Gynae-Pathology 2022 by IHC001

FRCPath Part 1 Course 19/07/2022 Dr Rohit Tewari Consultant Histopathologist Royal Lancaster Infirmary

MCQS

MCQs ⚫ Topic 1 –

Hormone producing ovarian

tumours ⚫ Topic 2 – ⚫ Topic 3 – ⚫ Topic 4 – ⚫ Topic 5 – ⚫ Topic 6 – ⚫ Topic 7 –

CIN and Cervical Ca Uterine spindle cell tumours Trophoblastic lesions Vaginal lesions Embryology Serous borderline tumours

General points ⚫ MCQs ⚫ Direct - First level ⚫ ⚫

History Question about the entity

⚫ Indirect -Second level ⚫ ⚫

History The examiner presumes you know the answer and you are asked further questions

MCQ – Question 1 A 48-year-old woman presented with vaginal bleeding for the past 2 months. An endometrial biopsy is performed and showed endometrial hyperplasia. An abdominal ultrasound reveals a solid right ovarian mass. Which of the following neoplasms is this woman most likely to have? ⚫ ⚫ ⚫ ⚫ ⚫

A -Mature cystic teratoma B -Granulosa cell tumour C -Serous papillary adenocarcinoma D -Mucinous cystadenoma E -Sertoli-Leydig cell tumour

B – Granulosa cell tumour ⚫Fibrothecomas and granulosa cell tumours can be

oestrogen producing. ⚫The excessive oestrogen causes endometrial hyperplasia, which can progress to atypical hyperplasia and carcinoma. ⚫Granulosa cell tumours make up 1-2% of ovarian tumours, but appear over-represented in exams ⚫Considered low grade malignancy

General comments ⚫Hormone-producing tumours of the ovary are

uncommon. ⚫The most common hormonally active sex cordstromal tumours (in decreasing order of frequency) are ⚫ Granulosa cell tumours ⚫ Thecomas ⚫ Sertoli cell tumours ⚫ Sertoli-Leydig cell tumours.

Histology ⚫ Can show variable patterns – macro or

microfollicular, solid, trabecular, insular – “watered silk” ⚫ ‘Coffee bean’ nuclei ⚫ Call-Exner bodies ⚫ Inhibin positive

Specific points – ovarian tumours producing hormones ⚫ Thecomas ⚫ Post menopausal ⚫ Oestrogen-producing ⚫ Bland nuclei and lipid in cytoplasm ⚫ Sertoli-Leydig cell tumours ⚫ Young women ⚫ Most non-functionning ⚫ May secrete androgens – virilization ⚫ Struma ovarii ⚫ Can produce thyroxine but subclinical ⚫ Carcinoid tumours secrete serotonin

MCQ – Question 2 Cervical smear from a 28-year-old woman showed severely dysplastic cells. A biopsy of the cervix showed cervical intraepithelial neoplasia III (CIN III). Infection with which of the following organisms is most likely to cause her disease? ⚫ ⚫ ⚫ ⚫ ⚫

A- Herpes simplex virus infection B- Epstein-Barr virus C- Candida albicans D- Human papillomavirus E- Trichomonas vaginalis

D – Human papilloma virus Almost all cervical neoplasias are associated with high-risk HPV infection ⚫Integration of oncogenic HPVs into host-cell chromosomes is followed by binding of HPV E6 and E7 oncoproteins to tumour-suppressor genes p53 and RB, respectively. ⚫This process results in impaired tumour suppressor gene function. ⚫

General comments ⚫ More than 150 types of HPV exist ⚫ High grade types include 16, 18, 31, 45 and 56 ⚫ Low grade types include 6 and 11 ⚫ Associated with benign lesions e.g. Condylomata ⚫ P16 immunohistochemistry can be used as a marker for

high risk HPV ⚫ (High risk – 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68) ⚫ (Low risk – 6, 11 , 42, 44, 53, 54, 62 and 66)

General comments ⚫ Other risk factors ⚫ Early age at first sexual intercourse ⚫ Multiple sexual partners ⚫ Increased parity ⚫ Male partner with multiple previous partners ⚫ Oral contraceptives and nicotine ⚫ Genital infections (e.g. Chlamydia)

General comments ⚫ Cervical cancer seems to come up a lot ⚫ Screening programme ⚫ High risk viruses ⚫ Prevention of cervical cancer ⚫ Get given cytology diagnosis – what is likely

histology? ⚫ State smear shows koilocytes and mild dyskaryosis ⚫ State smear shows severe dyskaryosis but

significant systemic symptoms of weight loss and anaemia

General comments ⚫ Infections seen on

smears ⚫ Staging of cervical cancer ⚫ Mimics of CGIN

Mimics of CGIN ⚫ Benign ⚫ Tuboendometriod metaplasia – hx of previous LLETZ or cone biopsy ⚫ Endometriosis ⚫ Microglandular hyperplasia ⚫ Mesonephric remnants/hyperplasia ⚫ Malignant ⚫ Endocervical v endometrial adenocarcinoma in canal

⚫ TUBOENDOMETRIOD HYPERPLASIA ⚫ Post LLETZ/cone/bx ⚫ Columnar epithelium, ciliated ⚫ ENDOMETRIOSIS ⚫ 2 of 3 of endometrial glands, spindled stroma, haemorrhage

⚫ MICROGLANDULAR HYPERPLASIA/ADENOSIS ⚫ Usually OCP/Pregnancy related ⚫ Can present with polyp ⚫ Back to back bland glands, flat/cuboidal epithelium ⚫ CD10 -, CEA ⚫ MESONEPHRIC REMNANTS ⚫ Deep in stroma ⚫ Bland glands, not back to back, no atypia, dense eosinophilic secretions ⚫ CD10 +, CEA -

http://www.seapcongresos.com/2011/SEAP/20_mayo_vienes/ 1.1/14.30/Michael_Wells.pdf

