Female Pathology Flashcards
What percentage of the breast tissue is fat?
90%
What are the two types of epithelium in the breast?
The epithelium of the breast:
- Lobules: clusters of glands that make milk during lactation
- Ducts: the plumbing that makes the milk to the nipple
What is significant about the terminal duct lobular unit?
At the tip of the duct is the terminal duct lobular unit. This is where most breast pathology and most neoplasm arise.
What are the Montgomery glands?
Montgomery glands are around the nipple and produce liquid to help lubricate the area.
Describe the role of prolactin in milk production
When a baby sucks on the nipple, prolactin is released from the anterior pituitary. There will be a neural pathway which involves the secretion of prolactin and inhibition of dopamine.
Prolactin will cause the synthesis and secretion of milk.
Describe the role of oxytocin in milk production
Oxytocin is responsible for milk let down. This will cause contraction of the myoepithelial ducts and cause milk ejection. It is released from the posterior pituitary.
Where do breasts sprout from?
Breast bud
Describe what happens to the breast during puberty
- Puberty: ducts sprout from the breast bud. In females, puberty initiates further development establishing the adult mammary gland
Describe what happens to the breast during pregnancy
- Pregnancy/lactation: increase in the number and size of lobular epithelial cells. Vacuolated cytoplasm. Secretions in lactation.
Describe what happens to the breast during menopause
- Menopause: lobules atrophic and less fibrous stroma
What are the two cell layers of the breast?
There are two cell layers in the breast:
- Luminal: lining of the duct
- Myoepithelial cells
What is significant about myoepithelial cells and malignancy?
Myoepithelial cells are important as these are lost in malignancy.
Will hyperplasia of the breast cease when the stimulus is removed?
Yes
Will malignancy of the breast cease when the stimulus is removed?
No
What is dysplasia?
Dysplasia describes tissue that is:
- Not normal
- Not invasive
It is the presence of cells or an abnormal type within a tissue, which may signify a stage preceding the development of cancer. Dysplasia is non-invasive and has no capacity to metastasise.
Dysplasia is somewhere on the pathway to becoming malignant.
The dysplasia is still within the epithelium where it arose.
What are the four categories of benign breast pathology?
- developmental
- inflammatory
- hyperplastic
- bening neoplasms
What are some examples of developmental breast conditions?
- ectopic breast tissue
- breast hypoplasia
- congenital nipple inversion
Describe ectopic breast tissue
This is the commonest congenital abnormality. It is where there is breast tissue outside the breast. Ectopic breast tissue occur when there is a failure of resolution of the milk line, which is an ectodermal thickening from the axilla to the groin. The milk line can be placed elsewhere, sometime with nipple or it is sometime just glandular material only. All other types of breast disease can happen in ectopic breast tissue.
What is the milk line?
Ectodermal thickening from the axilla to the groin
What is breast hypoplasia?
This is incomplete development of the breast
What conditions are associated with Breast hypoplasai?
This is associated with ulnar-mammary syndromes, Poland’s syndrome Turner’s syndrome and congenital adrenal hyperplasia.
Is ulnar-mammary syndrome associated with breast hypoplasia?
Yes
Is Poland’s syndrome associated with breast hypoplasia?
Yes
Is Turner’s syndrome associated with breast hypoplasia?
Yes
Is congenital adrenal hyperplasia associated with breast hypoplasia?
Yes
Describe congenital nipple inversion
Nipple inversion from birth is a benign congenital anomaly. A new nipple inversion in someone who has never had an inverted nipple may be a sign of cancer.
What are some examples of benign inflammatory breast conditions?
- acute mastitis
- granulomatous conditions
- peuidcutal mastitis
- fat necrosis
Describe Actue mastitis
This is acute inflammation of the breast and is associated with redness, swelling, pain and tenderness. This is often associated with breast feeding. It is usually a bacterial infection and the bacteria are able to invade trough small erosion and fissuring skin. The stagnant milk allow growth. Symptoms include redness, tenderness, cellulitis and risk of abscess.
Why is actue mastins associated with breast feeding?
This is often associated with breast feeding. It is usually a bacterial infection and the bacteria are able to invade trough small erosion and fissuring skin. The stagnant milk allow growth.
