Pathoma - Chapter 13 - FemaleGenitalSys

Pathoma - Female Genital System & Gestational Pathology - Fundamentals of Pathol
ogy
Study this set online at: http://www.cram.com/ashcards/pathoma-female-genital-sy
stem-gestational-pathology-fundamentals-of-pathology-2475908
The vulva represents what?
Skin and mucosa of the female genitalia that is external to the hym
en
The vulva is lined by what cells?
Squamous epithelium
What is a Bartholin cyst?
Cystic dilation of Bartholin gland. Arises due to inammation and ob

struction of the gland; usually occurs in women of reproductive age
.
"Unilateral lesion in the lower vestibule adjacent to the vaginal cana

l" sounds like?
Bartholin cyst
Presentation of Bartholin cyst?
Unilateral, painful cystic lesion.
What is a condyloma? What is it due to?
Warty neoplasm of vulvar skin, often large. MC due to HPV 6 or 11.
HPV can infect ___________.
the lower genital tract (vulva, vagina, cervix)
What key changes can you see in cells that are infected with HPV?
Koilocytic change (raisin-looking nucleus with halo)

ogy
How can HPV be divided?
Low risk type and high risk type.
How do we know whether an HPV strain is high or low risk?
DNA-sequencing allows us to determine or subclassify HPV as high

or low risk.
HPV is a _________ (DNA/RNA) virus.
DNA (remember we use DNA-sequencing to classify it)
High risk HPV?
16, 18, 31, 33
What classic lesion is a low risk HPV gonna produce?
Condyloma. Can occur anywhere along lower genital tract.
What do we call the lesions that develop in the lower genital tract a
fter infection with high risk HPV?
(1) Cervix: CIN (2) Vagina: VAIN (3) Vulva: VIN
Condyloma ___________ (often/rarely) progresses to carcinoma.
rarely
What is this?
Condyloma

ogy
What is this?
Higher power micrograph of previous picture of a condyloma. Note

the raisinoid appearance of nucleus.
What is Lichen sclerosis? How does it present?
Thinning of the epidermis with brosis of the dermis. Classically pre

sents with leukoplakia with a parchment (pergament)-like. It feels su
per thin.
Lichen sclerosis is usually seen in ___________.
postmenopausal women
Lichen sclerosis is __________ (benign/malignant).
Benign, but is associated with a slightly increased risk for squamou

s cell carcinoma.
What is Lichen simplex chronicus?
Sort of the opposite of Lichen sclerosis with thickening of the skin.

We see leukoplakia with thick leather like skin due to hyperplasia of
vulvar squamous epithelium.
What is Lichen simplex chronicus associated with?
Chronic irritation ("chronicus") and scratching.
Lichen simplex chronicus is __________ (benign/malignant).
Benign, no increased risk for squamous cell carcinoma. ("Simplex; i

t's a simple entity that doesn't want to do any harm")
Vulvar carcinoma arises from?
Squamous epithelium lining the vulva.

ogy
Vulvar carcinoma is ____________ (moderately frequent/relatively ra
re).
relatively rare
Vulvar carcinoma accounts for a _________ (signicant/small) percen

tage of female genital cancers.
small
How does vulvar carcinoma present?
With leukoplakia. You need biopsy to distinguish it.
What vulvar pathologies present with leukoplakia?
(1) Lichen sclerosis (2) Lichen simplex chronicus (3) Vulvar carcinom
a
What pathways can lead to vulvar carcinoma?
(1) HPV-related - High risk HPV (2) Non-HPV related - Long-standing l

ichen sclerosis
At what age would you expect to see vulvar intraepithelial neoplasi

a?
40-50 (it takes time to develop dysplasia after virus infection)
You would tend to see non-HPV related vulvar carcinoma in postme

nopausal woman. Why?
Greater than 70 for example, due to long standing lichen sclerosis.
What is extramammary Paget disease?
Malignant epithelial cells in the epidermis of the vulva. ("Paget was

a very busy man, he discovered many things; Pagets disease of th
e nipple, Paget's disease of the vulva, Paget's disease of the bone
etc")

ogy
How does Paget's disease of the nipple or vulva present?
What is this?
Presents as erythematous, pruritic, ulcerated skin.
Extramammary paget's disease. Note the "extra" cells in there that

doesn't belong.
What is your DDx when you have extramammary Paget's disease?

