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Y3- TO LEARN > Gynaecology + Breast > Flashcards

Gynaecology + Breast Flashcards

1
Q

What is ‘strawberry vagina’?

A

Trichomoniasis

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2
Q

Metrorrhagia?

A

Regular intermenstrual bleeding

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3
Q

Polymenorrhoea?

A

> 21 day cycle

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4
Q

Oligomenorrhoea?

A

> 35 day cycle

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5
Q

Amenorrhoea?

A

No bleeding >6 months

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6
Q

Some organic causes of menorrhagia?

A 
Fibroids
Polyps
Cervical erosion
Endometrial Hyperplasia
IUD/IUS
Pelvic Inflammatory disease
Endometriosis
Carcinoma
Trauma
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7
Q

Some systemic causes of menorrhagia?

A

Adrenal disease, hyper/hypothyroidism, diabetes, prolactin disorder
Drugs
Liver diseases
Renal diseases

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8
Q

Name a non-organic cause of menorrhagia?

A

Absence of pathology–> Dysfunctional Uterine Bleeding (DUB)

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9
Q

How is DUB divided up?

A

Anovulatory (85%)

Ovulatory

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10
Q

Diagnosis of DUB?

A

Exclusion of other causes

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11
Q

Age and period cycle of anovulatory DUB?

A

Extremes of reproductive age
Irregular cycle

(more common in obese women)

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12
Q

Age and period cycle of ovulatory DUB?

A

35-45 years
Regular heavy periods
(due to inadequate progesterone)

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13
Q

Investigations of DUB?

A

FBC, Hb, coag screen, TSH, LFTs and renal function
Cervical smear
Transvaginal USS
Endometrial sampling

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14
Q

Management of DUB?

A 
Merina IUS/oral contraceptive
GnRH analogues
NSAIDs
Endometrial resection/ablation
Hysterectomy
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15
Q

Which cells secrete progesterone during folliculogenesis?

A

Granulosa cells

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16
Q

What is formed from a secondary follicle?

A

Graffian follicle

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17
Q

What does the follicle form after ovulation of the new oocyte?

A

Corpus Luteum

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18
Q

What lines the fallopian tubes?

A

Simple columnar epithelium + some ciliated cells and secretory cells

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19
Q

What is the endometrium made of?

A

Tubular secretory glands

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20
Q

What is the myometrium made of?

A

3 layers of smooth muscle with collagen + elastic

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21
Q

What is the perimetrium made of?

A

Loose connective tissue

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22
Q

What is the cervix covered by and what does it transition to?

A

Stratified squamous epithelium
Transitions to:
Simple columnar epithelium

+ mucous secreting glands

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23
Q

What is common at the transition zone in the cervix?

A

Cervical cancers

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24
Q

What is the outer layer of the vagina?

A

Non-keratinised stratified squamous epithelium

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25
Q

What is the use of glycogen in the cells in the vagina?

A

Glycogen metabolised to lactic acid to INHIBIT PATHOGENIC BACTERIA

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26
Q

What kind of glands are present in the labia majora?

A

Apocrine sweat glands and sebaceous glands

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27
Q

What kind of gland are present in the labia minora?

A

Sebaceous glands

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28
Q

What is the most common approach to treatment of psychosexual dysfunction?

A

Psychodynamic psychotherapy

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29
Q

Consideration before vasectomy?

A

Age >30
Offspring
Medical conditions

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30
Q

How does female sterilisation work?

A

Blocks fallopian tubes

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31
Q

Effective treatment of premenstrual pain and dyspareunia in endometriosis?

A

Combined oral contraceptive

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32
Q

Which hormone is used to measure ovarian reserve before IVF?

A

Anti-mullerian hormone (AMH)

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33
Q

What forms the indifferent gonads in embryological development?

A

Genital ridges form primitive sex cords

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34
Q

What is another name for the Mesonephric duct?

A

Wolffian ducts

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35
Q

What is another name for the Paramesonephric duct?

A

Mullerian ducts

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36
Q

When does sexual differentiation occur?

A

Week 7 onwards

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37
Q

What triggers male development?

A

SRY (sex determining region of Y) transcription factor

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38
Q

How does the Y chromosome produce a male?

A

Sex determining region causes development of testes

Testes secrete testosterone and mullerian inhibiting factor

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39
Q

What do the male genital tracts arise from?

A

Wolffian ducts

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40
Q

What do the female genital tracts arise from?

A

Mullerian ducts

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41
Q

What are the 3 parts of the uterine cycle, and how long do they last?

A

Proliferative- day 1-14
Secretory (luteal)- day 16-28
Menstruation- day 1-3

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42
Q

What happens in the proliferative stage of the uterine cycle?

A

Oestrogen causes growth of glands, stroma and vasculature

Increased thickness

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43
Q

What happens in the secretory stage of the uterine cycle?

A

Progesterone causes glands to become more torturous with lumenal secretions

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44
Q

When sending an endometrial biopsy to the lab, what information is all important to give?

A

Date of last period and drug list

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45
Q

What is trans-vaginal ultrasound typically used to assess?

A

Endometrial thickness

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46
Q

What is normal endometrial thickness?

A

<16mm in pre-menopausal

<4mm in post-menopausal

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47
Q

What is the most common for endometrial sampling?

A

Dilatation and curretage

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48
Q

How does endometritis occur?

A

Failure of cervical mucous plug to protect from ascending infection

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49
Q

When are endometrial polyps most common?

