evaluated for the upper 1/3 d/t its origin from the Mullerian duct.
Lower 2/3 (from urogenital sinus) goes to inguinal nodes! |
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Production of what 2 proteins makes certain HPV strains high-risk? What tumor suppressor genes are increasingly destroyed due to these proteins?
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E6 protein -> p53
E7 protein -> Rb |
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Let's remind ourselves about p53 and Rb.
a) How does p53 regulate the cell cycle? b) How does Rb regulate the cell cycle? |
a) p53 regulates the G1->S phase by being a traffic cop. It can either cause repair of defects or induce apoptosis. It induces apoptosis by calling in BAX, which knocks out Bcl-2, damaging the mitochondrial membrane and causing cytochrome C to leak into the cytoplasm.
b) Rb holds on to E2F, a protein needed for the cell cycle to progress from G1->S. When Rb is phosphorylated, it releases E2F. Destruction of Rb would also make it so that there is a lot of free E2F hanging around allowing cell cycle progression. |
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Risk of CIN depends on HPV type, which is determined by what procedure?
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DNA sequencing (b/c it is a DNA virus)
High-risk: 16,18,31,33 Low-risk: 6,11 |
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Only persistent HPV infection leads to an increased risk for cervical dysplasia (CIN). How is most infection eradicated?
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Usually by acute inflammation
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What is the transformation zone of the cervix?
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The junction between the exocervix (nonkeratinizing squamous epithelium) and endocervix (simple columnar). It is the most commonly infected area of HPV and is scraped in a PAP smear.
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A 28 yo patient presents for a pelvic exam and receives a Pap smear. Results show immature cells with koilocytic change, disordered cell maturation, nuclear atypia, and increased mitotic activity involving half of the thickness of the cervical epithelium. The nuclei are hyperchromatic (dark) and have a high N:C ratio.
What is the result? |
High-grade dysplasia. More specifically, the grade is CIN II.
Low-grade = CIN I; High-grade = CIN II or III CIN I - <1/3 thickness CIN II - <2/3 thickness CIN III - slightly less than entire thickness CIS - entire thickness. Won't regress!! The higher the grade of dysplasia, the more likely it is to progress and less likely it is to regress. |
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A 45 yo female presents with impending postrenal failure, and she is found to also have hydronephrosis. She has always had normal Pap smear results and has been screened regularly. She says that she has experienced postcoital bleeding and discharge that she did not think was important enough to mention to her doctor previously. She has been a smoker since she was 17. What do you suspect she might have, therefore needing further investigation?
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Adenocarcinoma of the cervix.
Paps have limited efficacy in screening for adenocarcinoma! Therefore, the incidence has stayed about the same, although it is less common than squamous cell carcinoma (15% of cases, SCC is 80%). Cervical carcinoma is MC in middle-aged (40-50), presents with vaginal bleeding (especially postcoital) or cervical discharge. Advanced tumors can invade through anterior uterine wall into bladder, blocking the ureters -> a common cause of death in advanced cervical carcinoma! |
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Progression of CIN to carcinoma takes an average of how many years?
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10-20 years
Screening begins at 21 and is performed yearly at first - Pap smear is gold standard! |
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An abnormal Pap is followed by what?
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Confirmatory colposcopy and biopsy
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The HPV vaccine is effective against what strains?
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6,11,16,18 - therefore, patients still need to get Paps because of other possible strains. Protection lasts for 5 yrs.
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Which subtype of cervical carcinoma (squamous cell or adenocarcinoma) is related to HPV infection?
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BOTH are
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What drives each of the following phases?
1. Proliferative 2. Secretory 3. Menstrual |
1. estrogen
2. progesterone 3. loss of progesterone support |
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A 28 yo patient presents because she has not had a period in 4 months. She is trying to get pregnant after having a spontaneous abortion the previous year in her 1st trimester, and she says she needed to have a procedure done to prevent an infection from occurring in her uterus. She has taken home pregnancy tests which have all come up negative. You do a pregnancy test in the office, which also comes up negative. You suspect that she may be suffering from a condition that is caused by loss of stem cells in what layer of the endometrium?
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Basilis -> the regenerative layer!
This is Asherman Syndrome, caused by overaggressive D&C |
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A common cause of dysfunctional uterine bleeding, especially during menarche and menopause, occurs when there is an estrogen-derived proliferative phase without the subsequent progesterone-derived secretory phase. What causes this?