How do you distinguish?
Carcinoma vs melanoma Stains: Paget cells: PAS+ (only epithelial c

ells make mucus which this stains), Keratin + (it's a carcinoma), S10
0- Melanoma cells: PAS-, Keratin-, S100+
What does extramammary Paget's disease represent?
Carcinoma in situ.
When a patient has Paget's disease of the nipple, it means that ___
__________.
they have cancer somewhere in the breast, while in extramammary

Paget's disease there usually is no underlying carcinoma.
What is adenosis?
Focal persistence of columnar epithelium (normally it is nonkeratini

zing squamous cells) in upper third of vagina. (Lower two thirds sho
uld replace upper one third)
The cells lining the lower two thirds of the vagina in females are de
rived from __________.
Urogenital sinus
The upper one third of cells in the vaginal canal are derived from _
_____________.
the mllerian duct

ogy
There is an increased incidence of adenosis in females exposed to
________________ which would increase the risk for what?
DES in utero (diethylstilbestrol) Clear cell adenocarcinoma
What is clear cell adenocarcinoma of the vagina?
Malignant proliferation of glands with clear cytoplasm. Rare complic

ation of DES-associated vaginal adenosis.
What is an embryonal rhabdomyosarcoma?
Malignant mesenchymal proliferation of immature skeletal muscle. I

t is very rare.
How does embryonal rhabdomyosarcoma present?
Bleeding and grape-like mass protr

uding from vagina or penis in a chi
ld. Usually < 5 years of age. Also
called sarcoma botryoides.
Malignant cells in rhabdomyosarcoma is called a _________. What a

re some important characteristics of this cell?
Rhabdomyoblast Important: (1) Cytoplasmic cross-striations (2) Imm

unohistochemical stain positive for desmin (intermediate lament pr
esent in muscle cells) and myoglobin
Describe the region of lymph node spread if the patient gets a vagi
nal carcinoma.
(1) Cancer from lower 2/3 of vagina goes to inguinal nodes (2) Canc
er from uppwer 1/3 of vagina goes to regional iliac nodes
The cervix is the _______ of the uterus.
'neck'
How is the cervix divided?
Exocervix and endocervix. Diering types of epithelium cover them

.

ogy
What types of epithelium line the cervix?
(1) Exocervix: Squamous epitheliu

m (2) Endocervix: Columnar epithe
lium Exocervix is to the left of the
transformation zone.
HPV is a ___________ transmitted _______ (DNA/RNA) virus.
sexually; DNA
HPV especially likes to infect what?
Cervix at the transformation zone.
What is most likely to happen when you get an immune infection.
Most of the time the immune system rids itself of the virus. It's onl
y when persistent infection occurs we see a risk for progression to
CIN.
What makes high risk HPV high risk?
It produces two proteins: E6: Destruction of p53 E7: Destruction of

Rb (normally "holds" E2F)
CIN is characterized by what?
(1) Koilocytic change (2) Nuclear atypia (3) Increased mitotic activity
CIN grade is based on what?
Extent of dysplasia. E.g. lower third = CIN I
What is the key feature that distinguishes dysplasia from carcinom

a?
Reversibility

ogy
CIN I reverses about ________% of the time.
66%
CIN II reverses about _____ % of the time.
33%
How often does CIN III reverse?
It is unlikely that it will reverse.
What is this? It is taken from the c

ervix.
Carcinoma in situ, maybe CIN III to the left.
True or false: Carcinoma from CIN is inevitable.
False.
We have CIN I, CIN II, CIN III, CIS, so what is cervical carcinoma?
When CIS invades we call that cervical carcinoma.
Cervical carcinoma is MC seen in?
Middle-aged women (40-50)
How does cervical carcinoma present?
As vaginal bleeding. Could be postcoital bleeding.

