cancer Flashcards
what is endometrial hyperplasia
an increase in the number of glands
what are the types of endometrial hyperplasia
simple
complex
(atypical)
what is an endometrial polyp made up of
stroma
glands
how does endometrial hyperplasia present
abnormal bleeding
- dysfunctional uterine bleeding
- post-menopausal bleeding
describe simple hyperplasia with regard to distribution, component, glands and cytology
distribution: general
component: glands and stroma
glands: dilated, not crowded
cytology: normal
describe complex hyperplasia with regard to distribution, component, glands and cytology
distribution: focal
component: glands
glands: crowded
cytology: normal
describe atypical hyperplasia with regard to distribution, component, glands and cytology
distribution: focal
component: glands
glands: crowded
cytology: atypical
what is the risk of atypical endometrial hyperplasia
progression to endometrial cancer
management of complex atypical hyperplasia
hysterectomy
high chance of existing/progression to cancer
when is peak incidence of endometrial carcinoma
50-60 years
what should you consider in women <40 presenting with endometrial cancer
underlying predisposition eg PCOS or Lynch syndrome
what is Lynch syndrome
hereditary nonpolyposis colorectal cancer
what is the precursor of endometrioid carcinoma
atypical hyperplasia
what is the precursor of serous carcinoma
serous intraepithelial carcinoma
what is the macroscopic appearance of endometrial carcinoma
large
polypoid
what is the microscopic diagnosis of endometrial carcinoma
most are well-differentiated adenocarcinomas
where does endometrial carcinoma spread
directly into myometrium and cervix
lymphatic
haematogenous
what is the most common type of endometrial carcinoma
endometrioid
which endometrial carcinoma is associated with unopposed oestrogen
endometrioid
not serous
why is obesity a risk for endometrial cancer
adipocytes express aromatase that converts ovarian androgens into oestrogens, which induce endometrial proliferation
lower levels of sex hormone-binding globulin so higher unbound, active oestrogen
what type of inheritance does Lynch syndrome display
autosomal dominant
microscopic characteristics of serous carcinoma
complex papillary and/or glandular architecture with diffuse, marked nuclear pleomorphism
which cancer might present early with extrauterine disease
serous carcinoma
spreads along the Fallopian tube mucosa and peritoneal surfaces
what is prognosis of endometrial carcinoma dependent on
stage
histological grade
depth of myometrial invasion
how to grade endometrioid carcinoma
grade 1 = 5% or less solid growth
grade 2 = 6-50% solid growth
grade 3 = >50% solid growth
stage I endometrial cancer
IA = no or <50% myometrial invasion IB = invasion equal to of >50% of myometrium
stage II endometrial cancer
tumour invades cervical stroma
stage III endometrial cancer
III = local and/or regional tumour spread IIIA = tumour invades serosa of uterus and/or adnexae IIIB = vaginal and/or parametrical involvement IIIC = metastases to pelvic and/or para-aortic lymph nodes
stage IV endometrial cancer
IVA = tumour invades bladder and/or bowel mucosa IVB = distant metastases
common mets with endometrial stroll sarcoma
ovary or lung
common abnormality of the myometrium
leiomyoma (fibroid)
associated with menorrhagia and infertility
what are the layers of the normal ectocervix
exfoliating cells superficial cells intermediate cells parabasal cels basal cells basement membrane
what is the transformation zone of the cervix
squamo-columnar junction between ectocervical (squamous) and endocervical (columnar) epithelia
when does the position of the transformation zone alter
menarche
pregnancy
menopause
what is cervical erosion
exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia
what is a nabothian follicle
mucus-filled cyst on surface of the cervix
caused by stratified squamous epithelium of the ectocervix growing over the columnar epithelium of the endocervix
examples of inflammatory pathology of the cervix
cervicitis (diffuse) cervical polyp (localised inflammatory growth)
what are risk factors for CIN/cervical cancer
high risk HPV viruses (16, 18, etc) many sexual partners vulnerability of SC junction in early reproductive age (age at first intercourse, long term use of OC, non-use of barrier contraceptives) smoking immunosuppression
which types of HPV cause genital warts
6 and 11
microscopic description of genital warts
thickened papillomatous squamous epithelium with cytoplasmic vacuolation (koilocytoss)
which types of HPV are associated with CIN
16 and 18
microscopic appearance of CIN
infected epithelium remains flat but may show koilocytosis
how long does it take to progress from HPV infection to high grade CIN
6 months - 3 years
how long does it take to progress from high grade CIN to invasive cancer
5-20 years
how is CIN detected
cervical screening
where does CIN occur
transformation zone
what is koilocytosis indicative of
HPV infection
what is CIN I
basal 1/3 of epithelium occupied by abnormal cells
raised number of mitotic figures in lower 1/3
surface cells are quite mature, but nuclei slightly abnormal
what is CIN II
abnormal cells extend to middle 1/3
mitoses in middle 1/3
abnormal mitotic figures
what is CIN III
abnormal cell occupy full thickness of epithelium
mitoses, often abnormal, in upper 1/3
stage 1 of invasive cervical squamous carcinoma
stage 1A1 - depth up to 3 mm, width up to 7 mm
stage 1A2 - depth up to 5 mm, width up to 7 mm
stage 1B - confined to cervix
stage 2 of invasive cervical squamous carcinoma
spread to adjacent organs (vagina, uterus etc)
stage 3 of invasive cervical squamous carcinoma
involvement of pelvic wall
stage 4 of invasive cervical squamous carcinoma
stage 4A - involvement of bladder or rectum
stage 4B - extra-pelvic involvement
symptoms of invasive cervical carcinoma
abnormal bleeding (post-coital, post-menopausal, brownish or blood stained discharge, contact bleeding)
pelvic pain
haematuria/UTI
ureteric obstruction/renal failure
what is classed as local spread of squamous cervical carcinoma
uterine body, vagina, bladder, ureters, rectum
what is CGIN
cervical glandular intraepithelial neoplasia
what is CGIN the precursor of
endocervical adenocarcinoma
endocervical adenocarcinoma vs cervical squamous carcinoma; worse prognosis?
