46 Disease of female genital system Flashcards
What do the intraepithelial neoplasia of the female genital system all share?
Common aetiology: human papilloma virus.
Which HPV subtypes are low risk? (2).
What are they associated with?
6 + 11.
Genital warts and low grade cytological abnormalities.
Which HPV subtypes are high risk? (4).
What are they associated with?
16, 18, 31, 33.
High grade pre-invasive and invasive disease.
Differentiate between the cervarix and gardasil vaccinations:
Cervarix: subtypes 6 + 11.
Gardasil: 6, 11, 16, 18.
How does high risk HPV lead to cancer?
Integrates into host cell chromosome. Upregulates E6 and E7.
E6 inactivates p53. E7 binds to RB1 gene product.
Differentiate between early and late genes (of viruses).
Early: control replication.
Late: code for capsid proteins.
What does p53 control?
Mediates apoptosis in response to DNA damage.
What does RB1 gene do?
Tumour supressor gene.
Controls G1/S checkpoint in the cell.
What is the epidemiology of classical vulval intraepithelial neoplasia?
Classification?
Associated with HPV, occurs in young people.
Classical/warty/baseloid.
Grades 1 to 3.
What is the epidemiology of differentiated vulval intraepithelial neoplasia?
Not graded. Not HPV related.
Related to chronic dermatoses e.g. lichen sclerosus.
Occurs in older people.
Describe the behaviour of vulval intraepithelial neoplasia:
Who does it progress to invasive in?
Who does in spontaneously regress in?
35-50% recur.
Menopausal, immunocompromised.
Young, postpartum.
What is the most common vulval cancer?
Squamous cell carcinoma.
What is squamous cell carcinoma associated with?
Under 60: CIN, HPV +ve
70: lichen scleosus, lichen planus.
How does vulval squamous cell carcinoma spread?
Locally: vagina, distal urethra.
Ipsilateral inguinal lymph nodes.
Contralateral inguinal lymph nodes, deep iliofemoral LNs.
Which staging system is used for vulval squamous cell carcinoma?
FIGO.
Describe the behaviour of malignant melanoma as a vulval cancer:
Age, recurrence. Spread.
50-60y/o. Recurrence in 1/3rd.
Lymph/haematogenous spread common. Correlated with invasion depth.
What is Paget’s disease of the vulva? (extramammary).
Pruritic, burning, eczematous patch.
In situ-carcinoma that recurs following excision.
Which area is most vulnerable to the effects of HPV?
Transformation zone.
What is the transformation zone in women?
Physiological area of squamous metaplasia.
Describe the changes that occur over a woman’s lifetime to the transformation zone:
During menarche, squamocolumnar junction moves out into vagina, establishing a transformation zone. During menopause the transformation zone moves up into the endocervical canal.
What is cervical intraepithelial neoplasia?
The pre-invasive stage of squamous cell carcinoma.
Why doesn’t the cervical screening program test for cancer?
In cases of cancer, the swab picks up the inflammatory detritus covering the cancer, and not the malignant cells.
Who gets cervical screening?
25 -64.
25-49 is 3 yearly.
49-64 is 5 yearly.
Why is there no cervical screening for under 25’s? (2).
High HPV carriage rate - reactive changes.
Too many LLETZ procedures have obstetric consequences.
Who gets referred for colposcopy after a cervical screen? (2).
Low grade dyskaryosis with +HPV result.
High grade dyskaryosis.
What does LLETZ stand for?
Large loop excision of the transformation zone.
What are the risk factors for cervical squamous cell carcinoma? (5).
High risk HPV. (Most important). Multiple partners, young first intercourse, high parity. Low SEC. Smoking. Immunosuppression.
What are the stages in the FIGO system for cervical carcinoma?
I Confined to cervix.
II Invades beyond uterus.
III Extends to pelvic wall, lower 1/3rd vagina, hydronephrosis.
IV Invades bladder/rectum/outside pelvis.
Where does cervical carcinoma spread to via the lymph?
Pelvic and para-aortic lymph nodes.