A

Around/after menopause

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50
Q

What is adenomyosis?

A

Endometrial glands and stroma with myometrium

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51
Q

What is atrophic vaginitis?

A

Lack of oestrogen causes loss of lubrication, thinning and decreased elasticity

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52
Q

Symptoms of atrophic vaginitis?

A

Burning pain
Itch
Painful intercourse
Discharge

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53
Q

Treatment of atrophic vaginitis?

A

Topical oestrogen creams

HRT

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54
Q

What state does the bladder need to be in for transabdominal and transvaginal USS?

A

transabdominal- full

transvaginal- empty

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55
Q

4 indications for CT?

A

Acute abdo pain
Post-surgical complications
Staging gynae cancers
Response to treatments

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56
Q

What is hydrosalpinx?

A

Blocking of fallopian tube with fluid or serous

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57
Q

What is a hysterosalpingography (HSG) and what is it used for?

A

Real time X ray

Assesses tubal patency

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58
Q

Stress UI?

A

After effort or exertion or on sneezing/coughing

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59
Q

Urgency UI?

A

Accompanied by urgency- due to overactive detrusor muscle

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60
Q

Causes of incontinence?

A 
Age
Parity
Pregnancy
Smoking
Obesity
Menopause
UTI
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61
Q

Investigations of incontinence?

A

Urinalysis

Urodynamics

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62
Q

Management of incontinence?

A 
Reduce caffeine, alcohol, fluids
Weight loss
Pelvic floor exercises
Bladder retraining
Anti-muscarinics
Mirabegron (relax bladder)
Desmopressin
Botox injection
Topical oestrogen
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63
Q

Name some anti-muscarinics used in incontinence?

A

Oxybutynin

Tolterodine

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64
Q

Specific management of stress UI?

A

Physio
Pessary
Bladder neck bulking agent
Autologous sling (surgery)

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65
Q

How common is pelvic prolapse in parous women?

A

50%

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66
Q

Causes of pelvic prolapse?

A 
Age
Obesity
Parity/vaginal delivery
Chronic constipation
Oestrogen deficiency (menopause)
Connective tissue disorder
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67
Q

Important history in pelvic prolapse?

A

Pressure/dragging
Urinary/bowel symptoms (e.g. incomplete emptying)
Sexual dysfunction
Obs Hx

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68
Q

Types of prolapse? (4)

A

Anterior (cytocele)- bladder through vagina
Middle/apical (vault/enterocele)- vaginal/small bowel prolapse
Posterior (rectocele)- bowel through vaginal
Complete eversion- all compartments

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69
Q

Assessment of prolapse?

A

POP-Q

USS/MRI

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70
Q

Management of prolapse?

A 
Weight loss
Pelvic floor exercises
Pessaries- for mild/moderate or elderly
Rings/cubes- for young, sexually active
Shelves/Gelhorn- severe, not sexually active
Surgery
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71
Q

What is climacteric?

A

Start of symptoms leading up to menopause

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72
Q

What is menopause?

A

Last ever menstrual period- due to oestrogen deficiency

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73
Q

What is the average age of menopause?

A

51 years

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74
Q

How is early menopause defined?

A

<45 years

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75
Q

How is premature menopause defined and causes?

A

<40 years

Causes: chemotherapy, infections (e.g. mumps), oophorectomy, Turner’s, autoimmune disorders)

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76
Q

How is late menopause defined?

A

> 54 years

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77
Q

Symptoms of menopause?

A 
Hot flushes
Night sweats
Mood swings/Irritability
Palpitations
Joint aches
Headaches
Vaginal dryness
Decreased libido
Atrophy of breast
Dry skin/hair
Urinary symptoms of incontinence
May have dysfunctional bleeding
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78
Q

Diagnosis of menopause?

A
  1. Symptoms
  2. Pattern of periods
  3. Bloods
    - in women <45, hysterectomy, or merina coil
    - FSH + LH levels
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79
Q

Management of menopause?

A 
Increase calcium (osteoporosis)
Weight loss
Exercise
Decreased caffeine
HRT (O+P)- for symptoms
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80
Q

When is oestrogen only HRT used?

A

For people without uterus

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81
Q

When is topical oestrogen used?

A

In vaginal dryness

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82
Q

What is oestrogen + progesterone HRT protective against?

A

Endometrial cancer
Osteoporotic fractures
Bowel cancer

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83
Q

What is oestrogen only HRT protective against?

A

Breast cancer

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84
Q

What is there a higher risk of in oestrogen + progesterone HRT?

A

Breast cancer
VTE
CVA
Gallbladder disease

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85
Q

When should HRT be avoided?

A 
History of:
Breast, ovarian/cervical cancers
Blood clots
Heart disease
Stroke
Hypertension
Liver disease
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86
Q

When is HRT contraindicated?

A

History of VTE, stroke, angina/MI, or breast cancer

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87
Q

Most common cause of uterine mass?

A

Fibroids (cancers very rarely present with mass)

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88
Q

What is a uterine fibroid?

A

Leiomyoma (benign smooth muscle)

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89
Q

Features of fibroids?

A

Common in <40s
Often multiple
OESTROGEN DRIVEN- shrink after menopause

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90
Q

Classifications of fibroids?

A

intramural, submucous, subserous, intracavity, pedunculated

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91
Q

Symptoms of fibroids?

A 
Often asymptomatic/incidental
or
menorrhagia
pelvic mass
pain/tenderness
pressure (bowel/bladder)
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92
Q

Diagnosis of fibroids?