Endocervical adenocarcinoma

Endometrial adenocarcinoma

Vimentin

CEA

P16

+ strong and diffuse

+/- patchy

‘SMILE’ ⚫ Stratified mucin producing intraepithelial lesion ⚫ Rare ⚫ From reserve cells of cervix ⚫ Resembles CIN but with mucin production ⚫ Usually associated with CIN or CGIN ⚫ Mucin positive for ⚫ Alcian blue DPAS ⚫ Mucicarmine ⚫ Hale’s Colloidal iron

MCQ – Question 3 A hysterectomy was performed due to menorrhagia. On gross examination a reddish-tan mass was found with a fleshy cut surface. Microscopically the mass was highly cellular, with spindle cells having hyperchromatic nuclei and 10 to 20 mitoses per high power field. Which of the following is the most likely diagnosis? ⚫ ⚫ ⚫ ⚫ ⚫

A -Endometrial polyp B -Endometrial adenocarcinoma C -Adenomyosis D -Leiomyoma E -Leiomyosarcoma

E - Leiomyosarcoma ⚫ Sarcoma arising from smooth muscle cells

of myometrium ⚫ Usually arise de novo and not from prexisting leiomyomas ⚫ Classical history – rapid increase in size of uterine mass in post-menopausal woman ⚫ Macro – pale/yellow/red mass with areas of necrosis

⚫ Most important factors ⚫ Infiltrative growth pattern ⚫ Atypia ⚫

Diffuse or focal

⚫ Tumour necrosis ⚫ Mitoses ⚫ Useful reference:

http://www.uscap.org/site~/98th/pdf/companion12h02.pdf

Other spindle cell tumours ⚫ SMOOTH MUSCLE TUMOURS ⚫ Leiomyoma and variants ⚫ ⚫ ⚫ ⚫

Cellular leiomyoma Mitotically active leiomyoma Leiomyoma with bizarre nuclei Benign metastasizing leiomyoma

⚫ Smooth muscle tumour of uncertain malignant potential

⚫ STROMAL TUMOURS ⚫ Stromal nodule ⚫ Low grade uterine stromal sarcoma ⚫ High grade uterine stromal sarcoma ⚫ MIXED TUMOURS ⚫ Carcinosarcoma ⚫

Postmenopausal, polypoidal, glands and spindle cell components

Endometrial stromal tumours ⚫ Benign ⚫ Stromal nodule ⚫ Malignant ⚫ Low grade endometrial stromal sarcoma ⚫ High grade endometrial stromal sarcoma

⚫ Spindle cell lesions resembling

normal endometrial stroma ⚫ ER, PR, vimentin and CD10 positive ⚫ Desmin negative ⚫ Actin variable

⚫ Prominent spiral arterioles – can have

‘pericytoma’ pattern ⚫ Low grade indolent ⚫ High grade aggressive ⚫ Translocation t(7,17)

MCQ – Question 4 A 31-year-old woman at 14 weeks gestation had vaginal bleeding for 2 weeks. Laboratory studies showed an HCG level of 650,000 U/L. A D&C was performed with evacuation. A month later her vaginal bleeding persisted and her serum betaHCG was 35,000 U/L. Which of the following pathologic abnormalities is most likely to be present in this woman? ⚫ A -Endometriosis ⚫ B -Endometritis ⚫ C -Invasive mole ⚫ D -Tubal ectopic pregnancy ⚫ E -Placental site trophoblastic tumor

C – Invasive mole ⚫ Failure of HCG to reduce to near negative following

D&C suggests residual gestational trophoblastic disease

General comments ⚫ Management ⚫ Blood HCG every 2 weeks until normal then urine HCG monthly for 6/12 ⚫ Risk of persistent disease about 15% in

complete moles and 0.5% in partial moles ⚫ Persistent trophoblastic disease ⚫ HCG>20,000u/L 4/52 post evacuation ⚫ Metastases or haemorrhage ⚫ Rising HCG

General comments ⚫ Classification of trophoblastic disease ⚫ Hydatidiform mole (partial, complete, invasive) ⚫ Choriocarcinoma ⚫ Epithelioid trophoblastic tumour ⚫ Placental site trophoblastic tumour ⚫ Placental site nodule

Complete moles ⚫ Abnormal gametogenesis and

fertilization resulting in diploid genome of paternal origin only ⚫ No foetus (no foetal red blood cells) ⚫ Macro – vesicles ⚫ Micro – diffuse trophoblastic proliferation of large villi with central cisterns and karyorrhexic debris ⚫ P57 negative

Partial moles ⚫ Usually triploid

or tetraploid ⚫ Macro – Can see vesicles but normal tissue too ⚫ Micro – Variably sized villi with more focal trophoblast proliferation, scalloping and inclusions ⚫ Foetal red blood cells ⚫ P57 focally positive

Choriocarcinoma ⚫ 50% previous molar pregnancy, 25% previous abortion,

25% previous normal pregnancy ⚫ Risk if complete mole approx 1:40 ⚫ Cytotrophoblast and syncytiotrophoblast ⚫ Marked haemorrhagic necrosis ⚫ High mitoses ⚫ Diffusely positive for hBCG

Epithelioid trophoblastic tumour ⚫ Young-middle aged women ⚫ Present with PV bleeding or lung mets ⚫ Elevated bHCG ⚫ Hx molar pregnancy or choriocarcinoma ⚫ Pushing borders ⚫ Epithelioid cells resembling carcinoma or

intermediate trophoblast ⚫ Cells have distinct borders and eosinophilic cytoplasm

MCQ – Question 5 A small cystic slightly tender mass found in the right lateral wall of the vagina of a 30 year old woman. On microscopic examination the cyst was lined by cuboidal epithelium. Which of the following is the most likely aetiology for this lesion? ⚫ ⚫ ⚫ ⚫ ⚫

A -Diethylstilbestrol exposure B -Gartner duct cyst C -Foreign body reaction D -Metastatic adenocarcinoma E -Oral contraceptive use

B – Gartner duct cyst ⚫ Gartner duct cysts are remnants of

mesonephric ducts ⚫ Usually upper anterolateral vagina ⚫ 1-2% population

MCQ – Question 6 ⚫ A 40 year old woman presented with a solid ovarian tumour.

