Gyn

Front 1

40 YO woman h/o smoking/immunosuppression with multifocal vulvar lesions that can recurr or regress

Micro: dysplasia in the squamous epithelium


IHC: p16, Ki-67

1. % progression?
2. Grading?
3. variants?
4. if microinvasive, what is the risk of mets?

Back 1

Vulvar intraepithelial neoplasia(VIN)

1. % progression 4-7%

2. Full thickness dysplasia, <1/3 is VIN1, <2.3 VIN II, >2/3 VIN III

3. warty type, basaloid, simplex (p53 best marker for DX)

4. <1mm, microinvasive- no risk

Front 2

older woman with itchy, erythematous rash on the vulva

Micro: acanthosis, papillomatosis, intraepithelial clear cells throughout the squamous mucosa/epithelium.

IHC:mucicarmine, PAS+; HER2/neu, CAM 5.2, CK7, LMWCK +

1. recurrence rate?

Back 2

Padget's disease

NOT assc. with underlying invasion (20%- breast, GU)

1. 20-30%

Front 3

Squamous cell CA of the vulva

1. risk of mets with invasion at A:<1mm, B:<3mm, C:>3mm?

what are the 2 types?

Back 3

Squamous cell CA of the vulva

1. <1mm- microinvasive, no risk, <3mm, 8.3%, >3 mm- 41%

2. HPV assc, younger patients (40%), lichen simplex assc, older patients, (60%)

Front 4

woman with ill-defined vulvar mass

Gross: bulky, soft, rubbery, gelatinous

Micro: vascular lesion c/o variably sized vessles in a myxoid background

Back 4

Angiomyomyxoma

Front 5

Cervical intraepithelial neoplasia

1. Risk factors?
2. HPVs assc. with CA?
3. grading?
4. Asc. with adenoCA in situ?

Back 5

Cervical intraepithelial neoplasia

1. HPV/sexual activity at young age, multiple sex partners, STDs, smoking, high viral load, persistent SIL, HPV
2. 16, 18, 31, 33, 35, 45

3. I- koilocytes, II/III- entire thickness of dysplasia, hyperchromasia, increased N/C ratio, can involve glands

4. 50-70% of adenoCA in situ have CIN

Front 6

Microinvasive SCC in the cervix

1. definition?

2. What does Factor VIII, D2-40 do?

3. what to look for

Back 6

Microinvasive SCC in the cervix

1. FIGO depth>5mm, width<7mm; stromal invasion <3mm (SGO) from basement membrane (different than VIN)

2. Highlight LVI

3. stromal reaction

Front 7

1. What are the best stains to DDX microinvasive adenocarcinoma in situ of the cervix (AIS) from endocervial gland dysplasia?

Back 7

1. p16 and ki-67 (both positive in CA)

Front 8

Reactive changes with Tamoxifen

1.
2.
3.

Back 8

Tamoxifen reaction

1. Atrophy
2. inactive
3. decidual reaction
4. endometrial polyps

Front 9

Endometrial hyperplasia

1. Types?

2. cytologic features of atypia in endometrium?

3. risk for developing CA?

Back 9

Endometrial hyperplasia

1. Simple (cystic), Complex (adenomatous), Atypical (nuclear atypia)- nuclei should be cigar shaped, tubular cells, atypial - rounded cells

2. enlarged, rounded, vescicular nuclei, clumped chromatin, nucleoli

3. low (<5%) for simple and complex, high (>20%) for atypia

Front 10

Endometrial CA grading

1. what gets graded, squamous or glandular?

2. What consitutes grading?

3. what is worse, endometrioid or serous adenoca?

Back 10

Endometrial CA grading

1. only glandular

2. solid pattern of growth, 1- 5% or less, 2- less than 50%, 3- >50%; although marked atypia can raise grade from 1-2.

3. Serous- most at stage III/IV, not estrogen dept, rare (<10% of cases), stain with p53

Front 11

younger woman with vaginal bleeding, pain, and mass. may have extrauterine pelvic extension, rare assc. with tamoxifen or radiation

Micro: Highly cellular (almost small blue cell) lesion in the uterus that is well demarcated from surrounding myometrium (1) or invades into the myometrium (2). spiral arterioles with "naked" nuclei in hypercellular stroma

IHC: vimentin, MSA, CD10, ER/PR inhibin, CD99

Back 11

1- Endometrial stromal tumor
2- Endometrial stromal sarcoma

Front 12

How can you differentiate a uterine SM tumor from leiomyoma to a myosarcoma?

1.
2.
3.