A

USS (homogenous smooth muscle, often multiple)

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93
Q

Treatment of fibroids?

A

Leave + monitor if asymptomatic
Hysterectomy if family complete
Myomectomy- remove fibroids
Uterine artery embolisation- cut off blood to fibroids

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94
Q

Causes of tubal swellings? (6)

A 
Ectopic pregnancy (unlikely to cause mass)
Hydrosalpinx
Pyosalpinx- emergency
Paratubal cysts- wolffian tubule remnant
Endometriosis
Salpingitis
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95
Q

3 groups of ovarian masses?

A

Cysts
Endometriosis
Tumours

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96
Q

What are follicular (functional) cysts in the ovary, and what lines them?

A

Related to ovulation- occur when ovulation DOESN’T occur- follicle turns to cyst

Lined by granulosa cells

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97
Q

What are endometriotic cysts caused by?

A

Endometriosis (endometrial glands + stroma in wrong place)

Usually behind ovaries, pouch of Douglas, uterosacral, cervix, vulva, vagina etc.

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98
Q

Features of endometriotic cysts?

A

Under hormonal control- proliferative/secretory phases

Form CHOCOLATE CYSTS when try to menstruate

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99
Q

Symptoms of endometriosis?

A 
Painful periods
Irregular periods
Premenstrual bleeding
Painful intercourse
Subfertility
Tender mass (+ nodules)
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100
Q

What does endometriosis increase the risk of?

A

Ectopic pregnancy- scarring of tubes prevent egg progression

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101
Q

What is unique about the histology of ovarian masses?

A

Can have a mixture of benign, borderline and malignant tissue all in one tumour

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102
Q

When is a mass particularly concerning: solid, or solid and cystic

A

Solid and cystic

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103
Q

Where have secondary metastatic ovarian tumours most likely come from?

A

Breast, pancreas, stomach and GI

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104
Q

When should secondary metastatic ovarian tumours be particularly considered?

A

When tumours are small or bilateral

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105
Q

Which is the most common benign ovarian tumour?

A

Epithelial

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106
Q

Classification of epithelial ovarian tumours, and which is most common? (5)

A 
Serous (common, aggressive)
Mucinous
Endometrioid (often low grade)
Clear cell (often low grade)
Brenner
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107
Q

Which ovarian benign tumour is associated with endometriosis?

A

Endometrioid

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108
Q

Which ovarian benign tumours are associated with Lynch Syndrome?

A

Endometrioid + clear cell

Have younger presentation

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109
Q

What is a dermoid cyst?

A

Benign cystic teratoma (germ cell tumour)

Can differentiate into anything- teeth, hair, thyroid etc.

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110
Q

Other than dermoid cyst, name 3 other germ cell tumours in the ovary?

A

Dysgerminoma (children/young women)
Yolk sac tumour
Choriocarcinoma

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111
Q

Clinical triad and pathological features of fibroma?

A

Clinical- pleural effusion, ascites, uterine bleeding

Pathology- looks like potato

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112
Q

Name 3 kinds of sex-cord/stromal benign epithelial ovarian tumours, and what do they produce?

A

Granulosa cell- oestrogen
Theca/Leydig cell- androgens
Fibromas

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113
Q

Risk factors for ovarian cancer?

A 
Increase age
Nulliparity
Family History
BRCA 1 +2 (breast + ovarian)
Lynch syndrome
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114
Q

What is protective against ovarian cancer?

A

ORAL CONTRACEPTIVE PILL (due to decreased number of periods)

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115
Q

How can ovarian cancer spread?

A

Into peritoneum via open fimbrae
Haematogenous
Lymphatic

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116
Q

Symptoms of ovarian cancer?

A 
Bloating
Mass, swelling, pressure
ASCITES (peritoneal spread)
Low back pain
Fatigue
Weight loss/anorexia
Heartburn
Early satiety
Bowel/bladder changes (pressure)
Leg oedema
SOB/pleural effusion
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117
Q

Investigations of ovarian cancer? (5)

A 
Tumour markers- CA125, CEA
USS
CT for spread
Biopsy/fluid aspiration cytology
Risk of malignancy score
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118
Q

What is CA125 an indication of, and why can it be raised?

A

Marker of PERITONEAL INFLAMMATION

High in 80% of ovarian cancer (+ endometriosis, peritonitis, pregnancy, pancreatitis, ascites etc.)

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119
Q

What is CEA an indication of?

A

Main function is to EXCLUDE METS FROM GI PRIMARY

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120
Q

What USS findings would make a tumour more likely be malignant?

A 
Mixture of solid + cyctic
Multi-loculated
Thick septations
Ascites
Bilateral
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121
Q

How to calculate ‘Risk of Malignancy score’ and what is normal?

A

Menopausal status x serum CA125 x USS score

Normal= <200-250

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122
Q

Staging 1-4 of ovarian cancer (FIGO)?

A

I- confined to ovaries
II- ovaries + pelvic extension
III- ovaries + peritoneal mets/LN
IV- distant mets

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123
Q

Prognosis of each stage of ovarian cancer?

A

Stages 1 + 2 are usually curable with surgery

Stages 3 + 4 are treatable but not curable

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124
Q

Treatment of ovarian cancer?

A

Laparotomy- surgical debulking + examination/staging

+ fertility conserving surgery

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125
Q

When should adjuvant chemotherapy be used to treat ovarian cancer?