Histologically the tumour showed nests of transitional-like epithelium separated by fibrous stroma. The cells have grooved nuclei. Which of the following is the tissue of origin of this tumour? ⚫ A - Germ cells ⚫ B - Stromal cells ⚫ C - Surface epithelium ⚫ D - Urothelium ⚫ E - Walthard nests

C – Surface epithelium ⚫ Actually, histological origin of Brenners tumours is

unclear ⚫ Probably from surface epithelium ⚫ Get to the correct answer by ruling all the others out

General comments ⚫ Generally agreed serous ovarian neoplasms

arise from surface epithelium of ovary ⚫ Most endometriod and clear cell neoplasms probably arise from endometriosis

⚫Despite general agreement that most mucinous

neoplasms arise from the ovarian surface epithelium, it is uncommon to find a mucinous epithelial inclusion or mucinous metaplasia in an inclusion in an otherwise normal ovary.

MCQ – Question 7 ⚫ A 47 year old woman had a pelvic ultrasound scan

that reveals the presence of a left ovarian cyst, 10cm in diameter. She had a moderately raised level of the tumour marker CA125. A CT scan confirms the presence of the ovarian cyst but does not show any other lesion. A laparotomy is performed and a hystero-salpingo-oophrectomy is carried out, together with omentectomy and peritoneal washing. Histopathological examination of the cyst shows what appears to be a borderline ovarian tumour of serous type.

MCQ – Question 7 contd ⚫ ...However, the omentum shows Psammoma bodies

and small serous epithelial structures on the surface and embedded within the fat, the latter haphazardly arranged and surrounded by granulation tissue and an inflammatory infiltrate. Peritoneal washings contain papillary fragments of bland serous epithelium. ⚫ (Reference:

www.rcpath.org)

MCQ – Question 7 contd ⚫ Identify the correct designation of this tumour. ⚫ A Borderline ovarian tumour of serous type with

endosalpingiosis ⚫ B Borderline ovarian tumour of serous type with non-invasive desmoplastic implants ⚫ C Primary peritoneal adenocarcinoma of serous type with synchronous ovarian borderline tumour ⚫ D Stage 1 serous cystadenocarcinoma of ovary with benign serous implants ⚫ E Stage 3 serous cystadenocarcinoma of ovary with peritoneal spread

B – Borderline ovarian tumour of serous type with non-invasive desmoplastic implants ⚫ Benign/borderline/malignant diagnosis made on

primary tumour

General points ⚫ Very long question – from the RCPath website! ⚫ Datasets very popular for MCQs ⚫ Serous borderline tumour also very popular

for questions

MCQ – Question 7a ⚫ A 36 year old lady is found to have a large left sided

ovarian mass. She undergoes staging surgery and you receive an intact cysts with multiple papillary excresences to the internal surface. On microscopy, you diagnose a serous borderline tumour. ⚫ Identify the most important prognostic factor ⚫ A: Psammoma bodies ⚫ B: Papillary architecture ⚫ C: Cytological atypia ⚫ D: Invasive implants ⚫ E: Microinvasion

D – Invasive implants ⚫ Microinvasion doesn’t alter prognosis compared

with serous borderline tumours without invasion ⚫ Invasive implants associated with increased risk of recurrence

EMQs

EMQ – Question 1: Vagina and cervix 1. Extramammary Paget’s disease

A. Closely packed cystically dilated endocervical glands

2. Vaginal adenosis

B. Clusters of malignant cells within the epidermis and appendages

3. Microglandular hyperplasia

C. Glandular epithelium replacing the native squamous epithelium of vaginal the mucosa

4. Tunnel clusters

D. Occurs secondary to contraceptive use

5. Mesonephric remnants

E. Small clusters of tubules and glands usually at the lateral aspect of the cervix

EMQ – Question 1 1. Extramammary Paget’s disease

A. Closely packed cystically dilated endocervical glands

2. Vaginal adenosis

B. Clusters of malignant cells within the epidermis and appendages

3. Microglandular hyperplasia

C. Glandular epithelium replacing the native squamous epithelium of the vaginal mucosa

4. Tunnel clusters

D. Occurs secondary to contraceptive use

5. Mesonephric remnants

E. Small clusters of tubules and glands usually at the lateral aspect of the cervix

EMQ – Question 1 1. Extramammary Paget’s disease

A. Closely packed cystically dilated endocervical glands

2. Vaginal adenosis

B. Clusters of malignant cells within the epidermis and appendages

3. Microglandular hyperplasia

C. Glandular epithelium replacing the native squamous epithelium of the vaginal mucosa

4. Tunnel clusters

D. Occurs secondary to contraceptive use

5. Mesonephric remnants

E. Small clusters of tubules and glands usually at the lateral aspect of the cervix

EMQ – Question 1 1. Extramammary Paget’s disease

A. Closely packed cystically dilated endocervical glands

2. Vaginal adenosis

B. Clusters of malignant cells within the epidermis and appendages

3. Microglandular hyperplasia

C. Glandular epithelium replacing the native squamous epithelium of the vaginal mucosa

4. Tunnel clusters

D. Occurs secondary to contraceptive use

5. Mesonephric remnants

E. Small clusters of tubules and glands usually at the lateral aspect of the cervix

⚫ Extramammary Paget’s disease ⚫ In-situ carcinoma of apocrine glands ⚫ CAM5.2, CK7, GCDFP15 positive ⚫ CK20 negative ⚫ DD ⚫ ⚫

