Pathology

Front 1

This shows: proliferative endometrium with glandular and stromal break down, fibrin clumps in endometrial stroma, and stromal crumbling "blue balls". What is this characteristic of?
A. anovulatory cycles
B. chronic endometritis
C. chronic endometriosis
D. endometrial carcinoma

Back 1

A. anovulatory cycles

Continuous estrogen secretion unopposed by progesterone release --> thickening of the endometrial lining until it outgrows its blood supply --> endometrial lining breaks down and sheds "out of phase"

Front 2

Endometritis can be acute or chronic. Compare and contrast each with regards to:
A. clinical features
B. gross appearance
C. microscopic appearance

Back 2

Acute endometritis:
A. Clinical features = fevers, chills, pelvic tenderness, leukorrhea
B. Gross = pus filled uterine cavity, hemorrheage, necrosis
C. Micro = polymorphonuclear leukocytes, glands and stroma, hemorrhage and necrosis

Chronic endometritis:
A. Clinical = vague abdominal pain, menometrorrhagia, mucopurulent vaginal discharge
B. Gross = reddened endometrium, pus and blood in uterine cavity
C. Micro = ***PLASMA CELLS **** in the stroma

Front 3

This is localized or diffuse downward growth of basal endometrial glands with stroma into the myometrium.
Clinical feature: pelvic pain, abnormal uterine bleeding
Gross pathology: thickened and spongy myometrium

Back 3

Adenomyosis

Front 4

What are common sites of endometriosis? (5)

Back 4

COMMON:
ovaries
serosal surfaces
fallopian tubes
rectosigmoid
cervix

LESS COMMON:
bladder
surgical scars
vagina
umbilicus

Front 5

Two endometriosis theories mainly exist: describe them both.
A. Metastatic theory
B. Metaplastic theory

Back 5

A. Metastatic theory: reflux through the fallopian tubes, implanted after operative procedures, hematogenous dissemination (can be in brains or lung)
B. Metaplastic theory : proven in labs, but hasn't been seen in real life. Embryology of the Mullerian system tweaked where coelomic layer change from mesothelium --> glandular cell

ALSO CAN BE THOUGHT OF AS THREE THEORIES:
Sampson's/ Retrograde Menstration
Hematogenous/Lymphatic
Coelemic metaplasia

Front 6

On gross pathology, this can look like red-blue "powder burns" in the peritoneum or blood filled "chocolate cysts".
A. Endometritis
B. Endometriosis
C. Adenomyosis
D. Endometrial hyperplasia

Back 6

B. Endometriosis

Front 7

True or False:
Endometriosis can simulate cancer clinically and radiographically.

Back 7

TRUE

Can present as mass lesions or fibrous strictures on rectum, umbilicus, appendix.

Front 8

What is the microscopic criteria for diagnosis of endometriosis?

Back 8

At least 2 of the following:
1) Endometrial glands
2) Stroma
3) Hemosiderin laden macrophages

Clinical signs and symptoms: Infertility, dysmenorrhea, dyspareunia, pelvic pain, rectal bleeding

Front 9

True or False:
Endometrial polyps can possibly (though rarely) be the origin of endometrial carcinoma.

Back 9

True. though rare

Front 10

Endometrial hyperplasia is caused by unopposed prolonged stimulation by what hormone?

Back 10

estrogen!

Endometrial hyperplasia is caused by unopposed stimulation by estrogen.

Front 11

Endometrial hyperplasia can be divided into WHO histologic types of:
- Simple endometrial hyperplasia, without cytologic atypia
- Complex endometrial hyperplasia, without cytologic atypia
- Simple or Complex endometrial hyperplasia WITH atypia

Differentiate between em.

Back 11

Remember, normal = > 50% stroma with glands peppering.
Simple hyperplasia just means stroma is 1/3 or less of volume.
Complex hyperplasia means that glands have been more complex but importantly, they still have endometrial stroma between the glands!! That is the only thing that separates complex hyperplasia from a carcinoma histologically.

Atypia vs no atypia has to do with the nuclei. No atypia means normal, proliferative like cells. They retain normal nuclei. Atypica is rounding of the nuclei, prominent nucleoli, more size and shape variation in cells.

Front 12

Of all the endometrial hyperplasias, complex hyperplasia with atypia is the one with the highest risk for carcinoma. What is the risk?

Back 12

20-50%!

With progesterone treatment alone, disease will persist in 50% of people and will progress to carcinoma in 25%. The progesterone treatment causes endometrial glandular arrest, small inactive glands, no mitotic figures, stromal decidual reaction.

Front 13

How do you treat low risk endometrial hyperplasia or someone who is high risk but is a terrible surgical candidate?

Back 13

Progesterone treatment. That causes endometrial glandular arrest, small inactive glands, no mitotic figures and stromal decidual reaction.

Even with treatment, though, there is persistent disease in 50% with progression to carcinoma in 25%.

Front 14

Endometrial CANCERS come in two types, Type I and Type II. Differentiate the following:
A. Which is estrogen dependent and which is independent?
B. What are the common histologies?
C. What is the patient background for each?
D. What are the molecular alterations associated with each?