A

Improve surgery outcomes as need less radical surgery

Stage IC or grade 3= use adjuvant chemotherapy

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126
Q

When should chemotherapy after surgery be used to treat ovarian cancer?

A

Stage II, III and IV

or just chemo

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127
Q

How is ovarian cancer followed up?

A

Guided by symptoms

Serum CA 125 levels

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128
Q

What does endometrial hyperplasia cause?

A

DUB or post-menopausal bleeding

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129
Q

Why does endometrial hyperplasia occur?

A

Due to persistent oestrogen stimulation

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130
Q

Features of simple endometrial hyperplasia?

A 
General process- entire endometrium
Cytology normal (often)
Common around menopause
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131
Q

Features of complex endometrial hyperplasia?

A

Focal in one part
Crowded GLANDS
Not premalignancy

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132
Q

Features of atypical endometrial hyperplasia?

A

Focal in one part
Crowded GLANDS
ABNORMAL cytology

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133
Q

Which kind of endometrial hyperplasia is pre-malignant?

A

Atypical endometrial hyperplasia

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134
Q

Management of atypical endometrial hyperplasia?

A

Hysterectomy (prevent cancer formation)

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135
Q

Peak age of endometrial cancer?

A

50-60

Uncommon <40 (lynch syndrome, PCOS etc.)

136
Q

Presentation of endometrial cancer?

A

Abnormal, post-menopausal bleeding

137
Q

Risk factors for endometrial cancer?

A 
Obesity
Lynch Syndrome
Hypothyroidism
HRT
Tamoxifen
138
Q

How does obesity increase the risk of endometrial cancer?

A

Adipocytes express aromatase- convert androgens to oestrogens= endometrial proliferation

Higher insulin levels= endometrial proliferation

139
Q

What is Lynch Syndrome?

A

HNPCC
Predispose to colorectal, endometrial and ovarian cancer
–> Yearly screening

140
Q

How does Lynch syndrome occur?

A

AD inheritance of defective DNA mismatch repair genes

141
Q

What is the hallmark of Lynch Syndrome on histology?

A

Microsatellite instability

142
Q

What kind of carcinoma are most endometrial cancers?

A

Endometrioid (+mucinous) carcinoma –> type 1 tumours

143
Q

What kind of carcinoma are type 2 endometrial tumours?

A

Serous (+ clear cell) carcinoma

144
Q

Features of serous (+ clear cell) carcinoma of endometrium and who do they affect?

A

Unrelated to oestrogen
More aggressive + high grade
TP53 mutated/overexpressed

Affect elderly post-menopausal women

145
Q

How can endometrial cancers spread?

A

To myometrium/cervix
Lymphatic
Haematogenous

146
Q

Staging 1-4 of endometrial cancer?

A

I- confined to body of uterus
II- uterus and cervix
III- uterus + peritoneal cavity/LN
IV- distant mets

147
Q

Investigations of endometrial cancer?

A

Transvaginal USS
Biopsy
CT for mets

148
Q

Treatment of endometrial cancer?

A 
Total hysterectomy + BSO
Lymph node dissection
Adjuvant radiotherapy- reduce recurrence
Adjuvant chemotherapy- for high grade
Merina coil
149
Q

What is a BSO?

A

Bilateral salpingo-oophorectomy

150
Q

Why is chemotherapy sometimes used before radiotherapy?

A

To sensitise tumour

151
Q

Side effects of radiotherapy in endometrial cancer treatment?

A 
Cystitis
N+V
Diarrhoea
Colitis
PR bleeding
Infertility
152
Q

What can the Merina coil be used in endometrial cancer treatment?

A

Young women to maintain fertility
or
If surgery contraindicated

153
Q

How is endometrial cancer followed up?

A

Screen for surgery complications
Lose weight
Patient led- signs and symptoms

154
Q

What is a leiomyosarcoma, and where does it occur?

A

Occurs in myometrium

Rare- poor prognosis
Women >50
Spindle cell morphology

155
Q

What is Bartholin’s gland abscess due to?

A

Blockage of gland duct

156
Q

What is most Vulvar and Vaginal Pathology related to?

A

HPV

157
Q

What is grade 3 VIN?

A

Squamous cell carcinoma in-situ

158
Q

What does VIN often occur with?

A

CIN + vaginal neoplasia

159
Q

VIN in young people?

A

Multifocal, recurrent, persistent

160
Q

VIN in older people?

A

Greater risk of progression to invasive squamous carcinoma

161
Q

Presentation of vulvar invasive squamous carcinoma?

A

Elderly women
Related to HPV + VIN
Ulcer/mass
Mostly low grade, can spread to inguinal LN

162
Q

Presentation of vulvar Paget’s disease?

A

Crusting rash- tumour confined to epidermis, spread lateral
May become invasive Paget’s
Contains mucin

163
Q

Cells of the endocervix?

A

Columnar epithelium (+ goblet cells producing mucin)

164
Q

Cells of the ectocervix?

A

Squamous epithelium

Nuclei become smaller as they get closer to the surface

165
Q

What is the transformational zone?

A

Squamo-columnar junction between ectocervix and endocervix

Squamous epithelium over glands= indicative

166
Q

What happens to the transformational zone throughout life?

A

Changes position (e.g. at menarche, pregnancy and menopause)

167
Q

Why is the transformational zone significant?

A

More replication and so more chance for mutations in this area

168
Q

What is cervical erosion (ectropion or eversion)?

