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Pathology > Gynae > Flashcards

Gynae Flashcards

1
Q

What is the normal structure of the cervix

A
  • Ectocervix- outer part lined by squamous epithelium - no keratin layers
  • Endocervix- lined by single layer mucin secreting glandular epithelium - dips down into cervix stroma
  • Transformation zone- junction between ectocervix and endocervix - this is where premalignant lesions arise
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2
Q

What is the purpose of cervical screening

A

-Picks up lesions that could develop into cancer - detects cervical intraepithelial neoplasia (CIN)
Grading
if negative recall every 3-5 yrs
Unsuitable repeat in 3 months
Borderline nuclear changes- repeat in 6 months (mild abnormalities)
Mild dyskaryosis (CIN 1) repeat 6 months
Moderate dyskaryosis (CIN 11) - refer for colonoscopy
Severe dyskaryosis (CIN 111) - Refer to colposcopy

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3
Q

How is HPV shown in the cervix
How is CIN 1 shown
How is CIN 2 shown

A

HPV= -Koliocytosis- enlarged nuclei with a borderline smear - low grade squamous intraepithelial lesion

CIN 1 = Mild - bigger nuclei and abnormal nuclear chromatin- low grade squamous intraepithelial lesion, has koliocytes at the surface, cells enlarged in lower third

CIN 2 = nucleus occupies 2/3 of cell and speckled chromatin- High grade squamous intraepithelial lesion, confined to lower 2/3 of epithelium

CIN 3 = Abnormal chromatin and big nucleus, altered dark and light coloured areas- High grade squamous intraepithelial lesion- abnormal cells occupy full thickness of the epithelium, nuclei everywhere, no sign of maturation

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4
Q

What are the two types of preinvasive lesions seen in cervical screening

A
  1. Squamous- Cervical intraepithelial neoplasia

2. Glandular- Cervical Glandular Intraepithelial Neoplasia (more rare)

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5
Q

What is the significance of CIN and CGIN

and how do you manage these lesions

A

Cervical intraepithelial neoplasia= can develop into squamous carcinoma
Cervical glandular intraepithelial neoplasia= can develop into adenocarcinoma

Management
-Ablation- low grade lesion then the abnormal area is frozen or cauterised
-Excision- high grade lesion and a loop/ cone biopsy will be done
-Cytological +/- colposcopic follow up
Smear 6 months after then 1 every year for 10 yrs

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6
Q

What are the risk factors of preinvasive lesions

A
  • HPV (6 and 11= low risk) (16 AND 18= High risk)
  • Infectious agents
  • Early age at first intercourse
  • Multiple sexual partners
  • Smoking
  • OCP
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7
Q

What is the staging involved in cervical cancer

A

FIGO staging
Stage 1- carcinoma confined to cervix
1a = micro invasive very small and less than 5mm deep and 7mm wide confined within basement membrane
1b1= less than 4cm 1b2= greater than 4cm

Stage 2= spread beyond the cervix but has not extended into the pelvic wall - involves the vagina but not the lower 1/3

Stage 3= carcinoma extended into pelvic wall and lower third of bagina

Stage 4= extension beyond the true pelvis, or has involved mucosa of bladder or rectum

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8
Q

What are the various types of carcinoma of the cervix

A

Microinvasive squamous carcinoma- Involved by CIN3 - confined by basement membrane

Cervical carcinoma= large tumour involving whole cervix and thickening of whole cervix

Squamous carcinoma of cervix - looks like squamous carcinoma of lungs of skin, lots of lymph-vascular invasion

Adenocarcinoma - tumour forms glands

Adenosquamous carcinoma of cervix - adenocarcinoma and squamous carcinoma components

Small cell carcinoma of cervix- very aggressive can met easily even when small need aggressive chemo

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9
Q

What treatment is indicated for cervical cancer

A

Stage 1A1 - cone biopsy or simple hysterectomy- uterus left and abnormal area removed - young patients excellent prognosis

Other stage 1- Radical hysterectomy and pelvic lymphadenectomy plus chemo-radiation depending on margins good prognosis

Greater than stage 1= chemo radiation

All patients have MRI and cystoscopy for staging

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10
Q

Describe the features of endometrial hyperplasia

A
  • Precursor to type 1 endometrial cancer
  • Simple or complex depending on glandular architecture
  • Non-atypical or typical depending on cytology
  • Atypical hyperplasia= higher risk of progression to type 1 cancer*
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11
Q

What are the features of endometrial cancer

A

-Usually post menopausal bleeding
-Increased risk in
obesity , HTN , diabetes, exogenous unopposed osteogens , tamoxifen (in breast cancer treatment)
Endogenous oestrogenen (PCOS)

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12
Q

Discuss the two types of endometrial cancer

A

Type 1 (most common)

