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Um Got it. Yeah. And so general exam advice, I've spoken to some people in the year above and from the powerpoint last year, this is what people are saying. Um Don't worry about recognizing the organ because we're told, um don't worry about what every single cancer looks like, just focus on the high yield ones. Don't try and answer questions based on pathology. Um A alone, look at the vignette and they should only be worth a few, a few marks. So it shouldn't, it shouldn't be too bad. Um And what to do have a general approach, look at specific um pathologies um from cpcs because apparently they just use the same images, um learn some buzzwords. So hopefully we'll go through a few of those and we'll also go through a few of the high yield cancers um and paraneoplastic syndromes a bit. So, um to start off with um if we look at common stains, so, hematoxylin is the blue stain and it binds basophilic substances like DNA, which are negatively charged. And then we have eosin, which is the red stain and it binds um positively charged um proteins. Um And then if we look at um components of tissue slides, you can read yourself and looking at histology. So this is these are the three key components that you get in, in tissue. So you've got the parenchyma which is um what, what the cells that are responsible for, what, what the tissue does. Um the incision which is um supportive generally and you have the adventitia or the cirrhosa, which is the connective tissue um or the arter lining and we'll look at um a bit about each of these tissues and useful things to look out for in, in cancer. Sorry, I think presentation you, you present a view rather than the the slides. So we can see on the side. I don't know how to change that. I'm not gonna lie if you go on the the share screen uh and you pick the window that just has the slides and not your notes. Does it have that? Uh let's see. Mhm. Mm It won't let me swap but OK. Is that any different? Yeah, that's perfect. OK. Thank you, sir. Sorry. Go on. Um Yeah, so um OK. Yeah, that's better. Um So generally is that show up for everyone? Yeah, that's great. Ok. Um So um these are some different types of parenchyma organizations. Um So the affinis is basically just like a sac like cavity um in a gland and it's surrounded by secretory cells. Um So you might find this in the pancreas and then you've got ducts which you might find in different glands. Um like the um again, like the pancreas or various other glands in, in the body. And you can have specialized tissue, for example, in the kidneys. And you um it's also useful um for exams to be able to know and recognize different types of epithelium. So the last one there is stratified squamous and then you have simple columnar, um simple squamous and urothelium. Um And a big thing that's useful for when you are um describing cells in the exam for short answer questions is just having these like both phrases. So cancer cells will have a larger nuclear to cytoplasmic ratio and they'll look a bit darker because of it. Um they'll have lost their cell polarity. So the nucleus will be um will not necessarily be on one end of the cell. Um And they also have more um DNA um which means that there will be darker staining in general. Um And so hyperchromatic nuclei is how you describe that. Um and they'll have pleomorphism and atypia and they'll be discohesive compared to normal cells. And then here's II thought this was a useful diagram for describing um some non neoplastic cell changes. So um uh sometimes they can show they can show these and exams to kind of throw you off. Um So this is these are kind of like what what that would look like. Um And then this is an example of um the progression of pancreatic cancer. So you can see that in pancreatic ductal adenocarcinoma, um right at the end, um compared to a normal duct, there's complete um uh a complete change in the structure of the tissue. So, um there are, there are dilated ducts, there's a lot of destruction of the parenchyma. Um There's um disorganized blood vessel infiltration, um and irregular and enlarged nucleus and it's a lot of um there's a lot of desmoplastic tissue in there as well. Um But you can also see that there's a, a progression. Um and it, it's kind of a gradual process. Um Again, this just shows a progression and how, how cancers look at different, different grades. Um There's a loss of differentiation. Um There's a reduced amount of stroma in between. So, the glands are kind of back to back closer together. And another thing that um we mentioned earlier, um but to look for is the basement membrane. Um So those are the three places you find you, you'll find it underneath the epithelium, separating the epithelium and endothelium and surrounding um the large cells. Uh And it's just useful in if you're trying to identify a cancer to see if it's intact. Um And