Week 04 Women Problems

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Author:
mewinstanley@googlemail.com
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127739
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Week 04 Women Problems
Updated:
2012-02-01 13:37:23
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medicine
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Description:
week 4 at GLA, various topics including uterine pathology through to breast cancer
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  1. Give an account of HPV and its importance?
    • HPV → human papilloma virus
    • histo → borderline nuclear change w koilocytosis
    • oncogenic strains = 16 & 18
    • 95% of CIN infected
  2. Outline the cervical screening program
    • checks for precancerous state → CIN/Dyskaryosis [asymptomatic]
    • 1 pap smear betw 20-60yo every 5y

    • Results?
    • Borderline dyskaryosis → rpt in 6m [could be HPV]
    • mild dyskaryosis → colposcopy
    • ?invasion → urgent colposcopy
  3. What is CIN?
    How is it staged
    Cervical intraepithelial neoplasia

    CIN 1→ mild dysplasia, basal 1/3 of epithel, corresponds to HPV infection

    CIN 2 → moderate dysplasia, basal 2/3 of epithelium

    CIN 3 → >2/3 of epithel cervical carcinoma in situ
  4. When would CIN be treated and what are the treatment options?
    Tx on CIN 2 & 3 using colposcope

    Tx options

    • LLETZ → large loop excision of Transformation zone
    • Cold coagulation
    • cone biopsy
    • hysterectomy
    • May req Rt/Ct
  5. What are the RF & symptoms of Cervical Ca?
    • RF
    • early age sexual intercourse
    • ^^number of partners
    • smoking
    • not using barrier contraception methods
    • immunosuppression

    • Symptoms
    • Post-coital/extended menstrual bleeding
  6. Breifly outline the anatomy of the fallopian tubes
    • 8mm diameter
    • lined by ciliated columnar epithelium
    • also non-ciliated secretory cells & intercalated cells
    • Plica → folds of mucosa on inner aspect
    • sorrounded by SM & peritoneum
  7. What are the Pc, cause and complications of Salpingitis/PID?
    • Pc
    • Pelvic pain, adnexal tenderness & vaginal discharge

    • Cause
    • STI → Gonnorrhoea/Chlamydia
    • Non-STI → Enteric bacteria
    • Peurperal [6wk after birthing] → Staphylococci, Streptococci & Coliforms

    • Complications
    • Peritonitis [acute]
    • Adhesions & bowel obstruction [chronic]
    • infertility
    • tubal ectopic pregnancy
  8. Outline the features of Acute & Chronic Salpingitis/PID
    • Acute
    • Acute suppurative salpingitis
    • collections of pus → tubo-ovarian abscess, pyosalpinx [pus in fallopians]
    • lead to peritonitis

    • Chronic
    • fused plica
    • pelvic adhesions [bowel obstruction]
    • fibrosis of tubes
    • hydrosalpinx [watery dilation of fallopians]
  9. Breifly outline the ovarian structure
    outer covering = coelemic mesothelium

    • Outer cortex
    • compact ovarian stroma
    • functional cysts
    • germ cells

    • inner medulla
    • hilus cells [steroid synthesis]
    • supporting structures [BV & nerves]
  10. Outline the clinical features of Polycystic Ovarian Syndrome
    • PCOS
    • 3-6% reproductive age females
    • S&S → anovulation, obesity, hirsuitism, infertility, multiple cortical cysts in ovaries w stromal hyperplasia
    • ^^androgens [anormal synthesis]
    • unclear cause, linked to insulin resistance & obestiy
  11. Outline the clinical features of Stromal Hyperplasia
    • similar to PCOS, but in post menopausal
    • CF → similar to PCOS [hirsuitism, obesity, acanthosis nigricans], bilateral ovarian enlargement w stromal hypercellularity
    • Can be oestrogenic → endometrial hyperplasia/Ca
  12. Describe the 2 broad classifications of ovarian tumours
    • T1 tumours
    • borderline malignancy
    • e.g. low-grade serous carcinomas, endometriod & mucinous ovarian carcinomas
    • Pathogenesis → microsatallite instability & Mt [ KRAS, BRAF, pTEN etc]

    • T2 tumours
    • more common
    • high grade serous carcinoma
    • Pathogenesis → ovarian surface epithel/ mullerian inclusions/ fallopian tube mucosa
    • p53Mt rapid evolution, absence of preexisting benign disease
  13. Outline benign & borderline serous tumours
    • Benign Serous Tumours
    • 40-50yo, 20% bilateral
    • histo → monolayer cuboidal epithel, solid areas [adenofibroma]

