Female Genital Tract

Question 1

What is uterine leiomyoma?

Answer 1

• benign smooth muscle neoplasm
• “fibroids”
• may cause irregular bleeding (metrorrhagia)
• painful intercourse (dyspareunia)

Question 2

What are proliferative lesions of the endometrium?

Answer 2

• hyperplasia& polyps
  – glandular epithelium
  – bleeding

Question 3

What are the 2 major diseases of the endometrium?

Answer 3

• endometriosis
• adenocarcinoma

Question 4

Describe edometriosis?

Answer 4

• endometrial tissue outside of uterine cavity
• ectopic endometrial tissue influenced by hormonal changes
• recurring pelvic pain
• symptoms depend on site & worsen with menstrual cycle

Question 5

Typical locations for foci of endometriosis?

Answer 5

• ovary, uterine tube, pelvic wall, myometrium

Question 6

What is a chocolate cyst?

Answer 6

endometriosis of ovary filled with blood

Question 7

Risk factors for endometrial carcinoma?

Answer 7

• age (55-65), but seen in younger populations due to risk factors
• obesity: synthesis of estrogen in fat
• infertility: nulliparous increases risk

Question 8

How to screen for cervical squamous cell carcinoma?

Answer 8

exfoliative cytologic screening for early detection (PAP smear)

Question 9

Where is cervical squamous cell carcinoma often found?

Answer 9

squamo-columnar junction

Question 10

What are the high risk HPV sub-types?

Answer 10

16 & 18 (31&33)

Question 11

How to prevent cervical squamous cell carcinoma?

Answer 11

HPV vaccination

Question 12

What are the sequence of events that may follow an HPV infection?

Answer 12

low risk (6,11) –> condyloma (mostly cleared)
high risk (16,18) –> CIN –> persists higher grade CIN –> invasive cancer –> metastasis

Question 13

What does CIN mean? What are the types?

Answer 13

Cervical intraepithelial neoplasia
- LSIL: low grade
- HSIL: high grade

Question 14

describe CIN I

Answer 14

transforming into dysplasia
– active changes in basal 1/3 (proliferation)

Question 15

Describe CIN II

Answer 15

active changes spreading in basal 2/3

Question 16

Describe CIN III

Answer 16

squamous cell carcinoma (changes in all layers)

Question 17

What are you looking for in a pap smear?

Answer 17

koilocytes: nuclei abnormal, larger, abnormal chromatin

Question 18

What is a teratoma?

Answer 18

• tumor containing tissues from all 3 germ layers (ectoderm, mesoderm, endoderm)
  *2 layers is still diagnostic

Question 19

Where are teratomas most common?

Answer 19

ovary
–generally arise in gonadal tissues

Question 20

What is a dermatoid cyst?

Answer 20

benign cystic teratoma of ovary

Question 21

What are complications of ectopic tubal pregnancy?

Answer 21

rupture

Question 22

What is gonorrhea?

Answer 22

Neisseria gonorrhea
pelvic inflammatory disease
tubal scarring
ectopic pregnancy
can have abscess, pain, and discharge

Question 23

Tissues of the breast?

Answer 23

• glandular epithelium
• ducts
• lobules
• interstitial tissue (mostly fat)
• lymphatics (rich supply)

Question 24

What tissues of breast most commonly give rise to cancers?

Answer 24

ducts & lobules

Question 25

What are fibrocystic changes of breast tissue?

Answer 25

- common as we age - ductal & stromal changes - lots of cysts *blue dome cyst: cystic spaces (fill with blood or cystic fluids)

Question 26

What is gynecomastia?

Answer 26

- enlargement of male breast in response to estrogen - hyperestrinism - bilateral or unilateral

Question 27

Bilateral vs unilateral gynecomastia?

Answer 27

bilateral: rule out hormonal unilateral: rule out tumor

Question 28

Causes of hyperestrinism?

Answer 28

- cirrhosis of the liver (inability to metabolize estrogen) - klinefeller syndrome - estrogen- secreting tumor - estrogen therapy

Question 29

What is the most common benign neoplasm of the breast?