functions of the basement membrane would be for structural support to prevent tumor invasion, regulate cell behavior. And for angiogenesis. Also, I should say that these size will be available. So, don't worry about trying to get all the, the images and blue dots. So, uh this is a really common finding in his in histology. Um And for example, it's important to be able to describe what might be going on. So, in normal tissue, um you'll see lots of blue dots um and in, in the stroma and these are just normal um fibroblasts. Um But in pathology, for example, here, this is appendicitis and colitis, you'll be um a lot, a lot more of them generally. Um So you can see there's, there's loads and loads in in both of these images um and to try and figure out what they are, um try and look at the shape. So for example, neutrophils will have a lobulated shape or nucleus um which is a bit difficult to see in this image because it's, it's quite small. Um But it will also be um eosinophils will stay in a similar way. And then in ulcerative colitis, it's mainly lymphocytes and plasma cells some more images here. Um There are so cancers will have inflammatory cells as well. Um So that's just an important thing to look out for and something you can comment on that's colorectal cancer. Um So mentioned the buzzwords earlier. Um These are bits of like terminology, I won't read it or go through it all. Um But for cells tissue and uh a microscopic you um those are useful things that you could comment on or make a note of in the exam again. This will all be available. Uh Now we'll look at some high yield cancers um or fifth year women's health peds and gi cancers are come up really, really often. Oh, gi um Does anyone wanna hazard a guess at what? This first images? The part? No. OK. That's all right. The first one is um a benign polyp. Um You can see that the cells are well differentiated, you've got glands um and you can see the stalk here. Um So it's, it's a benign finding. So um something to look out for. Um and then the second image is a malignancy and you can see hypochromatism. Um So it's a lot darker than the first image. Um The architecture is a lot worse and it's less organized and there's also some hemorrhage um and way too many blue dots. Um Here, we've got an image of the colon. So the first one is again a bit bad. Um But there's, there's loads and loads of polyps here. So this is familial adenomatous poly polyposis. Um And it's commonly due to a mutation in the A PC gene and it's an autosomal dominant, um dominant condition can lead to colorectal cancer and it's also linked to cancers like thyroid cancer. And then in the second image, um there are some polyps um but obviously nowhere near as many. Um And it indicates hereditary nonpolyposis, colon cancer um which is associated um with mutations in Moh or MS H rags Um And um, with this syndrome, you can get colon cancer, endometrial cancer and ovarian cancers. Um, these are both gi stromal tissues just at different zooms. Um You can see there's a, a spindle shape um, of the cells here. Um, 20% of them are epithelio, epithelioid, epithelioid. Um And you have mutations in 70% and B raf mutations in 15%. Um, this is an exophytic, um, adenocarcinoma of the colon And exophytic basically means like a, a growth out from the bowel wall. Um And it can, it can present as um a sort of bowel obstruction in patients. Um And then in the second image, um there's a histology of an adenocarcinoma of the colon. Um So you can see again, hyperchromatism, increased nucleus to cell to cell ratio. There's barely any cell around those nuclei. Um, cells uh are producing mu mucin in, in some areas, it's paler, staining in some parts and there's lots and lots of glands with little stronger in between. So it's, it's very similar to lots of other, lots of others that we've looked at. And then this is linitis plastica. Um It's an infiltrative gastric adenocarcinoma giving uh a leather bag kind of appearance um inside the stomach. Um It causes mucosal erosion and a thickened gastric wall and you may have signet ring cells um inside of it. So the second image is a sign ring cell carcinoma. Um And so you can see it's got a very distinctive kind of appearance. Um If you find um signet ring cells in the ovary, um This is called Krien bad tumor. Um and it's a sign of a metastasis from, from the gastrointestinal tract. Um and this is uh breast cancers now. So this is a normal a normal breast architecture. So you can see the, the ducts, um the basement membranes surrounding the eye. And the second one is also a normal image um with healthy looking ducts um that are smooth. Um Yeah. And then you can see a clear difference here in lobular carcinoma in situ. Um it really distended lobules um and larger cells in general. And I think this diagram was really useful for just showing how each of the different cancers will kind of grow and look. So