Gynaecological and Breast Pathology Flashcards
What is screening
The process of identifying people who appear healthy but may be at an increased risk of disease or condition
What is the main aim of breast screening
To reduce mortality from breast cancer
Who is screened in the breast screening programme
50-70 years
Invited every 3 years
Mammography main tool
What is the breast triple assessment
Clinical examination (history, physical) Radiological examination (ultrasound, mammography) Pathological examination (core cut biopsy, FNAC)
How are the areas of breast triple assessment scored
P1, R1, B1: Normal P2, R2, B2: benign lesion P3, R3, B3: Atypical P4, R4, B4: Atypical, prob-malignant P5, R5, B5: malignant
Who are the members of the breast MDT
Surgeons Oncologists Radiologists Pathologists Specialist nursing team Research nurses Genetic counsellors
What are the synonyms of fibrocystic change
Fibrocystic disease Fibrous mastopathy Mammary dysplasia Schimmelbusch's disease Chronic cystic mastitis
What is fibrocystic change
Generally affects pre-menopausal women
Usually B/L and multifocal
Risk of FCC development is increased in women with hyperestogenism
No increased risk of subsequent carcinoma development
A constellation of benign, hormonally mediated breast changes including cyst formation, stroll fibrosis and mild epithelial hyperplasia without atypic
Symptoms cease 1-2 years following menopause
How does fibrocystic change present
Lumpy, premenstrually painful breasts
What is fibroadenoma
Common
Women 20-30 years
More common in Afro-caribbean women
Mobile, painless, well defined breast lump
How are fibroadenoma’s treated
Surgical excision
What is DCIS
Ductal carcinoma in situ
A malignant clonal proliferation of cells within breast parenchymal structures
No evidence of invasion
A precursor of invasive carcinoma
Most commonly identified as microcalifications on screening
Pure DCIS cannot produce metastasis
Can progress to invasion if left
What are the risk factors for breast cancer
Linked to oestrogen
Increased with early menarche, late menopause, obesity in postmenopausal women, OCP’s and normal therapy for menopause, alcohol
What should a path report tell about malignancy
In situ or invasive Type Grade Size Vascular invasion Nodal status Relationship to margins Molecular marker status
What are the main types of breast carcinoma
Ductal (75%) Lobular (12%) Tubular/cribriform (3%) Medullary (3%) Mucoid (2%) Metaplastic (1%) Others (4%)
What are the key prognostic factors
Tumour grade
Tumour size
Nodal status
What is the Nottingham Prognostic index
Grade + nodal status + 0.2 x tumour size
- 4 or less : good (80%+ 16 year survival)
- 41-5.4: moderate (46%)
- 41 +: poor (10%)
What is CIN
Cervical intraepithelial neoplasia
Dysplasia
Leads to squamous cell carcinoma
What is CGIN
cervical glandular intraepithelial neoplasia
Dysplasia
Leads to adenocarcinoma
What is VIN
Vulval intraepithelial neoplasia
Dysplasia
What is VaIN
Vaginal intraepithelial neoplasia
Dysplasia
What is AIN
Anal intraepithelial neoplasia
Dysplasia
What is dysplasia
Earliest morphological manifestation of multistage process of neoplasia
Cytological features of malignancy but no invasion
Removal is curative, if left then significant chance of developing invasive malignancy
What are the results of low risk HPV
Types: 6, 11
Lower genital tract warts (condylomata: benign squamous neoplasms), low grade INs
Very rare in malignant lesions
What are the results of high risk HPV
Types: 16, 18, 31, 33
High grade INs and invasive carcinomas
What are the HPV vaccines
Gardasil (HPV 6,11, 16,18)
Cervarix (HPV 16, 18)
What part of the cervix is vulnerable to the oncogenic effects of HPV
Transformation zone
What are the characteristics of CIN I
Regression 60%
Persistence 30%
Progression to CIN III 10%
Progression to invasion 1%
What are the characteristics of CIN II
Regression 40%
Persistence 40%
Progression to CIN III 20%
Progression to invasion 5%
What are the characteristics of CIN III
Regression 33%
Persistence ~56%
Progression to invasion 20-70%
What makes a good screening test
High sensitivity and specificity Not harmful Not too expensive Acceptable to population Define pre-invasive stage long enough to allow intervention Simple successful treatment Not a test for cancer
How are smear tests triaged
HPV triage
What is LLETZ
Large loop excision of the transformation zone
What are the FIGO staging of cervical carcinoma
I: Confined to cervix