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Anovulatory cycle
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A female patient presents with fever, abnormal uterine bleeding, and pelvic pain. It's been a few days since she delivered a baby. What should you suspect is the cause for her current condition?
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Retained products of conception -> Acute endometritis (occurs after delivery or miscarriage)
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In order to make the dx of chronic endometritis, what must be present in the histology?
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Plasma cells!
lymphocytes are normally found in the endometrium but are also a/w this dz |
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A patient presents with abnormal uterine bleeding, pain, and infertility. You send for an endometrial biopsy, which shows lymphocytes and plasma cells. What are some possible causes for the disorder she has?
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Chronic endometritis can be d/t:
retained POC's chronic PID (ex: chlamydia) IUD TB (granulomas) |
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What pathology, which presents as abnormal uterine bleeding, can be a side effect of taking tamoxifen? Why?
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Endometrial Polyp (hyperplastic protrusion of endometrium)
b/c it has weak pro-estrogenic effects on endometrium (despite it's anti-estrogenic effects on breast) |
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Endometriosis occurs when there is (endometrial glands/stroma/both/either one) outside of the uterine endometrial lining.
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Both
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What is the most likely theory for endometriosis?
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Retrograde menstruation with implantation at an ectopic site
2 other theories are the metaplastic theory (b/c Mullerian duct has ability to develop into many different tissues) and lymphatic dissemination (b/c you can sometimes see it in weird places, like the lungs) |
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If a patient presenting with dysmenorrhea and pelvic pain (possibly suffering from infertility) has endometriosis, where would you most likely see it located?
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Ovary -> "chocolate" cyst
Increased risk of carcinoma (especially in ovary!) Other sites include: uterine ligament (pelvic pain) pouch of Douglas (pain with defecation) bladder wall (pain with urination) bowel serosa (abdominal pain and adhesions) fallopian tube mucosa (scarring -> ectopics) soft tissue (gun-powder nodules) myometrium (adenomyosis) |
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How can endometriosis increase the risk for ectopic tubal pregnancy?
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If it occurs in the fallopian tube mucosa, it can lead to scarring
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Yellow-brown "gun-powder" nodules in the soft tissue of a woman is a characteristic of what?
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Endometriosis
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Endometriosis of the uterine myometrium is called what?
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Adenomyosis
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Endometrial hyperplasia is defined as...
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Hyperplasia of endometrial glands RELATIVE to stroma
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A 55 yo woman presents with postmenopausal uterine bleeding. You discover that she has endometrial hyperplasia due to unopposed estrogen. But she is postmenopausal.... how can this happen? What are some risk factors she might have?
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Obesity
Polycystic Ovary Syndrome Estrogen replacement therapy |
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How is endometrial hyperplasia classified histologically?
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Based on architectural growth pattern (simple vs complex) and presence or absence of cellular atypia.
Cellular atypia is the MOST important predictor for progression to CA. |
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What is the MC invasive carcinoma of the female genital tract?
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Endometrial carcinoma
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A 60 yo female who has never had children presents with postmenopausal bleeding. Endometrial biopsy shows endometrioid malignant proliferation of endometrial glands. What is the most likely pathway for this?
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Hyperplasia pathway (75% of cases of endometrial carcinoma)
Risk factors therefore have to do with estrogen exposure - early menarche/late menopause, nulliparity, infertility w/ anovulatory cycles, obesity |
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A 70 yo female presents with postmenopausal bleeding. Histology shows papillary serous morphology and psamomma bodies. This tumor is an aggressive, malignant proliferation of endometrial glands!
a) What is the pathway for this? b) What mutation is common? |
a) Sporadic pathway (25% of cases of endometrial carcinoma) arising in an atrophic endometrium w/ no precursor lesion
b) p53 mutation |
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What is the MC tumor in females? What is it related to?
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Leiomyoma! (fibroids)
benign, neoplastic proliferation of SM arising from myometrium Related to estrogen exposure! (premenopausal MC, often multiple, enlarge in pregnancy, shrink after menopause) |
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Gross exam of a uterus shows multiple, well-defined, white, whorled masses. What is this?
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Leiomyoma
may distort the uterus and impinge on pelvic structures |
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What is the MC clinical finding in a patient with leiomyoma?