Melanoma Squamous cell carcinoma in situ

⚫ Exclude internal malignancy ⚫

25% associated with internal malignancy

EMQ – Question 1 1. Extramammary Paget’s disease

A. Closely packed cystically dilated endocervical glands

2. Vaginal adenosis

B. Clusters of malignant cells within the epidermis and appendages

3. Microglandular hyperplasia

C. Glandular epithelium replacing the native squamous epithelium of the vaginal mucosa

4. Tunnel clusters

D. Occurs secondary to contraceptive use

5. Mesonephric remnants

E. Small clusters of tubules and glands usually at the lateral aspect of the cervix

EMQ – Question 1 1. Extramammary Paget’s disease

A. Closely packed cystically dilated endocervical glands

2. Vaginal adenosis

B. Clusters of malignant cells within the epidermis and appendages

3. Microglandular hyperplasia

C. Glandular epithelium replacing the native squamous epithelium of the vaginal mucosa

4. Tunnel clusters

D. Occurs secondary to contraceptive use

5. Mesonephric remnants

E. Small clusters of tubules and glands usually at the lateral aspect of the cervix

Vaginal adenosis ⚫ Benign endocervical or endometrial glands within

the vaginal wall ⚫ 2/3 related to diethylstilboestrol exposure in utero ⚫ Persistant Mullerian columnar epithelium which DES

prevents from being replaced by urogenital squamous epithelium in utero

⚫ 1/3 no hx of DES exposure ⚫ Hx 5FU Rx for condylomata ⚫ Hx trauma e.g. episiotomy ⚫ Can be associated with clear cell carcinoma

EMQ – Question 1 1. Extramammary Paget’s disease

A. Closely packed cystically dilated endocervical glands

2. Vaginal adenosis

B. Clusters of malignant cells within the epidermis and appendages

3. Microglandular hyperplasia

C. Glandular epithelium replacing the native squamous epithelium of the mucosa

4. Tunnel clusters

D. Occurs secondary to contraceptive use

5. Mesonephric remnants

E. Small clusters of tubules and glands usually at the lateral aspect of the cervix

EMQ – Question 1 1. Extramammary Paget’s disease

A. Closely packed cystically dilated endocervical glands

2. Vaginal adenosis

B. Clusters of malignant cells within the epidermis and appendages

3. Microglandular hyperplasia

C. Glandular epithelium replacing the native squamous epithelium of the vaginal mucosa

4. Tunnel clusters

D. Occurs secondary to contraceptive use

5. Mesonephric remnants

E. Small clusters of tubules and glands usually at the lateral aspect of the cervix

EMQ – Question 1 1. Extramammary Paget’s disease

A. Closely packed cystically dilated endocervical glands

2. Vaginal adenosis

B. Clusters of malignant cells within the epidermis and appendages

3. Microglandular hyperplasia

C. Glandular epithelium replacing the native squamous epithelium of the vaginal mucosa

4. Tunnel clusters

D. Occurs secondary to contraceptive use

5. Mesonephric remnants

E. Small clusters of tubules and glands usually at the lateral aspect of the cervix

EMQ – Question 1 1. Extramammary Paget’s disease

A. Closely packed cystically dilated endocervical glands

2. Vaginal adenosis

B. Clusters of malignant cells within the epidermis and appendages

3. Microglandular hyperplasia

C. Glandular epithelium replacing the native squamous epithelium of the mucosa

4. Tunnel clusters

D. Occurs secondary to contraceptive use

5. Mesonephric remnants

E. Small clusters of tubules and glands usually at the lateral aspect of the cervix

EMQ – Question 2: Random 1.

Sertoli-Leydig cell tumour

A. Can be oestrogen producing

Fibrothecoma

B. Can produce virilizing symptoms

3. Gartner duct cysts

C. Found in anterolateral vaginal wall

4. Ovarian serous adenocarcinoma

D. The cells make human placental lactogen

5. Placental site trophoblastic tumour

E. Psammoma body formation is common

EMQ – Question 2 1.

Sertoli-Leydig cell tumour

A. Can be oestrogen producing

Fibrothecoma

B. Can produce virilizing symptoms

3. Gartner duct cysts

C. Found in anterolateral vaginal wall

4. Ovarian serous adenocarcinoma

D. The cells make human placental lactogen

5. Placental site trophoblastic tumour

E. Psammoma body formation is common

EMQ – Question 2 1.

Sertoli-Leydig cell tumour

A. Can be oestrogen producing

Fibrothecoma

B. Can produce virilizing symptoms

3. Gartner duct cysts

C. Found in anterolateral vaginal wall

4. Ovarian serous adenocarcinoma

D. The cells make human placental lactogen

5. Placental site trophoblastic tumour

E. Psammoma body formation is common

EMQ – Question 2 1.

Sertoli-Leydig cell tumour

A. Can be oestrogen producing

Fibrothecoma

B. Can produce virilizing symptoms

3. Gartner duct cysts

C. Found in anterolateral vaginal wall

4. Ovarian serous adenocarcinoma

D. The cells make human placental lactogen

5. Placental site trophoblastic tumour

E. Psammoma body formation is common

EMQ – Question 2 1.

Sertoli-Leydig cell tumour

A. Can be oestrogen producing

Fibrothecoma

B. Can produce virilizing symptoms

3. Gartner duct cysts

C. Found in anterolateral vaginal wall

4. Ovarian serous adenocarcinoma

D. The cells make human placental lactogen

5. Placental site trophoblastic tumour

E. Psammoma body formation is common

EMQ – Question 2 1.

