11. Female repro. tract cancers

Question 1

which type of cancer occurs in vulva and what are the 2 main aetiologies

Answer 1

Squamous cell carcinoma

1. 30% related to HPV infection - more likely in 6th decade
2. 70% HPV-unrelated, often occur in long-standing inflammatory and hyperplastic conditions of vulva, e.g. lichen sclerosis - more likely in 8th decade

Question 2

which type of cancer occurs in cervix and what is the main aetiology

Answer 2

80% SCCs, 15% adenocarcinomas

both caused by HPV infection: infects immature metaplastic squamous cells in transformation zone… produces E6 and E7… interferes with activity of tumour suppressor proteins (p53 and pRB)… prevents damaged DNA repair and increases cell proliferation

Question 3

describe the progression of cervical SCC

Answer 3

1. cervical intraepithelial neoplasia (= dysplasia of squamous cells within cervical epithelium, induced by HPV)
   
   • CIN I: most regress spontaneously, only small % progress to
   • CIN II: a % of which progress to
   • CIN III (carcinoma in situ): 10% progress to invasive carcinoma in 2-10 yrs, 30% regress
2. invasive cervical carcinoma:
   - may be exophytic (protrude from surface) or infiltrative
   - metastasis to iliac and then aortic lymph nodes, before wider systemic dissemination

Question 4

what is colposcopy

Answer 4

cervical screening

Question 5

how does cervical cancer usually present

Answer 5

1. screening (colposcopy) abnormality
2. post-coital, intermenstrual or post-menopausal bleeding

average age = 45 yrs, 3rd most common cancer in women

Question 6

how does endometrial cancer usually present

Answer 6

• irregular or post-menopausal bleeding

- mainly affects perimenopausal women and older women (55-75 yrs)

Question 7

what is the usual aetiology in endometrial cancer

Answer 7

Often involves unopposed oestrogen increase from:

• obesity (increased adipose aromatase activity and oestrogen production)
• exogenous oestrogen administration (OCP)
• annovulation
• tamoxifen (breast cancer drug)

Results in endometrial hyperplasia with increased gland : stroma ration which can progress to endometrioid endometrial adenocarcinoma

Question 8

what are the 2 main types of endometrial adenocarcinoma and how does each spread

Answer 8

1. ENDOMETROID (more common)
   - mimics proliferative glands, typically arises in setting of endometrial hyperplasia
   - spreads by myometrial invasion and direct extension to adjacent structures (cervix, bladder and rectum), to local LNs and distant sites
2. SEROUS CARCINOMA
   - poorly differentiated, aggressive, worse prognosis
   - exfoliates, travels through Fallopian tubes and implants on peritoneal surfaces

Question 9

what is the most common tumour in women - how does this present

Answer 9

LEIOMYOMAS (fibroids) - benign tumours of uterine smooth muscle, oestrogen-dependent growth (regress after menopause)

Can be asymptomatic or cause heavy/painful periods, urinary frequency (bladder compression) and infertility.

Question 10

are ovarian tumours usually benign or malignant

Answer 10

80% benign (20-45 yrs)

20% malignant (45-65 yrs)

Question 11

describe the presentation of ovarian cancers

Answer 11

Most are non-functional but can have mass effects:

• abdominal pain
• abdominal distension
• ascites
• urinary and GI symptoms

If functional, hormonal probls. inc.

• menstrual disturbances
• inappropriate sex hormones (e.g. excess Oe or Test.)

Question 12

which tumour marker indicates ovarian cancer

Answer 12

CA-125

Question 13

name the 4 main types of ovarian tumour

Answer 13

Classification depends on tissue of origin

1. Mullerian epithelium - covering ovarian surface
2. Germ cell
3. Sex cord stromal cell (from endocrine apparatus of ovary) - can be functional
4. Metastases

Question 14

what are the 3 subtypes of Mullerian epithelium ovarian cancers

Answer 14

(Can be further classified as benign, borderline or malignant, and many are cystic)

1. SEROUS: often spread to peritoneal surfaces and omenta so commonly associated with ascites (looks firable, cell clusters that drop off and disseminate)
2. MUCINOUS: often large cystic masses filled with thick sticky fluid. Usually benign or borderline.
3. ENDOMETRIOID: contain tubular glands resembling endometrial glands, can arise in endometriosis.

Question 15

describe the different types of germ cell tumours

Answer 15

1. TERATOMAS: contain tissue from any of the 3 germ layers (e.g. skin, hair, teeth, bone, muscle, cartilage…), mostly benign .
   i. DERMOID CYSTS (maj.) - mature and benign
   ii. immature - malignant, rare, composed of tissues to resemble immature foetal tissue, e.g. primitive neuroepithelium
   iii. monodermal highly specialised (e.g. struma ovarii composed entirely of mature thyroid tissue and may be functional, causing hyperthyroidism)
2. Other types are malignant, and inc. dysgerminoma, yolk sac tumours, choriocarcinomas andembryonal carcinomas

Question 16

what are sex cord stromal cell tumours and what are their effects

Answer 16

Sex cord produces Sertoli/Leydig cells in testes and Granulosa/Theca cells in ovaries - tumours resembling all these 4 cell types can be found in ovary.

1. GRANULOSA CELL TUMOURS: may produce large amounts of oestrogen, causing endometrial hyperplasia/carcinoma in post-menopausal women (main group affected) or cause precocious puberty in girls
2. SERTOLI-LEYDIG CELL TUMOURS: often functional, may block normal female sex dev. in girls or cause masculinisation in women

Question 17

what is a Krukenberg tumour

Answer 17

metastatic GI tumour within ovaries, often bilateral and usually from stomach