what is the key histological description for endometrial clear cell carcinoma?
what are some risk factors for developing endometrial cancer?
chronic anovulatory cycles nulliparity PCOS, obesity LYNCH SYNDROME and or other positive FMH of endometrial cancer unopposed E2 therapy
what are the 3 broad grades of epithelial ovarian neoplasms?
which HPV subtypes are the 'high risk' subtypes?
16 and 18
describe vulvular lichen sclerosis
Analogue to balantitis XO
Can be associated with HPV --> differential VIN
Pruritic, dry scaly lesion
Autoimmune condition usually
what is the common name for leiomyoma?
what HPV subtypes are associated with condyloma acuminatum?
HPV 6 or 11 (low risk subtypes)
what is the most common type of cervical cancer?
if you looked at the histology of leiomyosarcoma, what would you see?
dense spindled appearance of smooth muscle cells
what is the most common type of endometrial cancer?
what is the pathology?
this is a cervical biopsy
on the left hand side there is full thickness atypia--> HSIL
right hand side = normal
what is the difference between 'squamous intraepithelial lesions' (SIL) and 'intraepithelial lesions' (IN suffix) when referring to lower genital tract neoplasia in women?
SIL refers to HPV related dysplasia whereas IN means the neoplastic change is NOT related to HPV infection
what does gestational trophoblastic disease refer to?
Gestational trophoblastic disease (GTD) describes a group of tumours that arise from the fetal trophoblast.
Tumour of the placenta due to abnormal conception of sperm and egg
what is the aim of cervical cytology?
to detect cervical changes at a pre-cancerous dysplasia stage
what are the features of dysplasic squamous epithelial cells on cervical cytology?
high nuclear to cytoplasmic ratio
enlarged dark nuclei
what is the hallmark histological feature of chronic endometritis?
what syndrome is associated with endometrial cancer?
what must you consider if you find malignant tumours in both ovaries?
metastatic cancer from elsewhere e.g. GIT, endometrium etc
what is the difference between the appearance of a VIN (vulval intraepithelial neoplasia) lesion and a vulval condyloma?
VIN is flat whereas a condyloma is not
what is the histological diagnostic criteria for endometriosis?
how might a woman with complete hyatidiform present?
increased uterus size for dates
hyperemesis gravidarum +++
common in asian ethnicity
what are the genetic risk factors for developing ovarian cancer?
BRCA 1 and BRCA 2
what is choriocarcinoma, and how do we treat it?
choriocarcinoma is a type of invasive gestational trophoblastic disease
you can treat it effectively with chemotherapy such as methotrexate
what are the risk factors of a molar pregnancy?
previous molar pregnancies
extremes of age (less than 20, greater than 40 yrs)
what is your management plan of a lady who has been diagnosed with a molar pregnancy?
Remove molar pregnancy
Monitor bHCG levels!! up to 6 months
encourage her to be on the GTN mole registry
encourage her to use contraception until bHCG normalise
If bHCG levels persists--> consider persistent trophoblastic disease.
This may indicate that the molar products may have embedded into other organs i.e. choriocarcinoma
where do we normally see metastases for choriocarcinoma?
lung and ovaries
What is the chromosomal differences between complete and partial molar pregnancy and their malignant potential
Complete molar pregnancy occurs as a result of fertilisation of an empty ovum with either two sperm or one that divides. The karyotype is generally 46XX (occasionally 46XY) and all of paternal origin.
Partial molar pregnancy results from the fertilisation of an ovum with two sperm or one that divides resulting in triploidy 69XXY, 69XXX or, rarely, 69XYY. (maternal and paternal) There is often a co-existing fetus that is prone to fetal death in utero and growth restriction.
Partial moles have a much lower malignant potential 2-4% whereas 20% chance complete moles becomes malignant
what are the histopathological features of hyatidiform mole?
avascular hydropic (oedematous) chorionic villi
describe the transitional zone of the cervix?
zone of metaplasia as columnar epithelium of everted cervix becomes stratified squamous epithelium as it is exposed to the acidic environment of the vagina
what is a condyloma?
papillomatous warty lesions of the cervix caused by HPV infection.
describe the histological classification of cervical cancer?
CIN 1= low grade
CIN 2, CIN 3= high grade
describe the changes to the future cervical screening program?
Starting from 2017, women will be screened every 5 years for cervical cancer rather than every 2 years. The clinician still needs to take cells from the cervix, but instead, will send the cells to a laboratory for liquid based cytology. This type of technology can also detect HPV infection and also screen for high risk genotypes, and is more sensitive at picking up early cervical changes.
Any woman with signs or symptoms suspicious of cervical pathology can be screened at any time.
Screening program will target women between 25-75yrs of age
describe the process of a colposcopy?
A colposcopy is a procedure performed when a pap test result is abnormal. The clinician will use a special pair of binoculars/microscope to look at the cervix and analyse for any abnormal cervical change.
The procedure will involve the insertion of a speculum into the vagina to view the cervix, and a repeat pap smear. Acetic acid/vinegar is then applied, and then iodine as well to allow the clinician to differentiate between abnormal and normal cells of the cervix.