ogy
Secondary risk factors for cervical carcinoma?
(1) Smoking (2) Immunodeciency
A patient with HIV infection develops cervical carcinoma. What is th

e signicance of this?
Cervical carcinoma is an AIDS dening illness.
What types of cervical carcinoma are there?
(1) Squamous cell carcinoma (more common) (2) Adenocarcinoma B

OTH types are related to HPV.
True or false: Cervical carcinoma metastasize early.
False. They tend to metastasize very late. Advanced tumors often i

nvade through the anterior uterine wall into the bladder.
One of the classic ndings when you have an advanced cervical car
cinoma is ___________.
hydronephrosis
One of the MCC of death in patients with advanced cervical cancer?
Postrenal failure These cancers tend to locally create symptoms rat

her than metastasize.
Gold standard for screening for dysplasia in cervix?
You have an abnormal pap smear. What now?
Papanicolaou smear It is the most

successful screening test develope
d to date.
You have to follow it with a conrmatory colposcopy and biopsy.

ogy
There are some limitations with pap smear, what is it?
(1) Inadequate sampling of the transformation zone results in false

negative screenings. (2) It does not detect adenocarcinoma very w
ell (doesn't go through same CIN sequence as squamous)
True or false: The incidence of adenocarcinoma of the cervix has d

ecreased signicantly after introduction of the pap smear.
False. Pap smear has limited ecacy in detecting adenocarcinoma.
Immunization is ________ (moderately eective/eective) in prevent

ing HPV infections.
eective
The current HPV vaccine we use is composed of what? How long do

es it last?
Quadrivalent vaccine that covers HPV 6,11, 16 and 18. Protection l

asts for 5 years.
A doctor tells a young female adult with previous history of HPV im

munization that she doesn't have to worry about pap smears any
more. Is he right?
He is not right, pap smear is still necessary. You're not protecting a

gainst other somewhat less common subtypes but still high risk str
ains of HPV.
Normal uterus histology.
How does the uterus respond to hormones?
What is Asherman syndrome? What is the cause?
(1) It grows with estrogen (2) It prepares for implantation with prog
esterone Shedding occurs with loss of progesterone support
Secondary amenorrhea because o

f loss of basalis layer (regenerativ
e layer) and scarring. Result of ov
eraggressive dilation and curettag
e ("scraping away") [D&C].

ogy
What is anovulatory cycle? Describe.
It means lack of ovulation. No ovulation results in estrogen-driven p

roliferative phase without progesterone-driven secretory phase (out
grow blood supply).
Anovulatory cycle is a common cause of what?
Dysfunctional uterine bleeding, especially during menarche and me

nopause.
What is acute endometritis usually due to?
Retained products of conception (nidus for bacterial infection)
A woman presents with fever, abdominal pain with bleeding from h

er vagina and pelvic pain 2 days after conception. What could this
be?
Acute endometritis
What inammatory cells are normally present within the endometri

um?
Lymphocytes
What is chronic endometritis? What characterizes it?
Chronic inammation of endometrium. Characterized by plasma cel

ls.
Common causes of chronic endometritis?
(1) Retained products of conception (2) Chronic PID (e.g., chlamydia

) (3) IUD (4) TB (granulomas)
It's common for __________ biopsies to be performed in patients wit

h infertility.
endometrial

ogy
How does chronic endometritis present?
What is an endometrial polyp? How does it present?
(1) Abnormal uterine bleeding (2) Pelvic pain (3) Infertility
Hyperplastic protrusion of endome

trium. Presents as abnormal uterin
e bleeding (stretches endometrium
).
A woman undergoing therapy for breast cancer. She now presents

with abnormal uterine bleeding. What might be going on?
Tamoxifen has anti-estrogenic eects on the breast but weak pro-a

gonistic eects on the endometrium. Could cause a polyp which cou
ld bleed.
What is endometriosis?
Endometrial glands and stroma outside the uterine endometrial linin

g.
How does endometriosis present?
(1) Dysmenorrhea - Displaced tissue can cycle as well. (2) Pelvic pai
n It may cause infertility (covers ovaries).
What theories do we have for how endometriosis develops?
(1) Retrograde menstruation theory - Prevailing theory (however do

