pathology part 2 (wk 4-6)

Follicle and luteal cyst

• From unruptured graafian follicles or follicle that ruptured them immediately sealed

• Lined by granulosa or luteal cells → shiny cyst

• may rupture causing intraperitoneal bleeding and pain

Polycystic ovaries

• stein leventhal syndrome

• ovaries w multiple cystic follicles

• produce excess oestrogen and androgens

• increased lh, decreased fsh

• sx : hirsutism, puberty characteristics

• in t2dm, atherosclerosis etc

Stromal Hyperthecosis

• cortical stromal hyperplasia

• uniform bilateral enlargement of ovaries

• Hypercellular stroma w luteinised stromal cells (like nests w vacuolated cytoplasm)

• sx like pcos (imcreased androgens, etc)

Ovarian torsion

• usually right, unilateral lower abd pain

• ovarian twist itself → decreased blood supply → necrosis

• enlarge, infarcted, necrotic cyst

Risk for ovarian cancers

• nulliparity (never pregnant)

• HRT, esp in oestrogen only

• BRCA1, 2

• smoking

Ovarian cancer clinical features and spread

• poor prognosis : tumours small, if v large alr outside ovary

• disease spread to POD and omentum/ln

• tx by surgery and chemi but modest imcrease in survival

Ovarian tumour origins (4)

• surface epithelial tumours : most frequent, usually malignant

• Germ cell tumours

• sex chird stromal tumours

• metastases

Surface epithelial tumours

• From mullerian epithelium that covers surface ofovary

• repeated ovulation and scaring → cyst that can undergo metaplasia

• Benign (cystic/cysticadenofibroma), malignant cystic/solid and borderline (atypia wo invasion)

epithelial stromal tumours main 4

• serous

• mucinous

• endometrial

• clear cell

Serous tumours of epithelial stromal (all types)

• most frequent

• benign ones are mostly large w smooth glistening capsule w singke layer of tall collumnar epithelium

• borderline ones are atypical wo invasion w papillary projection (usually confuned)

• malignant ones have nodular irregularities w internal papillary projections, usually w p53 and brca1 tumours (go to LN)

mucinous tumours

• mostly benign, lined w mucin secreting epithelial cells

• larger than serous tumours but better prognosis

• tumour can rupture → mucinous deposits in peritoneum (mucin pseudomyoma peritonei)

• kras Mutations

Endometrioid tumours

• solid or cystic, composed of tubular hlands

• usually malignant w mutatiins in PTEN

Clear cell carcinomas

• malignant tumours w broad papillae lined by clear and hobnail cells

• bad prognosis

Brenner tumours

• encapsulated, usually benign tumours

• abundant stroma containung nests

Sex cord stromal tumours (3)

• granulosa cell tumours : Sx of excess oestrogen w Call -exner bodies

• Sertoli leydig cell tumours :solid tumours resembling testes w tubules, dicer 1

• fibroma :Solid grey frbrous cells, sometimes produce meigs syndirme

Teratomas and types

• arise in first 2 decades, mostly benign

• mature cystic (dermoid) : cyst w epidermal linung + foci ifbone, cartilage, bronchial,etc

• immature : solid w areas of necrosis, characterised by immature differentiation of bone, cartilage, muscle nerves, etc

• monodermal/ specialised :struma (thyroid), carcinoid or struma, carcinoid

Primitive germ cell tumours (4+ explain)

• dysgerminoma : malignant, unilateral large solid mass female counterpart of seminoma, high tx rate

• yolk sac tumour : from endoderms, structures, well encapsulated , haemorrhage + necrosis in honeycomb pattern , schiller duval bodies

• embryonal : resembles embryonic disc / blastocyst that resemble early presomatic embryo

• chriocarcinoma : unilateral, small identical to placental tumour w 2 trophoblast cells

Metastases in ovarian canecr

• older women

• bilateral, at surface of ovary

• from gi, breast, lungs

• signet ring mucin secreting cells

Craniopharyngioma

• benign tumour of remnant of rathke pouch

• anywhere from nasopharynx to diencephalon

• sellar mass, tx by rt

Hypopituitarism ant vs post sx

• anterior

1. gh deficiency : dwarfism

2. acth : hyponatraemia, hypotension

3. lh/fsh deficiency : infertility, amenorrhea

4. prolactin deficient : cant lactate

5. msh deficient : pallor

• posterior

1. adh deficiency : DI

sheehans syndrome

• acute infarction w necrosis of ant. pituitary lobe

• post partum haemorrhage

• mild hypopituitarism (ant pituitary x2 size, partial necrosis)

somatotroph adenomas

• gh secreting → acromegaly

• acromegally effects :-

1. mass effect : visual fields

2. hypopituitarism : disturbs others

3. metabolic effects : diabetes, htn

4. ST effects : excessive jaw, internal organs

• diagnosed w igf1 (failure to suppress gh on gtt), mri

Prolactinoma

• amenorrhea, low lobido, galactorrhea

• dx w bloodwork +mri

• rx w dopamine agonists (eg cabergoline)