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NOTHING!!! but if symptoms are present, they can have abnormal uterine bleeding (from the lining being stretched), infertility (distorted cavity), and a pelvic mass
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T/F
Leiomyomas lead to an increased risk for the development of leiomyosarcoma. |
FALSE. Leiomyosarcoma arises de novo and has nothing to do with leiomyomas
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Gross exam of a uterus of a postmenopausal female shoes a single lesion in the myometrium with areas of necrosis and hemorrhage. What features would you also expect to see on histology?
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Because this is a malignant tumor (Leiomyosarcoma), you will see necrosis, increased mitotic activity, and cellular atypia.
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What is the functional unit of the ovary?
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Follicle - consisting of an oocyte surrounded by granulosa and theca cells.
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What hormone acts on theca cells to induce androgen production?
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LH
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What hormone acts on granulosa cells to convert angrogen to estradiol (drives proliferative phase of the endometrial cycle)?
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FSH
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What does the estradiol surge induce in the menstrual cycle?
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Induces an LH surge, which leads to ovulation (marking the beginnning of the secretory phase of the endometrial cycle)
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After ovulation, the residual follicle becomes a corpus luteum, which primarily secretes what?
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Progesterone, which drives the secretory phase (which prepares the endometrium for a possible pregnancy)
Hemorrhage into the corpus luteum can result in a hemorrhagic corpus luteal cyst, especially during early pregnancy. |
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Ultrasound of a woman shows a couple of cysts within one of her ovaries. What is the clinical significance of this?
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Most likely nothing. Small numbers of follicular cysts (resulting from degeneration of follicles) are common in women.
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Am obese young female patient presents with oligomenorrhea and hirsutism. She is also having trouble getting pregnant. You find that her LH:FSH ratio is 3:1. A subset of patients with this condition may also develop another condition later in their life. What might you want to test this patient for to see if she is at risk?
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Insulin resistance - may develop type 2 DM 10-15 yrs later
This patient has PCOD, which affects ~5% of women of reproductive age. |
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How does PCOD result in an increased risk for endometrial carcinoma?
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Because the high LH in PCOD leads to excess androgen, which is converted to estrone in adipose tissue. High levels of circulating estrone increase the risk for endometrial CA.
Also, estrone feedback decreases FSH (resulting in cystic degeneration of the follicles) and |
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What are the MC type of ovarian tumor (70% of cases)?
What are the 2 MC subtypes? |
Surface epithelial tumors
Serous and mucinous are MC subtypes (both are usually cystic) They are derived from coelomic epithelium which can embryologically produce epithelium of the fallopian tube (serous cells), endometrium, and endocervix (mucinous cells). They present late clinically with vague abdominal symptoms or signs of compression -> therefore they have a poor prognosis |
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A 35 yo female (b/w 30-40) presents with abdominal pain, fullness, and urinary frequency. A single ovarian cyst with a simple flat lining is found. Depending on what substance fills the cyst, what are the 2 most likely types of tumor it could be? Is it benign or malignant?
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Serous or mucinous cystadenoma (benign)
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A 65 yo woman (b/w 60-70) presents with abdominal pain, fullness, and urinary frequency. Complex ovarian cysts with a thick, shaggy lining are found. It has invaded into the CT. What tumors are most likely?
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Mucinous and serous cystadenocarcinomas (malignant)
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What mutation carries an increased risk for serous carcinoma of the ovary and fallopian tube?
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BRCA1
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An ovarian mass is found to be composed of endometrial-like glands and is likely malignant. 15% of these types of tumors are a/w what other tumor?
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An independent endometrial carcinoma (endometrioid type)
This is an endometrioid tumor (subtype of surface epithelial tumors) that MAY arise from endometriosis |
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What type of tumor is found in the ovary but is composed of tissue resembling urothelium?
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Brenner tumor (subtype of surface epithelial tumors)
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How do epithelial carcinomas of the ovary tend to spread?
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Locally, especially to the peritoneum (omental caking)
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A female patient presents with abdominal pain, fullness, and urinary frequency. You diagnose her as having a neoplasia of the surface epithelium of the ovary. What serum marker can be useful for monitoring treatment response and screening for recurrence?
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CA-125
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What type of ovarian tumors usually occurs in women of reproductive age (teens)?