esn't explain everything) (2) Metaplastic theory (3) Lymphatic disse
mination theory - Endometriosis has been seen in the lung.
Common sites of involvement in endometriosis?
(1) Ovary (chocolate cyst) (2) Uterine ligaments (pelvic pain) (3) Pou
ch of Douglas (pain with defecation) (4) Bladder wall (pain with urina
tion) (5) Bowel serosa (abdominal pain and adhesions) (6) Fallopian
tube mucosa (scarring; risk of ectopic pregnancy; infertility)
MC site of involvement in endometriosis?
Ovary

ogy
What is this?
Chocolate cyst (it's gonna grow and shed, grow and shed, grow and
shed etc., accumulating bloody debree)
What is this?
Gunpowder lesions. Endometriosis involving soft tissues.
You can get endometriosis that involves the myometrium. What is t

his called?
Adenomyosis
One of the important complications of endometriosis is ________.
Increased risk of carcinoma at the site of endometriosis; especially

the ovary
What is endometrial hyperplasia?
Hyperplasia of endometrial glands relative to stroma. Consequence

of unopposed estrogen. Instead of having glands and stroma equall
y spaced out, you start getting a lot of glands relative to the strom
a.
How does endometrial hyperplasia present?
Postmenopausal uterine bleeding. Androgen gets converted to estro

ne in adipose.
What is this?
How do we classify endometrial hyperplasia?
Endometrial hyperplasia
It is classied histologically. Based on architectural growth (simple o

r complex) and cellular atypia. E.g. "Simple hyperplasia with atypia"

ogy
What is the most important predictor for progression to carcinoma
in endometrial hyperplasia?
Cellular atypia
How does endometrial carcinoma present?
Postmenopausal bleeding (just like hyperplasia)
Endometrial CA can arise via what two pathways?
(1) Hyperplasia (2) Sporadic
What histology do we see in endometrial carcinoma that has arisen

via the hyperplasia pathway?
Endometrioid (cancer looks very much like the normal endometrium

)
What histology do we see in endometrial carcinoma that has arisen

via the sporadic pathway?
We don't have hyperplasia in this pathway. You get cancer from an

ATROPHIC endometrium. Histology is "serous" which often have for
mation of papillae or papillary structures.
The sporadic pathway leading to endometrial CA usually occurs in t

he _________ (young/elderly).
elderly (woman greater than 70)
The hyperplastic pathway leading to endometrial CA usually occurs

in the __________ (middle-aged/elderly).
middle-aged (~50-60)
What drives the sporadic type of endometrial carcinoma?
p53

ogy
What is the precursor lesion to sporadic endometrial carcinoma?
There is no precursors lesion.
What could happen in the sporadic type of endometrial carcinoma

on histology?
Papillae could necrose and undergo calcication (psammoma bodies

).
What is this?
Endometrial carcinoma.
How did this endometrial carcinom

a arise?
This is the endometrioid pattern. T

he cancer has arisen from hyperpl
asia. Note how piled up the glands
are with minimal stroma.
How did this endometrial carcinom

a arise?
Note the papillary projection with

brovascular core. This is the spora
dic type. We could see psammoma
bodies here (remember we can als
o see that in papillary carcinoma o
f the thyroid).
What is a leiomyoma? Leiomyoma is related to what?
Benign proliferation of smooth muscle arising from myometrium. R

elated to estrogen exposure.
Leiomyomas tend to occur in __________ (pre-/postmenopausal wom

en).
premenopausal women (related to estrogen exposure)
Leiomyomas are _____________ (single/often multiple).
often multiple (multiple masses within the uterine wall that grow wit
h pregnancy)

ogy
Leiomyomas tend to _________ (grow/shrink) after menopause.
shrink (estrogen exposure)
How do leiomyomas appear in the uterus?
Multiple, well-dened white whorled masses.
What is this?
Leiomyoma. When they are multiple it indicates that its benign. Lei
omyosarcomas are single. White-whorley masses also indicates ben
ign.
Leiomyomas are usually ___________ (asymptomatic/symptomatic).
asymptomatic
When leiomyomas present with symptoms how do they present?
Abnormal uterine bleeding, infertility, pelvic mass.
True or false: Leiomyosarcomas arise from leiomyomas.
False. They arise de novo.
Leiomyosarcomas are usually seen in?
Postmenopausal women
Leiomyosarcoma is usually _____________ (multiple/a single) lesion

with _________ and _________.
a single; necrosis; hemorrhage

ogy
What is seen on histology of a leiomyosarcoma?
(1) Necrosis (2) Mitotic activity (3) Cellular atypia