Answer 29

- fibroadenoma

Question 30

What are fibroadenomas?

Answer 30

- discrete, usually solitary, moveable nodule - typically young women

Question 31

What are factors that affect breast cancer?

Answer 31

genetics hormonal influences environmental variables

Question 32

Well established risk factors for breast cancer?

Answer 32

- Genetics & family history: BRCA1/2 & p53 - Menstrual hx: early start / later menopause (length of reproductive life) - Nulliparous - geographic - age

Question 33

What are the other "mild' risk factors to breast cancer?

Answer 33

- exogenous estrogens: hormone replacement - oral contraceptives - ionizing radiation during breast development

Question 34

What are some less well established risk factor to breast cancer?

Answer 34

- alcohol - fatty diet - obesity - smoking

Question 35

Familial syndromes related to genetic changes (breast cancer) & the impairment

Answer 35

- li fraumeni: p53 germline - cowden: PTEN germline - ataxia-telangiectasia: DNA repair gene - BRCA1/2: germline - HER2/NEU: proto-oncogene - estrogen/progesterone receptor positivity

Question 36

Why is HER2/NEU protooncogene important in breast cancer?

Answer 36

- epidermal GF amplified in 30% of breast cancers - overexpression associated with poor prognosis TX: herceptin (trastuzumab)

Question 37

Therapeutic intervention for estrogen receptor positive?

Answer 37

Tamoxifen

Question 38

What leads to increased exposure to estrogen?

Answer 38

- long reproductive life - nulliparity - late age at birth of first child

Question 39

How does obesity affect exposure to estrogen for breast cancer risk?

Answer 39

adipose tissue produces small amounts of estrogen *pre-menopausal fat does not increase breast cancer risk

Question 40

Where on the breast is breast cancer most common?

Answer 40

upper outer quadrant = 50% Central = 20%

Question 41

Invasive vs non-invasive breast cancer?

Answer 41

- non: has not penetrated basement membrane - invasive: penetrated basement membrane

Question 42

Most common invasive breast cancer?

Answer 42

invasive ductal carcinoma

Question 43

What is the MOA of tamoxifen?

Answer 43

antiestrogen if estrogen receptor + (blocks estrogen receptor)

Question 44

What is the MOA for aromatase inhibotors?

Answer 44

post menopausal women (blocks estrogen formation)

Question 45

What is Paget's disease of nipple?

Answer 45

- clinical variant of DCIS - up to lactiferous ducts & into contiguous skin of nipple - crusting exudate over nipple & areolar skin *underlying invasive carcinoma in 50% --> serious and must biopsy

Question 46

How often do women with lobular carcinoma in situ (LCIS) develop invasive carcinoma?

Answer 46

1/3 of women

Question 47

70-80% of breast carcinomas are due to ?

Answer 47

invasive ductal carcinoma

Question 48

Describe appearance of invasive ductal carcinoma?

Answer 48

- firm lesion with adipose tissue & lesion spreading into adipose tissue

Question 49

Clinical features common to all invasive carcinomas?

Answer 49

- fixation secondary to adherence to pectoral muscles or deep fascia of chest wall - adherence to overlying skin with retraction or dimpling of skin or nipple - lymphatic involvement can cause lymphedema & skin thickened around hair follicles with peau d' orange

Question 50

Describe the staging of breast cancer?

Answer 50

1: <2cm, no nodal involvement, no metastases 2: <5cm with <3 nodes & no metastases OR >5cm but no nodes 3: many categories; infiltration into skin, wall, nodes, NO disseminated metastases 4: disseminated metastases

Question 51

Prognostic factors for cancer?

Answer 51

- size of primary carcinoma - lymph involvement / # - distant metastases - histological grade & type - estrogen / progesterone receptor - proliferative rate - aneuploidy - HER2/NEU expression

Question 52

Where is the drop off rate of 5 year survival for breast cancer?

Answer 52

stage 3 drops to 46% in situ: 92%, 1: 87%, 2: 75% all stages combined 50% relatively good 10 year survival rate