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PATH 3500 > Female Genital Tract > Flashcards

Female Genital Tract Flashcards

1
Q

Non-neoplastic Vulvar Diseases

A

Infections (e.g. HPV)
Various dermatologic conditions

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2
Q

Neoplastic

A

Pre-cancerous changes
Cancers:
Squamous cell carcinoma (most common)
Other neoplasms (much less common)

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3
Q

Human Papillomavirus (HPV)

A

STI which infects squamous cells
Multiple HPV subtypes:

Low risk strains (e.g. 6, 11):

Condyloma (genital warts)
Rarely progress to anything concerning

High risk strains (e.g.16, 18):

Pre-cancerous changes
Cause squamous cells to proliferate (progress to cancer)

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4
Q

Risk factors of HPV

A

Behavioral based

Young age of first intercourse
Multiple sexual partners
Unprotected intercourse
Smoking

Biological based

Host factors
Immune response, etc.
Viral factors
HPV type, viral load, etc.
Weakened immune system

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5
Q

Vulvar Condyloma Accuminatum

A

Genital warts

Halo
“Raisins in a cage”
Cells grow more rapidly

In normal cells, there is a granular layer where cells fall apart (no nuclei in the keratin)
If grows too quickly, cells will fall into the keratin layer before getting rid of the nucleus

HPV-6 and HPV-11
Usually multiple
Recurrence common
30-50% associated cervical infection

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6
Q

Vulvar Intraepithelial Neoplasia (VIN)

A

Mostly squamous cell carcinoma
Preceded by pre-cancerous changes
Same as HPV risk factors

HPV associated (high risk viral strains)

Younger age
Multifocal disease
Recurrent

Non-HPV (p53 mutation)

Older age
Solitary lesions (not multifocal)
Linked to chronic inflammatory lesions
Higher risk of progression to invasion

Normal → high grade mutation (high grade VIN) → cancer
Mitosis should only be at the BASE - if this is occurring above, it is abnormal growth
You want to excise it before it progresses to cancer

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7
Q

Squamous Cell Carcinoma

A

There appear to be two distinct forms of vulvar squamous cell carcinomas that differ in pathogenesis and course.
1. The less common form is related to high-risk HPV strains and occurs in middle-aged women, particularly cigarette smokers.
a. This form is often preceded by precancerous changes in the epithelium termed vulvar intraepithelial neoplasia (VIN).
2. A second form of squamous carcinoma occurs in older women, sometimes following a long history of reactive epithelial changes, principally lichen sclerosus.
a. It is preceded by a subtle lesion, differentiated vulvar intraepithelial neoplasia (dVIN).
b. If left untreated it may give rise to HPV negative, well-differentiated, keratinizing squamous cell carcinoma.

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8
Q

Cervix

A

Lined by simple squamous epithelium
The cervix is a cylinder-shaped neck of tissue that connects the vagina and uterus.
Located at the lowermost portion of the uterus, the cervix also is the site of one of the most common cancers in women worldwide.

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9
Q

Transformation zone of cervix

A

During development, the columnar mucus-secreting epithelium of the endocervix is joined to the squamous epithelial covering of the exocervix at the cervical os.
During puberty, some columnar epithelium becomes visible on the exocervix and these exposed columnar cells eventually undergo squamous metaplasia, forming a region called the transformation zone, where tumours most commonly arise.

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10
Q

Diseases in the cervix

A

HPV infection in 99% of cases

Most HPV infections transient (can clear on their own)
Persistence in 10%
High risk HPV can integrate into host genome and drive cancer development
Cervical neoplasia preventable

HPV vaccine (main risk factor)
Condom use
Regular screening (pap smear)

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11
Q

PAP TEST

A

Transformation zone sampled

Area is more susceptible to infection

Most lesions pre-cancerous for years
Allows for early detection
Simple, inexpensive
High specificity, lower sensitivity

Not perfect for getting cells on a single test (test done periodically)