Describe granulomatous conditions of the breast
This is characterised by formation of granulomas. Causes include systemic granulomatous disease (for example tuberculosis and sarcoidosis), idiopathic granulomatous mastitis (when infection has been clinically excluded and treatment is steroids) and reactions to ruptured implants can be granulomatous (breast implants have a risk of bursting).
What are some causes of granulomatous conditions of the breast
Causes include systemic granulomatous disease (for example tuberculosis and sarcoidosis), idiopathic granulomatous mastitis (when infection has been clinically excluded and treatment is steroids) and reactions to ruptured implants can be granulomatous (breast implants have a risk of bursting).
What is the treatment of idiopathic breast Granulomatous?
Steroids
Describe Periductal mastitis
The central ducts become inflamed, blocked and dilated. This is associated with chronic inflammation and scarring. There is a known relationship to smoking.
Symptoms include:
- Redness, swelling, tenderness around the nipple
- Sometimes a mass underneath the nipple
- Sometimes nipple retraction
- Sometimes nipple discharge
This is one of the causes of breast abscess – along with acute lactational mastitis.
Describe fat necrosis
This is an inflammatory reaction caused by damage to the breast fat. Any sort trauma may cause it, including external trauma, previous surgery and other inflammatory condition.
What is the significance of inflammatory cancer?
Inflammatory cancer is not a type of cancer, but it is where lots of lymphatics are blocker by a tumour. The breast is diffusely oedematous red and tender. It mimic inflammatory conditions.
This is where the inflamed breast is actually cancer. It is where lots of lymphatic get blocked and there is unilateral breast tenderness.
Give some examples of hyperplastic changes in the breast
- fibrocystic change
- racial scar
Describe fibrocystic change
This is very common and has many microscopic appearances. The pathology is most likely due to an aberrant response of normal breast tissue to fluctuations in cyclical hormones. Clinically, there is a lumpy/bumpy appearance, breast pain, breast cysts and symptoms being worst before menstruation.
Microscopically, there can be:
- Small and large cysts
- Adenosis: more glands/lobular tissue (or sclerosing adenosis where the many glands are small and squashed)
- Epithelial hyperplasia: duct or lobular epithelial gets thicker and forms unusual shapes
- Apocrine metaplasia: where the epithelial cells of cysts change to look like apocrine sweat glands
What is the pathology of firbrocystic change?
Aberrant response of normal breast tissue to fluctuations in cyclical hormones
What is adenosis?
This is where there are more glands and lobular tissue
What is sclerosing adenosis?
This is where the increased number of glands becomes small and squashed
What is apocrine metaplasia?
- Apocrine metaplasia: where the epithelial cells of cysts change to look like apocrine sweat glands
What are some symptoms of fibrocystic change?
Clinically, there is a lumpy/bumpy appearance, breast pain, breast cysts and symptoms being worst before menstruation.
When are symptoms of fibrocystic change worse?
Before mensuration
Describe a Racial scar
A racial scar is a growth that looks like a scar when the tissue is viewed under a microscope.
This is important form of proliferate breast disease larger become mammographically they look like small cancers.
The features are:
- Fibrosis and elastic material at the centre
- ‘star shaped’ or ‘flower head’ appearance
- Trapped glands only ‘pseduo-infiltrative’
- Myoepithelial cells present in a way that is not seen in cancer
What are some features of a racial scar?
The features are:
- Fibrosis and elastic material at the centre
- ‘star shaped’ or ‘flower head’ appearance
- Trapped glands only ‘pseduo-infiltrative’
- Myoepithelial cells present in a way that is not seen in cancer
Are myoepithelail cells seen in a racial scar?
Yes: this is significant as myoepithelial cells are not seen in cancer
Give some examples of benign neoplasm of the breast
- fibroadenoma
- phyllodes tumour
- intraduit papilloma
Describe fibroadenoma
This is the commonest benign neoplasm and is commoner in young patients. It is often asymptomatic but can cause a lump. Fibroadenoma is the most common type of benign breast tumor, and most don’t increase your risk of breast cancer. It is a tumour of the fibrous tissue and the gland tissue.
The lump is firm but not hard and is mobile -hence called a ‘breast mouse’.