  • Endometriod carcinoma or adenocarcinoma
  • Perimenopausal or early post menopause
  • Associated with increased oestrogen
  • Hormone (oestrogen) receptor positive
  • Background of endometrial hyperplasia
  • Well differentiated and low stage, good prognosis
  • Polypoid tumour projecting into endometrial cavity OR well differentiated adenocarcinoma

Type 2 (less common)

  • Serous carcinoma or adenocarcinoma
  • Not associated with increased oestrogen
  • Hormone receptor negative
  • Comes from atrophic endometrium (not from hyper plastic endometrium)
  • Usually advanced stage and older age
  • Very aggressive poor prognosis
  • Associated with p53 mutations
  • Tumour extends into myometrium
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13
Q

What are the important prognostic factors in endometrial cancer

A
  • Tumour type and grade
  • Depth of myometrial invasion
  • Cervical involvement
  • Lymphovascular permeation (channels)
  • Peritoneal washings - if tumour cells found here during surgery- bad prognosis
  • Lymph node involvement
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14
Q

What is the staging system for endometrial cancer and what is the treatment

A

Stage 1- Uterine body or corpus
Stage 1a - endometrium
Stage 1b-Inner half of myometrium
Stage 1c- outer half of myometrium

Stage 2a- cervix involvement

Stage 3a- Ovaries, fallopian tubes, peritoneal washing

Treatment
Total abdominal hysterectomy and BSO (removal ovaries and fallopian tubes- common to get ovarian tumours or mets)
-Adjuvant radiotherapy or chemo depending on pathological parameters

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15
Q

What are the other 3 main malignant uterine neoplasms

A
  • Leiomosarcoma - malignant tumour coming from myometrium - high grade advanced tumours
  • Endometrial stromal sarcoma- malignant tumour from endometrial stroma - good prognosis
  • Carcinosarcoma/ malignant mixed mullein tumour - mixture
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16
Q

What is the anatomy of the female genital tract

A

Myometrium= wall of thick smooth muscle
Uterine body has 2 parts an inner endometrium and an outer myometrium

Tumours can come from endometrial gland ,endometrial stroma or the myometrium

17
Q

What are leiomyomas and what is their presentation

A
  • Fibroids
  • Benign smooth muscle neoplasms of the uterus
  • Occur in the myometrium
  • Very common
  • In reproductive yrs
  • No symptoms and usually decrease in size and disappear after menopause

Presentation

  • Abnormal uterine bleeding - excessive periods
  • Pressure symptoms- backache , urinary frequency
  • Pelvic pain
  • Abdominal mass
  • Can be aymptomatic

Can be

  • Submucosal- below endometrium and project into uterine cavity
  • Intramural - most common- middle of myometrium
  • Subserosal- under the external surface of the ureters projecting into pelvic/ abdominal cavity
18
Q

What is adenomyosis

A
  • Common in reproductive yrs
  • Associated with menorrhagia or abnormal uterine bleeding
  • Down growth of endometrial glands and stroma into the myometrium
19
Q

What is the normal histology of the vulva

A

-Lined with keratinising stratified squamous epithelium

20
Q

What is a vulval dystrophy and what are the main presentations

A

Presentation

  • Itch -Pain -Leukoplakia
  • Small risk of progression to invasive squamous carcinoma

Lichen sclerosis= sclerosis/ fibrosis within the dermis, surface squamous epithelium is atrophic

21
Q

What are the various preinvasive vuval lesions

A

VIN- vuval intraepithelial neoplasia to CIN

VIN 1, 2 and 3

Presentation
Pruitis, pain, gross lesions

Types of VIN

  • Bowenoid/ undifferentiated= younger associated with HPV low risk of invasion
  • Simplex/ differentiated- older, no HPV association, no CIN association , high risk of invasion
22
Q

What are various types of vulvval carcinoma and how are they staged

A

Same as preinvasive lesions
-Bowenoid/ undifferentiated- rarer and associated with HPV- More common as VIN less common as a carcinoma

-Simplex/ undifferentiated- more likely to develop deep invasion

Vulval carcinoma- atypical squamous cells invading the wall of the stroma

Staging
Stage 1- tumour confined to vulva
Stage 2- Tumour confined to vulva and or perineum and is greater than 2cm
Up to here surgical excision is treatment
Stage 3- spread to vagina , urethra or anus or any regional lymph nodes (will invade inguinal lymph nodes on same side 1st)
Stage 4- Invades upper urethra, bladder, rectal mucosa, pelvic bone, bilateral regional lymph nodes or distant mets
Chemoradiation as treatment

23
Q

Discuss Paget’s disease of the vulva

A
  • An adenocarcinoma arising in the squamous epithelium of the vulva and confined to within the squamous epithelium
  • Usually primary but can be secondary from internal organs (colorectal, bladder or cervix)

Symptoms
Pruritis, burning, eczema, ulceration

Management- surgical excision with free margins and exclude internal malignancy

Prognosis- recurrence is common, dermal invasion associated with poorer prognosis