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Germ cell tumors (such as cystic teratoma, dysgerminoma, endodermal sinus tumor, choriocarcinoma, and embryonal carcinoma)
It is the 2nd MC type of ovarian tumor (15% of cases) |
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If a 20 yo female presents with signs of hyperthyroidism and an ovarian mass, what should be included on your differential?
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Struma ovarii (a cystic teratoma composed primarily of thyroid tissue)
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An ovarian tumor that is bilateral in 10% of cases is derived from 2 or 3 embryological layers (ex: skin, hair, bone, cartilage, gut, & thyroid) is found in a female. It is usually a benign tumor, but what 2 possible features would indicate malignant potential?
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Presence of immature tissue (usually neural ectoderm)
Somatic malignancy (usually squamous cell carcinoma of the skin) This tumor is a cystic teratoma and is the MC germ cell tumor in females. |
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A young female is found to have an ovarian mass composed of large cells with clear cytoplasm and central nuclei. Her serum LDH is elevated. Is this benign or malignant, and how would you treat it?
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This is talking about Dysgerminoma, which is malignant (the MC malignant germ cell tumor) but has a good prognosis. It responds to radiotherapy.
Serum LDH is not always elevated. The testicular counterpart is a seminoma. |
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An ovarian mass, resembling a yolk sac, is found in a 5 yo female. She has elevated serum AFP. What is a classic finding in histology of this type of tumor? Is it benign or malignant?
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Schiller-Duval bodies (glomerus-like structures); malignant
This is an endodermal sinus tumor and is the MC germ cell tumor in children. Serum AFP is often elevated. |
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An ovarian tumor that has a reputation of having extensive metastases despite having a small primary tumor is what type?
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Choriocarcinoma, d/t its origin of trophoblasts and syncytiotrophoblasts (but NO villi) which resembles placental tissue, so it is genetically programmed to invade blood vessels! It is a small, hemorrhagic tumor with early hematogenous spread. This tumor responds POORLY to chemo.
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High levels of what is characteristic of choriocarcinoma?
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beta-HCG, which is produced by syncytiotrophoblasts. It may lead to thecal cysts in the ovary.
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An ovarian tumor is found to be malignant and composed of large primitive cells. It is aggressive with early metastasis (primitive cells have ability to move and spread). What type of tumor is this?
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Embryonal carcinoma
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Granulosa-theca cell tumors often present with what features in each of the following age groups?
a) prior to puberty b) reproductive age c) postmenopause d) Is it benign or malignant? |
Features are because it usually produces estrogen.
a) precocious puberty b) menorrhagia or metrorrhagia c) endometrial hyperplasia with postmenopausal uterine bleeding d) malignant, but minimal risk for metastasis |
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A female patient presents with hirsutism and virilization. A mass is seen in the ovary that has pink cells with crystals in them.
What type of tumor is this and what are these crystals called? |
Sertoli-Leydeg cell tumor
(Sertoli cells form tubules and Leydig cells are pink cells b/w the tubules; they may produce androgen) Reinke crystals are in the Leydig cells |
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A patient who suffers from pleural effusions, ascites and an ovarian fibroma is said to have what syndrome?
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Meigs Syndrome
(resolves with removal of fibroma - a benign sex cord-stromal tumor of fibroblasts) |
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A mass is removed from an ovary and is found to be a mucinous tumor. If this is a Krukenberg tumor (which is metastatic), what feature can help distinguish it from primary mucinous carcinoma of the ovary?
What cancer usually causes this type of tumor? |
Krukenberg tumors are usually bilateral, whereas primary tumors are usually unilateral.
Usually d/t metastatic gastric carcinoma (diffuse type), which has cells filled with mucous, causing the nuclei to become displaced to the periphery of the cell. |
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a) ____________ is massive amounts of mucus in the peritoneum, due to a mucinous tumor of the b) __________, usually with metastasis to the c) _________.
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a) Pseudomyxoma peritonei
b) appendix c) ovary sometimes referred to as "Jelly Belly" |
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A female patient with a history of endometriosis presents with lower quadrant abdominal pain. She says that her LMP was about 2 months ago. A pregnancy test is done and comes back positive. What should definitely be on your differential and what is the most common site that is affected?
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Ectopic pregnancy - lumen of fallopian tube
Key risk factor is scarring (PID or endometriosis). This can be a surgical emergency d/t bleeding into fallopian tube (hematosalpinx) and rupture |
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Spontaneous abortions occur before ___ weeks gestation and occur in up to ___% of recognizable pregnancies.