II: Invades beyond uterus, not to pelvic side wall
III: Extends to pelvic wall, lower 1/3 vagina, hydronephrosis
IV: Invades bladder or rectum or outside pelvis
What are the treatments for each stage of cervical carcinoma
IA1, IA2: No need for radical treatment, complete excision with LLETZ
IB, IIA, IIB: Consider radical therapy with surgery or chemo or radiotherapy
III, IV: Consider palliative care, chemotherapy
What are the characteristics of Vulval squamous cell carcinoma
Associated with VIN Associated with inflammatory dermatoses Eroded plaque or ulcer Spreads locally to involve: -Vagina and distal urethra -Ipsilateral inguinal LNs Contralateral inguinal LNs, deep iliofemoral LNs
What is endometriosis
Presence of endometrial tissue at sites other than the endometrium
How do patients with endometriosis present
25% asymptomatic Dysmenorrhoea Dyspareunia Pelvic pain Subfertility Pain on passing stool Dysuria
How is endometriosis diagnosed
Laparoscopy
How is endometriosis treated
Medically (COCP, GnRH agonists/antagonists, progesterone antagonists)
Surgically (ablation/ TAH-BSO)
What are some linked issues with endometriosis
Ectopic pregnancy
Ovarian cancer
IBD
What is endometritis
Inflammation of the endometrium
How do patients with endometritis present
Abdominal/pelvic pain Pyrexia Discharge Dysuria Abnormal vaginal bleeding
How is endometritis diagnosed
Biochemistry/microbiology
USS
How is endometritis treated
Analgesia
Antibiotics
Remove cause
How do patients with endometrial polyps present
Often asymptomatic
Intermenstrual/ post menopausal bleeding
Menorrhagia
Dysmenorrhoea
How is endometrial polyps diagnosed
USS
Hysteroscopy
How is endometrial polyps treated
medical (P4/GnRH agonists), surgical (curettage)
What is endometrial hyperplasia
Excessive endometrial proliferation
What are the risk factors for endometrial hyperplasia
Obesity Exogenous E2 PCOS E2-producing tumours Tamoxifen HNPCC (PTEN mutations)
What are the types of endometrial hyperplasia
simple non-atypical, simple atypical
Complex non-atypical, complex atypical
What is the history for endometrial hyperplasia
Abnormal bleeding
How is endometrial hyperplasia diagnosed
USS
Hysteroscopy
Biopsy
How is endometrial hyperplasia diagnosed
Medical (IUS,P4)
Surgical (TAH)
What is the prognosis for endometrial hyperplasia
Endometrial adenocarcinoma
or regression
What is the malignant progression of hyperplasia
Normal - Non-atypical hyperplasia - Atypical hyperplasia - Endometrioid adenocarcinoma
What is polycystic ovary syndrome
Endocrine disorder
Hyperandrogenism
Menstrual abnormalities
Polycystic ovaries
How is PCOS investigated
USS
Fasting biochemical screen (↓FSH, ↑LH, ↑testosterone, ↑DHEAS)
OGTT
How is PCOS treated
Lifestyle (weight loss)
Medical (metformin, OCP, clomiphene)
Surgical (ovarian drilling)
What are linked issues with PCOS
Infertility
Endometrial hyperplasia
Adenocarcinoma
What is endometrial adenocarcinoma history
PMB/IMB, pain if late
How is endometrial adenocarcinoma investigated
USS
Biopsy
Hysteroscopy
How is endometrial adenocarcinoma treated
Medical (P4)
Surgery (TAH-BSO)
Adjuvant therapy (chemo-radiotherapy)
What is the prognosis for endometrial adenocarcinoma
Stage 1: 90% 5 yr survival
Stage 2-3: <50% 5 yr survival
What are epithelial tumours
Most common group of ovarian neoplasms 3 major carcinoma histological types: Serous (tubal) Mucinous (endocervical) Endometrioid (endometrium) Each type contains benign/ borderline/ malignant variants
How are the benign epithelial tumours classes
Based on components
Cystic (cystadenomas)
Fibrous (adenofibromas)
Cystic and fibrous (cystadenofibromas)
How are malignant epithelial tumours named
Cystadenocarcinoma
What are germ cell tumours
15-20% of all ovarian tumours
Types:
Germinomatous:
- Dysgerminomas (malignant, chemosensitive)
Non-germinatous:
-Teratomas (differentiation towards multiple germ layers)
-Yolk sac tumours (differentiation towards extra embryonic yolk sac, malignant, chemosensitive)
-Choriocarcinomas (differentiation- placenta, malignant, often unresponsive
How are germ cell tumours treated
Surgical
Chemo
Radiotherapy
What are sex cord stroll tumours
Can generate cells from the opposite sex:
Thecoma/fibrothecoma/fibroma:
-Benign thecomas and fibrothecomas produce E2, fibromas hormonally inactive
-Comprised of spindle cells
-Meig’s syndrome:ovarian tumour, right sided hydrothorax, ascites
Granulosa cell tumours:
-low grade malignant, produces E2
Sertoli-Leydig cell tumours:
-Produce androgens, 10-25% malignant
What is ovarian cancer risk factors
: FH, ↑age, PMH breast cancer, smoking,
E2-only HRT, Lynch II syndrome, obesity, nulliparity
What are protective factors for ovarian cancer
OCP, breastfeeding, hysterectomy
What are the ways ovarian cancer patients present
Non-specific symptoms:
- Pain
- Bloating
- Weight loss
- PV bleeding
- Urinary frequency
- Anorexia
What are the treatments of ovarian cancer
Stage <1C epithelial tumours TAH/BSO, omentectomy, appendectomy, lymphadenectomy & adjuvant chemo - chemo only in sensitive GCTs
What are leiomyoma
Uterine fibroids
Benign smooth muscle tumours of the myometrium
What is the history of leiomyoma
Often asymptomatic menorrhagia
Subfertility/pregnancy problems
How is leiomyoma diagnosed
Bimanual examination
USS
How is leiomyoma treated
Medical (IUS/NSAIDs/OCP/P4/Fe2+); non-medical (artery embolization, ablation, TAH)
What can happen as a result of infection in pregnancy
- miscarriage
- congenital anomalies
- fetal hydrops
- fetal death
- preterm delivery
- preterm rupture of the membranes
What is the key message to give mothers during antenatal counselling to avoid infections
Avoid exposure to infection during pregnancy
Get vaccinations so maternal antibodies can cross the placenta and give passive immunity to the foetus
What should the mother be screened for early stage in pregnancy
Hepatitis B
HIV
What are the in utero infections which can be transmitted from mother to baby
TORCH Toxoplasmosis Others (syphilis, HIV, Coxsackie virus, Hep B, Varicella-zoster) Rubella Cytomegalovirus disease Herpes simplex disease
What are the potential foetal consequences of TORCH infections
Abortion Stillbirth Prematurity IUGR Congenital malformations (microcephaly, intracranial calcifications)
What are the managements of intra-amniotic infections
Intrapartum antimicrobials and delivery of the foetus
Antimicrobials should be administered at the time of diagnosis not after delivery
What are the clinical features of puerperal endometritis
Fever (38.5C in first 24 h post delivery or >38.0 for 4 hours, 24 h+ after delivery), no other apparent cause identified Uterine tenderness Purulent, foul-smelling lochia Increased white cell count General malaise, abdominal pain
What is early onset neonatal sepsis
Within 72 hours
A major cause of mortality and morbidity in new-born babies
High mortality, particularly in premature and low birth weight babies
Death in 1 in 4 babies who develop it, even when given antibiotics
What is the most common bacterial infection
Streptococcal pneumoniae
What are the upper respiratory tract infections in children
Common cold
Acute tonsillitis
Acute otitis media
What is a sore throat
Any various inflammations of the tonsils, pharynx, or larynx characterised by pain in swallowing
What causes a sore throat
Viral (70-80%)
Group A beta-haemolytic streptococcus (20-30%)
How does a patient with otitis media present
Unusual irritability Difficulty sleeping Tugging or pulling at one or both ears Fever Fluid draining from the ear Loss of balance Unresponsiveness to quiet sound or other signs of hearing difficulty
What is otitis media
Inflammation of middle ear
What are the Lower respiratory tract infections
Pneumonia
Acute bronchitis
Bronchiolitis
What is bronchiolitis
Inflammation of bronchioles/small airways in children younger than 2 years
A seasonal viral illness characterised by fever, nasal discharge and dry, wheezy cough.
On examination there are fine inspiratory crackles and/ or high-pitched expiratory wheeze
What are the causes of bronchiolitis
Respiratory Syncytial Virus (RSV) Metapneumovirus Adenovirus Para-influenza virus Influenza Rhinovirus
What is the clinical picture of LRTI
Acute febrile illness, possibly preceded by typical viral URTI
Breathlessness
Irritability
Poor feeding
Sleeplessness
Cough, chest, abdominal pain in older patients
Audible wheezing is rare but can occur
How does meningitis present in children
Fever Irritability Lethargy Poor feeding High pitched cry Bulging AF Convulsions Opisthotonus
How does meningococcemia present
Fever Non-specific malaise Lethargy Vomiting Meningism Resp distress Irritability Seizures Maculopapular rash common early in disease Petechial rash seen in 50-60%
What are the symptoms of UTI
Older children:
Dysuria, frequency, urgency, small-volume voids, lower abdominal pain
Younger children:
Nonspecific symptoms
Fever, irritability, vomiting, poor appetite
