11. Tumours Of The Reproductive Tract

Question 1

What are the possible vulval cancers and which is the most common?

Answer 1

Squamous cell carcinoma (most common)
Basal cell carcinoma
Melanoma
Soft tissues tumours (rare)

Question 2

What are the clinical features in vulval cancers?

Answer 2

Lumps
Ulceration
Skin changes (sensation, pain, redness)

Question 3

What are the histological changes in squamous cell carcinoma?

Answer 3

No distinguishing between layers of skin (dermis, epidermis)
Atypical squamous cells
Loss of architecture
Keratin produced

Question 4

What is VIN?

Answer 4

Vulval intraepithelial neoplasia
In situ precursor of vulval squamous cell carcinoma
Atypical cells, no invasion through basement membrane

Question 5

Can VIN and vulval SCC be related to HPV?

Answer 5

Yes in 30% of cases - peak onset 60s

No in 70% of cases - usually relate to longstanding inflammatory conditions, peak onset 80s

Question 6

How does vulval cancer spread?

Answer 6

Direct extension to anus, vagina and bladder
Lymph nodes - inguinal, iliac, para-aortic
Distant metastases - lungs, liver

Question 7

What is an ectropian?

Answer 7

Simple columnar epithelium being irritated by acidic vagina

Simple columnar then undergo metaplastic change and become squamous epithelium, does increase risk of dysplasia

Question 8

What are low risk HPV and what do they cause?

Answer 8

HPV 6 and 11

Cause warts

Question 9

What are high risk HPV and what can they cause?

Answer 9

HPV 16 and 18

Can cause cancer

Question 10

How do HPV 16 and 18 cause cancer?

Answer 10

Infect transformation zone of cervix
Produce viral proteins
Inactivated tumour suppressor genes

Question 11

What is cervical intraepithelial neoplasia?

Answer 11

Dysplasia
Confined to cervical epithelium (in situ)
Caused by HPV infection
Divided into CIN1/2/3

Question 12

What are the risk factors for CIN and cervical carcinoma?

Answer 12

Increased risk of exposure to HPV - sexual partner with HP, multiple partners, early age of first intercourse 
Early first pregnancy
Multiple births
Smoking
Low socio-economic status
Immunosuppression

Question 13

What is the treatment for CIN 1?

Answer 13

Often regresses spontaneously

Follow up cervical smear in 1 year

Question 14

What is the treatment for CIN 2 and 3?

Answer 14

Needs treatment - colposcopy, large loop excitation of transformation zone (LLETZ)

Question 15

Describe the cervical cancer screening programme

Answer 15

Brush used to scrape cells from transformation zone - tested for HPV, if positive cells looked a under microscope
Age 25-49 every 3 years
Age 50-64 every 5 years
Over 65 only if recent abnormality

Question 16

What do HPV vaccinations protect against?

Answer 16

HPV 6, 11, 16, 18

Protects from cervical, vulval, oral and anal cancers

Question 17

What are the types of invasive cervical cancer and which is the most common?

Answer 17

Squamous cell carcinoma (most common)

Adenocarcinoma - arise from endocervical glandular cells

Question 18

How does invasive cervical cancer present?

Answer 18

Bleeding - post coital, intermenstrual, post menopausal
Mass
Screening

Question 19

What is the treatment for invasive cervical cancer?

Answer 19

If advanced: hysterectomy, lymph node dissection, chemoradiotherapy

Question 20

What is endometrial hyperplasia?

Answer 20

Increased gland:stroma ratio
Thickened endometrium >7mm
Can be a precursor to endometrial cancer

Question 21

What is endometrial hyperplasia caused by?

Answer 21

Caused by excessive oestrogen

• endogenous: obesity, early menarche/late menopause, oestrogen secreting tumours
• exogenous: unopposed oestrogen HRT, tamoxifen
• irregular cycle: PCOS

Question 22

How can endometrial cancer present?

Answer 22

Bleeding - postmenopausal, intermenstrual

Mass

Question 23

What are the 2 types of endometrial cancer?