Cushings syndrome

• hypercortisolism

• acth dependent (if due to pituitary adenima = cushings disease)

• acth imdependent : adrenal tumours

• sx : truncal obesity, moon face, htn, bruising, hisuitism

• nb pseudocushings where clinical cortisol excess wo biochemical data and vv

dx and tx of hyperaldosteronism

• check plasma renin (suppressed in primary, elevated in secondary) and aldosterone

• salt loading to suppress aldosterone

Androgen excess possibilities

• CAH

• adrenal tumours : usually malignant

• pcos : oligomenorrhea, hirsuitism, ovarian cyst

• ovarian hyperthecosis

Addison disease sx

A : apetite loss, weight loss

D : darkened skin

D : dizziness

I : irritability

S . salt craving (hyponatraemia)

O : orthostatic hypotn

N : n&v, abd pain

dx addisons

• acth stimulation

• insulin tolerance test

• ct adrenals

adrenal cortical neoplasm

• adenoma : small, functional (cushings or conns)

• carcinoma : rare, large , in children unkess mets

Adrenal medulla neoplasm

• chromaffin cells

• phaechromocytoma

• neuroblastic tumours

What and why thyrotoxicosis

• elevated free t3/t4

• graves (most), multinodular goitre, follicular adenoma

• either excess release or extra thyroid source

hyperthyroidism cx

• increased bmr → weight loss, heat tolerance

• cardiac, ocular, skeletal → tachy, nervous, tremor

• thyroid storm

Hypothyroidism

• low t3/t4

• hashinotos thyroiditis, iodine deficiency, development

• sx : fatigue, cold intolerance, weight gain, myxoedma

Hashimotos thyroiditis

• autoimmune against tsh receptor

• painkess enlargement if thyroid

• hurthle cell metaplsia + fibrosis

Granulomatous thyroiditis what, macro and micro

• transient, viral likely

• gland is adherant to trachea and adjacent strap muscles

• neutrophils, aggregation kf macrophage, giant cells

Graves disease

• hyperthyroidism due to autoantibodies binding to tsh receptor (eg thyroid stimulating immunoglobulin)

• goitre, exopthalmos,pre tibial myxoedema

• tx by b blockers ir thyroidectomy (or radioiodine ablation, thinomide)

What is goitre and subtypes

• enlarged thyroid gland due to increased tsh

• diffuse nontoxic (simple) goitre : endemic ir sporadic

• multinodular : from simple goitre, mistaken for tumours

Thyroid storm

• extreme hyperthyroidism

• common after infection, also after discontinue anti thyroid

• sx : elevated T (>40), tachy, arrythmia, vomit

Thyroid neoplasia

• solitary palpable thyroid nodule

• 1% only malignant

• in young males, hx radiation tx

• if functional most likely benign

follicular adenoma

• benign neoplasm

• encapsulated

• oncocytic (hurthle) cell adenoma another variant

Common thyroid carcinomas (4, common to least)

• papillary

• follicular

• medullary

• others

Papillary carcinoma of thyroid

• most common due to ionising rafiation

• Asx but can also present as mass, hoarseness, dysphagia and met

• usually lymphatic invasion but bv also can

• genes : braf, rearrangements of chr 10 (eg ret/ptc)

follicular carcinoma of thyroid types

• minimally invasive : capsular and vascular invasion, lobectomy usually wo recurrence

• widely invasive : extensive, features of malignancy and high chance of met

medullary carcinoma of thyroid

• mostly sporadic but some assoc w men2 a/b (ret protooncogene)

• solid areas of haemorrhage and necrossi wo infiltration

• amyloid stroma from calcitonin

anaplastic carcinoma of thyroid

• in elderly, present w local compression

• v rapid w v high mortality

• braf mutation

• spindle cell, giant cell, squamoid variants

Congenital thyroid abnormalities

• dyshormonogenesis goitre

• thyroid dysgenesis : ectopic, hypoplasia, agenesis