Gynaecological Tumours Flashcards
How common are vulval tumours and who do they affect the most?
Uncommon (approx 3% of female genital cancers)
2/3rds in women over 60
What are the types of vulval tumours?
Squamous cell carcinoma - most common
Extramammary Paget’s disease
Basal cell carcinoma
Malignant melanoma
Risk factors for vulval squamous cell carcinoma?
Same for cervical carcinomas:
- HPV
- intercourse
- early marriage
- early first pregnancy
- multiple births
- many partners
- promiscuous partner
- long term use of OCP
- partner with carcinoma of the penis
- low socio-economic class
- smoking
- immunosuppression
What are the usual causes of squamous cell carcinoma of the vulva in older and younger women?
70s - long standing inflammatory and hyperplastic conditions of the vulva eg lichen sclerosis
50s - usually HPV and risk factors same as cervical carcinoma
What is the precursor to squamous neoplastic lesions of the vulva?
Vulvar intraepithelial neoplasia (VIN)
-atypical squamous cells within the epidermis (no invasion)
Which lymph nodes does vulval squamous cell carcinoma spread to?
Where else?
Inguinal, pelvic, iliac and para-aortic lymph node
Lungs and liver
Survival if a lesion of vulval squamous cell carcinoma is less than 2cm?
Following which procedures?
90% 5 year survival
Vulvectomy and lymphadenectomy
Where includes gynaecological tumours?
Cervix Endometrium Myometrium Ovary Vulva Tumours of gestation
What are the two important viruses causing cervical carcinoma?
HPV 16
HPV 18
How do the viruses cause squamous cell carcinoma?
Infect immature metaplastic squamous cells in the transformation zone
Produce viral proteins which interfere with activity of tumour suppressor genes - inability to repair damaged DNA and increase proliferation of cells
Risk factors for CIN and cervical carcinoma?
Sexual intercourse Early first marriage Early first pregnancy Multiple births Many partners Promiscuous partner Long term use of OCP Partner with carcinoma of penis Low socio-economic class Smoking Immunosuppression
Why is cervical screening so successful?
Cervix accessible to visual examination and sampling
Slow progression from precursor lesions to invasive cancers
Pap test detects precursor lesions and low stage cancers
Allows early diagnosis and curative therapy
How is the cervical screening done?
Cells from transformation zone are scraped off, stained with Papanicolaou stain and examined microscopically
When is cervical screening done?
Starts age 25
Every three years until 50
Every 5 years from 50-65
What happens if the result of cervical screening is abnormal?
Referred for colposcopy (visualisation of cervix) and biopsy
For how many years does the vaccine against HPV protect for?
Up to 10 years
What is cervical intraepithelial neoplasia?
Dysplasia of squamous cells within the cervical epithelium, induced by infection with high risk HPVs
What is dysplasia?
Enlargement of an organ/tissue by the proliferation of cells of an abnormal type - early stage in development of cancer
What are the CIN stages?
What is the outcome of each one?
CIN I - most regress spontaneously and a small % progress to..
CIN II
CIN III - carcinoma in situ - 10% progress to invasive carcinoma in 2-10 years, 30% regress
How long does it take to go from CIN I to CIN III
7 years
What is the management of each CIN stage?
CIN I - follow-up or cryotherapy
CIN II and III - superficial excision
Average age of presentation of cervical carcinoma?
45
What are the most common types of cervical carcinomas?
80% squamous cell carcinoma
15% adenocarcinoma
Where can cervical carcinoma spread to?
Para-cervical soft tissues, bladder, ureters, rectum, vagina
Lymph nodes - para-cervical, pelvic, para-aortic
Distally
How does cervical carcinoma usually present?
Screening abnormality
Postcoital, intermenstrual or postmenopausal vaginal bleeding
Treatment of cervical carcinoma?
Microinvasive - cervical cone excision - 100% survival
Invasive - hysterectomy, lymph node dissection, radiation and chemotherapy - 62% 10 year survival
What is the endometrium made up of?
