46 - Diseases of the female genital system

Question 1

VIN stands for

Answer 1

Vulval intraepithelial neoplasia

Question 2

CIN stands for

Answer 2

Cervical intraepithelial neoplasia

Question 3

CGIN stands for

Answer 3

Cervical glandular intraepithelial neoplasia

Question 4

VaIN stands for

Answer 4

Vaginal intraepithelial neoplasia

Question 5

AIN stands for

Answer 5

Anal intraepithelial neoplasia

Question 6

HPV virus - genetics and lifecycle

Answer 6

Double stranded DNA virus
Circular genome - 7 early genes, 2 late genes

> 100 subtypes
Different types over different tissues

Genital HPVs grouped into low and high oncogenic risk

Question 7

Low risk HPV numbers

Answer 7

6, 11 - linked with genital warts are most common

Question 8

High risk HPV numbers

Answer 8

Associated with high grade pre-invasive and invasive disease: 16, 18

Question 9

Low risk HPV 6,11

Answer 9

Lower genital tract warts

Low grade intraepithelial neoplasias which rarely form lesions

Question 10

High risk HPV 16, 18

Answer 10

High grade ‘IN’s and invasive carcinomas

Question 11

Low risk vaccine called

Answer 11

Gardasil

Question 12

High risk vaccine called

Answer 12

Cervarix

Question 13

High risk HPV - mode of action

Answer 13

Integrates into host chromosomes

Upregulates E6, E7 expression which inactivates p53 and binds to RB1 gene product

Question 14

What does p53 do?

Answer 14

Mediates apoptosis in response to DNA damage which leads to accumulation of genetic damage

Question 15

What does RB1 do?

Answer 15

Tumour suppression gene controls G1/S checkpoint in cell cycle

== dysregulation of cell proliferation

Question 16

How are VINs stained?

Answer 16

Toluidine blue

Question 17

Vulval intraepithelial neoplasia - histology

Answer 17

Classical / warty / baseloid:
Graded VIN 1-3
Related to HPV
In young people

Differentiated:
Not graded
Not HPV related
Occurs in chronic dermatoses
Older people

Question 18

Behaviour of VIN

Answer 18

50% recur

Progression to invasive carcinoma is 4-7% in treated women and 87% in untreated

Question 19

Most common vulval cancer is

Answer 19

Squamous cell (90%)

Question 20

Squamous cell carcinoma in

Answer 20

Associated with VIN

Question 21

Squamous cell carcinoma in >70

Answer 21

Inflammatory dermatoses in age>70

Due to lichen sclerosus and lichen planus

Question 22

Lymph nodes mets rely on what in vulval squamous cell carcinomas

Answer 22

Depth

4mm = 40%

Question 23

Malignant melanoma of the vulva

Answer 23

5% of vulval cancers
Mean age 50-60
Local recurrence in 1/3
Spreads to urethra
Lymph node/haematogenous spread common
Depth of invasion correlates with lymph node involvement

Question 24

Other vulval tumours

Answer 24

Paget’s disease

Question 25

Paget's disease

Answer 25

Usually no underlying tumour | 5% regional malignant disease - bladder, cervix, rectal

Question 26

What happens to the external os in a post menopausal state?

Answer 26

Transitional zone retracts up the canal and pulls up external os

Question 27

What do cervical screening programmes aim to find?

Answer 27

Cervical intraepithelial neoplasia To find pre-invasive stage of cervical squamous cell carcinoma

Question 28

How many CIN types are there?

Answer 28

3

Question 29

Which CIN type is most likely to become invasive?

Answer 29

CIN 3

Question 30

What do you do if low grade dyskaryosis is found on screening?

Answer 30

HPV screening, if positive, refer to colposcopy + Rx -ve = normal recall

Question 31

What is you have high grade dyskaryosis found on screening?

Answer 31

Refer to colposcopy + Rx

Question 32

What is colposcopy?

Answer 32

Examination of cervix with low powered stereoscopic microscope

Question 33

What does LLETZ stand for?

Answer 33

Large loop excision of the TZ

Question 34

What stain is used in colposcopy?

Answer 34

Acetic acid which highlights abnormal epithelium

Question 35

Risk factors for cervical squamous cell carcinoma

Answer 35

``` High risk HPV is most causative Multiple sexual partners Male partner with multiple partners Young age at first intercourse High parity Low socioeco Smoking Immunosuppression ```