A

Exposure of delicate endocervical epithelium to acid environment of vagina, leading to physiological squamous metaplasia (squamous grows over columnar)

169
Q

When does cervical erosion occur?

A

Hormone changes (e.g. in young women)
Oral contraceptive pill
Pregnancy

170
Q

Causes and complications of cervicitis?

A

Caused by chlamydia, herpes simplex etc.

Can lead to damage of fallopian tubes

171
Q

Which HPV causes CIN/cancer in 70% of cases?

A

16+18

172
Q

What does HPV do to cells?

A

Infects squamous cells
Takes over cell reproduction + replicates
Produce proteins to inhibit tumour suppressor genes

173
Q

What are koilocytes?

A

HPV infected squamous cells with large nuclei

174
Q

Who is at high risk of HPV? (6)

A

Many sexual partners (increased exposure)
Age at first intercourse (increased exposure)
Long term use of oral contraceptive
Not using condoms (esp. in MSM)
Smoker (x3 risk)
Immunosuppression

175
Q

Incubation of HPV before high grade CIN occurs?

A

6 months-3 years

176
Q

How long does it take to develop cancer after high grade CIN?

A

5-20 years

177
Q

Where is a cervical smear taken?

A

Transformational zone

178
Q

Difficult groups for cervical screening?

A 
Minority ethnic groups
Domestic violence/assault victims
Immigrants/travellers
Prisoners
Students
Disabled
Transgender patients
Illiteracy, deprived etc.
179
Q

When should someone be referred for colposcopy after a smear?

A

Any result over moderate dyskaryosis

180
Q

What is moderate dyskaryosis consistent with?

A

CIN II

181
Q

What is severe dyskaryosis consistent with?

A

CIN III

182
Q

What 4 steps are taken in colposcopy?

A
  1. Magnified inspection
  2. Acetic acid staining
  3. Iodine staining
  4. Biopsy or LLETZ
183
Q

Why is acetic acid used during colposcopy?

A

Abnormality appears white

184
Q

Why is iodine used during colposcopy?

A

Abnormality appears negative (no uptake of brown iodine)

185
Q

What is LLETZ?

A

Large loop excision of transformation zone- for histology

186
Q

Treatments of CIN?

A

LLETZ- excision

Cold coagulation- 100 degree probe causes cells to burst

187
Q

How is test of cure carried out for CIN?

A

Smear + HPV test after 6 MONTHS

Positive- further colposcopy

188
Q

What is CIN and where does it occur?

A

Cervical Intraepithelial Neoplasia

Pre-invasive stage of cervical cancer- at TZ

189
Q

Symptoms of CIN?

A

Asymptomatic

190
Q

Histology of CIN?

A 
Dysplasia of squamous cells
Large nuclei
Excess mitotic activity
Koliocytosis
Delay in maturation (immature basal cells)
191
Q

How is grade of CIN determined?

A

By 1/3s of epithelium affected

CIN I = 1/3
CIN II= 2/3
CIN III= 3/3 (full thickness)

192
Q

What is important to check in CIN III?

A

Basement membrane for breakthrough (one cell through= cancer)

193
Q

Prognosis of CIN?

A

Some regress, some persist, and some progress to higher grades, or to invasive cervical cancer

194
Q

When is cervical cancer most common?

A

<35 years

195
Q

When does screening for cervical cancer occur?

A

3 years- 25-49

5 years-50-64

196
Q

When is screening not appropriate?

A

If patient is SYMPTOMATIC

197
Q

Symptoms of cervical cancer?

A 
Abnormal bleeding (post coital, post menopause, inter-menstrual, brownish/bloody discharge)
Pelvic pain
Dyspareunia
Haematuria/UTI
Ureteric obstruction
198
Q

Risk factors for cervical cancer?

A

Parity
Smoking
FH/personal history

199
Q

What kind of carcinoma are 75-95% of cervical cancers?

A

Squamous carcinoma

200
Q

What does squamous cervical cancer occur from?

A

Pre-existing CIN

201
Q

Staging of squamous cervical cancer (FIGO)?

A

I- confined to cervix
II- to parametrium or top of vagina
III- to pelvic side wall or lower vagina
IV- to adjacent organs or distant mets

202
Q

At what stage are most cervical cancers found?

A

Stage 1A/B

203
Q

Prognosis for cervical cancer?

A

stage 1 -80-95% 5 year survival

204
Q

Grading of cervical cancers?

A

Well differentiated
Moderately differentiated
Poorly differentiated
Undifferentiated/anaplastic

205
Q

Where can cervical cancer spread to?

A

Lymphatic early- pelvis, para-aortic nodes

Haematogenous late- liver, lungs, bone

206
Q

Features of cervical adenocarcinoma?

A

Glandular formation
Can be mixed with squamous
Worse prognosis

207
Q

Risk factors for cervical adenocarcinoma?

A

Later onset of sexual activity,
Smoking
Higher socioeconomic class
HPV 18

208
Q

What is cervical adenocarcinoma preceded by and what is it equivalent to?

A

Cervical glandular intraepithelial neoplasia (CGIN)- adenocarcinoma in-situ

No grading- equivalent to CIN III

209
Q

First step in managing cervical cancer?

A

Planning with CT scan, PET scan or EUA

  • Identify tumour borders and affected lymph nodes
210
Q

How are cervical cancers that are confined to the cervix treated?

