Pathoma - Ovary, Ovarian Tumors, Gestational Pathology - Fundamentals Of Pathology

Front 1

What is the functional unit of the ovary?

Back 1

Follicle (oocyte surrounded by granulosa and theca cells)

Front 2

LH binds to what cells? What happens?

Back 2

Theca cells.

They produce androgens which diffuse into granulosa cells (which under FSH influence) and gets converted into estradiol. Estradiol bathes the egg.

Front 3

FSH binds to what cells?

Back 3

Granulosa cells. Allows granulosa cells to convert androgens to estrogens (estradiol)

Front 4

What is this?

Back 4

Follicle

Front 5

After ovulation, the residual follicle becomes _____________.

Back 5

corpus luteum

Front 6

What can happen to the corpus luteum?

Back 6

Hemorrhage into it causing a hemorrhagic luteal cyst.

Front 7

What is this? Why is it yellow?

Back 7

Corpus luteum.

Yellow because it produces hormones (steroid hormone; progesterone)

Front 8

Degeneration of follicle results in ___________. What disorder results in multiple cysts?

Back 8

follicular cyst

Polycystic ovarian disease

Front 9

What is PCOD? (brief) It is characterized by what?

Back 9

Multiple follicular cysts in ovary due to hormone imbalance. Characterized by increased LH and low FSH (LH:FSH > 2)

Front 10

What is hirsutism?

Back 10

Excess hair in a male distribution.

Front 11

Features of PCOD?

Back 11

(1) Hirsutism (heavy facial hair e.g.)
(2) Obese woman
(3) Infertility
(4) Oligomenorrhea
(5) Androgen --> Estrone will shut down FSH.
- Granulosa cells are unable to perform their job and follicle degenerates and become cystic.

Front 12

Some patients with PCOD have ________________.

Back 12

insulin resistance

Front 13

Patients with PCOD have increased risk for what?

Back 13

Endometrial carcinoma

Front 14

An easy way of remember what ovarian tumors we can get.

Back 14

Front 15

The ovary is composed of what three cell types?

Back 15

(1) Surface epithelium
(2) Germ cells
(3) Sex-cord stroma

Tumors can arise from any of these cell types or metastasis.

Front 16

What is the MC type of ovarian tumor?

Back 16

Surface epithelial tumor

Front 17

Surface epithelial tumors are derived from what? What is special about it?

Back 17

From the coelomic epithelium that lines the ovary. It has the ability to produce multiple different cell types, therefore we see multiple different subtypes of potential tumors.

Front 18

What are the two most common surface epithelial tumors? These are both usually _________.

Back 18

(1) Serous
(2) Mucinous

Both are usually cystic.

Front 19

The two most common types of surface epithelial tumors in the ovaries are classically named based on what?

Back 19

The fluid they produce.

Full of water when you cut it open = Serous
Full of mucus when you cut it open = Mucinous

Front 20

How can you categorize surface epithelial tumors?

Back 20

Based on how they behave, e.g. benign or malignant or tumors in between (borderline tumors).

Front 21

Benign tumors of surface epithelium of ovary are called ________. They are composed of?

Back 21

Cystadenoma. Composed of single cyst with simple, flat lining.

Front 22

Cystadenomas most commonly arises in?

Back 22

Premenopausal women (30-40 yo)

Front 23

What is this?

Back 23

Benign tumor of surface epithelium (cystadenoma)

Front 24

What is the malignant variant of the benign tumor that arises from surface epithelium of the ovary called?

Back 24

Cystadenocarcinoma.

Can be serous or mucinous.

Front 25

Cystadenocarcinomas are composed of what? It arises in?

Back 25

Composed of complex cysts with thick, shaggy (almost like a carpet) lining. MC arises in postmenopausal women (60-70 yo).

Front 26

What is the defining histologic feature of cystadenocarcinoma?

Back 26

That cells invade into the connective tissue of the cyst wall.

Front 27

Borderline tumors have what features?

Back 27

Features that are in between benign and malignant.

Front 28

Borderline tumors have better prognosis than frankly _______________ tumors, but [...]

Back 28

malignant

but they still carry metastatic potential

Front 29

What type of ovarian carcinoma can you get with BRCA1 mutations?

Back 29

Increases the risk for serous carcinoma of the ovary and fallopian tube.