24
Q

Describe the presentation of ovarian neoplasm

A
  • Non specific
  • Pain
  • Abnormal uterine bleeding
  • Abdominal mass
  • Ascites
  • Incidenal on imaging
  • No early symptoms so tumours often present late
25
Q

Discuss the features of an ovarian epithelial tumour

A

Mainly arise from surface epithelium
Usually post menopausal
Risk factors= Low parity (not many births) -Early menarche/ late menopause
Oral contraceptives protect against it
Breast carcinoma association BRCA 1 and BRCA 2

26
Q

What are the various types of primary epithelial ovarian tumours

A

Benign and malignant
Have morphological subtypes -serous -mucinous -endometrioid -clear cell -transitional
Can be solid or cystic
malignant tend to be solid

27
Q

Discuss the staging of ovarian cancer

A

pT1- growth limited to ovaries
pT2- growth involving ovaries and pelvis
pT3 Growth involving ovaries and mets to abdominal peritoneum and or regional nodes
pT4- ovaries and distant mets- liver ect

Most tumours present at stage 3 by the time they are picked up 25% chance of 5 yr survival

28
Q

What investigations are conducted in ovarian cancer and what treatment is given

A
  • Risk of malignancy index - Menopausal status -Serum CA125 -USS findings
  • Hard to biopsy an ovary and reluctance to biopsy incase tumour spills into pelvis

Treatment
Total hysterectomy or BSO (both tubes and ovary removed)- omentum also removes as this is where the tumour first spreads
-Peritoneal washings or ascitic fluid- sent for pathological examination
-Younger women if they want to stay fertile can do unilateral sapling-oophorectomy- remove rube and ovary with tumour in it
-Chemo after stage 1C

29
Q

What are the features of secondary ovarian carcinomas

A

Common site for mets from

  • other gynaecologist malignancies
  • Colorectum
  • Pancreas and biliary tree
  • Stomach
  • Breast
  • Often they are bilateral
30
Q

What are the main features of a germ cell tumour in the ovary

A
  • benign cyst teratoma (dermoid cyst)- most common, tissue comes from all 3 germ layers- has skin, teeth, hair etc, rarely get secondary malignant transformation, rare but occur in young people
  • Immature teratoma- - very young girls and quite rare - immature elements that make the tumour malignant
  • Teratoma with malignant transformation
  • Yolk sac tumour (serum alpha fetoprotein)- aggressive but responsive to chemo
  • Dysgerminoma- like testes seminoma
  • Choriocarcinoma (serum HCG)-rare
31
Q

Discuss the features of a sex cord stromal tumour

A
  • Uncommon
  • Middle aged
  • Hormone secreting (hormone symptoms)
  • Benign and malignant variants
32
Q

Discuss the features of a fibroma

A
  • Benign ovarian neoplasm

- Associated with ascites and or pleural effusion

33
Q

Discuss the features of a granuloma cell tumour

A

A variant of the ovarian sex cord stromal tumour
middle aged or elderly
low grade malignant
Recurrence and mets can happen 15-20 yrs later
Follow up with serum inhibin levels

34
Q

What are the features of follicular and corpus luteum cysts

A
  • Common
  • Reproductive years not during menopause
  • Aymptomatic
  • Associated with symptoms eg pain
  • Often multiple
  • Usually resolve spontaneously
35
Q

Discuss polycystic ovary syndrome

A
  • Young women
  • Hyperandrogenism (hirsutism- facial hair deep voice)
  • Amennorrhoea
  • Infertility
  • Histology- multiple cysts of follicular derivation mainly outside or in cortex of ovary
  • May get endometrial hyperplasia or carcinoma - androgens released in this syndrome are converted in peripheral blood to oestrogens
36
Q

Discuss polycystic ovary syndrome

A
  • Young women
  • Hyperandrogenism (hirsutism- facial hair deep voice)
  • Amennorrhoea
  • Infertility
  • Histology- multiple cysts of follicular derivation mainly outside or in cortex of ovary
  • May get endometrial hyperplasia or carcinoma - androgens released in this syndrome are converted in peripheral blood to oestrogens
37
Q

Discuss the features of endometriosis

A
  • It is the Extra-uterine version of adenomyosis (endometrial glands present in stroma and myometrium)
  • Common sites are ovary, POD, fallopian tube and peritoneum
  • Less common sites= bladder, intestine, lung
  • Usually in reproductive yrs

Presentation

  • Cyclical pelvic pain- due to menstrual bleeding gin the ectopic endometrium sites
  • Abnormal uterine bleeding
  • Infertility- bleeding may cause fibrosis and scarring of ovary
  • Haematuria if in bladder

Main pathophysiology theory= retrograde theory
When patient menstruates some endometrium refluxes and foes down through the fallopian tube, ovary and peritoneum - would explain the most common sites for the illness

Pathology (12 decks)

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