um cancers and cancers in general have lots of different ways that you can stay and, and grade but receptor status is important um for classifying breast cancers. Um Does anyone know why I want to say why it changes the management? Nice. Thanks Melinda. Yeah, it changes the management. So if it's er positive um you can give tamoxifen um if they're premenopausal or anest for postmenopausal. Um and it changes it, it guides um management because it tells me how aggressive the tumor is likely to be. Um and for example, triple negative um cancers you can still have adjuvant chemotherapy but not hormone therapy or biologics. So, um and this is invasive ductal carcinoma, um which is 7070 or 75% of breast cancers. Um It metastasizes um to bone very often. Um And you can see the, the ducts um but they're not contained by a basement membrane. Um And here in the 2nd, 2nd image, you can see it's a lipid rich rich tissue and there are lots of immune cells. Um and uh you may have to stay in er uh so cervical cancer is now. So that's a pap smear in the first image. Um And so should either stay in blue or an orangey, pinky type color. Um And um but here you can see that some of the nuclei um in the center are uh irregular shapes. So this is no abnormal pap smear. Um I think that this shows a difference between normal and abnormal. Um And then in the second image, you can see the progression of cervical ca c cervical cancer. So, um it's called um cervical intraepithelial neoplasia. Um 12 and three and one is basically where it's the lower third of the epithelium. Um Two is from the lower third, from one third to two thirds of the epithelium and three is over two thirds. And then, um this is the epithelium of the cervix. Um And you can see there's lots of dysplastic cell growth here and there are nests in the second image of squamous cell, um carcinoma, um called keratin ps, which I think uh rings a bell from bar. Um But most squamous cell carcinomas are non um keratinizing and then endometrial cancer. So, these are normal um ducts in the endometrium with um some procedure tissue around um in normal s tissue. Um And thing to watch out for with endometrial cancers is that the tissue has normal variation based on the menstrual cycle anyway. Um um Yeah. So this is uh endometrial cancer. Um There are two types. So type one is caused by hyperoestrogenism, um endometrial and mucinous carcinoma and it's caused by P 10 and Kras mutations type two will be more poorly differentiated. Um Types include serous, clear cell, um mucinous carcinoma and undifferentiated. Um And the second image is of an adenocarcinoma. Um Again, you can see pleomorphism, lots of different sizes. Um The duct structure has, has been lost. It's mostly uh glandular type growth. Um Yeah. And then ovarian masses. So, these are the four types. Um The first three tumors can either be um benign and malignant. So, these are examples of the benign ones. I won't go through them more. Um The comas are come up very often in exams. Um and some malignant ones. Um Yeah. Uh OK. So um these are, so the first image is a normal um normal ovary. It's just during the process of ovulation. Um Does anyone wanna guess what? The second one is, is it the f you know, sorry, I didn't get, I didn't get either of those cystadenocarcinoma, uh, cyst adenoma is the second one. but you're right, the third, the third one is, um, cyst adenocarcinoma. And I think the difference, the main differences are, there are growths in, there are smaller growths like, uh, like this in the cyst adenocarcinoma. And the last one is, uh, a thecoma or a fibroma. Um, and the cholesterol, um, produces this yellow color. Um, and then finally, um small round blue cell cells. Um These um there are various different type of cancers that come under. This. Um does no one know any. Is it like the blastomas? Maybe like nephroblastoma, that kind of thing? Yes, neuroblastoma is one. So yeah, these are um some, there are a lot more of these. Uh there are a lot more than, than just this. Um So we can go through a few cases now. Um hopefully to look at, to look at a couple of them. Um So if that's the case, four year old boy brought in by mother complaining of pain in um and swelling in the right leg. Um What could this be any ideas? It would be like a sarcoma? Yes. Uh Yeah, that's a really, really good idea. So, um osteosarcoma, soft tissue injury, osteomyelitis, metastatic disease. These are all different differentials. Um You also have an X ray. Um and I don't know if it's very clear but there's kind of uh a lucency in the distal distal bit of the femur here. Um So I think somebody said it in the chart. Um But during sarcoma, um I won't go through all of this, but it's um a common, common example, something that comes up a lot. Um And then finally, if you take a look at paraneoplastic syndromes, so these are symptoms um associated with cancer but not from the mass