Back 12

1. atypial? then, yes then (if no, skip to 3)
2. Tumor necrosis? if yes, sarcoma, of no
3. Mitotic index (>10), if less than that, leiomyoma

Front 13

Serous ovarian tumors

1. 30% of all ovarian neoplasms- what % is malignant? boderline?

2. Borderline- 30 %bilateral. what % confined to ovary? significance of microinvasion?

3. 5yr outcome for stages I-III for boderline tumors?

Back 13

1. 30%, 10%

2. 70%, none.

3. 95%

Front 14

Muscinous ovarian tumors

1. 5% assc. whith what other ST tumor?

2. what steroid hormones are produced?

3. what must be seen to DX invasion?

4. what is the difference between a borderline tumor and intramucosal carcinoma?

Back 14

Muscinous ovarian tumors

1. dermoid

2. CA125, CEA, CA-19-9, inhibin

3. stromal reaction

4. cribiform pattern

Front 15

young woman with intrabdominal mass, elevated lactate dehydrogenase


Micro: ovary with tumor c/o large cells with vacuolated cytoplasm, lots of stromal lymphocytes

IHC: SAL4, OCT4, NANOG

1. % bilateral?
2. granulomatous reaction?

Back 15

Dysgerminoma

1., 2. 20%

Front 16

young patient with abdominal mass with elevated serum AFP

gross: hemorrhagic, solid/cystic

Micro: micrcystic/reticular pattern, schiller duvall bodies (fibrovascular core with cells with eosinophilic cytoplasm, "hyaline bodies"

ICH: AFP, Leu-M1

Back 16

Yolk sack tumor

Front 17

child with abdominal mass or amenorrhea/hirsutism, elevated AFP, cHCG

Micro: syncytiotrophoblasts, ugly

Back 17

Embryonal CA

Front 18

What is the most common ovarian tumor?

1. what are the complications?

Back 18

Dermoid cyst

1. hemoperitoneum, peritonitis, infection

Front 19

Insular carcinoid tumor of the ovary

1. assc. with carcinoid syn?

2.

Back 19

Insular carcinoid tumor of the ovary

1. assc. with carcinoid syndrome 1/3 of the time

Front 20

older woman with abdominal mass, vaginal bleeding, isosexual pseudoprecocity, endometrial hyperplasia

Gross: yellow and areas of hemorrhage

Micro: trabecular, solid growth patterns, nuclear grooves, cal exner bodies

IHC: vimentin, CK, s100, inhibin, calretinin

1. what histologic features predict outcome?

2. Distinguish from juvenile form?

Back 20

Adult granulosa tumor

1. none

2. negative for inhibin, abscence of estrogenic manifistations, lack of nuclear grooves

Front 21

Thecoma/fibroma
1. assc. with what syndrome?

2. distinction?

Back 21

Thecoma

1. Gorlin's

2. Thecoma clinical hx of steroids, age at presentation -thecoma slightly older (60's), thecoma cells more polygonal than spindled

Front 22

Most common ovarian metastases

1.
2.
3.

MC features?

Back 22

1. Large bowel
2. stomach
3. breast

70% are bilateral, discrete nodules, on surface... solid- stomach/breast, cystic- colon

Front 23

How do you calculate the maturation index?
1. how many cells need to be counted?

Back 23

% parabasal cells:%IM cells:%superficial cells
high parabasal, low superficial- atrophy (example)
high superficial, low parabasal- high estrogen
1. 300

Front 24

woman with a mass on a peritoneal surface, may be fallopian tube, or uterus

Gross: small (1-2 cm), lobulated lesion

Micro: c/o anastamosing gland-like spaces lined by flattened cuboidal cells with little atypia, occasional signet ring cells. Non-destructive.

IHC: CK, calretinin, vim; negative for factor VIII or CD31.

Back 24

adenomatoid tumor

Front 25

younger woman with vaginal bleeding or asymptomatic

Gross: well circumscribed uterine mass, firm and gray.

Micro:biphasic growth- smooth muscle cells and intermixed glandular component. Glands resemble mature endocervix or endometrium. If endometrial, will show dyssynchrony with overlying endometrium.

Back 25

adenomyoma

Front 26

Older woman (MC AA) with uterine mass. May have h/o unopposed estrogen and abdominal pain.

Gross: 1. intramural mass that is well circumscribed and has a bulging, white and whorled surface when fixed. 2. similar appearance with obvious hemorrhage and necrosis.