HPV DNA analysis can help guide management

PAP smear slides

Low grade squamous - raisins in a cage; squamous cells
High grade squamous - less mature cells; no cage but raisins still present; squamous cells
Adenocarcinoma - atypical columnar cells (not squamous)

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12
Q

Colposcopy Clinic for the cervix

A

High grade squamous atypia
Persistent atypia
Atypical glandular lesions
Squamous cancer

Low grade - good chance of clearing
High grade - more intensive treatment at a colonoscopy clinic

Cervical biopsy to establish diagnosis

Precancerous lesion vs. invasive cancer

Squamous cell carcinoma (90%)
Often asymptomatic; may have post-coital spotting
Conservative treatment if minimal depth of invasion

Colposcopy (local excision) for microscopic disease

Advanced cancer can cause urinary
obstruction/impairment of kidney function

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13
Q

Treatments for the cervix

A

Cone biopsy
Hysterectomy
Radiation

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14
Q

Endometrium

A

The endometrium of the uterus consists of glands and stroma which makes up the innermost lining of the uterus.

Some pathologies under hormone influence

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15
Q

Ovarian cycle phases

A
  1. Proliferative phase
    a. Actively growing endometrium
  2. Secretory phase
    a. Spike of hormones
    b. Estrogen drops off
    c. Progesterone comes in
  3. Menstrual phase
    a. Hormones drop off if not used
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16
Q

Estrogen

A

Causes Gland proliferation
Growth of the endometrial lining

17
Q

Ovulation

A

OVULATION
Occurs when ↑ progesterone → convert to secretory

If Ovulation Impaired:

Estrogenic growth stimulus continues
“Unopposed” by progesterone

18
Q

Consequences of impairing ovulation

A

Dysfunctional bleeding
Endometrial hyperplasia
Possible progression to carcinoma

19
Q

CAUSES OF UNOPPOSED ESTROGEN

A

Failure to ovulate:

Older age
Hormonal imbalances (e.g. polycystic ovary disorder)

Obesity:

Fat cells convert androgens to estrogens

Medication:

Estrogen replacement therapy without balancing progesterone
Tamoxifen for breast cancer - stimulate estrogen receptors of endometrium

20
Q

Endometrial hyperplasia

A

An excess of estrogen relative to progestin, if sufficiently prolonged or marked, can induce exaggerated endometrial proliferation hyperplasia which is an important precursor of endometrial carcinoma (25% risk for atypical cells).

Hyperplasia without atypical cells can be treated with other therapies
Cancers (cytologically atypical) require hysterectomy

Proliferating Endometrium - we begin to more glands but also more dilated glands.

Fused together and crowded

21
Q

ENDOMETRIAL ADENOCARCINOMA

A

Most common malignancy of female genital tract
Usually postmenopausal
~85% associated with hyperestrinism (high estrogen)
Cases not associated with estrogen more aggressive

22
Q

Leiomyoma (Fibroid)

A

Benign tumors that arise from the smooth muscle cells in the myometrium are properly termed leiomyomas but because of their firmness often are referred to clinically as fibroids.

Benign tumor of smooth muscle
Very common
25% of women over 30 years

23
Q

Leiomyoma symptoms

A

Depend on size, location, and number
Pain, bleeding, infertility
May be asymptomatic

24
Q

TYPES OF FIBROIDS

A

Homogenous, whitish
Submucosa, subserosa, intramural
DO NOT PROGRESS TO CANCER - COMPLETELY BENIGN

25
Q

Endometriosis

A

Endometriosis is defined by the presence of endometrial glands and stroma in a location outside the uterus.

Ectopic endometrial tissue (e.g. bowel, bladder)

Breakdown products have nowhere to go – pockets of blood
Inflammatory response, pain, inflammation, fibrosis, scarring (lead to infertility)

Very common (10% of women)
Estrogen dependent

26
Q

Symptoms of endometriosis

A

Pelvic pain, often cyclical
May be severe: nausea, insomnia, fatigue, depression
Infertility

27
Q

ENDOMETRIOSIS ETIOLOGY

A

Deposits
Cysts
Theories based on:

Deposition of endometrial (stem?) cells

Retrograde menstruation?