Sertoli-Leydig cell tumour

A. Can be oestrogen producing

Fibrothecoma

B. Can produce virilizing symptoms

3. Gartner duct cysts

C. Found in anterolateral vaginal wall

4. Ovarian serous adenocarcinoma

D. The cells make human placental lactogen

5. Placental site trophoblastic tumour

E. Psammoma body formation is common

EMQ – Question 3: Random 1. Gliomatosis peritonei

A. Benign glands lined by tubal type epithelium in the peritoneum

B. Benign tumour of mesothelial origin

Endosalpingiosis

3. Walthard nests

C. Results from peritoneal dissemination of mature teratoma

4. Struma ovarii

D. Nests formed by transitional epithelium

5. Adenomatoid tumour

E. Predominently mature thyroid tissue

EMQ – Question 3 1. Gliomatosis peritonei

A. Benign glands lined by tubal type epithelium in the peritoneum

B. Benign tumour of mesothelial origin

Endosalpingiosis

3. Walthard nests

C. Results from peritoneal dissemination of mature teratoma

4. Struma ovarii

D. Nests formed by transitional epithelium

5. Adenomatoid tumour

E. Predominently mature thyroid tissue

EMQ – Question 3: Random 1. Gliomatosis peritonei

A. Benign glands lined by tubal type epithelium in the peritoneum

B. Benign tumour of mesothelial origin

Endosalpingiosis

3. Walthard nests

C. Results from peritoneal dissemination of mature teratoma

4. Struma ovarii

D. Nests formed by transitional epithelium

5. Adenomatoid tumour

E. Predominently mature thyroid tissue

EMQ – Question 3 1. Gliomatosis peritonei

A. Benign glands lined by tubal type epithelium in the peritoneum

B. Benign tumour of mesothelial origin

Endosalpingiosis

3. Walthard nests

C. Results from peritoneal dissemination of mature teratoma

4. Struma ovarii

D. Nests formed by transitional epithelium

5. Adenomatoid tumour

E. Predominently mature thyroid tissue

Adenomatoid tumours ⚫ Usually uterus/Fallopian tubes ⚫ Can get similar in male genital tract ⚫ Derived from mesothelial cells ⚫ Macroscopically looks like a fibroid ⚫ Microscopically ‘pseudoglandular’ cystic spaces ⚫ Positive for mesothelial cell markers

EMQ – Question 3: Random 1. Gliomatosis peritonei

A. Benign glands lined by tubal type epithelium in the peritoneum

B. Benign tumour of mesothelial origin

Endosalpingiosis

3. Walthard nests

C. Results from peritoneal dissemination of mature teratoma

4. Struma ovarii

D. Nests formed by transitional epithelium

5. Adenomatoid tumour

E. Predominently mature thyroid tissue

EMQ – Question 3 1. Gliomatosis peritonei

A. Benign glands lined by tubal type epithelium in the peritoneum

B. Benign tumour of mesothelial origin

Endosalpingiosis

3. Walthard nests

C. Results from peritoneal dissemination of mature teratoma

4. Struma ovarii

D. Nests formed by transitional epithelium

5. Adenomatoid tumour

E. Predominently mature thyroid tissue

EMQ – Question 3: Random 1. Gliomatosis peritonei

A. Benign glands lined by tubal type epithelium in the peritoneum

B. Benign tumour of mesothelial origin

Endosalpingiosis

3. Walthard nests

C. Results from peritoneal dissemination of mature teratoma

4. Struma ovarii

D. Nests formed by transitional epithelium

5. Adenomatoid tumour

E. Predominently mature thyroid tissue

EMQ – Question 3 1. Gliomatosis peritoneii

A. Benign glands lined by tubal type epithelium in the peritoneum

B. Benign tumour of mesothelial origin

Endosalpingiosis

3. Walthard nests

C. Results from peritoneal dissemination of mature teratoma

4. Struma ovarii

D. Nests formed by transitional epithelium

5. Adenomatoid tumour

E. Predominently mature thyroid tissue

EMQ – Question 3: Random 1. Gliomatosis peritonei

A. Benign glands lined by tubal type epithelium in the peritoneum

B. Benign tumour of mesothelial origin

Endosalpingiosis

3. Walthard nests

C. Results from peritoneal dissemination of mature teratoma

4. Struma ovarii

D. Nests formed by transitional epithelium

5. Adenomatoid tumour

E. Predominently mature thyroid tissue

EMQ – Question 3 1. Gliomatosis peritoneii

A. Benign glands lined by tubal type epithelium in the peritoneum

B. Benign tumour of mesothelial origin

Endosalpingiosis

3. Walthard nests

C. Results from peritoneal dissemination of mature teratoma

4. Struma ovarii

D. Nests formed by transitional epithelium

5. Adenomatoid tumour

E. Predominently mature thyroid tissue

EMQ – Question 4: 1. Mucinous borderline tumour A. Shows complex Triggers of the ovary architecture with fusion of atypical glands, solid areas and neutrophilic infiltration 2. Endometrioid adenocarcinoma

B. Shows cytological atypia and proliferation without stromal invasion

3. Non-invasive desmoplastic peritoneal implants

C. Sharply demarcated foci of atypical epithelium and granulation tissue with occasional single cells in the stroma

4. Krukenberg tumour

D. Signet ring carcinoma with a cellular stromal reaction

5. Granulosa cell tumour

E. Typically shows Call-Exner bodies

EMQ – Question 4 1. Mucinous borderline tumour A. Shows complex of the ovary architecture with fusion of atypical glands, solid areas and neutrophilic infiltration 2. Endometrioid adenocarcinoma

B. Shows cytological atypia and proliferation without stromal invasion

3. Non-invasive desmoplastic peritoneal implants

C. Sharply demarcated foci of atypical epithelium and granulation tissue with occasional single cells in the stroma

4. Krukenberg tumour

D. Signet ring carcinoma with a cellular stromal reaction

5. Granulosa cell tumour

E. Typically shows Call-Exner bodies

EMQ – Question 4 1. Mucinous borderline tumour A. Shows complex of the ovary architecture with fusion of atypical glands, solid areas and neutrophilic infiltration 2. Endometrioid adenocarcinoma

