Cervix and ovarian cancer Flashcards
Cervical cancer : Definition
Cancer arising from the changes in the squamous epithelial cells lining the cervix
- Squamous cell carcinoma is the most common type
Cervix : Anatomy
⦁ Cervix is split into 2 parts
1. Endocervix
⦁ closer to the uterus ‘upper part’
⦁ Histology : Columnar epithelial cells;that produce mucus.
-
Ectocervix
⦁ Continuous with the vagina
⦁ Histology :mature squamous epithelial cells. - **The squamocolumnar junction **
Where squamous epithelium of the ectocervix and the columnar epithelium of the endocervix meet. - **Transformation zone **
* right where the two types of cells meet
* where sub-columnar reserve cells multiply and transform into immature squamous epithelium through a process called metaplasia.
Cervical cancer : Pathophysiology
Cervical intra epithelial neoplasia : occurs when there is dysplasia in the immature squamous epithelium at the transformation zone
⦁ Transformation of normal cervical epithelium into precancerous lesions (cervical intraepithelial neoplasia, CIN)
⦁ eventually invasive carcinoma
Cervical cancer : Risk factors
- HPV
- Smoking
- Long term COOP use
- Immunosupression
- HIV
- High rate of sexual partners
Cervical cancer : Main risk factor
Human papillomavirus (HPV) infection
HPV 16
HPV 18
Cervical cancer : Clinical features
- Heavy/Irregular vaginal bleeding
- Pain during sex or bleeding after sex
- Pelvic or lower back pain
Cervical intraepithelial neoplasia : Defintion
Abnormal changes in the cells of the cervix
Pre cancerous lesion if untreated can progress to cervical cancer
Cervical intraepithelial neoplasia : Grading
- CIN 1 - Mild dyskaryosis
- 1/3 of cervical area
* Corressponds with infection of HPV and will self resolve within 6 months
* No treatment required - CIN II- moderate dyskaryosis
* 2/3 thickness of surface area of surface
* Moderate changes - CIN III - severe dyskaryosis
* Full thickness of cervic
CIN : Management
- Large loop excision of the transformation zone
Cervical cancer : Clinical features
⦁ May be detected during routine cervical cancer screening
⦁ Abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
⦁ Vaginal discharge
Cervical cancer : Sites of metastasis
Liver, lungs, bone
Cervical cancer : Staging - Stage 1
1A : Confined to cervix, only visible by microscopy and less than 7 mm wide
- A1 : < 3mm deep
- A2 : 3-5mm deep
1B : Confined to cervix, clinically visible or larger than 7 mm wide:
- B1 <4cm diameter
- B2 - > 4 cm diameter
Cervical cancer : Staging - Stage 2
Extension of tumour beyond cervix but not to the pelvic wall
Cervical cancer : Staging - Stage 3
- Extension of tumour beyond the cervix and to the pelvic wall
- Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III
Cervical cancer : Staging - Stage 4
Extension of tumour beyond the pelvis or involvement of bladder or rectum
Cervical cancer : Management- Stage 1 A
Gold standard : hysterectomy +/- lymph node clearance
- A2 (3-5cm deep) - Lymph nodal clearance
- If wanting to maintain fertility : Cone biopsy with negatve margins (removal of cone shaped wedge from cervix)
Cervical cancer : Management- Stage 1 B
- B1 tumours: radiotherapy with concurrent chemotherapy is advised
- B2 tumours: radical hysterectomy with pelvic lymph node dissection
Cervical cancer : Management- Stage 2/3
- Radiotherapy and chemotherapy
- Nephrostomy : In hydronephrosis
Cervical cancer : Management- Stage4
Radiation and/or chemotherapy is the treatment of choice } palliative
Cervical cancer : Complications of disease and management
-
Loss of fertility
⦁ Hysterectomy
⦁ Radiation therapy can lead to premature ovarian failure and uterine damage -
Urinary Dysfunction
⦁ Ureteral obstruction: Advanced cervical cancer can infiltrate the ureters, causing obstruction and hydronephrosis
⦁ Urinary incontinence and retention: Surgery and radiation therapy can damage nerves and muscles controlling urinary function, leading to urinary incontinence or retention. -
Bowel Dysfunction
⦁ Obstruction: Direct invasion of the tumour into the rectum, or radiation-induced fibrosis, can cause bowel obstruction.