Breakdown products of endometrium go back up the fallopian tubes (deposits)

Circulating stem cells?

Developed or implanted there

Metaplastic transformation?

Survival and growth of seeded tissue

Alterations in the biology of the ectopic tissue
Host inflammatory response
Genetic, epigenetic, and environmental influences

28
Q

Infection (pelvic inflammatory disease)

A

COMPLICATIONS

Pelvic pain
Abscess
Infertility
Adhesions
Ectopic pregnancy
Hydrosalpinx (dilated fallopian tube)

29
Q

Ectopic Pregnancy

A

Ectopic pregnancy is defined as the implantation of the fertilized ovum outside of the uterine corpus.
Approximately 1% of pregnancies implant ectopically; the most common site is the fallopian tube.

30
Q

Types and frequencies of ectopic pregnancies

A

Tubal 95-96%
Ampullary 70%
Isthmic 12%
Fimbrial 11%
Ovarian 3%
Interstitial and cornual 2-3%
Cervical <1%

31
Q

Causes of ectopic pregnancy

A

Endometriosis
Infection
Adhesions
Idiopathic (we don’t know)

32
Q

Complications of ectopic pregnancy

A

Fallopian tube can rupture (very thin)

33
Q

Treatments of ectopic pregnancy

A

Methotrexate (drugs)
Surgery

34
Q

Ovarian Cancer

A

Egg
Germ cells
Supporting cell layer
Sex core (granulosa, theca)
Surface epithelium
Each cell type can give rise to different tumours

Some cancers (adenocarcinoma) originate from tubal epithelium cells that are deposited onto the surface
*Don’t need to know all the types, just epithelial and germ cell

35
Q

Epithelial ovarian cancer

A

65-70% of cases
Adults
Majority benign
Cancer in older
Benign Epithelial Ovarian Neoplasm: cells are not invasive

Mucinous cystadenoma
Benign cystic tumour

36
Q

Germ cell ovarian cancer

A

15-20% of cases
Young (<25 yr)
Similarities with testicular tumors
Leading cause of death from gyn malignancy (>cervix or endometrium)
Often asymptomatic, or non-specific until late stage
No specific screening test
More likely to present at an advanced stage

37
Q

Ovarian Cancer

A

Many kinds of “ovarian cancer” (epithelial, germ cell, sex cord)
High grade serous carcinoma most common (epithelial differentiation)

Collection of solid and cystic material
Friable cells → tumours

38
Q

Contributing factors to ovarian cancer

A

Risk Factors

Age
(T post-menopausal)
Genetics
- Personal history breast
cancer
- Family history ovary & breast/colon cancer (BRCA/Lynch)
Hormonal
- No children / late first
pregnancy
- Estrogen therapy (w/o
progestin)
Endometriosis

Protective Factors

Progesterone effects:

Early age of 1st pregnancy
Breastfeeding
Oral contraceptives
Progesterone infused IUD

39
Q

Tubal vs. Ovarian Origin of Ovarian Carcinomas

A

TUBAL ORIGIN (HIGH GRADE SEROUS CARCINOMA)

Most common so-called “ovarian” ca
Tubal origin for HGSC a new concept
Pre-cancerous changes in tube
Strong p53 link; BRCA link in some

OVARIAN ORIGIN (ENDOMETRIOID, CLEAR CELL, MUCINOUS, LG SEROUS)

Pre-cancerous changes in ovary
From endometriosis or epithelial inclusions
Often less aggressive than HGSC
Different genetic mutations than HGSC

OUTCOME

Only 1/3 of cases confined to ovary
Surgery ± chemotherapy
5-year survival:

I: Confined to ovary – 90%
II: Pelvic spread – 70%
III: Lymph node or abdominal spread – 40%
IV: Distant metastasis – <20%

PATH 3500 (8 decks)

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