Breast cancer is rock hard, fixed and tethered.
Microscopically:
- Giant lobule: all the tissue expanded and distorted
- Ducts, glands and lots of variability cellular fibrous tissue
Rare fibroadenomas in adolescent girls may become very large (100mm+ - giant fibroadenoma). Juvenile fibroadenoma is a related entity in girls <18 years of age and often large.
Are malignant cancers fixed or loose?
Breast cancer is rock hard, fixed and tethered.
Describe the lump of a fibroadenoma
The lump is firm but not hard and is mobile -hence called a ‘breast mouse’.
Describe Phyllodes tumour
Phyllodes tumour is very similar to fibroadenoma but is commoner in older patients. They are more cellular, more mitotic and more atypical than fibroadenoma. They are fast growing masses that form from the periductal stromal cells. They are also often larger. While ALL fibroadenomas are benign only MOST Phyllodes behave in a benign fashion. SOME phyllodes are frankly malignant.
Describe intraductory papilloma
This is another relatively common benign neoplasm. It is a frond like growth usually in large ducts below the nipple. Patients will often present with nipple discharge. It benign but is often removed to ensure nothing worse lurking.
Papillomatosis is different. This is multiple papilloma’s in small ducts at the periphery of the breast. This is not dysplasia as such but does slightly increase cancer risk for the patient
What is papillomatosis?
Papillomatosis is different. This is multiple papilloma’s in small ducts at the periphery of the breast. This is not dysplasia as such but does slightly increase cancer risk for the patient
What is nipple adenoma?
This is where there are cysts alongside the nipple and can be mistake for cancer.
What is the difference between fibroadenoma and phyllodes tumour?
Phyllodes tumour is common more in older patients. They are more cellular, more mitotic and more atypical. There is a higher chance of Phyllodes tumour turning malignant.
What is the most common cancer diagnosed in women?
Breast cancer is the most commonly diagnosed cancer in women in the UK (but not the cancer with the highest mortality which is lung cancer).
How many women are diagnosed with breast cancer in the UK?
1/8
What is the age range of breast cancer?
Breast cancer is rare in women in their 20s and uncommon in the 30s. Incidence rises steadily from the later 30s to about 60, after which it does not change much.
What is the medium age for breast cancer?
Median age for breast cancer diagnosis is mid-60s.
What are some risk factors for breast cancer?
- Reproductive: early menarche, late menopause, late 1st pregnancy
- Hormonal: HRT therapy, oral contraceptive use
- Anatomical/physiological: dense breast on mammography
- Behavioural: alcohol, smoking
- Genetic: positive family history, some rare genetic conditions (BRCA 1 and 2, Li Fraumeni)
What are some reproductive risk factors for breast cancer?
Early menarche, late menopause and late 1st pregnancy (<30 years)
What are some hormonal risk factors for breast cancer?
HRT and oral contraceptive therapy
What are some anatomical risk factors for breast cancer?
Dense breast on mammography
What are some behavioural risk factors for breast cancer?
Alcohol and Smoking and obesity
What are some genetic risk factors for breast cancer?
Positive family history.
Some rare genetic (BRCA and Li Fraumeni and Cowden syndrome)
Is early menarche a risk factor for breast cancer?
Yes
Is HRT therapy a risk factor for breast cancer?
Yes
Is oral contraceptive therapy a risk factor for breast cancer?
Yes
Is a late first pregnancy (< 30 years) a risk factor for breast cancer?
Yes
What are some symptoms and signs of breast caner?
In the breast:
- Lump
- Thickening
- Skin changes: ‘peu d’organe’ (rare), redness
At the nipple:
- skin changes: rash, redness
- new inversion
- discharge: occurs when the tumour invades the duct
In the axilla:
- as a lump: the local lymph nodes for the breast are in the axilla.
What is Peu d’orange sign?
Peu d’Orange is where the skin over the lump gets dimples and resembles a orange. It will appear red and swollen.
Is pain a usual symptom of breast cancer?
No
Describe the breast screening service
Breast cancer can be discovered at breast screening. The Scottish Breast Screening Programme invites women aged between 50 and 70 years old for screening every three years.
Women over 70 years old are able to attend through self-referral.