Glands with a cellular stroma
What is the frequent precursor to endometrial carcinoma?
Endometrial hyperplasia
-increased gland to stroma ratio
What is endometrial hyperplasia associated with?
Annovulation
Increased oestrogen from endogenous sources eg adipose tissue
Exogenous oestrogen
How is endometrial carcinoma treated?
If complex and atypical, hysterectomy
What age does endometrial adenocarcinoma affect?
55-75, unusual before 40
Usual presentation of endometrial adenocarcinoma?
Irregular or postmenopausal vaginal bleeding
How common is endometrial adenocarcinoma?
Very common - most common invasive cancer of female genital tract
75% 10 year survival
What can endometrial carcinoma be classed as?
Polypoid or infiltrative
What are the two most common types of endometrial adenocarcinoma?
Endometrioid endometrial adenocarcinoma
-associated with unopposed oestrigen and obesity
Serous carinoma
Give pathophysiology of endometrioid endometrial adenocarcinoma and how it spreads
Mimics proliferative glands
Arises in setting of endometrial hyperplasia
Spreads by myometrial invasion and direct extension to adjacent structures - local lymph nodes and distal sites
Features of serous endometrial adenocarcinoma carcinoma?
Poorly differentiated, aggressive, worse prognosis
How does serous endometrial adenocarcinoma spread?
Exfoliates
Travels through Fallopian tubes
Implants on peritoneal surfaces and grows
What are fibroids?
Uterine leiomyoma
Benign tumour of myometrium (uterine smooth muscle)
Often multiple
Range from tiny to massive
Symptoms of fibroids?
Asymptomatic
Heavy/painful periods
Urinary frequency due to bladder compression
Infertility
What does uterine leiomyoma look like?
Well circumscribed, round, firm, whitish, well differentiated
Bundles of smooth muscle - resembles normal myometrium
How common is leiomyosarcoma and who does it affect?
40-60 years
Uncommon
Where do uterine leiomyosarcomas usually metastasise to?
Lungs
-highly malignant
Are most ovarian tumours benign or malignant?
80% are benign
When do most benign ovarian tumours occur?
When do most malignant tumours occur?
Benign: 20-45 years
Malignant: 45-65 years
Why is prognosis of ovarian tumours poor?
Usually spread beyond the ovary by the time of presentation - few symptoms
When do non-functional (don’t produce hormones) ovarian tumours usually give symptoms?
What symptoms do they produce?
When they become large, invade adjacent structures and metastasise
Abdominal pain
Abdominal distension
Urinary and GI symptoms
Ascites due to malignant spread through peritoneum
What hormonal problems can ovarian tumours cause?
Menstrual disturbances
Inappropriate sex hormones
Where do most malignant ovarian tumours spread to?
Regional nodes
Liver and lungs
50% to other ovary
What is used to diagnose and monitor disease recurrence of ovarian cancer?
CA-125
Possible future screening test
What are the general classifications of ovarian tumours?
Müllerian epithelium (including endometriosis) Germ cells (pluripotent) Sex-cord stromal cells (form the endocrine apparatus of the ovary) Metastases to the ovary
What are the three main histological types of ovarian Muüllerian epithelial tumours?
What can each be classified as?
Serous
Mucinous
Endometrioid
Benign, borderline or malignant
Risk factors for ovarian epithelial tumours?
Nulliparity or low parity
Heritable mutations eg BRCA1&2
Smoking
Endometriosis
OCP protective (fewer ovulations)
Why are serous Mullerian epithelial ovarian tumours commonly associated with ascites?
Often spread to peritoneal surfaces and omentum
What do mucinous ovarian tumours usually look like?
Large, cystic masses
Filled with sticky, thick, mucinous fluid
Usually benign or borderline
Give features of Mullerian epithelial endometrioid ovarian tumours
Contain tubular glands resembling endometrial glands
Can arise in endometriosis
Sometimes have associated endometrial endometrioid adenocarcinoma, probably arising separately
What are the types of germ cell ovarian tumours?