Front 30

Patients who have mutation in this gene have increased risk for breast cancer and ovarian cancer. What is the affected gene? What additional cancer are they at risk for?

Back 30

BRCA1

Remember ovarian carcinoma is serous (from surface epithelium). They are at risk for fallopian cancer.

Front 31

A patient has a BRCA1 mutation. What could organ(s) could she elect to get surgically removed?

Back 31

Breasts, ovaries, fallopian tubes

Front 32

What types of surface epitheliai tumors of the ovary do you know?

Back 32

(1) Serous
(2) Mucinous
(3) Endometrioid
(4) Brenner

Front 33

What histology does endometrioid tumor of the ovary have?

Back 33

Endometrial-like.

Front 34

An endometrioid tumor of the ovary is usually ___________ (benign/malignant).

Back 34

malignant

Front 35

What tumor may be associated with endometriosis?

Back 35

Endometrioid carcinoma of the ovary

Front 36

Average time of diagnosis of endometriosis is ____ to ____ yo.

Back 36

25;29

Front 37

A 26 year old woman comes in with complaints of pain during menstruation. During intercourse she also has pain. She has been trying to conceive but with no results. An adnexal mass is felt and confirmed to be endometrioid type of ovarian carcinoma. What should be your next concern?

Back 37

Patients with endometrioid, in 10-15% of cases, will have a separate endometrioid tumor in the endometrium as well.

Front 38

A biopsy of a suspected ovarian carcinoma contain cells that resemble urothelium. What might this be? Is this tumor benign or malignant?

Back 38

Brenner's tumor.

Usually benign.

Front 39

When do surface-epithelial tumors present?

Back 39

They present late (poor prognosis).

Front 40

How do patients with a surface epithelial tumor of the ovary present?

Back 40

They present late:

(1) Vague abdominal symptoms (pain, fullness)
(2) Signs of compression (urinary frequency)

Front 41

You palpate the ovaries in a postmenopausal woman. Should you be able to do this?

Back 41

Palpable ovaries in postmenopausal women is cancer until proved otherwise.

Front 42

Epithelial tumors tend to spread _________, and especially to the _________.

Back 42

locally; peritoneum

Front 43

A surface-epithelial tumor of the ovaries may release this marker into the blood, what is it and what is it useful for?

Back 43

CA-125.

It is useful for monitoring treatment response and recurrence.

Front 44

What is the second most common ovarian tumor that can arise?

Back 44

Germ cell tumors (15% of causes)

Front 45

Germ cell tumors usually arise in?

Back 45

Women of reproductive age.

Front 46

What type of tumor would you consider if a 15-30 year old presented with a tumor of the ovary? How about 35-40? 60-70?

Back 46

15-30: Germ cell tumor
35-40: Benign surface epithelial tumor
60-70: Malignant surface epithelial tumor (top of your DDx)

Front 47

How could you easily remember what type of germ cell ovarian tumors there are?

Back 47

Germ cells give rise to fetal tissues.

(1) One tumor that can resemble fetal tissues is called a cystic teratoma (different embryological layers)
(2) You can also get fetal type tissues that's very primitive. This is embryonal carcinoma.
(3) Germ cells can make the yolk sac --> Yolk sac tumor.
(4) Germ cells can make additional germ cells. When we get a mass of germ cells we get a dysgerminoma.
(5) Oocyte/egg has to make placenta --> choriocarcinoma.

Front 48

What is a cystic teratoma?

Back 48

Cystic tumor composed of fetal tissue derived from two or three embryologic layers (germ cell tumor).

Front 49

This is the MC germ cell tumor in females.

Back 49

Cystic teratoma.

Front 50

True or false: Cystic teratomas are always unilateral.

Back 50

False, they are bilateral in 10% of cases.

Front 51

What could this be?

Back 51

Cystic teratoma (benign).

Front 52

Cystic teratomas are _________ (benign/malignant)

Back 52

Benign

Front 53

What do we have to exclude when we have a cystic teratoma?

Back 53

(1) Immature tissue, it has malignant potential.
(2) The tissue itself can contain a malignancy (somatic malignancy)
- E.g., carcinoma in the skin

Front 54

What's the MC type of tissue that's immature in an immature teratoma?

Back 54

Neuroectoderm

Front 55

What is the MC somatic malignancy that arises in a teratoma?

Back 55

Squamous cell carcinoma of the skin of the teratoma.