B. Shows cytological atypia and proliferation without stromal invasion

3. Non-invasive desmoplastic peritoneal implants

C. Sharply demarcated foci of atypical epithelium and granulation tissue with occasional single cells in the stroma

4. Krukenberg tumour

D. Signet ring carcinoma with a cellular stromal reaction

5. Granulosa cell tumour

E. Typically shows Call-Exner bodies

EMQ – Question 4 1. Mucinous borderline tumour A. Shows complex of the ovary architecture with fusion of atypical glands, solid areas and neutrophilic infiltration 2. Endometrioid adenocarcinoma

B. Shows cytological atypia and proliferation without stromal invasion

3. Non-invasive desmoplastic peritoneal implants

C. Sharply demarcated foci of atypical epithelium and granulation tissue with occasional single cells in the stroma

4. Krukenberg tumour

D. Signet ring carcinoma with a cellular stromal reaction

5. Granulosa cell tumour

E. Typically shows Call-Exner bodies

EMQ – Question 4: Ovarian tumours 1. Mucinous borderline tumour A. Shows complex of the ovary architecture with fusion of atypical glands, solid areas and neutrophilic infiltration 2. Endometrioid adenocarcinoma

B. Shows cytological atypia and proliferation without stromal invasion

3. Non-invasive desmoplastic peritoneal implants

C. Sharply demarcated foci of atypical epithelium and granulation tissue with occasional single cells in the stroma

4. Krukenberg tumour

D. Signet ring carcinoma with a cellular stromal reaction

5. Granulosa cell tumour

E. Typically shows Call-Exner bodies

EMQ – Question 4 1. Mucinous borderline tumour A. Shows complex of the ovary architecture with fusion of atypical glands, solid areas and neutrophilic infiltration 2. Endometrioid adenocarcinoma

B. Shows cytological atypia and proliferation without stromal invasion

3. Non-invasive desmoplastic peritoneal implants

C. Sharply demarcated foci of atypical epithelium and granulation tissue with occasional single cells in the stroma

4. Krukenberg tumour

D. Signet ring carcinoma with a cellular stromal reaction

5. Granulosa cell tumour

E. Typically shows Call-Exner bodies

Peritoneal Implants ⚫ Bit of a nightmare……. ⚫ (Good ref: http://www.uic.edu/depts/mcpt/anatomic) ⚫ Non-invasive Epithelial Implants ⚫ Well-defined nests and/or papillary structures surrounded by

reactive mesothelium. ⚫ Mild to moderate cytologic atypia consistent with that seen in a borderline tumor. ⚫ No associated stromal proliferation

⚫ Non-invasive Implants - Desmoplastic Type ⚫ Implants lie on peritoneal surfaces without evidence of infiltration of the underlying tissue ⚫ The epithelial component appears as irregular glands, papillae or single cells ⚫ Surrounding stroma is desmoplastic, fibroblastic or granulation tissue-like ⚫ Mild to moderate atypia only

⚫ Invasive Implants ⚫ Destruction and replacement of the lobular architecture of the adipose tissue by irregular nests of serous epithelium. ⚫ The epithelial proliferation is seen as irregular glands, papillary formations or single cells ⚫ Frequently show nuclear features of malignancy

B. Shows cytological atypia and proliferation without stromal invasion

3. Non-invasive desmoplastic peritoneal implants

C. Sharply demarcated foci of atypical epithelium and grnaulation tissue with occasional single cells in the stroma

4. Krukenberg tumour

D. Signet ring carcinoma with a cellular stromal reaction

5. Granulosa cell tumour

E. Typically shows Call-Exner bodies

EMQ – Question 4 1. Mucinous borderline tumour A. Shows complex of the ovary architecture with fusion of atypical glands, solid areas and neutrophilic infiltration 2. Endometrioid adenocarcinoma

B. Shows cytological atypia and proliferation without stromal invasion

3. Non-invasive desmoplastic peritoneal implants

C. Sharply demarcated foci of atypical epithelium and granulation tissue with occasional single cells in the stroma

4. Krukenberg tumour

D. Signet ring carcinoma with a cellular stromal reaction

5. Granulosa cell tumour

E. Typically shows Call-Exner bodies

B. Shows cytological atypia and proliferation without stromal invasion

3. Non-invasive desmoplastic peritoneal implants

C. Sharply demarcated foci of atypical epithelium and grnaulation tissue with occasional single cells in the stroma

4. Krukenberg tumour

D. Signet ring carcinoma with a cellular stromal reaction

5. Granulosa cell tumour

E. Typically shows Call-Exner bodies

EMQ – Question 4 1. Mucinous borderline tumour A. Shows complex of the ovary architecture with fusion of atypical glands, solid areas and neutrophilic infiltration 2. Endometrioid adenocarcinoma

B. Shows cytological atypia and proliferation without stromal invasion

3. Non-invasive desmoplastic peritoneal implants

C. Sharply demarcated foci of atypical epithelium and grnaulation tissue with occasional single cells in the stroma

4. Krukenberg tumous

D. Signet ring carcinoma with a cellular stromal reaction

5. Granulosa cell tumour

E. Typically shows Call-Exner bodies

Other Gynae Topics ⚫ Insignificant/incidental lesions ⚫ Microglandular hyperplasia/adenosis of cervix ⚫

“Regular rounded glands, no atypia, CEA negative”

⚫ Walthards nests ⚫ Rete ovarii ⚫

“Hilum of ovary shoes aggregates of glands lined by bland non-ciliated epithelium”

⚫ Mesonephric remnants ⚫

“Round glands, deep cervical stroma, easinophilic secretions, CD10 positive”

