46 Disease of female genital system

Question 1

What do the intraepithelial neoplasia of the female genital system all share?

Answer 1

Common aetiology: human papilloma virus.

Question 2

Which HPV subtypes are low risk? (2).

What are they associated with?

Answer 2

6 + 11.

Genital warts and low grade cytological abnormalities.

Question 3

Which HPV subtypes are high risk? (4).

What are they associated with?

Answer 3

16, 18, 31, 33.

High grade pre-invasive and invasive disease.

Question 4

Differentiate between the cervarix and gardasil vaccinations:

Answer 4

Cervarix: subtypes 6 + 11.
Gardasil: 6, 11, 16, 18.

Question 5

How does high risk HPV lead to cancer?

Answer 5

Integrates into host cell chromosome. Upregulates E6 and E7.

E6 inactivates p53. E7 binds to RB1 gene product.

Question 6

Differentiate between early and late genes (of viruses).

Answer 6

Early: control replication.
Late: code for capsid proteins.

Question 7

What does p53 control?

Answer 7

Mediates apoptosis in response to DNA damage.

Question 8

What does RB1 gene do?

Answer 8

Tumour supressor gene.

Controls G1/S checkpoint in the cell.

Question 9

What is the epidemiology of classical vulval intraepithelial neoplasia?
Classification?

Answer 9

Associated with HPV, occurs in young people.
Classical/warty/baseloid.
Grades 1 to 3.

Question 10

What is the epidemiology of differentiated vulval intraepithelial neoplasia?

Answer 10

Not graded. Not HPV related.
Related to chronic dermatoses e.g. lichen sclerosus.
Occurs in older people.

Question 11

Describe the behaviour of vulval intraepithelial neoplasia:
Who does it progress to invasive in?
Who does in spontaneously regress in?

Answer 11

35-50% recur.
Menopausal, immunocompromised.
Young, postpartum.

Question 12

What is the most common vulval cancer?

Answer 12

Squamous cell carcinoma.

Question 13

What is squamous cell carcinoma associated with?

Answer 13

Under 60: CIN, HPV +ve

70: lichen scleosus, lichen planus.

Question 14

How does vulval squamous cell carcinoma spread?

Answer 14

Locally: vagina, distal urethra.
Ipsilateral inguinal lymph nodes.
Contralateral inguinal lymph nodes, deep iliofemoral LNs.

Question 15

Which staging system is used for vulval squamous cell carcinoma?

Answer 15

FIGO.

Question 16

Describe the behaviour of malignant melanoma as a vulval cancer:
Age, recurrence. Spread.

Answer 16

50-60y/o. Recurrence in 1/3rd.

Lymph/haematogenous spread common. Correlated with invasion depth.

Question 17

What is Paget’s disease of the vulva? (extramammary).

Answer 17

Pruritic, burning, eczematous patch.

In situ-carcinoma that recurs following excision.

Question 18

Which area is most vulnerable to the effects of HPV?

Answer 18

Transformation zone.

Question 19

What is the transformation zone in women?

Answer 19

Physiological area of squamous metaplasia.

Question 20

Describe the changes that occur over a woman’s lifetime to the transformation zone:

Answer 20

During menarche, squamocolumnar junction moves out into vagina, establishing a transformation zone. During menopause the transformation zone moves up into the endocervical canal.

Question 21

What is cervical intraepithelial neoplasia?

Answer 21

The pre-invasive stage of squamous cell carcinoma.

Question 22

Why doesn’t the cervical screening program test for cancer?

Answer 22

In cases of cancer, the swab picks up the inflammatory detritus covering the cancer, and not the malignant cells.

Question 23

Who gets cervical screening?

Answer 23

25 -64.
25-49 is 3 yearly.
49-64 is 5 yearly.

Question 24

Why is there no cervical screening for under 25’s? (2).

Answer 24

High HPV carriage rate - reactive changes.

Too many LLETZ procedures have obstetric consequences.

Question 25

Who gets referred for colposcopy after a cervical screen? (2).

Answer 25

Low grade dyskaryosis with +HPV result.

High grade dyskaryosis.

Question 26

What does LLETZ stand for?

Answer 26

Large loop excision of the transformation zone.

Question 27

What are the risk factors for cervical squamous cell carcinoma? (5).

Answer 27

High risk HPV. (Most important).
Multiple partners, young first intercourse, high parity.
Low SEC.
Smoking.
Immunosuppression.

Question 28

What are the stages in the FIGO system for cervical carcinoma?

Answer 28

I Confined to cervix.
II Invades beyond uterus.
III Extends to pelvic wall, lower 1/3rd vagina, hydronephrosis.
IV Invades bladder/rectum/outside pelvis.

Question 29

Where does cervical carcinoma spread to via the lymph?

Answer 29

Pelvic and para-aortic lymph nodes.