Back 14

Front 15

Back to back growth of atypical glands, without intervening normal stroma, with invasion of stroma or myometrium is microscopically characteristic for:
A. endometrioid adenocarcinoma
B. serous carcinoma
C. carcinosarcoma
D. Complex endometrial hypersplasia with atypia

Back 15

A. endometrioid adenocarcinoma

Front 16

Which of the following is FALSE about serous carcinoma?
A. Is very aggressive and can disseminate rapidly thru the peritoneum even without evident myometrial invasion
B. p53 mutation is associated
C. precursor lesion associated is endometrial intraepithelial carcinoma
D. psammoma bodies present
E. All the above are true

Back 16

E. ALL ARE TRUE

A. Is very aggressive and can disseminate rapidly thru the peritoneum even without evident myometrial invasion
B. p53 mutation is associated
C. precursor lesion associated is endometrial intraepithelial carcinoma
D. psammoma bodies (inclusions of calcium) present

Front 17

______ is very aggressive and can disseminate rapidly thru the peritoneum even without evident myometrial invasion. It is associated withp53 mutations and a precursor lesion of endometrial intraepithelial carcinoma.
A. Endometrioid adenocarcinoma
B. clear cell carcinoma
C. serous carcinoma
D. carcinosarcoma / Malignant mixed mullerian tumor MMMT

Back 17

C. serous carcinoma

Also, for this serous carcinoma, psammomma bodies might be present too.

Front 18

What is the precursor lesion associatd with serous carcinomas?

Back 18

Endometrial intraepithelial carcinoma (EIC)

Front 19

What endometrial cancer is described?
- is commonly a polyploid mass that extends thru cervical OS
- grossly, is fleshy, necrotic, hemorrhagic
- microscopically is very undifferentiated

Back 19

Carcinosarcoma
aka Malignant Mixed Mullerian Tumor (MMMT)

Front 20

What tumor of the endometrium is described?
- benign glandular epithelium, but malignant proliferative stroma!
- often in younger patients
- polyploid or leaf-like projections, stromal condensation around glands

Back 20

adenosarcoma ,
a tumor of the endometrium with stromal differentiation /
endometrial stromal sarcoma (?)

Front 21

Fibroids is a misnomer for the tumor of the myometrium that is more correctly named ______________________.

Back 21

Leiomyoma

These are sharply circumscribed, round, firm, gray-white, adn whorled cut surfaces. Can be submucosal, intramural, subserosal, can become pedunculated.

Front 22

Where are the possible locations for a leiomyoma? (4)

Back 22

submucosal, intramural, subserosal, pedunculated

these are sharply circumscribed, round, firm, gray-white, and whorled cut surface tumors of the myometrium.

Note that leiomyosarcomas, malignant versions, are intramural or polypoid in nature and have >50% hematogenosu metastasis to lungs, bone and brain. These have cytologic atypia.

Front 23

Leiomyosarcomas
A. present located in what two general areas
B. display what type of and where to metastasis
C. have microscopic features of what 4 things

Back 23

Leiomyosarcoma
A. are intramural or polypoid tumors
B. hematogenous metastasis >50% to lungs, bones, brain
C. microscopic: infiltrative borders, 10 mitosis per HPF or more, cytologic atypia, tumor necrosis

Front 24

What does "decidualized stroma" refer to?

Back 24

The appearance of the uterine linign under the presence of high levels of progesterone, most often seen during pregnancy but can also be caused by ectopic pregnancies, exogenous hormones (ex. birth control pills), sometimes called pseudodecidulization if caused by extauterine source.

Front 25

Chronic endometritis is characterized by what type of cells?

Back 25

PLASMA CELLS

Front 26

What is the management for
A. simple endometrial hyperplasia and complex hyperplasia without atypia?
B. compex hyperplasia with atypia

Back 26

A. without atypia: cyclic progestins, then resample endometrium after 6 months of therapy
B. with atypia: should be considered premalignant and thus a hysterectomy should be performed OR if fertility is important and or patient is a terrible surgical candidate, then progestin therapy is necessary

Front 27

What is the role of hormone replacement therapy and endometrial hyperplasia?

Back 27

Use of estrogen alone in postmenopausal women increases relative risk of endometrial carcinoma approximately eight times! So, progestins are added to eliminate the risk. Duration and dose is important. HRT can be cyclic or continuous. If cyclic, patient will have cyclic withdrawal bleeds. If continuous, most women will eventually become amenorrheic.

Front 28

What is the MOST reliable method of diagnosis of an endometrial polyp?
A. office endometrial biopsy or D&C alone
B. routine pelvic exam
C. hysteroscopy

Back 28

C. hysteroscopy!!

routine pelvic exam could work IF the polyp has prolapsed thru the cervix

Front 29

What is the primary treatment for endometrial cancer, irrespective of type?

Back 29

surgery!

surgery + radiation in adjuvant setting can be CURATIVE even in advanced stage disease!

Radiation alone can be used in extremely medically compromised patients but cure rates are much lower.

Front 30

What is the result of this?

Back 30

More easily compressed or ruptured placental sac, often leads to preterm labor.

