Week 6 Flashcards
1
Q
The majority of arteries in the pelvis and perineum arise from what vessel?
What are the exceptions?
A
Majority arise from the internal iliac artery
Exceptions - gonadal artery (which comes directly off the abdominal aorta at L2) and the superior rectal artery (continuation of the inferior mesenteric artery)
2
Q
Describe the anterior and posterior divisions of supply by the internal iliac artery in the male
A
Anterior
- obturator artery
- inferior gluteal artery (usually, however may come from posterior division)
- umbilical artery
- internal pudendal artery
- middle rectal artery
- inferior vesical artery
- superior vesicular artery
Posterior
- Iliolumbar artery
- Lateral sacral artery
- Superior gluteal artery
3
Q
What is the corona mortis?
Why is it important and what surgical procedure should it be carefully avoided in?
A
The corona mortis is an artery between the inferior epigastric artery and the obturator artery
It is important because, if damaged, it may go unnoticed but continue to bleed into the pelvis.
It should be kept in mind for hernia repair operations
4
Q
What are the 3 folds found on the internal aspect of the abdominal wall?
A
Lateral umbilical fold (caused by the inferior epigastric vessels)
Medial umbilical folds (remnant of the umbilical artery)
Median umbilical fold a.k.a. urachus
5
Q
Describe the arterial supply to the male perineum
A
Internal pudendal artery > perineal artery, which goes on to form the posterior scrotal artery
Internal pudenal > dorsal arteries of the penis
Internal pudendal > deep arteries of the penis (vasoconstricted in erection)
External iliac > anterior scrotal artery
6
Q
The uterine artery is a branch of the ____
The vaginal artery is a branch of the ____
A
Uterine is a branch of the anterior division of internal iliac artery
Vaginal is a branch of the uterine artery
7
Q
Describe the arterial supply of the ovary
A
Ovarian artery (directly from the abdominal aorta)
ANASTOMOSIS WITH…
Uterine artery
8
Q
Why does the uterine artery have a curved, tortuous path along the uterus?
A
Allows the artery to expand with the uterus during pregnancy
9
Q
Describe the arterial supply to the perineum in the female
A
Internal pudendal a > inferior rectal artery
Internal pudendal a > perineal artery > labial arteries
Internal pudendal a > dorsal artery of the clitoris
10
Q
What vessel do the majority of veins in the pelvis drain to?
What is the alternative?
A
The internal iliac vein and onto the vena caval circulation
Some will drain into the superior rectal vein, which drains into the portal system
Some others may drain via the lateral sacral veins into the internal vertebral venous plexus
11
Q
Regarding lymphatics of the pelvis, where do the following drain?
- Superior pelvic viscera
- Inferior pelvic viscera
- Superficial perineum
A
Superior pelvic viscera
- external iliac nodes
- on to common iliac nodes, then aortic, then thoracic duct and finally venous system
Inferior pelvic viscera
- i.e. deep perineum
- internal iliac nodes
- then on to the same as the above
Superficial perineum
- superficial inguinal nodes
12
Q
Where does the fundus of the uterus drain to?
What is important to note about lymph drainage of the pelvis? Why does this matter clinically?
A
The fundus of the uterus drains to the superficial inguinal nodes
There is a considerable degree of overlap, meaning that cancers can spread in any direction and, as such, the pattern of lymph involvement is not sufficient to predict spread
13
Q
What nodes do gonadal lymphatics drain to?
A
Aortic/caval nodes
14
Q
How does the histology of the endocervix differ to that of the ectocervix?
A
Ectocervix has numerous layers…
- exfolitating cells
- superficial cells
- intermediate cells
- parabasal cells
- basal cells
- basement membrane
While the endocervix is completely different in that it is a single monolayer of mucinous epithelium
15
Q
What is the transformation zone?
Why is it clinically relevant?
A
Squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelium
Position of TZ changes through life as a physiological response to menarche, pregnancy and menopause
The TZ is the most common site of cervcal intraepithelial neoplasia (CIN)
16
Q
What types of pathology might arise at the transformation zone?
Both benign and neoplastic
A
Benign inflammation (common)
- cervicitis - non-specific acute/chronic inflammation, usually of unknown cause, but can be caused by Chlamydia, HSV infection etc.
