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53 Cards in this Set

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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 endometriosi
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
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"
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"
Endometritis can be acute or chronic. Compare and contrast each with regards to:
A. clinical features
B. gross appearance
C. microscopic appearance
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
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
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
Adenomyosis
What are common sites of endometriosis? (5)
COMMON:
ovaries
serosal surfaces
fallopian tubes
rectosigmoid
cervix

LESS COMMON:
bladder
surgical scars
vagina
umbilicus
Two endometriosis theories mainly exist: describe them both.
A. Metastatic theory
B. Metaplastic theory
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
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
B. Endometriosis
True or False:
Endometriosis can simulate cancer clinically and radiographically.
TRUE

Can present as mass lesions or fibrous strictures on rectum, umbilicus, appendix.
What is the microscopic criteria for diagnosis of endometriosis?
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
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
True or False:
Endometrial polyps can possibly (though rarely) be the origin of endometrial carcinoma.
True. though rare
Endometrial hyperplasia is caused by unopposed prolonged stimulation by what hormone?
estrogen!

Endometrial hyperplasia is caused by unopposed stimulation by estrogen.
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.
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!!
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.
Of all the endometrial hyperplasias, complex hyperplasia with atypia is the one with the highest risk for carcinoma. What is the risk?
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.
How do you treat low risk endometrial hyperplasia or someone who is high risk but is a terrible surgical candidate?
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%.
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 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
A. endometrioid adenocarcinoma
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
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 (
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
______ 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
C. serous carcinoma

Also, for this serous carcinoma, psammomma bodies might be present too.
What is the precursor lesion associatd with serous carcinomas?
Endometrial intraepithelial carcinoma (EIC)
What endometrial cancer is described?
- is commonly a polyploid mass that extends thru cervical OS
- grossly, is fleshy, necrotic, hemorrhagic
- microscopically is very undifferentiated
Carcinosarcoma
aka Malignant Mixed Mullerian Tumor (MMMT)
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
adenosarcoma ,
a tumor of the endometrium with stromal differentiation /
endometrial stromal sarcoma (?)
Fibroids is a misnomer for the tumor of the myometrium that is more correctly named ______________________.
Leiomyoma

These are sharply circumscribed, round, firm, gray-white, adn whorled cut surfaces. Can be submucosal, intramural, subserosal, can become pedunculated.
Where are the possible locations for a leiomyoma? (4)
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 ha
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.
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
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
What does "decidualized stroma" refer to?
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.
Chronic endometritis is characterized by what type of cells?
PLASMA CELLS
What is the management for
A. simple endometrial hyperplasia and complex hyperplasia without atypia?
B. compex hyperplasia with atypia
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
What is the role of hormone replacement therapy and endometrial hyperplasia?
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.
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
C. hysteroscopy!!

routine pelvic exam could work IF the polyp has prolapsed thru the cervix
What is the primary treatment for endometrial cancer, irrespective of type?
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.
What is the result of this?
What is the result of this?
More easily compressed or ruptured placental sac, often leads to preterm labor.
This placental membrane is oddly cloudy white.  Why? (What condition is this?)
This placental membrane is oddly cloudy white. Why? (What condition is this?)
ACUTE CHRIOAMNIONITIS. Infection of the fetal membranes! Yields cloudy white membrane (due to inflammatory infiltrates).
What condition is depicted? (hint: white area is amnion)
What condition is depicted? (hint: white area is amnion)
Fetal membranes with acute chorioamnionitis.
True or False: 
This is a product of preeclampsia.
True or False:
This is a product of preeclampsia.
TRUE
low uretoplacental blood flow --> infarct in villous (white area is infarct)
TRUE
low uretoplacental blood flow --> infarct in villous (white area is infarct)
What is depicted?
What is depicted?
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!
What is depicted?
What is depicted?
A complete hydatidiform mole microscopically!What makes a hydatidiform mole is presence of trophoblast proliferation circmuferentially. (Normally should be polarized only.)
True or False: 
Upon biopsy, one would find trophoblasts and chorionic villi.
True or False:
Upon biopsy, one would find trophoblasts and chorionic villi.
FALSE.

THis is choriocarcinoma, which is only comprised of trophoblast cells!! If chorionic villi were present, would be a mole!
What is depicted?
What is depicted?
Branching papillary structures lined by squamous epithelium with koilocytic atypia.

Condyloma
True or False:
Vaginal adenosis carries a risk of developing into endometriod carcinoma.
FALSE.
Vaginal adenosis carries a risk of becoming a clear cell adenocarcinoma!
How is this treated?
How is this treated?
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.
What is depicted if this were a pap smear?
What is depicted if this were a pap smear?
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”.
What are the two most common types of cervical cancer?
A. adenocarcinoma
B. adenosquamous
C. neuroendocrine
D. squamous cell carcinoma
D. squamous cell carcinoma (80%) HSIL is precursor lesion
A. adenocarcinoma (15%) adenocarcinoma in situ is precursor lesion
True or False:
Ovarian serous cystadenomas are often unilateral and found in younger women.
FALSE! Often bilateral, found in older women!
True or False:
Ovarian mucinous cystadenoma is usually unilateral.
TRUE

Serous cystadenomas are often bilateral, found in older women.
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
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)
What is the "jelly belly" condition called and what is it commonly caused by?
What is the "jelly belly" condition called and what is it commonly caused by?
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
If told these were primitive neuroepithelium- small hyperchromatic cells arranged in rosettes - what is this a picture of?
If told these were primitive neuroepithelium- small hyperchromatic cells arranged in rosettes - what is this a picture of?
An immature teratoma! Primitive neuroepithelium is immature fetal tissue.
There are two fibroma-associate syndromes. Describe each the components of each:
A. Meig's syndrome
B. Basal cell nevus syndrome
Call-Exner bodies present!! This must be an ovarian stromal cell tumor, specifically.....
Call-Exner bodies present!! This must be an ovarian stromal cell tumor, specifically.....
ovarian stromal cell tumor..... specifically, a granulosa cell tumor

low grade malignant. solid, cystic, yellow, hemorrhagic
What is a Krukenberg Tumor?
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
powder burns are indicative of...
powder burns are indicative of...
endometriosis
what is this?
what is this?
Leiomyoma, microscopic. Fascicles of uniform spindle cells
compress adjacent normal myometrium (arrow). Other than
pattern the tumor cells and normal myometrium look the same.
Signet cell pattern is found in...
A. Granulosa Cell tumors
B. Krukenberg Tumor
C. Ovarian borderline tumors
D. Thecomas
B. Krukenberg Tumor

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