Front 56

This is a special type of teratoma, what's the name and what's so special about it?

Back 56

Struma ovarii: Cystic teratoma composed primarily of thyroid tissue.

Front 57

What is a dysgerminoma composed of?

Back 57

This is a germ cell tumor. Composed of large cells with clear cytoplasm and central nuclei (resembles oocyte).

Front 58

What is the MC malignant germ cell tumor?

Back 58

Dysgerminoma (most common benign is cystic teratoma).

Front 59

The testicular counterpart of a dysgerminoma is a?

Back 59

Seminoma

Front 60

What is the prognosis of a dysgerminoma?

Back 60

Good. Responds to radiotherapy.

Front 61

What tumor marker may be elevated with a dysgerminoma?

Back 61

LDH

Front 62

What is this?

Back 62

Dysgerminoma.

Front 63

What is an endodermal sinus tumor?

Back 63

Germ cell tumor. Malignant tumor that mimics the yolk sac.

("Sinus = Yolk sac")

Front 64

What is the MC germ cell tumor in children?

Back 64

Endodermal sinus tumor.

Front 65

A five year old girl has an ovarian mass. What serum tumor marker may be elevated?

Back 65

This is most likely an endodermal sinus tumor and AFP may be increased.

Front 66

What do we see on histology of an endodermal sinus tumor?

Back 66

Schiller-Duval bodies (glomeruloid structures)

Front 67

This biopsy was taken from a young girl. What could it be?

Back 67

Schiller-Duval body, could be taken from an endodermal sinus tumor.

Front 68

What is a choriocarcinoma? What is it composed of?

Back 68

Germ cell tumor, a malignant proliferation of placental-like tissue. Composed of trophoblasts and syncytiotrophoblasts (villi are absent).

Front 69

What key cell surrounds the villi in the placenta?

Back 69

Trophoblasts

Front 70

Choriocarcinoma: How does it classically look? Does it spread?

Back 70

(1) Small, hemorrhagic tumor
(2) Early hematogenous spread
- It's genetically programmed to invade blood vessels from the very beginning (trophoblasts are designed to invade and find blood vessels).

Front 71

What serum marker may we see with choriocarcinoma?

Back 71

Syncytiotrophoblasts may produce beta-hCG

Front 72

True or false: Patients with a choriocarcinoma have a poor response to chemotherapy.

Back 72

True

Front 73

What is an embryonal carcinoma? What is it composed of?

Back 73

Germ cell tumor. Composed of large primitive cells.

Front 74

An embryonal carcinoma is ________________ (only locally destructive/aggressive with early metastasis).

Back 74

Aggressive with early metastasis.

("Embryonal indicates something very immature and less differentiated and therefore more aggressive. Primitive cells also have the ability to move and spread naturally, that's what they do")

Front 75

Sex-cord stromal tumors are tumors that resemble ___________.

Back 75

the normal sex-cord stroma tissues of ovary

Front 76

What is a granulosa-theca cell tumor? (brief)

Back 76

A sex-cord stromal tumor. It is a neoplasm of granulosa and theca cells.

Front 77

A granulosa-theca cell tumor often produces __________.

Back 77

estrogen

Front 78

How does a granulosa-theca cell tumor present?

Back 78

Presents with signs of estrogen excess (symptoms vary with age). Can present at any age.

Front 79

What is a sertoli-Leydig cell tumor?

Back 79

Tumor that mimics the sex-cord stromal elements of the testicle. Ovaries and testicles have same embryological origin.

Front 80

How would a sertoli-leydig cell tumor look like histologically?

Back 80

(1) Sertoli cells form tubules
(2) Leydig cells contain characteristic Reinke crystals

Front 81

How could a woman with a sertoli-leydig cell tumor present?

Back 81

May produce androgen; associated with hirsutism (hair in a male distribution) or virilization.

Front 82

What is a fibroma?

Back 82

Sex-cord stromal tissue. Benign tumor of fibroblasts.

Front 83

Fibroma is associated with a strange syndrome. Describe.

Back 83

Meig's syndrome in a subset of patients with a fibroma. Shows up as pleural effusion and ascites.

Photo shows fibroma, note the white bands.

Front 84

What is a Kruckenberg tumor?