Micro: 1. intersecting fascicles of cells with abundant eosinophilic cytoplasm and elongated "cigar-shaped" nuclei. Paranuclear vacuoles seen in transversely cut. Variants include cellular (resemble ESTs), symplastic/atypical/bizarre nuclei (atypical cells with pleomorphic nuclei), mitotically active (5-15/HPF), hydropic change (edema), apoplectic (hormonal chages-central hemorrhage, and others. Can become intravascular and metastasize.
2. As above with infiltrative growth, hypercellular, nuclear atypia with hyperchromasia, >10 mitoses/HPF, tumor necrosis. Can have epithelioid (pseudogland formation) or myxoid variants. Often (20%) with vascular invasion.

3. How can you distinguish DX1 from 2?

4. How do you distinguish the cellular variant from an endometrial stromal tumor (EST)?

IHC: desmin, vimentin, CD10, CK, EMA

Back 26

1. Leiomyoma
2. Leiomyosarcoma
3. 2 of the following 3: Mitoses >10/HPF, tumor necrosis, severe atypia. If only 1 of the 3, then qualifies for STUMP (SM tumor of uncertain malignant potential)
4. Spiral arterioles seen in ESTs, thick walled vessels in cellular leiomyomas

Front 27

woman with uterine bleeding and uterine mass

Gross: well circumscribed or with areas of poorly diff margins. May have whorled or soft cut surface

Micro: "tongu-like" infiltrative growth- tumor cells in sheets with scant stroma. Cells are round/oval with well defined borders, abundant eosinophilic or granular cytoplasm, and oval to round nucleus. Cells may be packed around blood vessels.

IHC: HMB-45, Melan A; s-100, CK, CD10 negative.

Assc. with what genetic disease?

Back 27

PEComa

2. Tuberous sclerosis

Front 28

older woman with abnormal vaginal bleeding

Gross: polypoid mass that may protrude from the cervical os, connected to the endometrium with a thin stalk or broad base. Is fleshy and can be cystic

Micro: Thick walled vessels in stroma, irregular gland architecture, fibrosis.

2. What if you seen periglandular condensation (looks like phylloides tumor)?

3. What if you see fibromuscular stroma under glands?

Back 28

Endometrial polyp

2. R/O low-grade mullerian adenosarcoma

3. atypical polypoid adenomyoma

Front 29

Dating endometrium

1. Features of proliferative endometrium?
A.
B.
C. (early)
D. (late)
2. Day 16 endometrium?
2b. Day 17?
3. Secretory?
A- (early)
B- (mid)
C- (late)

Back 29

1. PROLIFERATIVE
A- round/tubular glands, pseudstratified
B- no vacuoles
C- early shows residual stromal breakdown
D- mitoses, telescoping glands
2. DAY 16
SUBnuclear vacuoles- discuntinuous
2B- prominent subnuclear vacuoles, no mitoses

3. SECRETORY
A- early- SUPRAnuclear vacuoles
B- mid- stromal edema, intralumenal secretions, stromal changes
C- stromal cells become basophilic and well-defined, predecidua cuff spiral arterioles

Front 30

younger woman with irregular vaginal bleeding,may have infertility

Micro: plasma cells in the functionalis of the endometrium- just below areas of stromal breakdown

Back 30

chronic endometritis

Front 31

older woman with abnormal vaginal bleeding

Gross: friable uterine mass involving the endometrium, may show invasion into the myometrium

Micro: a variety of histologic patterns that show invasion or atypia, including:

1. papillary, tubulocystic and solid patterns of small, rounded cells with prominent clear cytoplasm due to abudant glycogen. Cells in hobnail pattern. Nucleus bulges into the lumen. Cysts present with flat cells lining. "targetoid cells".

2. atypical endometrial glands with a variety of normal or atypical architectures. Gland complexity. Solid pattern seen. Cells are larger than normal with mitoses and apoptosis. Stromal desmoplasia. Subtypes can show squamous morules, long-slender papillae with fibrovascular cores, or metaplastic changes.
3. intracytoplasmic mucin in at least 50% of cells, resembling endocervical cells, often with polys.
4. complex papillae that are thick with cellular stratification and cellular budding. Cells show significant pleomorphism and eosinophilic cytoplasm. Often deeply invasive. Thought to arise from precursur lesion (EIC)

5 other variants?

Back 31

Endometrial carcinoma (variants:)
1. Clear cell adenocarcinoma
2. Endometrioid carcinoma- with squamous differentiation, villoglandular or metaplastic changes
3. Mucinous adenocarcinoma
4. Serous
5. Squamous cell, transitional cell, small cell, undifferentiated

Front 32

What is the difference between type 1 and type 2 endometrial carcinomas?

Back 32

Type 1- in younger women with h/o estrogen effects- also h/o endometrial hyperplasia. These are low grade. Endometrioid and mucinous variants, may have PTEN and k-RAS, MSI.