- cervical polyps - localised inflammatory outgrowth, may cause bleeding, not premalignant
Neoplastic
- Cervical intraepithelial neoplasia (CIN) - graded I-III
- Cervical cancer
- squamous carcinoma (most common)
- adenocarcinoma
17
Q
What is a Nabothian follicle?
A
Mucous-filled cyst on the surface of the cervix
Most commonly caused by stratified squamous epithelium of the ectocervix growing over the simple columnar epithelium of the endocervix
18
Q
What virus (specifically what subtypes) is associated with cervical cancer?
A
HPV, types 16 and 18
19
Q
Is HPV a sexually transmitted infection?
A
Not really, but it only appears in people who have been sexually active. Symptoms can occur years after being infected with the virus
The virus can be found elsewhere in the body
20
Q
CIN/Cervical Cancer - risk factors
A
Many sexual partners - increased exposure to high risk HPV types
Early age of first intercourse
Long term use of oral contraceptives
Non-use of barrier contraception
Smoking - 3x risk
Immunosuppression
21
Q
What subtypes of HPV cause genital warts?
A
6 and 11
22
Q
What criteria dictates if CIN has become cervical cancer?
A
If the abnormal cells have broken through the basement membrane, even if it is just one cell!
23
Q
How long do the following take…
- HPV infection progressing to high grade CIN
- CIN progressing to cervical cancer?
A
HPV to CIN - 6 months to 3 years
High grade CIN to cervical cancer - 5 to 20 years
24
Q
What are the key features of CIN?
A
Pre-invasive stage of cervical ca
Occurs at the TZ
Area involved can be variable
Dysplasia of squamous cells is seen (dyskaryosis)
Not visible with the naked eye, only detected on smear test
Asymptomatic
25
What are the 3 grades of CIN characterised by?
Degree of koilocytosis
CIN I - raised number of mitotic figures first third of cells from basement membrane
CIN II - mitosis in first 2 thirds
CIN III (squamous carcinoma in situ) - full thickness of koliocytosis
26
What is seen in the histology of CIN?
Delay in maturation/differentiation of basal cells
Nuclear abnormalities (hyperchromasia, increased nucleus:cytoplasm ratio, pleomorphisms)
Excess mitotic activity
27
How is invasive squamous carcinoma of the cervix staged?
Stage 1A1 - depth up to 3mm, width up to 7mm
Stage 1A2 - depth up to 5mm, width up to 7mm
Stage 1B - confined to the cervix
Stage 2 - spread to adjacent organs
Stage 3 - involvement of pelvic wall
Stage 4 - sites of distant mets/involvement of rectum or bladder/any presence of hydronephrosis
28
Invasive squamous carcinoma of the cervix - symptoms
Usually **none** early
**Abnormal bleeding** (post coital, post menopausal, contact bleeding suggesting friable epithelium, brownish vaginal discharge)
**Pelvic pain**
Haematuria/urinary infections
Ureteric obstruction/hydronephrosis (automatic stage 4)
29
What is more common - squamous carcinoma or adenocarcinoma of the cervix?
Squamous carcinoma is more common - 75-95% of malignant cervical tumours
30
What cell types are seen on histology in HPV infection?
Koilocytes
31
What are the various FIGO stages for invasive squamous carcinoma of the cervix?
1A1 - depth up to 3mm, width up to 7mm
1A2 - depth up to 5mm, width up to 7mm. Low risk of lymph node mets
1B - confined to the cervix
2 - spread to adjacent organs
3 - involvement of pelvic wall
4 - spread to distant organs/involvement of the rectum or bladder
32
Regarding spread of squamous carcinoma of the cervix, where might you see mets if spread occurred via...
- local spread
- lymphatics
- haematogenous
Local spread - uterine body, vagina, bladder, ureters, rectum
Lymphatics (early) - pelvic and para-aortic nodes
Haematogenous (late) - liver, lungs, bone
33
What is the precursor to adenocarcinoma of the cervix?
How does it compare in terms of occurrence and aggression to cervical intraepithelial neoplasia?
Is it easier or harder to diagnose than squamous carcinoma via smear?