⦁ Radiation proctitis: Radiation therapy can induce inflammation and damage to the rectum, causing symptoms such as diarrhoea, urgency, and rectal bleeding. -
Lymphedema
⦁ Lymph node dissection and radiation therapy can disrupt the lymphatic system, leading to lymphedema. -
Sexual Dysfunction
⦁ Treatments for cervical cancer, such as surgery and radiation, can affect sexual function by causing changes in anatomy
⦁ vaginal dryness, pain during intercourse, and a decrease in sexual desire.
6.** Fistula Formation**
⦁ Advanced cervical cancer or treatment-related damage
⦁ lead to the development of fistulas such as vesicovaginal (bladder and vagina) or rectovaginal (rectum and vagina) fistulas.
Cervical cancer : Screening : Describe process
A smear test is offered to all women between the ages of 25-64 years
⦁ 25-49 years: 3-yearly screening
⦁ cervical screening in pregnancy is usually delayed until 3 months post-partum
⦁ 50-64 years: 5-yearly screening
- HPV first system : sample is tested for high-risk strains of HPV first
- Cytotological sample : only done if +ve for HPV cervical cancer causing strain
Cervical cancer : Screening : Negative hrHPV
return to normal recall
Cervical cancer : Screening : Positive hrHPV - next step
- Samples are examined cytologically
- If the cytology is abnormal ie. epithelial changes or dyskaryosis of any degree → colposcopy
- If cytology is normal -> Repeat HPV first test in 12 months
* - If Repeat HPV test is negative } normal recall
* - If repeat HPV test is positive } repeat again in 12 months
* - Repeat HPV test is positive 24 months later } Colposcopy
Cervical cancer : Screening : Positive hrHPV - ‘Inadequare sample’
I. Repeat the sample within 3 months
II. If two consecutive inadequate samples then → colposcopy
Germ cell ovarian tumor : Pathophysiology
- Ovaries contain multiple folliciles
- Each follicle is made up of a germ cell - also known as oocyte which is an immagure cell
- Germ cells are pluripotent cells found in the ovaries which eventually differentiate into eggs.
- Uncontrollable division of the germ cells in the ovaries can lead to ovarian tumors or cancer
Ovarian cancer : most common type
- 90% are epithelial cancer - majority of which are serous carcinomas
Ovarian cancer : Risk factors
- BRCA1 or the BRCA2 gene
- HNPCC - Lynch syndrome
Anything which increases the number of ovulation cycles in a lifetime - early menarche, late menopause, nulliparity
Ovarian cancer : Clinical features
⦁ abdominal distension and bloating
⦁ abdominal and pelvic pain
⦁ urinary symptoms e.g. Urgency
⦁ early satiety
⦁ diarrhoea
Ovarian cancer : Investigation
- CA125 : FIRST LINE
may also be raised due to endometriosis/ovarian cysts - CA124 > 35 } Raised
- Urgent US of Abdomen and Pelvis
- Labs : Beta HCG/ AFP/LDH
Germ cell Ovarian tumor :Teratoma
Contains all types of tissues - hair, teeth, neurons
-
Immature teratomas :
- Arise from neuroectoderm
- Malignant and metastasise quickly -
Mature cystic teratoma / Dermoid cyst
* Arise from any germ layer : lines with epithelial tissue thus contain skin, hair, teeth
* Most common benign ovarian tumor in young women <30
Sx : Non symptomatic, increased risk of torsion
Germ cell Ovarian tumor : Yolk sac tumor
- Definition : consists of germ cells which differentiate into yolk sac tissue
- Incidence : Most common germ cell tumor in children
- Histology : Schiller-Duval bodies seen under the microscope - rings of cells around blood vessels
- Progression : malignant and very aggressive
Release AFP - Alpha fetal protein
Germ cell Ovarian tumor : Choriocarcinoma
- Definition : Germ cells which differentiate in to syncytiotrophoblast cells - placental tissue which releases Beta HCG
- Progression : small tumors which secrete high levels of Beta HCG causing -> ovarian cysts to form
Germ cell Ovarian tumor : Dysgerminoma
Definition : Germ cells differentiate into oocytes and grow uncontrollable
Histology : central nucleos surrounded by clear cytoplasm
Presentation : Release LDH
Incidence : Most common malignant ovarian tumor
Epithelial-Stromal ovarian tumors : definition
Ovaries contain multiple folliciles
Each follicle is made up of a germ cell - also known as oocyte which is an immature cell
1. Stromal tissue : connective tissue cells found between the follicles
1. Epithelium tissue : layer of epithelial cells lining the surface of the ovaries
Epithelial-Stromal ovarian tumors : Pathophysiology
- During ovulation, the follicle ruptures and releases the egg, which inadvertently leads to epithelial cell damage.