A

Surgery:
LLETZ
Wertheim- remove cervix, vaginal sutured to uterus
Hysterectomy

211
Q

How are cervical cancers that have spread out of the cervix treated (1B and above)?

A

Radiotherapy/chemotherapy/brachytherapy

212
Q

When is radiotherapy used in cervical cancers, and how does it work?

A

In post-menopausal/family complete

Produces free radicals to attack DNA
normal tissue recovers better than cancer

213
Q

What is brachytherapy?

A

Internal radiation treatment- intrauterine tube using a ring applicator (CT guided)

214
Q

Why is brachytherapy used? (3)

A

Greatly increases dose given
Spares dose to bladder/rectum
Reduces recurrence rate

215
Q

What might affect brachytherapy effectiveness?

A

Anaemia (need adequate blood flow)

216
Q

3 ways that chemotherapy can be used in cervical cancer treatment?

A
  1. Concomittant with radiotherapy (more radiosensitive)- routine
  2. Neoadjuvant- before definitive treatment (shrink tumour)
  3. Palliative (disease outside pelvis)
217
Q

What is cisplatin, and name some side effects?

A

Chemotherapy drug

VOMITING, pins and needles, tinnitus

218
Q

Carboplatin and paclitaxel can be used as chemotherapy for cervical cancers. What side effects do they have?

A

Renal failure
Bone marrow suppression- bleeding + neutropenia
Hair loss (paclitaxel)

219
Q

Describe breast gross anatomy?

A

Subcutaneous fat + glands in front of deep fascia and pectoralis major muscle

220
Q

In young women, what is the tissue of the breast like (compared to older women)?

A

Younger- more dense tissue

Older- more fat

221
Q

What are women with more dense breasts at higher risk of?

A

Breast cancer

222
Q

How many lobes are in the breast, and how do they drain?

A

15-25 (each with compound tubule-acinar gland)

via ducts leading to nipple

223
Q

What surrounds the secretory lobe of the breast?

A

Dense fibrous tissue (suspensory ligaments)- dermis to deep fascia

224
Q

Why does puckering/dimpling of the skin sometimes occur with breast tumours?

A

Puts pressure on the ligaments which is attached to the dermis- pull the skin inwards

225
Q

What is the TDLU of the breast?

A

Terminal Duct Lobular Unit – basic functional secretory unit

226
Q

Pathway of milk from the TDLU of the breast?

A

Terminal ductules
Intralobular collecting ducts Lactiferous ducts
Lactiferous sinus
Nipple

227
Q

What contracts to release the milk?

A

Myoepithelial cells around lobules

228
Q

Why are plasma cells present in the breast?

A

To release antibodies (IgA) into breastmilk

229
Q

What happens in the breast during pregnancy?

A

Longer + more branched ducts
Proliferation of epithelial cells
Form secretory alveoli- mature + lots of rough ER

230
Q

What happens in the breast in menopause?

A

Secretory cells degenerate- duct left only

Reduced collagen and elastic fibres

231
Q

How are lipids secreted into breastmilk?

A

Apocrine secretion- surrounded by membrane

232
Q

How are proteins secreted into breastmilk?

A

Merocrine secretion- in vesicles then exocytosis

233
Q

Which is the most common breast lump in <30s?

A

Fibroadenoma

234
Q

Which is the most common breast lump in 30-50s?

A

Cyst

235
Q

Which is the most common breast lump in >50s?

A

Breast cancer

236
Q

What is a hamartoma?

A

Benign solid mass-rare

normal breast cells, in abnormal proportion or distribution

237
Q

Symptoms of breast cyst?

A

Smooth, mobile lump
Cyclical pain
Sudden pain in rupture/bleed
Blue domed with pale fluid

238
Q

How do breast cysts occur?

A

Ducts fill with fluid quickly- system can’t absorb quick enough

239
Q

What are breast cysts associated with?

A

Menstrual abnormalities, early menarche and late menopause

240
Q

Management of breast cyst?

A

Exclude cancer
Reassure
(most resolve after menopause)

241
Q

Examination findings in fibroadenoma?

A

Painless
Firm
Smooth
Mobile (breast mouse- move away from fingers)

242
Q

How is a fibroadenoma investigated?

A

USS- solid

US core biopsy

243
Q

Management of fibroadenoma?

A

Reassure (most resolve after menopause)

Excise if growth/change

244
Q

What is fat necrosis?

A

Damage to adipocytes + inflammatory infiltration
Often due to local trauma (e.g. seatbelt)
May be associated with warfarin

245
Q

What can be seen on fat necrosis biopsy?

A

Foamy macrophages

246
Q

What is the pathology behind both sclerosing adenosis and radial scar?

A

Benign proliferation of the TDLU
Increased acini and their glands
May cause calcification

247
Q

Symptoms of sclerosing adenosis?

A

Asymptomatic
or
pain, tenderness, lumpiness/thickening

248
Q

Where are radial scars mostly found?

A

Bilateral + multiple (may cause puckering)

249
Q

What is a radial scar called what it’s >10mm?

A

Complex sclerosing lesion

250
Q

Investigations of radial scar?

A

USS- spiculations, may look like cancer

Vacuum biopsy

251
Q

Treatment of radial scar?

A

Excision

252
Q

What is duct ectasia?

A

Blocked/clogged sub-arerolar ducts causing inflammation and fibrosis

253
Q

Symptoms of duct ectasia?