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Pathoma - Female Genital System & Gestational Pathology - Fundamentals of Pathol

The vulva represents what?

The vulva is lined by what cells?

What is a Bartholin cyst?

Cystic dilation of Bartholin gland. Arises due to inammation and ob

"Unilateral lesion in the lower vestibule adjacent to the vaginal cana

Presentation of Bartholin cyst?

Unilateral, painful cystic lesion.

What is a condyloma? What is it due to?

Warty neoplasm of vulvar skin, often large. MC due to HPV 6 or 11.

HPV can infect ___________.

the lower genital tract (vulva, vagina, cervix)

Koilocytic change (raisin-looking nucleus with halo)

Pathoma - Female Genital System & Gestational Pathology - Fundamentals of Pathol

How can HPV be divided?

Low risk type and high risk type.

How do we know whether an HPV strain is high or low risk?

DNA-sequencing allows us to determine or subclassify HPV as high

HPV is a _________ (DNA/RNA) virus.

DNA (remember we use DNA-sequencing to classify it)

High risk HPV?

16, 18, 31, 33

What classic lesion is a low risk HPV gonna produce?

Condyloma. Can occur anywhere along lower genital tract.

(1) Cervix: CIN (2) Vagina: VAIN (3) Vulva: VIN

Condyloma ___________ (often/rarely) progresses to carcinoma.

Pathoma - Female Genital System & Gestational Pathology - Fundamentals of Pathol

Higher power micrograph of previous picture of a condyloma. Note

What is Lichen sclerosis? How does it present?

Thinning of the epidermis with brosis of the dermis. Classically pre

Lichen sclerosis is usually seen in ___________.

Lichen sclerosis is __________ (benign/malignant).

Benign, but is associated with a slightly increased risk for squamou

What is Lichen simplex chronicus?

Sort of the opposite of Lichen sclerosis with thickening of the skin.

What is Lichen simplex chronicus associated with?

Chronic irritation ("chronicus") and scratching.

Lichen simplex chronicus is __________ (benign/malignant).

Benign, no increased risk for squamous cell carcinoma. ("Simplex; i

Vulvar carcinoma arises from?

Squamous epithelium lining the vulva.

Pathoma - Female Genital System & Gestational Pathology - Fundamentals of Pathol

Vulvar carcinoma accounts for a _________ (signicant/small) percen

How does vulvar carcinoma present?

With leukoplakia. You need biopsy to distinguish it.

What vulvar pathologies present with leukoplakia?

What pathways can lead to vulvar carcinoma?

(1) HPV-related - High risk HPV (2) Non-HPV related - Long-standing l

At what age would you expect to see vulvar intraepithelial neoplasi

40-50 (it takes time to develop dysplasia after virus infection)

You would tend to see non-HPV related vulvar carcinoma in postme

Greater than 70 for example, due to long standing lichen sclerosis.

What is extramammary Paget disease?

Malignant epithelial cells in the epidermis of the vulva. ("Paget was

Pathoma - Female Genital System & Gestational Pathology - Fundamentals of Pathol

How does Paget's disease of the nipple or vulva present?

Presents as erythematous, pruritic, ulcerated skin.

Extramammary paget's disease. Note the "extra" cells in there that

What is your DDx when you have extramammary Paget's disease?

Carcinoma vs melanoma Stains: Paget cells: PAS+ (only epithelial c

What does extramammary Paget's disease represent?

they have cancer somewhere in the breast, while in extramammary

Focal persistence of columnar epithelium (normally it is nonkeratini

the mllerian duct

HPV is a _____ transmitted _ (DNA/RNA) virus.