21 - Malignancy of the Reproductive Tract Flashcards
What are most vulval cancers and what are they caused by?
Squamous cell carcinoma (rare)
- Older women: long standing chronic irritation e.g lichen sclerosus and squamous hyperplasia
- Pre-menopausal: HPV 16 causing vulval intraepithelial neoplasia (VIN) which leads to SCC. 70% of vulval cancers
How does vulval cancer spread and how is it treated?
- Locally to inguinal lymph nodes
- Definitive surgery to remove primary tumour and nodes. Higher survial in smaller lesions
What is the transformation zone of the cervix?
- Endocervix is glandular epithelium and ectocervix is squamous
- Metaplasia occurs in the glandular epithelium that forms ectropion to protect from the low pH in vagina
What type of cancers form in the cervix?
- Squamous cell carcinom in 80%
- 15% adenocarcinoma
What is the cause of cervical cancer?
- HPV causing infection in metaplastic squamous cells leading to increased proliferation. Works by producing E6 and E7 which inactivate p53 and Rb
- Also can develop from cervical intraepithelial neoplasia
What are the different stages of cervical intraepithelial neoplasia?
- Dysplasia caused by HPV that can lead to cervical carcinoma
- CIN1 means bottom third have dyplasia and so on
- Higher the CIN more risk for SCC
What are risk factors for developing CIN and what have the government put into place to try and overcome some of these risks?
- Since 2008 girls aged 12-13 have been vaccinated against 4 high risk HPV’s and it lasts for 10 years
- Vaccine protects against oral, anal, vulval and cervical cancers
What would you do if you had CIN1/2/3 on a cervical screening?
- CIN1: often regresses spontaneously, just have a follow up biopsy in a year
- CIN 2/3: Need treatment as increased risk of progression to SCC. Need large loop excision of transformation zone LLETZ
How does cervical screening work?
- Brush used to scrape cells from transformation zone
- Cells with abnormally large nuclei are positive and will look down microscope
- Aim is to detect preinvasive lesion so can excise it
- If positive will refer for colposcopy and removal of these areas by diathermy
Where does cervical carcinoma spread to?
- Iliac and aortic nodes before wide spread dissemination
- Can spread locally to ureters, bladder and rectum and this can cause pain and fistula formation
- Staged using FIGO
What may invasive cervical cancer present as and how do we treat it?
- Bleeding post coital, intermenstrual, post menopausal
- Palpable mass
- Can’t just do excision with invasive
What type of cancer forms in the endometrium and what is this cause of this?
- Adenocarcinoma (most common gynaeological cancer)
- Often in perimenopausal and older women due to unopposed oestrogen
- Endometrial hyperplasia is a precursor for endometrioid endometrial adenocarcinoma
How does endometrial cancer present and what are the two different histological types?
- Bleeding post menopausal or intermenstrual
- Mass
- Serous has worse prognosis
Where does endometrial carcinoma spread to?
- Invades myometrium and spreads to cervix, bladder and rectum, peritoneal cavity and regional lymph nodes
- Serous spreads transcoelomic as exfoliates form, travel through fallopian tubes and deposit on peritoneal surface
What type of endometrial cancer is this and why?
- Serous
- Poorly differentiated so higher grade
- Psammoma bodies (collections of calcium)
What type of mass is this that was found in the myometrium and what symptoms would this mass cause?
- Leiomyoma: benign mass of smooth muscle
- Can be asymptomatic or heavy period, menorrhagia, infertility
- Uterine enlargement so pressure symptoms like urinary frequency
- Oestrogen dependent so regress after menopause
What is this mass found in the myometrium and how does it behave?
- Leiomyosarcoma
- Similar symptoms to fibroids but does not develop from leiomyoma
- Spreads via blood stream as sarcoma, to lungs and then systemic
What are some of the symptoms for ovarian cancer and the tumour markers for this cancer?
- Ca125 for diagnosis and recurrence
- BRCA1/2 associated with high grade serous epithelial tumours. May want to do prophylatic salpingo-oophrectomy
What are the different tumours that can occur in the ovary?