Tumours discovered at screening are often:
- asymptomatic
- small
- lower grade and stage than symptomatic tumours
How often are women aged 50-70 called for breast screening?
Every three years
What are the characteristics of tumours discoveed in screening?
- asymptomatic
- small
- lower grade and stage than symptomatic tumours
What is the most common method for diagnosing breast cancer?
Core biopsy
What is a triple assessment?
A triple assessment is for breast cancer where pathology, radiology and examination are carried out at the same time and diagnosis can be given
Describe Wide local excision
Wide local excision: the aim is to take just the tumour with a rim of normal tissue in order to preserve the remaining breast. It usually combined with radiotherapy in order to minimise the risk of recurrence. Pathological assessment of the margins is important.
Describe mastectomy and when it must be useful
Mastectomy (removal of the whole breast) usually takes places when tumours are large, multiple or extensive. Neo-adjuvant chemotherapy can shrink some of these large tumours to make wide local excision possible.
Other tumours size, extent or location may mean that mastectomy is clinically safest.
Multiple tumours and smaller breasts, have a better outcome with mastectomy.
Describe the old and new axillary surgery
Axillary surgery is involved when the breast cancer spread to local lymph nodes via lymphatics (the ones for the breast are the axilla).
Formerly the only option was to excise all of the nodes in the axilla to ensure that all the nodes with cancer were removed. This “Axillary clearance” sometimes caused poor post op arm function or gross arm oedema. The modern alternative is Sentinel node biopsy.
Sentinel node biopsy. The sentinel node is the node that cancer will likely spread to first before it involves any other axillary nodes.
Identifying and removing the sentinel node allows pathologists to assess whether or not there is tumour in the sentinel node
Describe the process of removing the sentinel node
The removal of a sentinel node involves injecting blue ink into the breast and operating. During the operation, the surgeons will trace the dye from the breast into the first node that turns blue.
What happens when sentinel node is negative for breast cancer?
If sentinel node is negative, no further treatment is required
What happens when sentinel node is positive for breast cancer?
If it is positive, then further surgery and clearance is required. Axillary radiotherapy can be done. Treatment is stopped when oncological treatments in play mop up any residual carcinoma
When is radiotherapy given for breast cancer?
Radiotherapy: this is given to the breast following a WLE to reduce risk of recurrence. It is always given to the axilla if the positive nodes have been found.
Describe hormonal theory in breast cancer
Hormonal therapy: In tumours with high levels of residual hormone receptors (oestrogen receptor/progesterone receptor +) the use of drugs which block hormone function such as tamoxifen may be used. These are often used after surgery for ER, PR + tumours.
In post-menopausal women there is no endogenous oestrogen from the ovaries but oestrogen can be produced in soft tissue (fat etc).
Aromatase inhibitors such as Letrozole can inhibit this process in post-menopausal women and reduce recurrence after surgery.
What is the mechanism of action of Tamoxifen?
Block hormones.
- hormone positive breast cancer
Where can oestrogen be produced in post-menopsasual women
Soft tissue for example fat
What drug can be used to inhibit oestrogen production in post-menopausal women?
Aromatase inhibitor
What is Neo-adjuvant chemotherapy?
- Before surgery to reduce the size of a tumour
What is adjuvant chemotherapy?
- After surgery to reduce the risk of metastasis at a distant site. Not all patients will benefit and stratification of risk is important using various prognostic factors (grade, stage etc) to identify “high risk” tumours.
- Particularly useful in “triple negative” breast carcinoma which lack targets for the usual hormonal therapies (ER, PR, HER 2 –Negative) and are thus difficult to treat.
What are the two types of dysplastic lessons of the breast?
- Ductal carcinoma in-situ (DCIS)
- Lobular carcinoma in-situ (LCIS)
Both of these come from TDLU.
What is a dysplastic lesion of the breast?
Dysplastic represents the stage before invasive malignancy. There is malignant looking proliferation of epithelial cells within the basement membrane.
There is no extension into the breast stroma, no communication with blood vessels or lymphatics and no possibility of metastases.