**Cervical Glandular Intraepithelial Neoplasia** (CGIN)
**Less** common, **more** aggressive
**Harder** to diagnose on smear, meaning screening is less effective and **prognosis is worse**
34
What are some of the risk factors associated with adenocarcinoma of the cervix?
Higher socioeconomic class
**Later onset** of sexual activity
Smoking
HPV again, particularly **HPV 18**
35
Vulvar intraepithelial neoplasia (VIN) is described as being bimodal in its distribution, affecting younger women and older women.
How does the condition tend to differ in these two groups?
Younger women - often multifocal disease, recurrent/persistent and causing treatment problems
Older women - **greater risk of progression to invasive squamous carcinoma**
36
What's the diagnosis? Crusting rash over the vulva, tumour cells seen in epidermis that contain mucin and arise from sweat glands in the skin
**Vulvar Paget's Disease**
37
What is the arterial blood supply to the ovary?
2 contributing parts
1. **Ovarian artery** (from the abdominal aorta, given off at L2)
2. **Uterine artery** (from internal pudendal, from internal iliac)
These two **anastomose together**
38
In surgery, how can you tell the difference between the ureter and the uterine artery?
What is the most likely site of damage for the ureter?
Ureter **runs underneath** the uterine artery (water under the bridge)
The ureter will also **vermiculate** when stroked
Most common site of ureter damage is the **uterosacral ligament**
39
What muscles are involved in micturition and which nerves supply these muscles?
Contraction of the **detrusor** in response to parasympathetic innervation from the **pelvic splanchnic nerve (S2-S4)** - overrides sympathetic control over the bladder that is inhibiting bladder contraction
Stretch sensation of the bladder is carried by **visceral afferents** to the sacral region of the spinal cord (follows the **parasympathetic fibres**)
**External urethra and pelvic floor (levator ani)** muscles relax
**Abdominal muscles** contract
40
What is the name of the greate vestibular gland when it is in...
a) males
b) females
Males - **Cowper's gland**
Females - **Bartholin's gland**
41
How does urinary catheterisation differ in the male and the female?
Males - **longer catheter** required but easier to do. Increased prostate size may make it harder
Females - **shorter catheter** used
42
What are the 3 muscles that make up the levator ani?
What nerve innervates these muscles?
Puborectalis
Pubococcygeus
Iliococcygeus
Innervated by the **pudendal nerve (S2-S4)** and the **nerve to levator ani (S3-S5)**
43
Other than the levator ani, what other muscles make up the pelvic floor?
Coccygeus
Piriformis
Fascia of the obturator internus (tendinous arch)
44
What vessels can become damaged when inserting a trochar through the obturator membrane, or through the sacrospinous ligament?
Obturator artery
Internal pudendal artery
Superior gluteal artery
45
What is the clinical relevance of the ischioanal fossa?
The **pudendal canal** runs through this space (containing the internal pudendal artery, the internal pudendal veins and the pudendal nerve)
46
What is the average age of menopause?
Define the following terms...
- early menopause
- premature menopause
- late menopause
Average age of menopause - **51 years**
Early menopause - **\<45 years**
Premature menopause - **\<40 years**
Late menopause - **\>54 years**
47
What are some of the effects of oestrogen?
Development of secondary sex characteristics
Affects hair growth, body shape and fat distribution
Affects bone growth and collagen
Causes **proliferation of the endometrium**
48
How is menopause diagnosed?
Clinical history + age + history of menstruation
Explore symptoms
Possible blood tests (including pregnancy test!) - can also look at **FSH** (recommended if woman is younger) and **oestradiol** (**oestradiol** is the dominant oestrogen BEFORE menopause, **oestrone** is the dominant oestrogen AFTER menopause)
49
LH and FSH are released steadily/in a pulsatile manner
Is a raised level indicative of menopause?
LH and FSH are released **in a pulsatile manner**
A single raised level does NOT indicate menopause (is raised prior to ovulation, is raised when stopping the COCP, raised with breastfeeding and certain medications e.g. SSRIs)
50
What are some of the physical symptoms of the menopause?
Hot flushes
Night sweats
Palpitations
Insomnia
Joint aches
Headaches
Later symptoms - frequency, recurrent UTIs, dysuria, incontinence, dry hair and skin, atrophy of breasts and genitals
51
What are some of the psychological and sexual symptoms of the menopause?