    • Borderline Serous Tumours
    • 37% bilateral, 40% extra-ovarian disease
    • Histo → moderate cytological atypia, nuclear crowding & stratification, mitotic figures
  14. Outline high grade serous tumours
    • High grade serous Tumour
    • 57yo, late presentation, often bilateral
    • Features → microscopic - 20cm, fast growing, solid & cystic masses
    • RF → nuliparity, FH, BrCA1 & 2Mt
  15. Breifly outline the features of the following ovarian epithelial tumours
    -Mucinous
    -Endometrioid
    -Clear cell
    • Mucinous
    • Benign → mucinous cystadenoma/ cystadenofibroma [30-60yo, endocervical/ GI epithel (mixed)]
    • Mucinous adenocarcinoma → most = mets [esp if bilateral]

    • Endometrioid
    • related to endometriosis
    • Endometriod Adenocarcinoma → solid & cystic [chocolate cysts]

    • Clear Cell
    • strong association w endometriosis
  16. Outline the following ovarian tumours
    -Transitional cell Tumour
    -Germ cell Tumour
    -Secondary Tumour
    • Transitional Cell Tumour
    • most = benign
    • Brenner tumour → <2cm & incidentaloma [well demarcated, benign, desnse fibrous stroma]

    • Germ Cell tumour
    • embryonic/extra-embryonic structures
    • e.g. benign dermoid cyst
    • ~32yo
    • smooth outer surface, thick capsule
    • contains sebaceous material & hair, adult tiss from 2-3germ lines [Mature/Immature]

    • Secondary Tumour
    • anything can met to ovary
    • more likely if bliateral & solid
    • e.g. lymphoma, GI Ca
  17. Breifly outline the anatomy of the uterus and how is changes during the menstrual cycle.
    • Anatomy
    • strongest smooth muscle
    • Endometrium → glands & stroma
    • Myometrium → smooth muscle
    • Resistant to infection → drainage, cycles, endocervix

    • Changes during cycle
    • Proliferative → [menstruation til ovulation] Oestrogen induced proliferation of glands & stroma, spiral arteries elongate
    • Secretory → [ovulation - menstruation] Progesterone induced secretion [glycogen & mucus] Glands = tortuous & ^^lumen [secretion]
    • Absence of fertilisation decreases Oestrogen & Progesterone, endometrium involutes. Endothelin & Thromboxin mediate spiral artery constriction. Ischaemia & apoptosis Functionalis
    • Menstrualspiral arteries rupture. Functionalis sloughs off, completely shed
  18. What is endometriosis?
    How does it present?
    What is the pathophysiological mechanism?
    • Endometriosis
    • presence of endometrial glands/stroma outwith uterus
    • e.g. ovaries, uterine ligaments, rectovaginal septum pelvic peritoneum or just plain random as fuck.

    • Pc
    • Dysmonorrhoea, pelvic pain
    • 30-40yo
    • related to menstrual cycle
    • Sequelae → infertility, rarely malignancy

    • Pathophysiology
    • regurgitation theory → retrograde menstruation
    • metaplastic theory → mullerian metaplasia
    • Vascular dissemination → spread via BV/ Lymph
  19. Outline the staging of Uterine Ca
    • 1 → inner/outer half of myometrium
    • 2 → Cervical stromal involvement
    • 3 → [serosal surface/adnexae] or [vagina/parametrium] or [pelvic/paraortic lymph nodes]
    • 4 → bladder/bowel/distant mets
  20. Describe Endometrial Stromal Ca
    • Endometrial Stromal Sarcoma
    • low grade dysplasia, local tumour
    • late mets

    • Undifferentiated Uterine Sarcoma
    • high grade dysplasia
    • early & multi mets
  21. Describe a Leiomyoma [Fibroid]
    • Leiomyoma [Fibroid]
    • benign tumour of myometrium
    • often multiple & asymptomatic
    • Sites → subserosal/ Intra-mural/ Submucosal
    • Myometrium = hormone responsive, should regress after menopause
  22. Describe a Leiomyosarcoma
    • Leiomyosarcoma
    • Malignant neoplasm of myometrium
    • Softer mass, less well circumscribed
    • CF → 60s, post menopausal bleeding, irregular menses, abdo/pelvic pain
    • Patho → haemorrhage & necrosis, vascular invasion [mets to lungs]
    • Poor prognosis
  23. Desribe the anatomy & development of the breast. [incl developmental abn]
    • Anatomy
    • Tubulo-alveolar gland
    • **should be able to describe from 2nd year

    • Development
    • from mammary ridge
    • mainly develop during puberty
    • duct elongation & stromal proliferation = oestrogen