Other Gynae topics ⚫ Adenomyosis v adenomatoid tumour

v angioleiomyoma ⚫ Adenomyosis ⚫ Presence of endometrial tissue in the

uterine wall ⚫ Remains in continuity with the endometrium ⚫ Irregular nests of endometrial stroma, with or without glands, within myometrium ⚫ Under hormonal control – results in haemorrhage and dysmeorrhoea

Other Gynae topics ⚫ Datasets ⚫ Especially staging and grading of endometrioid tumours ⚫ “How may blocks from 16cm ovarian mass” ⚫ Endometrioid endometrial adenocarcinoma risk

factors ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ ⚫

Age Obesity Diabetes Hypertension Nulliparity Oestrogen excess Atypical hyperplasia

Other Gynae topics ⚫ Endometrial metaplasias ⚫ Tend to be due to hormonal manipulation ⚫ Squamous ⚫ Occurs in normal or hyperplastic endometrium, polyps and leiomyomas; also as part

of malignant processes ⚫ Usually diffuse (adenoacanthosis) or in morules (rounded aggregates of bland cells with indistinct cytoplasmic borders) ⚫ Usually in pre-menopausal women with exogenous hormones

⚫ Papillary proliferation/change ⚫ Rare; postmenopausal ⚫ Probably similar to papillary syncytial change

⚫ Tubal ⚫ Markedly increased ciliated cells; resembles fallopian tube ⚫ Often seen with endometrial hyperplasia and other hyperestrogenic states ⚫ Presence of atypia does not affect prognosis

⚫ Mucinous ⚫ Resembles endocervical glands ⚫ Associated with hyperoestrogenic states ⚫ Multifocal ⚫ Mucin associated with neutrophils ⚫ Can produce mucometria

⚫ Easinophilic (oxyphilic) ⚫ Oestrogen related ⚫ Resembles atypical hyperplasia but no atypia ⚫ MUC5A+

⚫ Hobnail/clear cell ⚫

Tall cells, apical nuclei, clear cystoplasm, no atypia ⚫ DD Clear cell carcinoma ⚫ Intestinal metaplasia ⚫ Rare; CK20 and CDX2 positive

⚫ Stromal ⚫ Formation of smooth muscle, cartlidge and bone

Infections ⚫ Follicular cervicitis – Chlamydia ⚫ Strawberry cervix – Trichomonas ⚫ Diabetic, pruritic white lesions – Candida ⚫ CIN – HPV ⚫ Papules followed by ulceration vulva – HSV

Extra questions A: B:

t(14,18)(q32,q31) hMLH

G: H:

BRCA1 Alk1

C: D: E: F:

t(11,22)(q24,q12) APC KVLQT1 PiZZ

I: J: K: L:

cKIT Rb WT1 NF1

1. 2. 3. 4. 5.

Follicular lymphoma Alpha -1-antitrypsin HNPCC Osteosarcoma Ovarian carcinoma

Extra questions A: B:

t(14,18)(q32,q31) hMLH

G: H:

BRCA1 Alk1

C: D: E: F:

t(11,22)(q24,q12) APC KVLQT1 PiZZ

I: J: K: L:

cKIT Rb WT1 NF1

1. 2. 3. 4. 5.

Follicular lymphoma Alpha -1-antitrypsin HNPCC Osteosarcoma Ovarian carcinoma

A F B J

Extra questions A: B: C:

t(14,18)(q32,q31) hMLH t(11,22)(q24,q12)

Follicular lymphoma HNPCC

D: E: F: G: H: I: J: K: L:

APC KVLQT1 PiZZ BRCA1 Alk1 cKIT Rb WT1 NF1

FAP Romano-Ward (Long QT) Alpha-1-antitrypsin Breast/ovary carcinoma

Ewing’s sarcoma

Hereditary haemorrhagic teleangiectasia

GIST Osteosarcoma Wilms tumour Neurofibroma

Extra questions A: B:

CIN1 CIN3

G: H:

LGCGIN HPV

C: D: E: F:

Endometriosis SqCCa Tubal metaplasia HGCGIN

I: J: K: L:

Invasive adenoca Radiation atypia Endocervicosis Condyloma acuminatum

Relate histology/cytologys below to the most fitting pathology above.

1. Smear containing clusters of cells with low grade dysplasia

Extra questions A: B:

CIN1 CIN3

G: H:

LGCGIN HPV

C: D: E: F:

Endometriosis SqCCa Tubal metaplasia HGCGIN

I: J: K: L:

Invasive adenoca Radiation atypia Endocervicosis Condyloma acuminatum

Relate histology/cytologys below to the most fitting pathology above.

Smear containing clusters of cells with low grade dysplasia Answer: A

Extra questions A: B:

CIN1 CIN3

G: H:

LGCGIN HPV

C: D: E: F:

Endometriosis SqCCa Tubal metaplasia HGCGIN

I: J: K: L:

Invasive adenoca Radiation atypia Endocervicosis Condyloma acuminatum

Relate histology/cytology below to the most fitting pathology above.

Smear with background neutrophils and debris with sparse elongate atypical orangeophilic cells.

Extra questions A: B:

CIN1 CIN3

G: H:

LGCGIN HPV

C: D: E: F:

Endometriosis SqCCa Tubal metaplasia HGCGIN

I: J: K: L:

Invasive adenoca Radiation atypia Endocervicosis Condyloma acuminatum

Relate histology/cytologys below to the most fitting pathology above.

Smear with background neutrophils and debris with sparse elongate atypical orangeophilic cells. Answer: D

Extra questions A: B:

CIN1 CIN3

G: H:

LGCGIN HPV

C: D: E: F:

Endometriosis SqCCa Tubal metaplasia HGCGIN

I: J: K: L:

Invasive adenoca Radiation atypia Endocervicosis Condyloma acuminatum

Relate histology/cytologys below to the most fitting pathology above.

3. Core biopsy containing an exophytic squamous lesion with clear paranuclear haloes, binucleate nuclei and keratinised cells.