Back 84

A mucinous carcinoma from some other site that has metastasized to both ovaries. The primary site for such a tumor classically would be from a gastric carcinoma (diffuse subtype). A tumor from breast could cause this as well, e.g. a breast cancer with signet cells such as lobular carcinoma. Another example would be colon cancer.

Front 85

How could we tell whether a tumor that is mucinous is a metastatic mucinous tumor to the ovary or a primary tumor?

Back 85

If it involves one or both of the ovaries.

Front 86

Abundant amount of mucin in the peritoneal cavity is called _____________. What tumor usually can cause this?

Back 86

Pseudomyxoma peritonei ("Gelly belly").

A tumor within the appendix; a mucinous carcinoma of the appendix. Often it will also have metastasized to the ovary.

Front 87

What is ectopic pregnancy?

Back 87

Implantation of a fertilized ovum at a site other than the uterine wall.

Front 88

MC site of ectopic pregnancy?

Back 88

Fallopian tube (lumen)

Front 89

What is a key risk factor for ectopic pregnancy?

Back 89

Scarring
(1) PID
(2) Endometriosis

Front 90

What is this?

Back 90

Ectopic pregnancy (ruptured)

Front 91

Classic presentation of ectopic pregnancy?

Back 91

(1) Lower quadrant pain weeks after missed period

It's a surgical emergency.

Front 92

What should you consider doing when a woman (pregnancy range of age) with severe lower abdominal pain comes in?

Back 92

Pregnancy test (initial test)

Front 93

What is a spontaneous abortion? (brief)

Back 93

Miscarriage of a fetus (foster), usually occurs < 20 weeks of gestation

Front 94

Spontaneous abortion is relatively ________ (rare/common).

Back 94

common

Front 95

How frequently does spontaneous abortions occur?

Back 95

Recognizable in up to 1/4 of all pregnancies

Front 96

How do women with spontaneous abortion present?

Back 96

(1) Vaginal bleeding
(2) Cramp-like pain
(3) Passage of fetal tissue

Front 97

Spontaneous abortion is most often due to what?

Back 97

Chromosomal anomalies.

Front 98

Aside from chromosomal anomalies, what are some causes of spontaneous abortion?

Back 98

(1) Hypercoagulable states (e.g., lupus anticoagulant)
(2) Congenital infection
(3) Exposure to teratogens

Front 99

When you have exposure to a teratogen within the first two weeks of embryogenesis that can result in __________.

Back 99

spontaneous abortion

Front 100

If exposure to a teratogen occurs between weeks 3 to weeks 8 there is a risk of ______________. After that, any time from months 3 to months 9 there is a risk of __________.

Back 100

organ malformation; organ hypoplasia

Front 101

Alcohol as a teratogen is the MC cause of ___________.

Back 101

mental retardation

Front 102

Cocaine as a teratogen can lead to ___________ and __________.

Back 102

Intrauterine growth retardation, placental abruption (constriction)

Front 103

Thalidomide was withdrawn form the market. It was initially helpful for morning sickness in pregnant women. What did it cause?

Back 103

Limb defects

Front 104

What is the significance of cigarette smoke as a teratogen?

Back 104

Intrauterine growth retardation, increases risk for sudden death after birth

Front 105

What is the significance of isotretinoin as a teratogen?

Back 105

Spontaneous abortion, hearing and visual impairment

Front 106

What is the significance of tetracycline as a teratogen?

Back 106

Discolored teeth

Front 107

What is the significance of warfarin as a teratogen?

Back 107

Fetal bleeding

Front 108

What is the significance of phenytoin as a teratogen?

Back 108

Digit hypoplasia, cleft lip and palate

Front 109

What is placenta previa? How does it present?

Back 109

Implantation of previa in the lower uterine segment. Placenta overlies the cervical os. It presents as third trimester bleeding.

("You're getting a _preview_ [previa] of the placenta")

Front 110

Placenta previa often requires what action to be taken? And why?

Back 110

Delivery of fetus by C-section.

Baby can compress the placenta and therefore its blood supply.

Front 111

What is placental abruption? This is a common cause of _________.

Back 111

Placenta abruptly begins to separate from the uterine wall (decidua).

It's a common cause of still birth.

Front 112

Placental abruption presents with [...]?

Back 112

Third trimester bleeding and fetal insufficiency.

Front 113

What is this?

Back 113

Placental abruption. Note the blood and blood clots on the surface.

Front 114

What is placenta accreta?