effect of the tumor, more from um the immune response against um the tumor or the cy cytokines released by the tumor. Um Why it's important? Um If people are presenting strangely, it might be useful. Um they, it may be the first or only presentation in, in AAA patient with cancer and it's necessary for exams anyway. Um So in this case, there's a 6 to 7 year old male with small cell carcinoma of the lung. He presents to Amy with his wife. Um, she's worried. Um, she says he's drowsy, confused and irritable. So, does anyone have any ideas and what the syndrome may be? So, it's um small cell producing um syndrome of sorry syndrome of inappropriate ADH secretion. Um So the small cell cancer produces the A DH. Um And it's the symptoms are caused by hyponatremia. Um, as a result of the syndrome, uh we've got now a 67 year old female with small cell carcinoma of the lung. Um, she has bilateral leg weakness and this is worse in the morning and gets better through the day. Any ideas? Is this Lambert Eaton syndrome? Yes. Yes, exactly. Thanks. Um So it's an autoimmune attack um against the calcium channels on presynaptic presynaptic calcium channels, um affects the lower limb more than the upper limb and there's no fatiguability um which could help differentiate it from other conditions. Um And then here we've got a 52 year old male with renal cell carcinoma, um which was an incidental finding. Um his observations are normal but he has a very high BP of 1 80/100. Um Does anyone know what this could be? Maybe like a ACTH releasing something? Yeah. So uh along the right lines, um hyperaldosteronism um because of um the renin produced by the renal cell carcinoma. So quick reminder in this next slide of how this could cause an increase in BP. Um Yeah. Um and also dermatology, there are lots of dermatological conditions that count as paraneoplastic syndromes. So for example, does not know what this first image is. Acanthosis migraines. How do you pronounce it? Yeah. Um Yeah. And this is often found linked to um stomach cancers, um metastatic breast cancers. Um And it's thought the exact causes is unknown yet, but it's thought to be due to transforming growth factor which acts on epidermal growth factor receptors um and causes a post mi um And the second one is called lesser trine. I don't know if I said that right. Um But it's when lots and lots of seborrheic keratosis appear suddenly. Um And it, it's associated with cancers like adenocarcinoma of the stomach. Um Colon, squamous cell carcinomas, lymphomas and leukemias. Um So I've just put this here cause it, it might be useful. Um So these are the different screening programs um in the UK. Um OB TSP fecal are called blood tests and check for blood, um which might be colon cancer or polyps in the colon or rectum. And these are some presentations um for each of the, the common cancers. Um But again, I'll, I'll leave this for your slides. I won't go through more and staging. The T NMT and M staging system is the most commonly used. I'm sure you've come across this already at some point. Um But for Gyne, there's also the fecal staging and for colorectal, you've got the jun classification that might also be um the breast um receptor classification, which we, we went through earlier and then treatment um can either be radical. Um for long term disease control, which doesn't, doesn't always have to be cure or, or it can be palliative um whether there is no intention of cure, but it's again, disease control or for symptoms, neoadjuvant before uh your treatment, you're given um some more treatment like chemo before surgery um which improves prognosis, um or adjuvant which is treatment afterwards to reduce um any recurrence from happening. That's generally how most cancers are treated. I'll see you. Um does anyone have any questions? And please, can you fill in this this form here, QR code? I think you get a certificate you put it in as an incentive. Yeah, we've also got the, the link and the the chat as well if, if that's easier for people. Um Yeah, thank you very much fatima if anyone's got any questions, feel, feel free to to put, put in the chat or, or shout out loud. Um But otherwise we have our next session same time next week, uh looking at the unwell child. So again, very high yield for the SBA S the OSK and especially, um, obviously competes. Um But yeah, any questions, please go ahead. I quickly advertise this for a CS. So, um, our next talk is on the 29th of November with Gyne Society, um Doctor Deborah Gregory Oncology training Pathway and the introduction to Brachytherapy. I hear it's gonna be very good and I just ask for the, um, the short answer question paper does, do they mainly use um, pictures that were in the cpcs? Uh This is what I've heard but um, it could be this year where they decide not to, you know, you never know. But that's, that's what's happened in the past, I think. Ok, great. Thank you.