Psychological
* mood swings
* irritability
* anxiety
* difficulty concentrating
* forgetfulness
Sexual
* vaginal dryness
* decreased libido
52
What diagnosis needs to be excluded in women presenting with perimenopausal dysfunctional uterine bleeding (irregular periods, intra-menstrual bleeding, post-menopausal bleeding)?
**Endometrial ca** needs to be excluded - requires biopsy
53
Menopausal symptoms can be managed conservatively with diet modification, weight loss, exercise etc.
If the woman complains of menorrhagia, what treatments can be given?
**Mefenamic acid** (NSAID that reduces the blood supply to the womb)
**Tranexamic acid** (antifibrinolytic, stops clots from breaking down)
**Progesterones** (thin the lining of the womb)
**IUS**
Endometrial ablation
Hysterectomy
54
What hormone replacement therapy (HRT) options are there for a woman going through the menopause?
Oestrogen alone
Oestrogen + progesterone
(either topical or oral)
55
What are the risks of HRT?
Oestrogen therapy alone is a risk factor for **endometrial cancer**, only given to women that have had a hysterectomy
Combined progesterone and oestrogen is associated with a **small increase in breast cancer risk**
Increased risk of **blood clots**
Increased risk of **heart disease, strokes and MI**
Increased risk of **gallbladder disease**
(these risks are largely negligble in younger, healthy women)
56
Other than HRT, what medications might be used to manage the symptoms of menopause?
**Clonidine** (treats hypertension and hot flushes by stimulating alpha2 receptors in the brain stem)
SSRIs - useful for managing anxiety and mood swings
Regelle - vaginal moisturiser
Sylk - lubricant
57
What are some of the causes of dysfunctional uterine bleeding?
**Fibroids** and **polyps** - common, and often occur around/after the menopause
**Endometrial hyperplasia** (simple, complex or atypical [precursor of carcinoma])
Adenomyosis (presence of endometrial tissue in the myometrium)
Ovulation disorders
Bleeding disorders
58
Describe 'Simple' endometrial hyperplasia in terms of distribution, affected components, gland appearance and cytology
Distribution - general
Affected components - glands and stroma
Gland appearance - dilated, not crowded
Cytology - normal
(see cystically dilated glands. This presentation is common around menopause)
59
Describe 'Complex' endometrial hyperplasia in terms of distribution, affected components, gland appearance and cytology
Distribution - focal
Affected components - glands
Gland appearance - crowded
Cytology - normal
(see **cigar shaped nuclei** along the basement membrane, but cells retain their shape so are not atypical)
60
Describe 'Atypical' endometrial hyperplasia in terms of distribution, affected components, gland appearance and cytology
Distribution - focal
Components affected - glands
Glands appearance - crowded
Cytology - atypical
(management is w/ hysterectomy, nuclei appear rounder and more prominent)
61
What age is the peak incidence for endometrial carcinoma?
If present in younger groups, what underlying conditions might you consider?
Peak incidence is **50s-60s**, uncommon to see in under 40s
If seen in younger women, consider underlying predisposing conditions such as **PCOS** or **Lynch Syndrome**
62
What are the two main clinico-pathological types of endometrial carcinoma? Which is most common?
What are the precursors to each?
**Endometrioid (and mucinous) carcinoma (type 1 tumours, 80% of cases)** - precursor is **atypical hyperplasia**
**Serous (and clear cell) carcinoma (type 2 tumours)** - precursor for serous carcinoma is **serous intraepithelial carcinoma**
63
Type 1/Type 2 endometrial tumours are associated with **unopposed oestrogen**
**Type 1** (endometrioid and mucinous) is associated with **unopposed oestrogen**
64
What is often found to be mutated in type 2 endometrial tumours (serous and clear cell)?
**TP53** is often seen to be mutated
65
What mutations are seen in type 1 endometrial tumours (endometrioid and mucinous)?
The feature of what genetic abnormality, associated with type 1 tumours, suggests that there is an error in DNA mismatch repair?