A

Pain
Bloody/purulent discharge
Nipple retraction/distortion
FISTULA between duct + skin (around nipple)

254
Q

What is duct ectasia associated with?

A

Smoking

255
Q

Management of duct ectasia?

A

Treat acute infections
Exclude malignancy
Stop smoking
Excise ducts in extreme cases

256
Q

2 main causes of mastitis?

A

Duct ectasia

Lactation

257
Q

Causative bacteria in mastitis caused by duct ectasia?

A

Mixed + anaerobes

use metronidazole

258
Q

Causative bacteria in mastitis caused by lactation?

A

Staph aureus

Strep pyogenes

259
Q

Complication of mastitis?

A

Abscess

260
Q

Mastitis + breastfeeding?

A

Continue

and/or the infected breast can be pumped until the mastitis clears

261
Q

Management of mastitis?

A

Antibiotics
Percutaneous drainage
Incision and drainage

262
Q

Inflammatory changes in breast + no response to antibiotic therapy?

A

Inflammatory carcinoma

263
Q

Causes of mastalgia?

A

Mastitis
Cysts
Lump
Menstruation

264
Q

Management of mastalgia?

A

Take paracetamol
Well-fitting bra
Evening Primrose Oil
Dopaminergic agonists- e.g. Bromocriptine, Cabergoline

265
Q

Causes of nipple discharge?

A 
Physiological
Intraductal papilloma
Malignancy
Paget’s disease of the nipple
Eczema
266
Q

What is a phyllode tumour?

A

BENIGN
Slow growing unilateral breast mass- can resemble fibroadenoma
Looks like leaf in histology

267
Q

When do phyllode tumours occur?

A

40-50s

268
Q

Management of phyllode tumour?

A

Excise

prone to recur if not done fully

269
Q

Symptoms of an intraductal papilloma?

A

Nipple discharge +/- blood

or asymptomatic

270
Q

Pathology of intraductal papilloma?

A

Like skin tag inside duct
Sometimes fluid/cysts
May have nodules/calcifications

271
Q

Diagnosis and treatment of intraductal papilloma?

A

US guided core biopsy

Excise

272
Q

What is gynaecomastia?

A

Ductal growth with lobular development- not fat overgrowth IN BOYS

273
Q

Causes of gynaecomastia?

A

Result of excess oestrogen or reduced androgens:

Persistent pubertal gynecomastia - 25%
Drugs - 10-25% e.g. cannabis, verapamil, steroids, spironolactone, heroin, methotrexate, 
Obesity
Liver cirrhosis
Prolactinoma
Primary hypogonadism 
Hyperthyroidism
Kleinefelter Syndrome (47XXY)
etc.
274
Q

Treatment of gynaecomastia?

A

Often resolve spontaneously
Weight loss
Tamoxifen
Mastectomy

275
Q

In-situ breast carcinoma is a precursor of invasive cancer, confined to the basement membrane. It may be…?

A

Ductal (80%) or lobular (20%)

276
Q

Types of ductal precursor?

A

Atypical ductal hyperplasia
Ductal carcinoma in situ (DCIS)
Paget’s Disease of nipple

277
Q

What does DCIS look like on screening?

A

Enlarged ducts

MICROCALCIFICATION

278
Q

What is Paget’s Disease of the nipple?

A

High grade DCIS extending along duct to reach epidermis of nipple
(still in-situ- non invasive)

279
Q

Types of lobular precursor?

A

Atypical lobular hyperplasia- ALH (<50% of lobule involved)

Lobular carcinoma in situ- LCIS (>50% of lobule involved)
- multifocal and bilateral

280
Q

What is invasive breast carcinoma?

A

Malignant epithelial cells (from the TDLU) which have breached the basement membrane

281
Q

How many will have breast cancer?

A

1/8

282
Q

Average age of breast cancer?

A

65-69

283
Q

10 year survival of breast cancer?

A

8%

284
Q

How is breast carcinoma staged?

A

TNM staging

285
Q

Where can breast carcinoma metastases to?

A

Bone, liver, brain, lungs, abdominal viscera, ovaries, uterus

286
Q

Risk factors for breast carcinoma?

A 
Female
Increased age
Early age of menarche
Late menopause
Nulliparity
Oral contraceptive + HRT
Preview breast disease
FH (1st degree)
BRCA 1+2 mutations (tumour suppressor genes)
Alcohol
High fat diet
Smoking
Obesity (esp post-menopausal)
287
Q

Which contraceptive is contraindicated in diagnosed breast cancer?

A

Merina coil

288
Q

Name 2 protective factors for breast cancer?

A

Breastfeeding

Physical activity

289
Q

Symptoms of breast cancer?

A 
50% asymptomatic
Lump
Dimpled/depressed skim
Nipple change
Bloody discharge
Texture/colour change
290
Q

Breast cancer on examination?

A

More likely to be painless, solid/craggy, and immobile

291
Q

When is breast screening carried out?

A

From 50-70, every 3 years= mammography

more if high risk + MRI

292
Q

Breast carcinomas can express hormone receptors- what are they? (3)

A 
Oestrogen receptor (ER)
Progesterone receptor (PR)
Human epidermal growth factor receptor 2 (HER2)
293
Q

Tumours which are ‘triple negative’ have a … prognosis?

A

Very poor

294
Q

Breast carcinoma has which 2 main features on imaging?

A

Calcification

Spiculations (star-like lesion)

295
Q

Which imaging modalities are used in breast carcinoma?