Describe Lobular carcinoma in situ
Lobular carcinoma in situ (LCIS) is an area (or areas) of abnormal cell growth that increases a person’s risk of developing invasive breast cancer later on in life. Lobular means that the abnormal cells start growing in the lobules, the milk-producing glands at the end of breast ducts. Carcinoma refers to any cancer that begins in the skin or other tissues that cover internal organs — such as breast tissue. In situ or “in its original place” means that the abnormal growth remains inside the lobule and does not spread to surrounding tissues.
LCIS of less clinical concern than DCIS. It is more of a risk factor for malignancy. The person will be at a higher risk of breast cancer.
LCIS usually does not cause any signs or symptoms, such as a lump or other visual change to the breast. Doctors usually find LCIS through an abnormal mammogram.
Describe DCIS
Ductal carcinoma in situ (DCIS) is non-invasive breast cancer. Ductal means that the cancer starts inside the milk ducts.
DCIS is more significant and usually requires treatment. Up to between 14 -50 % of patients with DCIS will develop invasive cancer if left untreated
DCIS can be extensive and form a significant mass or lesion without progressing to invasive cancer. It can co-exist with invasive malignancy. It is usually treated with surgery but without axillary surgery.
DCIS generally has no signs or symptoms. It’s not common, but some women will feel a lump or have nipple discharge; but typically, DCIS is found on a mammogram.
Describe ductal carcinoma
- Around 70-80% of all breast cancer
- Also called invasive carcinoma NST – “No Special Type”
- Classic histological features of malignancy: variation in size, necrosis
What is the most common breast malignant cancer?
Ductal carcinoma (accounting for around 70-80%)
Describe lobular carcinoma
- Around 10 -15% of all breast cancer
- More likely to be Bilateral and Multifocal
- Does not have the classical features of malignancy
- Small
- Bland: the cells look the same
- Discohesive cells – loss of cell adhesion molecule E-Cadherin
What are the features of lobule carcinoma?
- small cells
- bland cells
- discohesive cells (loss of E-cadherin)
What is lost in lobular carcinoma?
E-cadherin
What are some examples of special types of breast cancer
- Papillary / micropapillary
- Tubular
- Medullary
- Mucinous
What are some cancers of the epithelium in the breast tissue?
- Sarcoma
- Lymphoma
- Malignant phyllodes
Does luminal A ER+ have a good or bad prognosis?
Good
Does luminal B ER+ have a good or bad prognosis?
No
What are the two molecular subtypes of ER+ breast cancer?
ER +
• “Luminal A” – Better prognosis
• “Luminal B” – Less good prognosis
What are the three molecular subtypes of ER- breast cancer?
Triple negative” – Her2, PR, ER all negative
• Basal Type – aggressive – includes some BRAC cancers
• Normal breast type
What is the mechanism of hercepin?
Some breast and stomach cancers have large amounts of human epidermal growth factor receptor 2 (HER2). They are called HER2 positive cancers. HER2 makes the cancer cells grow and divide.
Trastuzumab (Herceptin) is a type of targeted cancer drug called a monoclonal antibody. It works by attaching to HER2 so it stops the cancer cells from growing and dividing.
Describe the three grades of breast cancer?
- Grade 1 – slow growing
- Grade 2 – intermediate growing
- Grade 3 – fast growing
What is grade one breast cancer?
Slow growing
What is grade two breast cancer?
Intermediate growing
What is grade three breast cancer?
Fast growing
Describe the NPI calculation
Devised by Ellis and Elston in Nottingham the Nottingham Prognostic Index (“NPI”) is a way of combining grade and stage together into a single number that can be used as a shorthand to stratify prognosis.
NPI = [0.2 x S] + N + G
• Where:
• S is the size of the index lesion in centimetres
• N is the node status: 0 nodes = 1, 1-3 nodes = 2, >3 nodes = 3
• G is the grade of tumour: Grade I =1, Grade II =2, Grade III =3
What does S Stand for in NPI = [0.2 x S] + N + G ?
Size of lesion in cm
What does N Stand for in NPI = [0.2 x S] + N + G ?
Node staus
What does G Stand for in NPI = [0.2 x S] + N + G ?
Grade of tumour
What is the cervix?
This is the lower part of the vagina. It is around 2-3cm and is roughly cylindrical in shape.