    • Abnormalities
    • hypoplasia/amastia
    • macromastia
    • polymastia [accessory breast]
  24. Outline changes to the breast due to
    -Menstrual cycle
    -Pregnancy
    -Menopause
    • Menstrual cycle
    • proliferation of tiss in proliferative phase [oestrogen]
    • Myoepithelial changes & proliferation in luteal [progesterone]
    • variable water content [^^nearer menstruation, dec in follicular]

    • Pregnancy
    • early → lobar enlargement & stromal depletion
    • continued enlargement && secretory change
    • Post lacteal involution[3m]

    • Menopause
    • dec oestrogen & progesterone
    • epithelial & lobar atrophy
    • Stromal thickening
    • MMG = easier
  25. What are the Pc of BrCa?
    • Breast Lump
    • Pain
    • Nipple discharge
    • Skin Changes [Peau D'Orange]
  26. Give 4 benign proliferative breast diseases
    • 4 Fs
    • Fibroadenoma [breast mouse]
    • Fibrocystic Change
    • Fat necrosis
    • Phyllodes tumour

    Also Duct ectasia
  27. Outline the features of the following
    -fibroadenoma
    -Phyllodes
    -Fibrocystic Change
    • Fibroadenoma [breast mouse]
    • 20-30yo
    • discrete mobile lump
    • benign lesion of stroma & epithelium

    • Phyllodes Tumour
    • epithelial margin, ^stroma [pleomorphic]
    • necrosis
    • can be benign/Malignant

    • Fibrocystic Change
    • 30-40yo
    • worse premenstrually, ~pain
    • features; fibrosis, cysts, apocrine change, epithelila hyperplasia
  28. Outline the features of the following
    -Fat necrosis
    -Duct Ectasia
    • Fat Necrosis
    • post-trauma
    • superficial mass w skin tethering & thickening
    • MMG → spiculate mass
    • always biopsy → inflamm cells & macrophages

    • Duct Ectasia
    • Features → nipple discharge/inversion, ~pain, assoc w smoking
    • Histo → squamous metaplasai of lactiferous duct, micro-dilated ducts & inflamm
  29. What are the risk factors for Breast Carcinoma?
    • age [40-70]
    • FH → immediate relative
    • early menarche/late menopause
    • nuliparity/ late-parity
    • Hormonal Rx → OCP
    • Breast feeding = protective
  30. Outline BrCa 'insitu'
    • Insitu Carcinoma
    • malignant proliferation of epithel cells contained within BM
    • no risk of Met [unless invades]
    • no extension into stroma/BV/Lymphatics
  31. Outline Ductal Ca 'insitu'
    • Ductal Ca insitu [DCIS]
    • Found on MMG
    • CF → lump, discharge, pagets [eczema-like appearance around areola]
    • 2% symptomatic Pc, 20% MMG
    • no invasion of connective tiss
    • Tx → excision, mastectomy +/- reconstruction, local excision + Rt
  32. Outline Lobular Ca insitu
    • incidental on biopsy
    • no CF/MMG findings
    • multifocal & bilateral
    • RF in developing invasive BrCa
    • Mx → clinical exam per year, 2 year MMG, bilateral mastectomy
  33. Briefly outline the features of invasive BrCa including 3 different types
    • Invasive BrCa
    • most common = invasive ductal or Ca of no known type
    • variable histology, invasion of malignant cells → stellate distortion of epithel
    • histological features → tubules, pleomorphism, mitoses

    • Lobar Carcinoma
    • 10%
    • dificult to find [exam/MMG]
    • histo → signet ring cells + diffuse infiltration
    • O/E → multicentric & bilateral
    • Usually grade 2 & ER+

    • Tubular Ca
    • histo → well differntiated teardrop tubules

    • Mucoid
    • >70yo
    • well circumscribed tumour w mucin
    • 90% 5yr
  34. Outline the pathological prognostic features of Invasive BrCa
    • Size of tumour
    • Type [ductal/ no special type = worse]
    • Grade
    • Node status [+ve sentinel = poor]
    • ER [+ve → tamoxifen]
  35. Outline the Tx for invasive BrCa
    • Mastectomy +/- reconstruction
    • Lumpectomy & Rt
    • Axillary surgery [clear nodes]
    • Hormone Therapy → ER+ [tamoxifen]
    • Chemotherapy [?^^risk of recurrance]
    • Biologic therapies [Herceptin if HER2+ → assoc w poor outcome, reduces recurrance]
  36. What is the Nottingham prognostic index?
    • Nottingham Prognostic Index [NPI]
    • estimate prognosis
    • Determines Tx & follow-up
    • Grade 1-3 [ea grade = 1pt 1=1, 3=3 etc]
    • Size in cm x 0.2 [1cm tumour = 0.2]
    • num of nodes [ 0 = 1, 1-3 = 2, >4 = 3]
    • ^^NPI = poorer prognosis, recommend Ct

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