Extra questions A: B:

CIN1 CIN3

G: H:

LGCGIN HPV

C: D: E: F:

Endometriosis SqCCa Tubal metaplasia HGCGIN

I: J: K: L:

Invasive adenoca Radiation atypia Endocervicosis Condyloma acuminatum

Relate histology/cytologys below to the most fitting pathology above.

Core biopsy containing an exophytic squamous lesion with clear paranuclear haloes, binucleate nuclei and keratinised cells. Answer: L

Extra questions A: B:

CIN1 CIN3

G: H:

LGCGIN HPV

C: D: E: F:

Endometriosis SqCCa Tubal metaplasia HGCGIN

I: J: K: L:

Invasive adenoca Radiation atypia Endocervicosis Condyloma acuminatum

Relate histology/cytologys below to the most fitting pathology above.

4. Cone biopsy containing non-invasive glandular lesion with hyperchromatic stratified nuclei, abnormal mitoses and intestinal metaplasia.

Extra questions A: B:

CIN1 CIN3

G: H:

LGCGIN HPV

C: D: E: F:

Endometriosis SqCCa Tubal metaplasia HGCGIN

I: J: K: L:

Invasive adenoca Radiation atypia Endocervicosis Condyloma acuminatum

Relate histology/cytologys below to the most fitting pathology above.

Cone biopsy containing non-invasive cells with hyperchromatic stratified nuclei, abnormal mitoses and intestinal metaplasia. Answer: F

Extra questions A: B:

CIN1 CIN3

G: H:

LGCGIN HPV

C: D: E: F:

Endometriosis SqCCa Tubal metaplasia HGCGIN

I: J: K: L:

Invasive adenoca Radiation atypia Endocervicosis Condyloma acuminatum

Relate histology/cytologys below to the most fitting pathology above.

5. Peritoneal biopsy containing glands with columnar epithelium, oval nuclei and no nucleoli. Associated stroma and brown pigment are seen.

Extra questions A: B:

CIN1 CIN3

G: H:

LGCGIN HPV

C: D: E: F:

Endometriosis SqCCa Tubal metaplasia HGCGIN

I: J: K: L:

Invasive adenoca Radiation atypia Endocervicosis Condyloma acuminatum

Relate histology/cytologys below to the most fitting pathology above.

Peritoneal biopsy containing glands with columnar epithelium, oval nuclei and no nucleoli. Associated stroma and brown pigment are seen. Answer: C

Extra questions ⚫ A 34 year old woman has a loop biopsy showing

CIN1. What advice should her Physician give her regarding minimising her risk of a future cervical neoplasm. ⚫ A Refrain from sexual activity ⚫ B Use a barrier method of contraception ⚫ C Stop smoking ⚫ D Stop drinking ⚫ E Regular colposcopy

Extra questions ⚫ A 34 year old woman has a loop biopsy showing

Extra questions ⚫ The cervical screening programme requires storage of

slides. According to the requirements of the screening programme for how long should the slides be kept for? ⚫ A 3 years ⚫ B 10 years ⚫ C until age 65 ⚫ D Until 3 negative smears are performed ⚫ E Until colposcopy

Extra questions ⚫ The cervical screening programme requires storage of

Extra questions ⚫ A 38 year old woman with dysmenorrhoea is examined

under ultrasound and a bulky uterus is detected. A hysterectomy is performed and macroscopically several well circumscribed pale masses are detected in the myometrium. What is the most likely pathology? ⚫ A Leiomyosarcoma ⚫ B Endometrial stromal tumour ⚫ C Endometriosis ⚫ D Leiomyoma ⚫ E Thecoma

Extra questions ⚫ A 38 year old woman with dysmenorrhoea is examined

under ultrasound and a bulky uterus is detected. A hysterectomy is performed and macroscopically several well demarcated well circumscribed masses are detected in the myometrium. What is the most likely pathology? ⚫ A Leiomyosarcoma ⚫ B Endometrial stromal tumour ⚫ C Endometriosis ⚫ D Leiomyoma ⚫ E Thecoma

Extra questions ⚫ A Cantonese woman who speaks no English attends

an accident and emergency clinic and requires an FNA procedure. In order to perform the procedure: ⚫ A Send the woman home and give her a date to return with the interpreter present ⚫ B Use sign language to indicate procedure ⚫ C Get a nurse to hold her steady and perform FNA ⚫ D Phone surgeon and perform urgent open biopsy ⚫ E Tru-cut the lesion

Extra questions ⚫ A Cantonese woman who speaks no English attends

Extra questions ⚫ A 50 year old woman presents with an ovarian mass.

It measures 12cm and is solid and cystic. The solid areas are tan-yellow in colour. Immunohistochemistry was positive to: ⚫ A Alpha fetoprotein ⚫ B Inhibin ⚫ C CEA ⚫ D CA125 ⚫ E OM-1

Extra questions ⚫ A 50 year old woman presents with an ovarian mass.

It measures 12cm and is solid and cystic. The solid areas are tan-yellow in colour. Immunohistochemistry was positive to: ⚫ A Alpha fetoprotein ⚫ B Inhibin ⚫ C CEA ⚫ D CA125 ⚫ E OM-1

Extra questions ⚫ A Consultant receives a slide with an associated form

that indicates a colonic sample. Under the microscope the slide contains endometrial tissue. What is the first thing the Consultant might do to correct this error? ⚫ A Check handwritten annotation under label ⚫ B Check block ⚫ C Phone surgeon for history of endometriosis ⚫ D Recut slide ⚫ E Throw away slide and get recut

Extra questions ⚫ A Consultant receives a slide with an associated form

Final points ⚫ Knowledge based exam ⚫ Robbins or similar ⚫ Exam technique ⚫ Can be tight for time ⚫ Some of the questions are mini essays ⚫ “No trick questions” ⚫ Some questions will be taken out…

GOOD LUCK