Most are teratomas - benign
Other types are malignant
-non-gestational choriocarcinoma (aggressive and often fatal, produces human chorionic gonadotropin)
-yolk sac (produces alpha-fetoprotein)
Three groups of ovarian teratomas?
Mature (benign) - most common
Immature (malignant) - rare, composed of tissues resembling immature fetal tissue)
Monodermal (highly specialised - one cell type)
Who do ovarian teratomas usually occur in?
Young women usually
What do teratomas often contain?
Cystic -hair -sebaceous material -teeth AKA dermoid cysts as they often have skin-like structures
Also tissue from other germ layers
- cartilage
- bone
- thyroid
- neural tissue
Common types of monodermal ovarian tumours?
Struma ovarii
- benign
- composed of mature thyroid tissue
- hyperthyroidism
Carcinoid
- malignant
- can be function producing 5HT (serotonin) and can cause carcinoid syndrome
Where are ovarian sex-cord stromal tumours derived from?
Ovarian stroma derived from sex cords of the embryonic gonad
What do sex cords normally give rise to?
Sertoli and Leydig cells in testes
Granulosa and theca cells in the ovaries
What can sex cord stromal tumours cause?
Feminising if from granulosa/theca cell
Masculinising if from Leydig cells
Who do granulosa cell tumours usually occur in?
Post-menopausal women
What are the signs and symptoms of granulosa cell tumours?
Produce lots of oestrogen
- precocious puberty in pre-pubertal girls
- adults - associated with endometrial hyperplasia, endometrial carcinoma, breast disease
What problems can Sertoli-Leydig cell tumours produce?
In children - block normal female sexual development Women - defeminisation and masculisation -breast atrophy -amenorrhoea -sterility -hair loss -hirsutism with male hair distribution -clitoral hypertrophy -voice changes
When is the peak incidence of Sertoli-Leydig cell tumours?
Teens/twenties
Where do metastases to the ovaries usually come from?
Mullerian tumours
- uterus
- Fallopian tubes
- contralateral ovary
- pelvic peritoneum
Sometimes GI
- colon
- stomach
- biliary tract
- pancreas
- appendix
Breast
Krukenberg tumour - drops down from stomach
What is gestational trophoblastic disease?
Tumours and tumour-like conditions which show proliferation of placental tissue
Types of gestational trophoblastic disease?
Hydatidiform mole (growing mass of tissue in the uterus due to abnormal conception) Invasive mole (tumorous growth associated with gestation) Choriocarcinoma
What is a hydatidiform mole?
Cystic swellings of chorionic villi and trophoblastic proliferation
Presentation of a hydatidiform mole?
Diagnosed in early pregnancy with ultrasound scan
Miscarriage
Highest risk group of hydatidiform mole?
Extremes of repro life
- teens
- 40-50 years
Types of hydatidiform mole?
complete
partial
What do hydatidiform moles look like?
Friable mass of thin-walled, translucent, grape-like structures = swollen oedematous villi
How is a hydatidiform mole treated?
Curettage followed by HCG monitoring - if HCG doesn’t fall, may indicate an invasive mole (rarely happens)
What is an invasive mole?
Mole that penetrates or perforates uterine wall
Locally destructive - can cause uterine rupture requiring hysterectomy
Symptoms and signs of an invasive mole?
Vaginal bleeding and uterine enlargement
Persistently elevated HCG
How is an invasive mole treated?
Chemotherapy
What is a gestational choriocarcinoma?
Malignant neoplasm of trophoblastic cells derived from previously normal or abnormal pregnancy, with no villi present
Rapidly invasive, metastasises widely but responds well to chemo
How can non-gestational choriocarcinomas arise?
From germ cells in the ovary or in the mediastinum
How does gestational choriocarcinoma present?
Vaginal spotting
High HCG levels
How is gestational choriocarcinoma treated?
Uterine excavation and chemotherapy
-high cure rate