Prior to puberty, what is the epithelium the ectocervix?
Prior to puberty, the ectocervix is covered by non-keratinizing stratified squamous epithelium
Prior to puberty, what is the epithelium the endoocervix?
the endocervix is lined by columnar (glandular) epithelium.
Describe the transformation zone that occurs after puberty in the cervix
With growth of the cervix after puberty the squamo-columnar junction is everted into the vagina and the squamous epithelium adapts to the vaginal environment by squamous metaplasia in the ‘transformation zone’.
Columnar cells are constantly changing into squamous cells in an area of the cervix called the transformation (transitional) zone.
Where is cervical neoplasia most likely to develop?
The transformation zone, a zone of unstable differentiations.
What virus causes HPV?
Human papillomavirus infection (HPV infection) is an infection caused by the human papillomavirus(HPV).
What are the two main cancerous strains of HPV?
16 and 18
What cancer can HPV cause?
Cancer of the oropharynx, larynx, vulva, vagina, cervix, penis, and anus
How is HPV transmitted?
Sexually transmitted infection of HPV to the stratified epithelial tissue.
Is HPV more likely to cause cancer when there is one infection of multiple infections?
Persisting infection with an oncogenic strain of HPV is thought to be a necessary cause of cervical cancer and precancer. This means that persistent and repeated infections of HPV are likely to give cancer rather than just one case.
What does the presence of dyskaryosis suggest?
CIN: cervical intraepithelial neoplasia
What is dysaryosis?
Nuclear abnormalities
Describe CIN 1
The CIN 1 grade is used to describe mild dyskaryosis, which signifies mild changes to the cervical cells. This affects only one-third of the cervical surface area. These changes definitely do not signify cancer and in the majority of cases will not cause cancer in the future. CIN1 usually corresponds to infection with Human Papilloma Virus (HPV) and will often resolve by itself within six months.
What percentage of the cervix does CIN 1 affect?
1/3
What percentage of the cervix does CIN 2 affect?
2/3
What percentage of the cervix does CIN 3 affect?
All (more than 2/3)
Describe CIN 2
A CIN 2 grade refers to two-thirds of the thickness of the surface layer of the cervix showing cell changes. It is used to describe moderate dyskaryosis and again, does not mean cancer.
Describe CIN 3
CIN 3 refers to severe dyskaryosis and affects the full thickness of the cervix surface. Even with this result, it is unlikely that a woman already has cervical cancer. However, it is important to treat severe dyskaryosis as soon as the changes are detected.
How many times should the probe be turned in cervical screening?
5-6 times clockwise
Who is screened for cervical cancer?
The current policy in Scotland is that women aged 25 -65 are invited. That is inclusive of those that have been vaccinated.
• Age 25 to 50 three yearly
• Age 50 to 65 five yearly
How many times are women aged 25-50 called for cervical screening?
Every 3 years
How many times are women aged 50-65 called for cervical screening?
Every 5 years
If the cervical screening report is negative, what is the outcome?
Routine screening
If the cervical screening report is borderline, what is the outcome?
Repeat in 6 months
If the cervical screening report is three times borderline, what is the outcome?
Refer to colposcopy
If the cervical screening report is twice low grade dyskaryosis, what is the outcome?
Colposcopy
If the cervical screening report is high grade dyskaroysis, what is the outcome?
Colposocpy
What type of cancer is CIN?
Squamous carcinoma
What type of cancer is cGIN?
Adenocarcinoma
When was the HPV vaccination introduced?
2008
- catch up programme for older girls
What strains of HPV are used in the HPV vaccination and what do they cause?
Scotland is now using a quadrivalent vaccine to cover against HPV 6, 11, 16 and 18.
Is it mostly delivered in the schools in S1.
HPV 6 and 11 are for genital warts. HPV 16 and 18 are for cancer.
Who is the HPV vaccination aimed at?
12/13 year olds
Describe the pocess of colposcopy
- Cervix visualised
- Washed with acetic acid
- Application of iodine
- Green light filter
- Abnormal area can be biopsied or treatment performed at the time or at further appointment
What is the cervix washed with in colposcopy?
Acetic acid
What kind of light filter is applied in colposcopy?