Type 2- post-menopausal, higher grade variants (clear cell, squamous, undifferentiated), P53

Front 33

what IHC can help distinguish endometrioid from endocervical adenoCA?

Back 33

ER and vimentin are more likely positive in endometrioid CA.

CEA more likely in endocervical. Also HPV-p16.

Front 34

Grading for endometrial CA

what defines high grade?
1.
2.

Back 34

1. Serous or clear cell variants
2. amount of solid component of endometrioid type (grade 2- 5-50%, grade 3 >50%)

Front 35

post-menopausal black woman with vaginal bleeding and pelvic pain.

Gross: large, bulky, polypoid uterine mass. May prolapse through the cervix.

Micro: high-grade mixed epithelial and stromal components.

2. What if epithelial components are not malignant? often have phylloides-like growth

Back 35

Carcinosarcoma (malignant mixed mullerian tumor (MMMT))

2. Adenosarcoma

Front 36

reproductive age woman with abdominal mass/vaginal bleeding/ or incidental.

Gross: frequently bilateral, 1-10 cm mass in the ovary. c/o fibrous stroma, may contain cysts.

Micro: cysts and/or fibrous stroma with glands lined by ciliated secretory cells that resemble falopian tube.

IHC: CK7+, CK20-, also WT1, Leu-M1 (CD15) +

Back 36

Serous cystadenoma (serous cystadenofibroma or serous adenofibroma)

Front 37

Woman on OCP, incidental lesion

Gross: polypoid sessile lesion at cervix

Micro: complex proliferation of smal back-to-back glands lined by cuboidal cells with vacuoles and vescicular nuclei. No atypia. Cells may hobnail.

IHC: mucin + (vescicles). CEA, CD10, vimentin neg.

Back 37

microglandular hyperplasia of the cervix

Front 38

middle age woman with vaginal bleeding and a cervical polyp.

Gross: small polyp (1cm)

Micro: dilated cervical glands with inflamed stroma, may be papillary. Thick walled blood vessels at the base.

Back 38

endocervical polyp

Front 39

preadolescent girl with vaginal bleeding and an exophytic cervical mass

Gross: vaginal wall or cervix mass

Micro: papillary fronds lined by columnar or cuboidal epithelium with eosinophilic cytoplasm. no atypia. The cells may form solid nests, and have PAS-positive globules.

Back 39

Mullerian papilloma/metanephric papilloma

Front 40

Requirements for CIN diagnosis

1. CIN I
2. CIN II
3. CIN III

Back 40

1. Low grade features (LSIL), with koilocytic atypia, acanthosis, papillomatosis.
2. loss of maturation and nuclear atypia occupying 2/3 of epithelium. Syncitial growth, crowding. mitoses.
3. full thickness dysplasia

Front 41

younger woman with vaginal bleeding or watery discharge

Gross: induration in the cervical wall, with a friable or hemorrhagic cervix

Micro: complex, variably sized cervical glands with papillary infoldings or angular outpouchings. Cells are tall and mucin-producing, with basal, hyperchromatic nuclei. Appears low-grade. Glands extend deep below normal endocervical glands (>8mm). May elicit a desmoplastic response

Back 41

minimal deviation mucinous adenocarcinoma (adenoma malignum)

Front 42

Woman with abnormal pap

Micro: resembles basal cell carcinoma of the skin- with central squamous differentiation. Lumens seen in the center of nests.

Back 42

adenoid basal carcinoma

Front 43

woman with ovarian tumor associated with hyperestrinism (50%)
1/3 with tumor have Peutz-Jegher’s syndrome

Gross: yellow or brown tumor

Micro: ixture of simple and complex annular tubules with eosinophilic hyaline bodies, often calcified; resembles granulosa cell tumor with Sertoli growth pattern; simple annular tubules are ring shaped, with peripheral oriented nuclei around a central hyalinized body composed of basement membrane material; most of ring is anuclear cytoplasmic zone
Complex annular tubules are made of intercommunicating rings revolving around multiple hyaline bodies, often calcified

Back 43

Sex cord stromal tumor with annular tubules

Front 44

woman with bilateral cystic neoplasms

Gross: cystic lesion with variable amounts of papillary epithelial projections

Micro: complex branching papillae with detached cellular buds. Epithelial cells are not atypical. Lots of psammoma bodies. No invasion of the ovarian stroma. (1) yes invasion of stroma. (2) extensive papillary projections with elongated papillae. (3) with cytologically atypical cells

4- where do these arise? What is the most common serous tumor in order?

Back 44

Serous borderline tumor

(1) low grade serous carcinoma of the ovary
(2) Micropapillary borderline tumor
(3) serous carcinoma

4- fallopian tube. B9, then malignant, then borderline