PTEN
KRAS
PIK3CA
**Microsatellite instability** is seen in type 1 tumours and suggests errors in DNA mismatch repair
66
The presence of sawtooth, irregular glands on histology of suspected endometrial carcinoma would suggest what type of tumour?
**Endometrioid** endometrial carcinoma
67
What lifestyle factor is strongly associated with the development of endometrial cancer?
Why is this the case?
**Obesity**
Excess adipose tissue results in increased endocrine and inflammatory effects.
Adipocytes express **aromatase** that converts ovarian androgens into **oestrogens** - induces endometrial proliferation
Insulin action also tends to be altered in obese women - the level of insulin-binding globulins is reduced and free insulin levels are elevated. **Insulin/Insulin-like growth factors (IGF) exert proliferative effects on the endometrium**
68
What is the lifetime risk of developing endometrial cancer in a woman with Lynch syndrome?
What is the inheritence pattern for this condition?
28%
(Also an increased risk of developing ovarian cancer)
**Autosomal dominant**
69
What other genetic feature do Lynch Syndrome tumours demonstrate (hint: same as type 1 endometrial tumours!)
**Microsatellite instability** indicating errors in DNA mismatch repair
70
Type 2 tumours are less aggressive/more aggressive than Type 1 tumours
What is the precursor to these tumours?
Type 2 tumours are **more aggressive**
Precursor lesion is **serous endometrial intraepithelial carcinoma**
71
How does serous carcinoma appear on histology?
Complex papillary/glandular architecture
Diffuse, marked nuclear polymorphisms
72
How do endometrioid and serous carcinomas spread, and as such which has a better prognosis?
Serous - may spread along the fallopian tubes early and get into peritoneal cavity. Worse prognosis, usually requires more intensive surgery and adjuvant chemo/radiotherapy
Endometrioid - better prognosis, tends to be confined to the uterus at presentation
73
How is endometrial carcinoma treated?
Hysterectomy +/- adjuvant chemo/radiotherapy
74
How is endometrioid carcinoma graded?
(serous carcinoma and clear cell carcinoma are not formally graded)
Graded 1-3, primarily by architecture
Grade 1 - **5% or less** solid growth
Grade 2 - **6-50%** solid growth
Grade 3 - **\>50%** solid growth
75
How is endometrial carcinoma staged?
FIGO/TNM staging
**Stage I - confined to the uterus**
IA - no or \<50% myometrial invasion
IB - invasion equal to or \>50% of mymetrium
**Stage II - tumour invades local cervical stroma**
**III - local and or regional tumour spread**
**IV - tumour invades bladder and/or bowel mucosa (IV A), or distant metastases (IV B)**
76
Which is more likely to affect elderly, post-menopausal women - type 1 or type 2 endometrial tumours?
**Type 2** are more likely due to having a thinner, non-hypertrophic endometrium
77
What's the condition/organism/treatment: fishy smelling vagina with a positive 'whiff' test, clue cells seen on histology and thin white vaginal discharge?
Condition - **bacterial vaginosis**
Organism - **Gardnerella vaginalis**
Treatment - **metronidazole**
78
What benign smooth muscle tumour is very common and associated with menorrhagia and inferility?
Leiomyoma (fibroids)
79
Leiomyosarcomas are common/rare. What age group are they seen in?
What does their cell morphology show?
What is the 5 year survival?
Leiomyosarcomas are **relatively rare,** accounting for 1-2% of all uterine malignancies
Most commonly seen in women **\>50 years old**
Malignant smooth muscle tumours that commonly display a **spindle cell morphology**
5 year survival is only 15-25%
80
What are some gynaecological causes of palpable pelvic mass?
**Uterine** - body (pregnancy, fibroids, rarely cancer as usually presents early with post-menopausal bleeding) or cervix (again, rarely cancer)
**Ovaries**
**Tubal** (or para-tubal)
81
What is the most common cause of pelvic mass in women over 40 years of age?
Leiomyomas - very common
82
Other than a palpable pelvic mass, how might uterine fibroids present?
Menorrhagia
Pain/tenderness
'Pressure' symptoms i.e. sensation of pushing, heavy etc.
83
How are suspected fibroids investigated?
Hb levels if heavy bleeding
USS usually diagnostic, and can MRI for precise location
84
What options are there for treating fibroids?