Answer 23

Endometrioid adenocarcinoma (most common) - commonly arises from hyperplasia
Serous adenocarcinoma - more aggressive, poorly differentiated cells

Question 24

How does serous adenocarcinoma spread?

Answer 24

Exfoliates
Travels through Fallopian tubes
Deposits on peritoneal surface (transcoelomic spread)
Associated with collections of calcium (psammoma bodies)

Question 25

What is the management for endometrial cancer?

Answer 25

Hysterectomy Bilateral salpingo-oophorectomy +/- lymph node dissection +/- chemoradiotherapy

Question 26

What is a leiomyoma?

Answer 26

Most common tumour of myometrium Benign Pale, homogenous, well circumscribed mass

Question 27

How does leiomyoma present?

Answer 27

Asymptotic Pelvic pain Heavy periods Urinary frequency

Question 28

What is a leiomyosarcoma?

Answer 28

Malignant tumour of smooth muscle Atypical cells Doesn’t arise from a leiomyoma Metastasis to lung

Question 29

What is the presentation of ovarian cancer?

Answer 29

Early - vague and non-specific, delayed diagnosis | Later - abdominal pain, abdominal distension, urinary symptoms, GI symptoms, hormonal disturbances

Question 30

What are the types of tumours of the ovary?

Answer 30

Epithelial tumours Germ cell tumours Sex cord stromal tumours

Question 31

What are ovarian epithelial tumours?

Answer 31

Often present as cystic mass Subtypes - serous, mucinous, endometrioid (all adenocarcinoma) Can be benign, borderline or malignant

Question 32

Describe serous adenocarcinoma (ovarian)

Answer 32

Highly atypical cells Often show psammoma bodies Often spread to peritoneal surface

Question 33

What is a teratoma?

Answer 33

Most common germ cell tumour | 3 subs types: mature (benign), immature (malignant), monodermal (highly specialised)

Question 34

Describe a mature teratoma (dermoid cyst)

Answer 34

Contain fully mature, differentiated tissue from all germ cell layers Can be bilateral Often contains skin and hair structures

Question 35

What are some other less common germ cell tumours?

Answer 35

Dysgerminoma Choriocarcinoma Embryonal carcinoma Yolk sac tumour All malignant

Question 36

What are the sex cord cells in testes?

Answer 36

Sertoli cells, leydig cells

Question 37

What are the sex cord cells in ovaries?

Answer 37

Granulosa cells | Theca cells

Question 38

What do theca and granulosa cell tumours produce?

Answer 38

Oestrogen

Question 39

How do theca and granulosa cell yours present?

Answer 39

Patient pre-puberty - precocious puberty | Patient post-puberty - breast cancer, endometrial hyperplasia, endometrial carcinoma

Question 40

What do Sertoli and leydig tumours produce?

Answer 40

Testosterone

Question 41

How do Sertoli-Leydig tumours present in women?

Answer 41

Patient pre-puberty - present normal female pubertal changes Patient post-puberty - infertility, amenorrhoea, hirsuitism, male pattern baldness, breast atrophy

Question 42

Which cancers can cause metastases to the ovary?

Answer 42

Breast cancer GI cancers Other gynae tumours - endometrial, other ovary, Fallopian tube Krukenberg tumour - metastatic GI tumour

Question 43

What is an important risk factor for testicular cancer?

Answer 43

Cryptorchidism (undescended testicle)

Question 44

How does testicular cancer present?

Answer 44

Mass +/- pain

Question 45

What are the investigations for testicular cancer?

Answer 45

Scans (USS) | Tumour markers

Question 46

When are testicular cancer tumour markers useful?

Answer 46

In germ cell tumours - for diagnosis, response to treatment, monitoring for recurrence

Question 47

What are the testicular cancer tumour markers?

Answer 47

``` Beta hCG - choriocarcinoma Alpha fetoprotein (AFP) - yolk sac tumours ```

Question 48

What are the seminomatous germ cell testicular cancers?

Answer 48

Seminoma (most common) | Spermatocytic seminoma

Question 49

What are the non-seminomatous germ cell testicular cancers?

Answer 49

Teratoma Yolk sac tumour Choriocarcinoma Embryonal carcinoma