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20 weeks (usually 1st trimester)
25% |
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A 27 yo female, 10 weeks gestation, presents with vaginal bleeding and cramps. Your physical exam shows that she has passed fetal tissues. What can you tell her is the most likely cause for her miscarriage?
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Chromosomal anomalies (especially trisomy 16)
Other causes include hypercoagulable states (antiphospholipid syndrome, SLE can have recurrence), congenital infection, exposure to teratogens (especially during first 2 wks of embryogenesis) |
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During what times of gestation are teratogens most likely to cause each of the following problems (also depending on dose and agent)?
a) Spontaneous abortion b) Organ malformation c) Organ hypoplasia |
a) first 2 weeks
b) weeks 3-8 c) months 3-9 |
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A patient who experienced third-trimester bleeding needed to deliver by C-section due to the placenta's location in the uterus. What is this condition?
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Placenta previa - where the placenta implants in the lower uterine segment, overlying the cervical os
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Separation of the placenta from the decidua prior to delivery of the fetus presents with fetal insufficiency and third-trimester bleeding, and it is a common cause of what?
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Still birth (this condition is called placental abruption)
There will be blood on the maternal surface of the placenta |
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A patient presents with a difficult delivery of the placenta and postpartum bleeding. In this condition, the placenta implants into the myometrium with little or no intervening decidua. What tx is often required in these patients?
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Hysterectomy
This is called placenta accreta |
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What are the 3 classic features of preeclampsia?
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Pregnancy-induced hypertension, proteinuria, and edema, usually arising in the 3rd trimester. It is seen in ~5% of pregnancies.
The HTN may be severe, leading to headaches and visual abnormalities. |
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What causes preeclampsia?
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abnormality of the maternal-fetal vascular interface in the placenta; resolves with delivery
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Eclampsia is preeclampsia with _________.
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Seizures
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Describe what happens when preeclampsia involves the liver.
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There is thrombotic microangiopathy, characterized by Hemolysis (occurs when RBC's shear when passing plaque), Elevated Liver enzymes (d/t infarction), and Low Platelets (used up to form thrombi) (HELLP)
Both eclampsia and HELLP usually warrant immediate delivery. |
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What are the risk factors for SIDS, which occurs in healthy infants b/w 1 mo and 1 yr old without obvious cause, usually during sleep?
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Sleeping on stomach
Cigarette smoke exposure Prematurity |
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An overweight female presents to the ER because she is concerned about these grape-like masses that she has been passing through the vaginal canal. When questioned, she can't remember the last time she had her period. A pregnancy test comes back positive, and you can feel that the fundal height indicates a likely pregnancy as well. What do you suspect is the problem with this patient?
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Hydatidiform Mole - uterus is much larger and beta-HCG much higher than should be expected. This patient is likely in the 2nd trimester d/t lack of prenatal care and the passage of grape-like masses.
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A patient in her first trimester presents for a check-up. A routine ultrasound shows that fetal heart sounds are absent and a "snowstorm" appearance. How should you treat this?
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D&C (Hydatidiform Mole)
Subsequent beta-HCG monitoring is important to ensure adequate mole removal and to screen for development of choriocarcinoma |
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Which patients WILL respond well to chemotherapy? Those who develop choriocarcinoma from the spontaneous germ cell pathway or those from the gestational pathway?
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Gestational pathway (spontaneous abortion, normal pregnancy, hydatidiform mole)
Germ cell will NOT respond well to chemo |
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Describe the following characteristics for a PARTIAL mole.
a) Genetics b) Fetal tissue c) Villous edema d) Trophoblastic proliferation e) Risk for choriocarcinoma |
a) Normal ovum, 2 sperm (or 1 sperm that duplicates chromosomes), 69 chromosomes
b) Present c) some villi hydropic, some normal d) focal proliferation present around hydropic villi e) minimal |
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Describe the following characteristics for a COMPLETE mole.
a) Genetics b) Fetal tissue c) Villous edema d) Trophoblastic proliferation e) Risk for choriocarcinoma |
a) empty ovum, 2 sperm (or 1 sperm that duplicates chromosomes), 46 chromosomes
b) Absent c) most villi hydropic d) diffuse, circumferential proliferation around hydropic villi e) 2-3% (higher than partial) |