Front 31

This placental membrane is oddly cloudy white. Why? (What condition is this?)

Back 31

ACUTE CHRIOAMNIONITIS. Infection of the fetal membranes! Yields cloudy white membrane (due to inflammatory infiltrates).

Front 32

What condition is depicted? (hint: white area is amnion)

Back 32

Fetal membranes with acute chorioamnionitis.

Front 33

True or False:
This is a product of preeclampsia.

Back 33

TRUE
low uretoplacental blood flow --> infarct in villous (white area is infarct)

Front 34

What is depicted?

Back 34

Classic image of complete mole. CV are dilated and looks like grapes. This is diploid (two sperms and a barr body or empty egg). AND more malignant risk than a partial mole!

Front 35

What is depicted?

Back 35

A complete hydatidiform mole microscopically!What makes a hydatidiform mole is presence of trophoblast proliferation circmuferentially. (Normally should be polarized only.)

Front 36

True or False:
Upon biopsy, one would find trophoblasts and chorionic villi.

Back 36

FALSE.

THis is choriocarcinoma, which is only comprised of trophoblast cells!! If chorionic villi were present, would be a mole!

Front 37

What is depicted?

Back 37

Branching papillary structures lined by squamous epithelium with koilocytic atypia.

Condyloma

Front 38

True or False:
Vaginal adenosis carries a risk of developing into endometriod carcinoma.

Back 38

FALSE.
Vaginal adenosis carries a risk of becoming a clear cell adenocarcinoma!

Front 39

How is this treated?

Back 39

Metronidazole

Trichomonas infection. The organism is a flagellate parasite but the flagella is not
seen in Pap smears. These irregular gray smudgy structures are typical (arrows).
There may be a large number of organisms with little inflammation.

Front 40

What is depicted if this were a pap smear?

Back 40

Herpes infection! Pap smear from the cervix
demonstrating epithelial cells with multiple ground glass appearing nuclei. This nuclear change has been referred as “eggs in a basket” or “seeds in a pomegranate”.

Front 41

What are the two most common types of cervical cancer?
A. adenocarcinoma
B. adenosquamous
C. neuroendocrine
D. squamous cell carcinoma

Back 41

D. squamous cell carcinoma (80%) HSIL is precursor lesion
A. adenocarcinoma (15%) adenocarcinoma in situ is precursor lesion

Front 42

True or False:
Ovarian serous cystadenomas are often unilateral and found in younger women.

Back 42

FALSE! Often bilateral, found in older women!

Front 43

True or False:
Ovarian mucinous cystadenoma is usually unilateral.

Back 43

TRUE

Serous cystadenomas are often bilateral, found in older women.

Front 44

Borderline ovarian tumors (both serous or mucinous) are often associated with
A. p53 mutations
B. KRAS or BRAF mutations
C. PTEN, MSI, beta-catenin mutations

Back 44

B. KRAS or BRAF mutations

p53 are associated with ovarian serous cell carcinomas and endometrial Type II cancers (serous, clear cell, MMTMT)
PTEN, MSI, beta-catenin mutations are associated with endometrial Type I cancer (endometriod)

Front 45

What is the "jelly belly" condition called and what is it commonly caused by?

Back 45

Pseudomyxoma Peritonei

Peritoneal dissemination of bland appearing neoplastic epithelium within abundant mucin

Origin of Ovarian tumor is, in most cases, from metastatic primary mucinous carcinoma of the appendix

Front 46

If told these were primitive neuroepithelium- small hyperchromatic cells arranged in rosettes - what is this a picture of?

Back 46

An immature teratoma! Primitive neuroepithelium is immature fetal tissue.

Front 47

There are two fibroma-associate syndromes. Describe each the components of each:
A. Meig's syndrome
B. Basal cell nevus syndrome

Back 47

Front 48

Call-Exner bodies present!! This must be an ovarian stromal cell tumor, specifically.....

Back 48

ovarian stromal cell tumor..... specifically, a granulosa cell tumor

low grade malignant. solid, cystic, yellow, hemorrhagic

Front 49

What is a Krukenberg Tumor?

Back 49

Mean age 45 yrs
bilateral 80% of cases
Gross
Solid, white to yellow
Gelatinous cut surface – mucin
Micro
Signet cell pattern – typical
primary tumors – stomach most
common with this pattern
Others – breast, bladder, cervix
colon

metastatic dz to the ovaries

Front 50

powder burns are indicative of...

Back 50

endometriosis

Front 51

what is this?

Back 51

Leiomyoma, microscopic. Fascicles of uniform spindle cells
compress adjacent normal myometrium (arrow). Other than
pattern the tumor cells and normal myometrium look the same.

Front 52

Signet cell pattern is found in...
A. Granulosa Cell tumors
B. Krukenberg Tumor
C. Ovarian borderline tumors
D. Thecomas

Back 52

B. Krukenberg Tumor

Granulosa cell tumors have call-exner bodies

Front 53

Call-Exner bodies are found in in...
A. Granulosa Cell tumors
B. Krukenberg Tumor
C. Ovarian borderline tumors
D. Thecomas

Back 53

A. Granulosa Cell tumors