If asymptomatic, just leave them
If family complete, hysterectomy
Alternatively - myomectomy, uterine artery embolisation or hysteroscopic resection
85
What are some of the causes of tubal swellings?
**Ectopic pregnancy**
**Hydrosalpinx** (blockage of tube and accumulation of serous or clear fluid near the ovary)
**Pyosalpinx** (as above, but fills with pus)
**Paratubal cysts**
86
What are 'functional' cysts?
Related to ovulation - follicular or luteal cysts
Rarely larger than 5cm and usually resolve spontaneously, often asymptomatic
May cause mentrual disturbances, or rupture causing pain
87
What symptoms are endometriotic cysts typically associated with?
What classical distinguishing appearance do endometriomas have?
Endometriotic cysts typically present with severe dysmenorrhoea, premenstrual pain, dyspareunia and are often associated with infertility
Classic appearance is of **"chocolate cysts"** which may rupture
88
There are lots of types of primary ovarian tumour...
What are the subtypes that arise from the surface epithelium (adenoma/adenocarcinomas)?
Which age group is affected?
Serous
Mucinous
Endometrioid
Clear cell
Brenner
**20+ year olds. NB - this is the most common type of ovarian tumour**
89
There are lots of types of primary ovarian tumour...
What are the subtypes that arise from germ cells?
Which age group is affected?
Benign cystic teratoma (aka dermoid cyst)
Dysgerminoma
Yolk sac
Choriocarcinoma
Embryonal carcinoma
**0-25 year olds**
90
There are lots of types of primary ovarian tumour...
What are the subtypes that arise from sex-cord stroma?
Which age group is affected?
Adult granulosa cell tumours (may secrete oestrogens)
Fibromas/thecomas (may secrete androgens)
All ages affected
91
What is Meigs syndrome?
Triad of ascites, benign ovarian tumour (fibromas) and pleural effusion
Resolves after resection of the tumour
92
What's the tumour type?
Once removed, was found to contain hair, teeth and sebaceous material. Could also potentially contain thyroid tissue, leading to thyrotoxicosis
Teratoma (dermoid cyst)
93
What's the tumour type?
Patient had precocious puberty and presented with post-menopausal bleeding
Granulosa cell tumour, secreting oestrogens
94
What's the tumour type?
Patient presented with hirsutism and virilisation
Thecal tumour producing androgens
95
The ovaries are a common site of metastatic disease spread.
Where are primaries most commonly found?
Breast
Pancreas
Stomach
GI locations
96
Ovarian cancer can have a varied presentation. What are some of the symptoms that someone might complain of?
Heartburn/indigestion
Early satiety
Weight loss/anorexia
**Bloating**
Pressure symptoms (especially the bladder)
Changes in bowel habit
Shortness of breath/pleural effusion
Leg oedema or DVT
+/- pelvic mass
97
What % of ovarian cancers have a genetic basis?
What genes are implicated?
Only 5% have a genetic basis, but always remember to ask about family history!
**BRCA1 and BRCA2** (also associated with breast cancer)
98
What are some of the risk factors for developing ovarian cancer?
**Things related to having had MORE menstrual cycles**
Early menarche/late menopause
Increasing age
Nullparity
FHx
NB - **OCP is protective**, stops ovulation
99
In a patient with suspected ovarian cancer, what investigations would you perform?
Look for tumour markers **Ca 125** and **Carcino-embryonic antigen (CEA)**
Imaging - USS, CT is better for assessing disease outwith of the ovary
100
What are the pros and cons of measuring Ca 125?
It's raised in 80% of ovarian cancers
It's presence is not diagnostic, as loads of other things can also cause it to be raised (endometriosis, peritonitis, pregnancy, pancreatitis etc.)
101
What is the main function of measuring CEA?
Main purpose is to exclude GI primary
May be moderately elevated in ovarian ca (especially mucinous tumours)
102
What features on USS would make you suspicious of ovarian cancer?
Complex mass with a solid and cystic area
Multi-loculated
Thick septations
Associated ascites
Bilateral disease
103
How are ovarian cysts/masses managed?
If malignant, how likely is surgery to be curative?