A

USS= <40s
Mammogram= >40s (younger= more dense= not suitable)
or MRI

+ USS of axilla!!

CT for mets

296
Q

Why can breast screening lead to over-diagnosis?

A

Find low grade tumours that are then treated, despite would have never been systemic or symptomatic

297
Q

What is tomosynthesis?

A

3D mammogram

298
Q

Which breast problem can MRI be useful for?

A

Breast implant rupture

299
Q

What is the next stage in breast carcinoma after imaging?

A

Biopsy for cyto/histo-pathology

300
Q

Which biopsy type is most common for breast?

A

Core (needle) biopsy

301
Q

Advantage of using vacuum biopsy over core biopsy?

A

Can leave in breast until enough tissue is sampled

302
Q

Advantage of using core biopsy over vacuum biopsy?

A

Can use big needles to take out papillomas and radial scars (malignant potential) completely

303
Q

How else can a biopsy sample be tested?

A

Xray to see that area of calcification has been removed

304
Q

B1-5 classification of breast biopsy?

A 
B1- normal/unsatisfactory
B2- benign
B3- atypical, probably benign
B4- suspicious
B5- malignant
305
Q

How is the prognosis of breast cancer determines?

A

Nottingham Prognostic Index
(0.2 x tumour diameter, tumour grade, lymph node status)

<3.4 = good
>5.41= bad
306
Q

What treatment for breast cancer can be used before surgery?

A

Chemotherapy or hormonal therapy

–> Reduce need for radical surgery + smaller incisions required

307
Q

3 types of surgery for breast cancer?

A

Breast Conservation
Oncoplastic Breast Reconstruction
Mastectomy

308
Q

What is a radical mastectomy?

A

Breast tissue + axillary nodes + pectoralis major

309
Q

What does breast conservation surgery involve?

A

Wide local incision + radiotherapy

310
Q

What does oncoplastic breast reconstruction surgery involve?

A

Implant (saline/silicon- may use expander) +/- ADM (acellular dermal matrix)
or
Autologous- using own tissue
(free/pedicle flap- tissue for abdomen, back, bum, thigh)

311
Q

Advantage of autologous oncoplastic breast reconstruction surgery?

A

NO tissue rejection/allergic reactions

312
Q

Which breast surgery is best for psychological wellbeing?

A

Breast conservation

313
Q

Some finishing touches of breast cancer surgery?

A

Nipple reconstruction, lipomodelling, contralateral symmetrising

314
Q

Complications of surgery for breast cancer?

A 
Surgical risks
Delayed wound healing
Loss of nipple sensation
Infection
Recurrence
Pain
Body image
LYMPHOEDEMA- poor lymph drainage in arm
315
Q

How are lymph nodes cleared in breast cancer treatment?

A

Sentinel node biopsy (using blue dye)
Axillary level 1 + 2 clearance
Radiotherapy

316
Q

Why is radiotherapy given after surgery in breast cancer treatment?

A

To reduce rate of local recurrence

317
Q

Why is chemotherapy sometimes given in breast cancer treatment?

A

Improves 10 year survival

318
Q

When and why is ER blockade used in breast cancer treatment?

A

In tumours +ve for oestrogen receptors

- to reduce relapse

319
Q

Name the method of ER blockade used in breast cancer treatment?

A

Tamoxifen

320
Q

Side effects/complications of tamoxifen?

A

Menopausal symptoms, alopecia, anaemia

Increased risk of endometrial cancer, endometrial hyperplasia + polyps

321
Q

When should Tamoxifen be avoided?

A

Pregnancy

322
Q

When and why are aromatase inhibitors used in breast cancer treatment?

A

In post-menopausal women

For ER +ve tumours:
Blocks aromatase enzyme which converts androgens to oestrogen in adipose tissue- reduce oestrogen levels

323
Q

Examples of aromatase inhibitors?

A

Letrozole

Anastrozole

324
Q

Side effects of aromatase inhibitors?

A

Joint stiffness/pain

325
Q

When can antibody therapy be used in breast cancer treatment, and what is used?

A 
Use Trastuzumab (Herceptin) to target HER-2 receptor (over-expressed in 15% of breast cancers)
For 1 year
326
Q

Side effects of Trastuzumab?

A

Allergic reactions

Reversible cardiac failure

327
Q

When can breast angiosarcomas occur?

A

2-5 years post radiation therapy

328
Q

Which metastatic tumours are common in the breast?

A 
Lung
Ovarian
CC carcinoma of kidney
Melanoma
Leimyosarcoma
329
Q

Which type of breast cancer can also occur in men?

A

Ductal carcinoma

no lobules present in men

330
Q

Risk factors for breast cancer in men?

A 
Age
High BMI
Alcohol
Lack of exercise
High levels of oestrogen
Low testosterone
History of prostate cancer
Family history
Radiation
331
Q

Which pelvic structures drain into the para-aortic nodes?

A

Fallopian tubes
Ovaries
Uterine fundus

332
Q

Which pelvic structures drain into the inguinal nodes?

A

Vulva + vagina

333
Q

Which pelvic structures drain into the external iliac nodes?

A

Cervix

Uterine body

334
Q

Being nulliparous increases the risk of which cancer?

A

Ovarian + endometrial cancer

335
Q

Being multiparous increases the risk of which cancer?

A

Cervical cancer

336
Q

Being multiparous decreases the risk of which cancer?

A

Ovarian cancer

Y3- TO LEARN (13 decks)

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