endocervical adenocarcinoma
risk factors for cervical adenocarcinoma
higher socioeconomic class
later onset of sexual activity
smoking
HPV (18)
where does vulvar invasive squamous carcinoma often spread
inguinal lymph nodes
important prognostic factor
surgical treatment of vulvar invasive squamous carcinoma
radical vulvectomy and inguinal lymphadenectomy
how does the presence of node involvement affect the prognosis of vulvar invasive squamous carcinoma
90% 5-year survival node negative
<60% 5 year survival node positive
what is vulvar Paget’s disease
crusting rash affecting the vulva
tumour cells in epidermis contain mucin
mostly no underlying cancer, tumour arises from sweat gland in skin
non-gynae causes of pelvic mass
constipation caecal carcinoma appendix abscess diverticular abscess urinary retention retroperitoneal tumour
causes of uterine mass
pregnancy
fibroids (most common)
endometrial cancer (usually present early so pelvic mass is unusual)
cervical cancer (pelvic mass = late presentation)
what are leiomyomas
uterine fibroids
benign smooth muscle tumours
presentation of uterine fibroids
asymptomatic/incidental finding menorrhagia pelvic mass pain/tenderness 'pressure' symptoms
investigation of suspected fibroids
Hb if heavy bleeding
USS usually diagnostic
MRI for more precise localisation
treatment of fibroids
expectant if asymptomatic
hysterectomy if no more children
(myomectomy, uterine artery embolisation, hysteroscopic resection)
causes of tubal swellings
ectopic pregnancy
hydrosalpinx
pyosalpinx
paratubal cysts
causes of ovarian mass
tumours/neoplastic
functional cysts
endometriotic cysts
what are endometriotic cysts
blood filled cysts on ovaries associated with endometriosis
aka endometriomas/chocolate cysts
symptoms of endometriotic cysts
severe dysmenorrhoea
premenstrual pain
dyspareunia
subfertility
endometriotic cysts on examination
typically tender mass with nodularity and tenderness behind uterus
primary ovarian tumours arising from surface epithelium
serous mucinous endometrioid clear cell brenner benign = cystadenoma malignant = cystuadenocarcinoma
primary ovarian tumours arising from germ cells
benign cystic teratoma
malignant germ cell tumours (v rare)
what might tumours arising from the stroma secrete
granulosa cell - oestrogens
theca/leydig cell - androgens
what is meig’s syndrome
benign fibroma with pleural effusion
where do secondary ovarian tumours often metastasise from
breast
pancreas
stomach
GI
presentation of ovarian cancer
mass swelling pressure symptoms heartburn/indigestion early satiety weight loss/anorexia bloating bowel habits SIB/pleural effusion leg oedema/DVT
genetic causes of ovarian cancer
BRCA 1 and 2
- breast and ovarian ca
HNPCC (Lynch syndrome)
- bowel, endometrial, ovarian
risk factors for ovarian cancer
increasing age
nulliparity
FHx
(OCP protective)
investigation of suspected ovarian Ca
tumour markers (CA 125, Cancino-Embryonic Antigen (CEA)) USS to determine nature of cyst CT to assess extra-ovarian disease
in what other situations might CA 125 be raised
endometriosis peritonitis/infection pregnancy pancreatitis ascites from any cause other malignancy
what its he main function of CEA
exclude mets from GI primary
treatment of ovarian cyst/mass
removal/drainage if benign
removal of ovaries and uterus with removal/biopsy of omentum, debunking of tumour and complete examination of all peritoneal surfaces
chemo pre/post surgery
is treatment of ovarian ca curative
unlikely unless confined to ovary at presentation
history of pelvic mass
speed of onset/duration of all Sx mass/swelling/bloatedness pressure symptoms (bladder/bowel) pain menstrual Hx cervical smear Hx parity and fertility FHx previous gynae and surgical Hx ovarian Ca symptoms