Green light
What percentage of cervical carcinomas are due to HPV?
99%
What kind of virus is HPV?
DNA
What is the effect on HPV from early genes E1 to E7?
Early genes E1 to E7 interact with intracellular molecules to interfere with cell proliferation machinery to replicate the virus.
What is the effect on HPV from late genes L1 to L7?
Late genes L1, L2 encode capsid proteins. Disruption of cell cycle checkpoints may contribute to accumulation of oncogenic mutations and carcinogenesis
What appears when there is abnormal change in the cervix when acetic acid is applied?
Whitsh appearance.
This is will get more dense as the grade increases.
What happens to blood vessel in CIN 3?
Mosaic pattern
What is the most common treatment for cervical cancer?
The most common treatment is large loop excision of the transformation. Zone. This involves removing the abnormal cells through a thin wire loop that is heated with electrical current.
What are some complications of cervical cancer treatment?
Immediate – Pain – Haemorrhage Delayed – Secondary haemorrhage (1-2%) – Infection – Cervical stenosis (~1%) – No good evidence of impact on fertility
Describe cGIM
Endocervical glandular epithelium also undergoes premalignant change-Cervical Glandular Intraepithelial Neoplasia (cGIN ).
The malignant change from glandular epithelium is Adenocarcinoma.
Signs include pseuostratification, abnormal Rosette, smaller cells and darker nuclei
What are some cervical caner symtpoms?
- Post coital bleeding (after sexual intercourse)
- Intermenstrual bleeding.
- Irregular vaginal bleeding.
- Pain.
- None.
What hormones maintains the elasticity of the vagina?
Oestrogen
What is the effect of low oestrogen on the cervix?
Low oestrogen after the menopause may lead to atrophic vaginitis with discomfort, dyspareunia, and bleeding. Polyps and cysts are not uncommon.
Are cancers of the vagina common?
VAIN and squamous carcinoma of the vagina are uncommon, but primary cancers of the cervix or vulva can involve the vagina.
Infections including bacterial vaginosis, thrush, and trichomonas vaginalis are sometimes identified in smears.
What are some examples of infections on the vagina?
Infections including bacterial vaginosis, thrush, and trichomonas vaginalis are sometimes identified in smears.
What is the histological feature of thrush?
Threads appearing.
Thrush is a fungal infection and it will cause the discharge to have a cottage cheese appearance. No smell will be present.
What is the feature of Actinomyces?
Actinomyces: this is a bacteria infection and cells appear star shaped. There is a link with this infection and the coil.
What does Actinomyces have a link with?
The coil
Are skin tags common on the vagina?
Yes
Are melanocytes nevi common on the vagina?
Yes
Are benign cysts common on the vagina?
Yes
Describe squamous cell carcinoma with vulvar intraepithelial neoplasia
- Occurs almost exclusively in females less than 60 years old.
- Associated with high incidence of lower genital tract neoplasia particularly CIN and invasive cervical cancer.
- Usually related to high risk type HPV 16/18.
- Warty or basaloid cancers.
Describe vulvar cancer (SCC associated with Dermatoses)
- Occurs in an older age group – most over 60, many over 70.
- Most of the cancers are well differentiated and keratinising.
- Not associated with HPV infection or VIN.
- Adjacent squamous hyperplasia and/or lichen sclerosus common.
What percentage of vulvar cancer is caused by HPV?
20%
What is Lichen sclerosis?
Lichen sclerosus is a skin condition that causes itchy white patches on the genitals or other parts of the body.
What is inflammation of the fallopian the called?
Salpingitis
What is Salpingitis?
Inflammation of the fallopian tube
Is Salpingitis part of the spectrum of pelvis inflammatory disease?
Yes
What is the usual cause of Salpingitis?
Bacterial infection.
- chlamydia, gonorrhoea
What is Tuberculous salpingitis ?
Tuberculous salpingitis uncommon, usually associated with tuberculosis of the endometrium.
What are some symptoms of salpingitis?
- fever
- lower abdominal pain
- pelvic pain
- pelvic masses will occur if they are distended with exudate or secretions
What are some complications of salpingitis?
