Female Genital Tract Flashcards
Most common histological subtype of invasive cervical carcinoma
squamous cell (80%), then adenocarcinoma (15%).
8 most frequent sites of endometriosis (descending order)
- ovaries
- uterine ligaments
- rectovaginal septum
- cul de sac
- pelvic peritoneum
- large and small bowel and appendix
- mucosa of the cervix, vagina, fallopian tubes
- laparotomy scars
define endometriosis
the presence of “ectopic” endometrial tissue at a site outside of the uterus
define adenomyosis
the presence of endometrial tissue within the uterine wall (myometrium)
endometrial polyps have been associated with which drug?
tamoxifen (anti-estrogenic effects on breast but weak pro-estrogenic effects on endometrium)
define endometrial hyperplasia
An increase in endometrial gland:stroma ratio compared with normal proliferative endometrium
common genetic alteration in endometrial hyperplasia and endometrial (endometroid type, type 1) carcinoma
Inactivation of the PTEN tumour suppressor gene
common genetic alteration in endometrial (serous type, type 2) carcinoma
TP53. Arise in small, old, atrophic uteri.
Histological distinction of a leiomyoma from a leiomyosarcoma
based on nuclear atypia mitotic index, zonal necrosis. FYI leiomyosarcomas do not arise from leiomyomas
WHO classification of ovarian neoplasms (4 groups)
Surface Epithelial-Stromal Tumours
Sex Cord-Stromal Tumours
Germ Cell Tumours
Metastatic Cancer from Non-Ovarian Primary
Risk factors for ovarian serous carcinomas (3)
Nulliparity FHx Heritable mutations (BRCA1 and 2) Divided into low and high grades based on nuclear atypia almost 70% are bilateral
Consistent genetic alteration present in mucinous ovarian tumours (benign and malignant)
Mutation of KRAS proto-oncogene
the majority of mucinous ovarian tumours are
bilateral or unilateral?
unilateral - need to look for non-ovarian origin if bilateral mucinous tumours (think metastatic mucinous adenocarcinoma)
Ways mucinous ovarian tumours differ from serous ovarian tumours
- Only 5% mucinous cystadenomas or carcinomas are bilateral
- Mucinous often larger
approx ….% of endometroid carcinoma coexist with endometriosis
15-20%
Surface (mullerian) ovarian tumours (5), and their bilaterality
- Serous 70%
- Mucinous 5%
- Endometroid 40% - note this is a solid-cystic lesion
Much less common: - Clear Cell
- Brenner (TCC tumours containing epithelial cells resembling urothelium and are usually benign)
Classification of epithelial (Surface/mullerian) tumours - three groups
- Benign - well differentiated epithelial cells with minimal proliferation
- Borderline - increased cell proliferation, but lack stromal invasion
- Malignant - increased epithelial atypia and are defined by the presence of stromal invasion
Describe the cut-off for calling simple ovarian cyst benign, and follow up algorithm depending on patient demographic
Low risk - 5-7cm yearly f/u until resolved. >7cm, MRI assessment or surgery (mention but dismiss 3-5cm)
High risk - 2-7cm yearly f/u until resolved. >7cm MRI or surgery.
Diagnostic approach/cut off values when assessing haemorrhagic ovarian cyst
Low risk >5cm 6-12/52 f/u with USS. If unchanged proceed to MRI. (mention but dismiss 3-5cm)
Early postmenopausal is <5cm, 6-12/52 f/u with USS, if unchanged proceed to MRI. If cyst >5cm, evaluate with MRI or surgery.
High risk any cyst needs further evaluation with MRI or surgery.
1-2-3 ovarian cyst rule
<1cm = follicle 1-2cm = dominant follicle >3cm = cyst
Diagnostic approach to endometrioma (cut offs etc)
Low risk
- any one without echogenic foci do 6-12/52 follow up to rule out haemorrhagic cyst
- With echogenic foci is likely an endometrioma, do yearly follow up with US or surgical removal
High risk
- (early post menopausal) do 6-12/42 follow up to rule out haeorrhagic cyst.
- (late post menopausal) - without echogenic foci may be haemorrhagic cyst do further evaluation with MRI or surgical removal
- (late post menopausal) with echogenic foci may be endometrioma do yearly follow up with US or surgical removal
Define “low risk” vs “high risk”
Low risk - premenopausal and no risk factors
High risk - postmenopausal or other risk factors such as personal or FHx of breast or ovarian cancer, BRCA 1/2 carriers, Lynch-II HNPCC, Ashkenazi descent
When in women’s cycle should FDG-PET be performed and why?
First week, as mid-cycle can have physiological FDG uptake
define placenta praevia
Abnormally low lying placenta such that it lies close to or covers the internal cervical os.
- risk factors: previous plac previa, prev CS, old mum, increased parity, large placenta (multiple gestation), maternal hx smoking, assisted conception, previous manual removal of placenta.
- ax with abnormal placental villous adherence
- Classification:
- -grade I: low lying (in LUS but lower edge 0.5-2cm from internal os)
- -grade II: marginal praevia ( placental tissue reaches margin of internal cervical os but does not cover it)
- -grade III: partial praevia
- -grade IV: complete praevia (placent completely covers the internal os).
dx not made before 20/40. Due to placental trophotropism the placenta can move at about 1mm per week.
Spectrum of abnormal placental villous adherence. Describe, and define the three types
The degree to which there is an invasion of chorionic villi into the myometrium because of a defect in the decidua basalis.
- placenta accreta:
- 75% of cases. 1/7000 pregnancies.
- combination prior CS and anterior placenta praevia raises probability.
- maternal mortality up to 7% -mildest form. Villi are attached to the myometrium but do not invade the muscle - placenta increta
- 25% cases
- villi partially invade the myometrium - placenta percreta
- 5% cases
- most severe form, villi penetrate through the entire myometrium or beyond serosa
Risk factors:
- prior CS
- placenta praevia
- old mum
- uterina anomalies
- intrauterine adhesion bands
- previous surgery
TORCH infections
Toxoplasmosis Other - syphyllis, TB, listeriosis Rubella CMV Herpes simplex
which mole is ax with choriocarcinoma?
Complete (46XX/46XY) 2.5% of these.
Partial is 69XXX/XXY
Gestational choriocarcinoma can arise from these 3 situations:
50% complete moles 25% previous abortions 22% following normal pregnancy Remainder following ectopic Tiny amount nongestational from ovarian or mediastinal germ cells.
Approximately 1% of dermoids/benign teratomas undergo malignant transformation, most commonly to
squamous cell carcinoma, but also thyroid, melanoma
The histologic grade of immature malignant teratoma is based on what? (1)
Proportion of tissue containing immature neuroepithelium
Types of germ cell tumours
Teratoma
Dysgerminoma (all malignant but only 1/3 aggressive. Range from tiny nodule to whole abdo)
Yolk Sac tumour - aFP. Schiller-Duval body on histo
Choriocarcinoma
Types of sex-cord stromal tumours
- Granulosa-thecal cell tumour. Granulosa usually unilateral and produce estrogen. Indolent but can recur 10-20y after resection.
- Fibroma, thecoma and fibrothecoma. Usually unilateral. Associated with weird clinical findings such as ascites, right hydrothorax (combination of ovarian tumour, ascites and hydrothorax is Meigs syndrome)
- Sertoli-Leydig. Usually masculinising