- Epithelial
- Germ cell
- Sex cord-stromal
- Metastases from GI, gut or mullerian epithelium e.g ovary, fallopian tube
How can epithelial tumours of the ovary be classified?
- Benign, malignant, borderline
- Mucinous, serous, endometrioid
What type of ovarian cancer is this and why?
- Ovarian serous adenocarcinoma
- Psammoma bodies
- Often transcoelemic spread and diagnosed from cytology of peritoneal aspiration
What type of ovarian cancer is this and why?
- Ovarian mucinous adenocarcinoma
- Atypical epithelial cells secreting mucin, with nucleus pushed to side
What type of ovarian cancer is this and why?
What is this ovarian tumour?
- Benign
- Would be malignant if immature tissue
Apart from a teratoma, what are some other malignant germ cell tumours in a female and what are some markers for these?
- hCG
- AFP
- Commonly found in testes
What are the different sex cord tumours that can arise in the ovary and how do they present?
- Sertoli-Leydig produce testosterone so breast atrophy, hirtuitism etc.
What type of cancer of the ovary is this?
Kruckenberg: signet ring with foamy cytoplasm and nucleus to one side
What are the different types of testicular cancer and what age group do they most commonly affect?
- 15-34 year olds
- Germ cell, sex cord or lymhoma
What are some non germ cell tumours?
- 95% of testicular tumours are germ cell so only 5% non
- Sex cord stromal like Sertoli-Leydig
- Often benign and uncommon
Why does never having children or taking the OC pill give you a greater risk of developing ovarian cancer?
- Maximal ovulations so lots of scarring and more cell proliferation so more chance of mutations
- Also more at risk with BRCA1/2 mutations
What are the main risk factors for testicular cancers and how is this risk reduced?
- All germ cell tumours malignant and often familial predisposition
- Cryptorchidism in 10% of cases, increasing risk in both descended and maldescended
- Perform orchiopexy before puberty to reduce risk
How does testicular cancer normally present and what are some investigations when this presentation occurs?
- Painless mass due to intratubular germ cell neoplasia
- Do scans and check tumour markers e.g hCG (choriocarcinoma) and AFP (yolk sac tumour)
What are the two classifications of germ cell tumours?
- Seminomas
- Non-seminomas
50/50 for both cancers
How do seminomas tend to act?
- Peak in men aged 40-50
- Rarely metastasise but when they do after a long time they go to iliac and paraortic lymph nodes but don’t tend to go any further
How do NSGCT’s act?
- Split into yolk sac, embryonal carcinomas, choriocarcinomas and teratomas but most contain components of two
- Metastasise early via lymphatics and blood vessels
- May present with the metastases and the primary tumour not palpable
What are the characteristics of a yolk sac tumour in a male?
- Common in young children and has good prognosis
- Assoicated with rise in AFP
What are the charactertistics of embryonal carcinomas and choriocarcinomas in a male?
- Occur in young adults
- Chorios are associated with rise in hCG
- Mixed NSGCT’s are associated with rise in hCG and AFP
What are the characteristics of teratomas in males?
- Occur at all ages
- Prepuberty they are often benign but post they are malignant
- 10% of these have a rise in hCG
How are testicular tumours treated?
- Radical orchiectomy
- Seminomas then followed by radiotherapy as radiosensitive and they have a better prognosis
- NSGCT’s have aggressive chemotherapy
What type of cancer does this woman have and why does she have bowel obstruction?
- Ovarian serous adenocarcinoma
- Psammoma body
- Erosions sat on the serosal surface of the bowel and invading
What is the triple approach to investigating breast cancer?
How does tamoxifen work?
binding to the estrogen receptor and the blocking of the proliferative actions of estrogen on mammary epithelium.
What are some of the side effects of tamoxifen?
Endometrial cancer as partial agonist not anatagonist at the endometrium
Why do you get oedema in pregnancy?
- Increased fluid retention
- Compression of vena cava leading to high hydrostatic pressure in the venous end
- Low albumin in the blood due to increased GFR of mother