- To fix that damage the epithelial cells have to undergo cell division to replace and heal the tissue.
- Each time cells divide there is a chance of a mutation and the possibility of tumor formation
- This means that with more ovulatory cycles, there’s increased risk of tumor formation.
Which is the most common benign epithelial tumor?
Serous cyst adenoma
Epithelial-Stromal ovarian tumors : Serous tumors
Can be malignant or benign tumors
Benign : Serous cystadenomas
Malignant : Serous cystadenocarcinoma
Histology : arise from epithelial cells that line the outside of the ovaries
Presentation : Fluid filled cysts in both ovaries
Incidence : Post menopausal women
Epithelial-Stromal ovarian tumors : Mucinoid tumors
Can be malignant or Benign
- Malignant : Mucinous cystadenocarcinoma
- Benign : Mucinous cysadenoma
- Histology : mucus filled cysts, typically very very large
- Presentation Unilateral ovary
Ovarian cysts : Definition and incidence
- Fluid filled growths that develop in the ovary
- Incidence :during reproductive years
Name two types of physiological cysts
- Follicular cysts
- Corpus luteum cysts
Physiological cysts : Follicular cyst
Commonest type of ovarian cyst
1. Physiology : due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle
- Progress : regresses after several menstrual cycles
Physiological cysts : Corpus luteum cyst
Physiology : corpus luteum doesn’t breakdown after menstrual cycle and instead may fill with blood or fluid forming cyst
Ovarian cysts : Clinical features
- Pelvic or lower abdominal pain
- Dyspareunia : Painful sexual intercourse
Ovarian cyst : management
*Ultrasound shows cyst *
- Premenopausal women
- If < 5cm } repeat US 8 - 12 weeks - Post menopausal women
} refer to gynae for assesment regardless of size
Layers of the uterus
- Endometrium : mucosal layer made up of single layer of columnar epithelial cells
- Under goes monthly cyclic changes
- Perimetrium : layer continous with the lining of the peritoneal cavity
- Myometrium : smooth muslce which contracts during childbirth
Endometrial carcinoma : Definition
- Abnormal growth of the columnar epithelial cells which make up the endometrial glands
- Excess oestrogen stimulates endometrial hyperplasia which increases the risk of a mutation occurring
Endometrial carcinoma : Risk factors
-
Excess oestrogen
* Many menstrual cycles : nulliparity, early menarche, late menarche
* Tamoxifen : blocks oestrogen receptor in breasts for breast cancer but stumulates receptors in the uterus -
Excess adipose tissue : fat cells convert andrenal precursors into sex hormones
* obesity
* diabetes mellitus
* polycystic ovarian syndrome
Endometrial cancer : Genetic risk factor
HNPCC - Lynch syndrome
Endometrial cancer : Clinical features
- Post menopausal bleeding } most common sx
- Menorrhagia or intermenstrual bleeding
- Unusual vaginal discharge
Endometrial cancer : criteria for 2ww pathway
All women >= 55 years who present with postmenopausal bleeding
- First-line investigation : trans-vaginal ultrasound
- a normal endometrial thickness (< 4 mm) has a high negative predictive value
Endometrial cancer : Investigation
First line : Transvaginal US - endometrial thickness
: if > 4mm
Second line : Hysteroscopy with Endometrial Biopsy
Endometrial cancer : Management
Localised disease :
* total abdominal hysterectomy with bilateral salpingo-oophorectomy
+ Post operative radiotherapy
Vulval carcinoma : type
80% are squamous cell carcinomas
Vulval carcinoma : Incidence
Women > 65
Vulval carcinoma : Risk factors
- HPV infection
- Vulval intraepithelial neoplasia
- Immunosupression
- Lichen sclerosis
Vulval carcinoma : Clinical features
- Lump or ulcer on the labia majora
- Inguinal lymphadenopathy
- itching, irritation
Vulval intraepithelial neoplasia : defintion
- Non invasion squamous lesion
- Precursor of squamous cell carcinoma of the vulva
*
Uterine cancer
Leiomyosarcoma - malignant growth in the myometrium of the uterus
- Rapidly enlarging pelvic mass
- Abnormal vaginal bleeding and discharge
- Pain and increased urinary frequency