Depending whether the cells appear abnormal, a punch biopsy may be required
a woman comes into gynae clinic for a colposcopy after having an abnormal pap smear. on colposcopy, the clinician determines that it is a low grade lesion, most likely CIN1. what is the management?
repeat cytology in 12 months
what are the two types of excisional therapies used for cervical lesions (CIN 2,3)?
loop wire excision (LEEP)
what is a consideration of performing a cone biopsy on a young woman with CIN 2/3 cervical lesion?
increased risk of cervical incompetence
implications for future desire for pregnancy
a woman with confirmed HSIL is treated. what is the management post HSIL treatment?
Perform follow up pap test and repeat colposcopy 4-6 months after treatment.
If negative, pap test and HPV test should be performed at 12 months post treatment, and then annually until both pap and HPV test are negative. At this point, the woman can go back to two-yearly screening (currently, this will change in 2017)
a woman has a pap test and the results are sent off to LBC (liquid based cytology) as per new 2017 guidelines. The lab picks up HPV 16,18 infection and notifies you, her GP. What do you need to do now?
Refer her for a colposcopy regardless of the LBC results bc she has high risk HPV genotypes
a woman comes in complaining of vulvar pain. what are your differentials?
intimate partner violence/assault/trauma
bartholin duct abscess
aphthous ulcers on vulva
what do we mean by 'usual VIN' and 'differentiated' VIN?
VIN usual type (HPV-related)
VIN differentiated (dermatosis-related).
what are two cancers that we can find in the vulvar area?
extramammary Paget's disease
what are the two subtypes of endometrial cancer which have the worst prognosis?
papillary serous endometrial cancer
clear cell endometrial cancer
what do we mean by a 'chocolate cyst' in gynaecology?
another name for endometrioma
which is a blood filled cyst found on the ovaries as a result of endometriosis
what is uterine artery embolisation?
interventional radiologist uses catheter via femoral artery to deliver particles that block blood supply to the uterine artery--> used for treating large fibroids
what does subserosal fibroids mean?
fibroids projecting into the peritoneal cavity
why might GnRH agonists be used for fibroids? what is the main side effect of this drug?
reduces the size of fibroids prior to myomectomy
can help with symptoms and also make laparoscopy more likely
main side effect to consider- induces menopausal like state in the woman
how do we biopsy endometrial lining?
hysteroscopy D and C usually
some countries use pipelles
which lymph nodes may be involved in cervical cancer?
Lymphatic spread is first to the parametrial nodes lateral to the cervix, and then to the internal iliac, obturator and external iliac nodes. Spread then occurs to the common iliac nodes and paraaortic nodes.
what are the clinical features/symptoms of complete hyatidiform mole?
Hyperemesis gravidarum +++
Larger for dates, soft uterus
Early onset preeclampsia
Vaginal blood loss
how is partial mole usually diagnosed?
Silent miscarriage- molar pregnancy often diagnosed via histological analysis of passed products of conception
how does untreated choriocarcinoma spread through the body?
Spread of the disease most frequently
occurs locally in the pelvis and by haematogenous
spread, notably affecting the liver, lungs and brain
describe the process of colposcopy
Colposcopy is an examination of the cervix and lower genital tract with a low power, stereoscopic microscope with an attached light source.The cervix and vagina are cleaned of any blood and debris with normal saline, and, after inspecting the cervix and vagina, a dilute 3–5% solution of acetic acid is applied to the cervix. Acetic acid dehydrates the cells and causes a reversible coagulation of the nuclear proteins. Characteristic acetowhite epithelial changes will occur in cells rich in proteins such as dysplastic cells. Significant acetowhite features include intensity or colour tone, margins and surface contour, and vascular changes. A solution of Lugol’s iodine may be applied, being taken up by glycogen-rich cells and leaving dysplastic and immature cells as iodine negative
how might we remove an endometrial polyp?
hysteroscopy and then resection of polyp with loop diathermy
why are most solid ovarian masses removed even if they are benign e.g. dermoid cyst?
Risk of malignancy
Risk of ovarian torsion
what can we do for a woman with known BRCA mutation to reduce her risk of developing ovarian cancer?
Surgical prophylaxis may be offered to high risk women with BRCA mutations- bilateral salpingoophrectomy
how might we screen for ovarian cancer?
no effective screening test available
what are some protective factors for ovarian cancer?
what is the difference between radical vs simple hysterectomy?
radical= removal of uterus, parametrium, cervix and upper part of the vagina
simple hysterectomy= removal of uterus and cervix
describe the 4 stages of cervical cancer
Stage I - The cancer is found only in the cervix.
Stage II - The tumour has spread beyond the cervix and uterus to the vagina or other tissue next to the cervix (parametrium)
Stage III - The cancer has spread right out to the sidewall of the pelvis or has blocked a ureter (the tube carrying urine from the kidney to the bladder)
Stage IV - The cancer has spread to the bladder or rectum, or beyond the pelvis to other organs including the lungs, liver or bones.
a lady has a colposcopy which shows grade 1a cervical cancer. what needs to be done?
cone biopsy. if cancer is within surgical margins then you can leave it as that, but if it extends past the margins then a hysterectomy and pelvic lymph node dissection is recommended.
other options that are fertility sparing = cone biopsy + pelvic lymphadenectomy or trachealectomy