If likely benign - removal or drainage
If otherwise - removal of ovaries and uterus w/ removal/biopsy of omentum. 'Debulking' of tumour and complete examination of all peritoneal surfaces
Chemo may be given as either neo-adjuvant or adjuvant
Cure is **unlikely** unless cancer is confined to the ovary at presentation
104
Patients may present acutely with pelvic mass (causing acute abdomen).
What are some of the gynaecological causes of acute abdomen?
Cyst
* rupture
* haemorrhage into cyst
* torsion
Fibroid degeneration
* usually 'red' degeneration (seen around pregnancy, haemorrhagic infarction of uterine fibroid)
105
What is a follicular cyst?
Benign ovarian cyst that may form when ovulation doesn't occur, resulting in polycystic ovaries. Follicle doesn't rupture, just continues to grow into a cyst
Very common
Thin-walled and lined by granulosa cells
Usually resolve within a few months
106
What symptoms are caused by endometroisis?
Where might it be found?
Symptoms - pelvic inflammation, pain and infertility
Sites - ovaries (chocolate cysts), Pouch of Douglas, peritoneal surfaces including the uterus, cervix, vagina, vulva, bladder, bowel....
Basically anywhere!
Can disseminate via vascular or lymphatic means
107
What are some of the potential complications associated with endometriosis?
Cyst formation
Adhesions
Infertility
Ectopic pregnancy
Malignancy (becoming endometrioid carcinoma)
108
What are the various classifications of ovarian tumour (based on cell type)?
Epithelial (adenoma/adenocarcinoma)
Germ cell
Sex-cord/Stromal
Metastatic
109
What are the main types of epithelial ovarian tumour?
Serous
Mucinous
Endometrioid
Clear cell
Brenner
110
When classifying epithelial ovarian tumours, what key feature determines if the tumour is benign or malignant?
Has the **stroma been invaded?** If so = malignant
111
Endometrioid and clear cell carcinomas of the ovary are strongly associated with what conditions?
Endometriosis of the ovary
Lynch syndrome
112
What is the precursor lesion seen prior to the development of high grade **serous** carcinoma?
Serous tubal intraepithelial carcinoma (STIC)
113
What is a Brenner tumour?
Are they usually benign, borderline or malignant?
Tumour of transitional epithelium
## Footnote
**Usually benign**
114
Germ cell tumours comprise 15-20% of all ovarian tumours
What is by far the most common type of germ cell tumour?
**Teratomas (dermoid cysts)** - 95% of all germ cell tumours
Benign, cystic
Contain sebum, hair, teeth etc. (material from ectoderm, mesoderm and endoderm)
Can rarely become malignant
115
Other than teratomas, what other types of germ cell tumour are there?
Dysgerminoma (seminoma in males, usually malignant)
Yolk sac tumour (rare, malignant)
Choriocarcinoma
Mixed germ cell tumour
116
What age group is typically affected by dysgerminomas?
Almost exclusively children and young women
Average age is **22**
1-2% of all malignant ovarian tumours and the most common malignant primitive germ cell tumour
117
What diagnosis should be considered in any woman of reproductive age that presents with amenorrhoea and acute hypotension or acute abdomen?
Ectopic pregnancy
118
What are the 4 stages of FIGO staging?
What feature isn't really included in FIGO staging that is included in standard TMN staging?
I - confined to cervix
II - included basal tissue, periepithelial and fundus
III - distant spread to nodes/tissues in pelvis
IV - distant mets
**Lymph nodes** are not really featured as much in FIGO staging
119
What is brachytherapy?
What possible complications might develop as a result of this treatment?
Brachytherapy - form of radiotherapy in which a sealed source of radiation is placed inside or near the site of the tumour
Avoids surrounding structures being exposed to radiation, as is the case with standard beam radiotherapy
Complications - vaginal stenosis and effects on sexual function. If the patient has a history of anaemia, this could also result in hypoxia developing
120
What investigation is used to grade and stage cervical cancer?
PET-CT
121
What are some causes of post-menopausal bleeding?
Which is the most common cause?
Endometrial cancer
Endometrial polyp
Atrophic vaginitis (**most common cause**)
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If a patient presented complaining of post-coital bleeding and inter-menstrual bleeding, what would be the main diagnosis you should be concerned about?
Cervical cancer
