L20: tumours of the reproductive tracts

Question 1

Describe vulval tumours

Answer 1

Relatively uncommon, most are squamous cell carcinomas & affect older women
Older women -> causative agents are unknown, but are probably related to chronic irritation & longstanding dermatoses
Pre-menopausal women -> HPV with invasion developing from the precursor, vulval intraepithelial neoplasia

Question 2

Describe the spread and treatment of vulval tumours

Answer 2

Tumour spreads locally & metastasises predominantly to the inguinal lymph nodes
Definitive surgery would include removing the primary tumour and nodes, with higher survival rate in smaller lesions
Areas of intraepithelial neoplasia may be detected by the patient herself or during gynaecological examination

Question 3

Describe the location of cervical carcinomas

Answer 3

Inner part of the cervix (endocervix) is made of simple columnar epithelium, whereas the outer part of the cervix (ectocervix) is covered by stratified squamous epithelium
Transformation zone is where metaplasia occurs between the two epithelial types -> important when thinking about cervical carcinoma

Question 4

Describe cervical carcinomas

Answer 4

Most are squamous cell carcinomas, followed by adenocarcinomas
Both have common aetiology of HPV infection, which causes infection in the metaplastic squamous cells in the transformation zone -> increased proliferation
Squamous cell carcinomas can also develop from cervical intraepithelial neoplasia (CIN)

Question 5

Describe vaccination for HPV

Answer 5

Since 2008, girls aged 12-13 have been offered vaccination against high-risk HPVs
Vaccination offers protection against HPV infection for up to 10 years

Question 6

Describe cervical screening

Answer 6

Detects cells with abnormally enlarged nuclei possessing abnormal chromatin
Aim – detect the pre-invasive lesion & to excise the involved area completely before an invasive malignancy can develop
Indication for referral for colposcopy where abnormal areas can be identified – excised by diathermy

Question 7

Describe where cervical carcinomas can spread

Answer 7

Spreads initially to the iliac & then aortic lymph nodes, before wider systemic dissemination
Local spread can involve the ureters, bladder and rectum
Extremely distressing with pain and fistula formation

Question 8

Describe the different types of endometrial carcinoma

Answer 8

Endometrial adenocarcinoma – tumour of peri-menopausal and older women
2 main types are endometroid and serous

Question 9

Describe endometrioid endometrial adenocarcinoma

Answer 9

Perimenopausal women – unopposed oestrogen from obesity, exogenous oestrogen administration or hormone-secreting tumour (tamoxifen may also be implicated)
Unopposed oestrogen results in endometrial hyperplasia -> can progress into endometrioid endometrial adenocarcinoma

Question 10

Describe serous endometrial adenocarcinoma

Answer 10

Less common, but more aggressive & worse prognosis
Advanced endometrial carcinoma spreads to cervix, bladder & rectum, through the peritoneal cavity & to regional lymph nodes

Question 11

What are fibroids?

Answer 11

Benign tumours of uterine smooth muscle (leiomyomas)
Symptoms: heavy menstrual loss, menorrhagia & infertility
Single or multiple leiomyomas can cause massive uterine enlargement and this results in pressure symptoms in the pelvis
Growth is oestrogen dependent & usually regress after menopause

Question 12

Describe a leiomyosarcoma

Answer 12

Malignant tumour of the myometrium
Present with similar symptoms to fibroids
Aetiology is not known
Like other sarcomas, they infiltrate locally with metastasis by the blood stream to the lungs & then systemically

Question 13

Describe epithelial tumours of the ovaries

Answer 13

Majority of primary ovarian tumours
Classified by the type of epithelium present – serous, mucinous or endometrioid
Malignant epithelial tumours do not present until late stage & prognosis is often poor -> spread within the abdomen where they cause ascites, intestinal obstruction and death
BRCA1 and BRCA2 genes have been identified as markers for familial ovarian epithelial carcinoma (less than 1% of cases)

Question 14

Describe germ cell tumours of the ovaries

Answer 14

Usually benign, most common is a mature cystic teratoma = dermoid cyst

• contain tissues from any of the three germ layers
• presence of immature tissue indicates malignancy, a risk for intra-abdominal spread & potential to cause death

Question 15

Describe germ cell tumours more commonly found in testes

Answer 15

Seminoma 
Yolk sac tumours 
Choriocarcinoma 
Embryonal carcinomas
Useful tumours markers – alpha-fetoprotein (AFP) & beta-human chorionic gonadotropin (hCG)

Question 16

Describe granulosa cell tumours

Answer 16

Resemble the cells lining the ovarian follicle
Commonly produce oestrogen & may be responsible for endometrial hyperplasia, adenocarcinoma & iso-sexual precocious puberty

Question 17

Describe Sertoli-Leydig cell tumours

Answer 17

Rare sex-cord stromal tumours

May produce androgens & cause defeminisation, masculinisation, amenorrhoea & infertility

Question 18

Describe testicular tumours

Answer 18

Commonest tumours in men aged 15-34
Can be classified as germ cell tumours and sex cord-stromal tumours
Lymphomas can also affect the testes

Question 19

Describe non-germ cell tumours in the testis

Answer 19

Sex cord-stromal tumours
Most common types seen in the testes are Sertoli or Leydig cell tumours
Uncommon & benign

Question 20

Describe germ cell tumours in the testis

Answer 20

Post-pubertal males and all tumours are malignant
Aetiology is unknown, but familial predisposition is well recognised
Increased risk of testicular cancer in cryptorchidism (failure of testicular descent into the scrotum)
Orchiopexy (surgical placement of the undescended testis into the scrotum) before puberty decreases this risk of cancer

Question 21

List the different types of germ cell tumours in males

Answer 21

Present with a painless testicular mass
Pre-invasive precursor of germ cell tumours has been recognised = intratubular germ cell neoplasia
Two groups:
1) Seminomas
2) Nonseminomatous (tend to metastasise early & do so via lymphatic and blood vessels) - yolk sac tumours, embryonal carcinomas, choriocarcinomas & teratomas

Question 22

Describe seminomas

Answer 22

Approx. 50% of germ cell tumours are seminomas
Peak age of development is 40-50 years
Often remain confined to the testis for long periods of time
When they do metastasise it is by lymphatics, most commonly the iliac & paraaortic lymph nodes

Question 23

Describe yolk sac tumours

Answer 23

Occur in young children & have a very good prognosis

Almost all of them produce alpha fetoprotein (AFP) which can be detected in the blood as a tumour marker

Question 24

Describe embryonal carcinomas, choriocarcinomas and mixed NSGCTs

Answer 24

Occur in young adults
Choriocarcinomas – associated with elevated serum concentrations of the tumour marker B-hCG
Most mixed NSGCTs – associated with elevated serum concentrations of both AFP & B-hCG

Question 25

Describe teratomas in men

Answer 25

Occur in men of all ages
If in prepubertal men, usually benign
If in postpubertal men, malignant
10% are associated with raised serum concentrations of hCG – syncytiotrophoblast cells that produce hCG are present

Question 26

Describe the management of testicular tumours

Answer 26

Radical orchiectomy
Seminomas – very radiosensitive and treated with radiotherapy (best prognosis)
NSGCTS – after surgery, treated with aggressive chemotherapy
Treatment if often successful & results in a cure