Adherence of tube to ovary; tubo-ovarian abscess
Adhesions involving tubal plicae increase risk of tubal ectopic pregnancy
Damage or obstruction of tube lumen may produce infertility with may not be easy to treat
Where is there an increased risk of ectopic pregnancy with salpingitis?
There is increased risk of ectopic pregnancy. This is because the lumen is different and this can interfere with the transport of the oocyte.
Is Tubo-ovarian abscesses a complications salpingitis?
Yes
Are primary adenocarcinomas (glands) arising from the fallopian tubes rare or common?
Rare
What genetic link is there with Fallopian tube carcinomas?
BRCA1 mutations
What is a serous tubal intraepithelial carcinoma (STIC)?
• STIC: serous tubal intraepithelial carcinoma. This is a lesion limited to the fallopian tube epithelium that is a precursor to extrauterine (pelvic) high grade serous carcinoma. It is confined the epithelium. Common mutations for the type of cancer are ones related to p53.
Is STIC confined in the epithelium.
Yes
What is an example of a mutation that is linked to STIC?
p53
Describe the cortex of the ovary
This is where the follicles are
Describe the medulla of the ovaries
This is where there are vessels and connective tissue
What is ovarian stromal hyperplasia?
A non-neoplastic disorder that usually affects postmenopausal women. It is characterized by proliferation of ovarian stromal cells without evidence of atypia. There is usually bilateral ovarian involvement. The ovaries may or may not be enlarged
What are the three examples of non-neoplastic cysts in the ovary?
Inclusion, Follicular and Luteal cysts
Describe follicular cysts
A follicular cyst occurs when follicle fails to rupture and contains to grow
Describe a luteal cyst
A luteal cyst will form when the corpus lutuem fails to involute and continues to grow.
What are the hormone levels in PCOS?
• Over-production of androgens by multiple cystic follicles in the ovaries (reasons unclear); LH high, FSH low.
What is the level of LH in PCOS?
High
What is the level of FSH in PCOS?
Low
What are the macroscopic/microscopic features of PCOS?
- enlarged ovaries
- multiple subcortical cysts
- thickened, fibrotic outer surface
- cysts lined by hypertrophic. and hyper plastic luteinized theca interna
- absence of corpora luted and corpora albicans (due to ovulation not occurring)
Is insulin resistance a feature of PCOS?
Yes
What is Ovarian Adnexal Torsion
Ovarian Adnexal Torsion: this is where the ovary is twisted around its ligamentous support. Risk factors include ovarian neoplasm and cysts. Symptoms include abdominal pain, nausea, vomiting and tenderness.
What is a tubal pregnancy?
Tubal pregnancy: this is where the pregnancy is located in the fallopian tube.
How common is ovarian cancer?
5th most common cancer in women
- fifth leading cause of death in women
What there cell types are the tumours of ovaries related to?
- 1- surface (coelomic) epithelium
- 2- germ cells
- 3- sex cord/stromal cells.
What is nulliparity?
Nulliparous is the medical term for a woman who has never given birth either by choice or for any other reason.
What is the effect on the oral contraceptive pill on ovarian cancer?
Reduces risk
About 5%-10% of ovarian cancers are familial. What genes are they related to?
Mostly related to BRCA1 and BRCA2 gene mutations.
Lifetime risk of ovarian cancer is ~30% in BRCA1 carriers; lower in BRCA2 carriers.
HER2 can be over expressed in ovarian cancer. Does this have a good or bad prognosis?
Poor
• HER2 overexpressed in 35% of ovarian cancers
KRAS mutations are present in 30% of ovarian tumours. What is the most common tumour related to this mutation?
Mucinous cystadenocarcinomas.
P53 mutations are present in 50% of ovarian tumours. What is the most common tumour related to this mutation?
High grade serous cancers
What percentage of serous ovarian tumours are benign?
60%
- 25% malignant
- 15% borderline
What is endometriosis?
This is the presence of endometrial tissue outside the uterus
What is adenomyosis?
This is the present of endometrial tissue within the myometrium
What is the presence of endometrial tissue in the myometrium called?
Adenomyosis
What are some sites of endometriosis?
Ovaries Peritoneal surfaces (uterine ligaments and rectovaginal septum) Large and small bowel Appendix Mucosal of the cervix