Back 114

Improper implantation of placenta into myometrium with little or no intervening decidua.

Front 115

How does placenta previa present?

Back 115

Presents with difficulty delivery of the placenta and post-partum bleeding.

Front 116

Placenta accretia often requires _____________.

Back 116

hysterectomy (placenta can't be removed and the mother loses a lot of blood)

Front 117

What is preeclampsia? When does it arise?

Back 117

Pregnancy-induced HTN and proteinuria (with edema). It's a problem with the maternal-fetal vascular interface (kontaktflate) in placenta.

Arises in the third trimester.

Front 118

Preeclampsia is seen in about ____ % of pregnancies.

Back 118

5%

Front 119

How severe is the HTN in preeclampsia? Based on this, what would you expect to see in the vessels of the placenta?

Back 119

Can be severe (almost malignant HTN) where patients get headaches and visual abnormalities.

Fibrinoid necrosis.

Front 120

What is eclampsia?

Back 120

Preeclampsia with seizures

Front 121

Eclampsia mandates what action to be taken?

Back 121

Removal of placenta.

Front 122

Preeclampsia can be part of what syndrome? Describe it.

Back 122

HELLP

H - Hemolysis
EL - Elevated liver enzymes
LP - Low platelets

This is an example of a thrombotic microangiopathy involving the liver.

Front 123

What is sudden infant death syndrome?

Back 123

Death of healthy infant (1 month to 1 year) without cause. Usually during sleep.

Front 124

Risk factors for sudden infant death syndrome?

Back 124

(1) Sleeping on stomach
(2) Smoking in household
(3) Prematurity

Front 125

What is hydatidiform mole?

Back 125

Instead of growing a baby you grow abnormal placental tissue. The villi are swollen and edematous with proliferation of trophoblasts.

Front 126

A pregnant woman is in your office for a checkup early first trimester. On ultrasound you notice that her uterus is abnormally large and you notice a "snowy" appearance on the screen. No fetal heart sounds are heard. Her beta-hCG is higher than expected. What could it be?

Back 126

Hydatidiform mole

Front 127

What is this?

Back 127

Grapelike mass (edematous villi) that a woman with hydatidiform mole can begin to pass, especially is she hasn't received any prenatal care.

Front 128

Hydatidiform mole usually presents when?

Back 128

In early second trimester.

Front 129

After you determine that a woman has a molar pregnancy, what do you have to do?

Back 129

Classify it, they are either complete or partial.

Front 130

What type of hydatidiform mole has the highest risk for progression to cancer? What type of cancer is it?

Back 130

Complete (2-3%); choriocarcinoma

("A complete mole has the 'complete' risk of choriocarcinoma")

Front 131

How does hydatidiform mole occur and how could you remember properties that classify a mole as partial or complete?

Back 131

"It's dads' fault!"

(1) Two sperm enter an empty ovum. All genetic material is from dad (completely from dad). This is a complete mole (46 chrom). There is no fetal tissue in this case. (Complete mole, no baby tissue). All villi are edematous ("Completely edematous"). Trophoblasts proliferate all around the circumference of a villus (completely). Beta-hCG is higher than partial.

Front 132

How does partial hydatidiform mole arise?

Back 132

Two sperm from dad enters an ovum with moms genetic material. Gives 69 chromosomes.

Front 133

What is this?

Back 133

Hydatidiform mole.

Encircled (left): Proliferation of trophoblasts
Encircled (right): Massively dilated villi

Front 134

Treatment of molar pregnancy? Consequence of procedure?

Back 134

Dilatation and curettage. Beta-hCG is monitored to ensure adequate mole removal and to screen for development of choriocarcinoma.

Asherman syndrome.

Front 135

When does a choriocarcinoma classically develop in context of complete mole?

Back 135

Usually within the first year of removal.

Front 136

Choriocarcinoma comes in two "flavors". Elaborate.

Back 136

(1) Gestational pathway
- Could arise as complication of spontaneous abortion
- Normal pregnancy
- Hydatidiform mole

(2) Spontaneous (germ cell pathway)

Front 137

A choriocarcinoma can arise via two pathways. How do the cancers from their respective pathways respond to chemotherapy?

Back 137

(1) Spontaneous one does NOT respond well to treatment
(2) Gestation pathway-cancer responds well to chemotherapy (methotrexate)
- Excellent response, they "melt" away.