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Malignancy Flashcards

1
Q

What masses can be in the anterior compartment of the pelvis?

A
  • bladder tumours

- bladder distension

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2
Q

What masses can be in the middle compartment of the pelvis?

A
  • uterine fibroids
  • adenomyosis
  • carcinosarcomas
  • leiomyosarcomas
  • cervical cancers can also cause a midline mass when the obstruction at the uterocervical junction can cause haematometra or pyometra
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3
Q

What masses can be in the lateral compartment of the pelvis?

A
  • PID; tubal swelling, hydrosalpinx
  • TO abscess
  • ectopic pregnancy
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4
Q

What masses can be found in the posterior compartment of the pelvis?

A
  • bowel tumours
  • appendiceal mass
  • hernias
  • diverticular abscess
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5
Q

Masses originating from the surface epithelium of the ovary can be what?

A
  • serous
  • mucinous
  • endometrioid
  • clear cell
  • or transitional cells
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6
Q

Masses originating from germ cells in the ovary can be what?

A
  • dysgerminoma
  • yolk sac
  • embryonal carcinoma
  • choriocarcinoma
  • teratoma
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7
Q

Masses originating from the sex cord stroma in the ovary can be what?

A
  • granulosa cell
  • thecoma
  • fibroma
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8
Q

What type of ovarian mass is commonest in younger woman than post-menopausal women?

A

Germ cell tumours

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9
Q

What type of ovarian mass is the commonest?

A

Surface epithelial masses

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10
Q

What investigations are undertaken for ovarian masses?

A
  • tumour markers; e.g. CA-125, CEA
  • USS
  • MRI (premenopausal)
  • CT (postmenopausal)
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11
Q

What is CA-125?

A
  • main tumour marker
  • glycoprotein that is elevated in ovarian cancer
  • an isolated CA125 on its own can be falsely positive as it is produced by any mesothelial cell so is not diagnostic
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12
Q

Name conditions in which CA-125 can be elevated

A
  • ovulation, pregnancy, retrograde menstruation
  • endometriosis, benign ovarian cysts, uterine leiomyomata (fibroids)
  • malignant ascites
  • disseminated malignancies from any site involving pleural or peritoneal surfaces
  • many others
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13
Q

What is CEA?

A
  • carcinoembryonic antigen
  • protein normally found in embryonic or foetal tissue
  • serum levels disappear almost completely after birth but can be elevated in ovarian mucinous cancers
  • however again not diagnositc as can be raised in many conditions
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14
Q

How is the CA-125/CEA ration helpful?

A
  • if ratio of CA-125 to CEA ratio is less than 25, then the ovarian mass could very well be metastatic spread from a primary cancer in the colorectal or upper GI tract
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15
Q

Name other tumour markers that are looked art in women under the age of 40

A
  • alpha fetoprotein; raised in embryonal carcinom a
  • HCG; raised in choriocarcinoma
  • LDH; raised in dysgerminoma
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16
Q

Describe the benign features on ultrasound of ovarian masses

A
  • B1; unilocaular
  • B2; presence of solid component with largest diametes <7mm
  • B3; presence of acoustic shadows
  • B4; smooth multilocular tumour with largest diameter <100mm
  • B5; no blood flow
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17
Q

Describe the malignant features on ultrasound of ovarian masses

A
  • M1; irregular solid tumour
  • M2; presence of ascites
  • M3; at least 4 papillary structures
  • M4; irregular multilocular solid tumour with largest diameter >100mm
  • M5; very strong blood flow
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18
Q

Describe the risk of malignancy index

A
  • premenopausal = 1
  • postmenopausal = 3
  • ultrasound featues (1 feature =1, >1 feature =3)
  • scerum Ca125
  • RMI <30 = 3 IN 100
  • RMI 30-200 = 20 in 100
  • RMI >200 75 in 100
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19
Q

What are the most common benign ovarian masses?

A

Functional ovarian cysts, endometriotic cysts and dermoid cysts

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20
Q

Describe functional cysts

A
  • related to ovulation; they are enlarged graffian follicles or corpus luteal cysts
  • rarely >5cm and usually resolve spontaneously
  • may cause menstrual disturbance
  • sharp pain
  • unilocular, single compartment cysts
  • intervene when large or causing problems e.g. haemorrhage, torsion
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21
Q

Endometriotic cysts present with what?

A
  • severe dysmenorrhoea / premenstrual pain
  • dyspareunia
  • associated with sub-fertility
  • occasionally asymptomatic
  • acute abdomen if ruptures
    Examination;
  • tender mass with modularity
  • tenderness behind uterus (kissing ovaries in pouch of douglas, this is where maximum pain for the patient is)
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22
Q

Describe the features of a dermoid cysts

A
  • common
  • originate from totipotent cells so the contents can be teeth, hair, thyroid tissue etc
  • surgery when symptomatic
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23
Q

Describe the management of benign ovarian tumours

A
  • conservative
  • medical; basically ovarian suppression, GnRH analogues, OCP
  • surgical; laparoscopic/ laparotomy, cystectomy, oophorectomy, pelvic clearance
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24
Q

What is the management of borderline ovarian tumours?

A
  • young women; unilateral cystectomy / oophrectomy with close follow up
  • postmenopausal women; pelvic clearance
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25
Q

What investigations does NICE recommend when a woman presents with new IBS aged over 50 or if there is pressure symptoms occur at least 12 times a month?

A

CA-125 and USS pelvis - think ovarian cancer

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26
Q

Describe the managment of ovarian cancer

A
  • surgery; stage 1a cancers or fertility sparing surgery in young women with germ cell tumours
  • neoadjuvant chemotherapy followed by surgery
  • surgery followed by adjuvant chemotherapy
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27
Q

What is cytoreductive surgery?

A

To remove as many cancerous cells as possible

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28
Q

Describe surgery in early ovarian cancer disease

A
  • staging should be through a midline incision to allow palpation of all peritoneal surface
  • assessment of peritoneal cytology, hysterectomy, removal of ovaries and fallopian tubes and infracolic omenectomy should be performed
  • aim to exclude disease involving the liver, spleen, peritoneum, retroperitoneal nodes, appendix and diaphragm
  • one disease extent clarified total abdominal hysterectomy with BSO and infracolic omentectomy is done
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29
Q

Describe treatment of advanced ovarian cancer

A
  • aggressive surgical cytoreduction with the aim of leaving residual disease
  • cytoreduction where residual deposits are no more than 1cm in diameter
  • can involve removal of the supracolic omentum, peritoneal stripping or ablation, removal of the spleen +/- small or large bowel resection
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30
Q

Describe neoadjuvant chemotherapy in ovarian cancer

A
  • usually 3 cycles of carboplatin and paclitaxel followed by repeat CT and if good response proceed to surgery followed by 3 further cycles of chemo
  • stage 3 and 4 are most often managed by neoadjuvant chemo
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31
Q

Metastases on the ovary most commonly come from where?

A
  • breast
  • pancreas
  • stomach
    GI primaries
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32
Q

Which tumour has a characteristic signet ring histology?

A
  • krukenburg tumour
  • usually metastatic from stomch
  • suspect when the ratio of CA125/CEA <25
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33
Q

Describe follicular cysts

A
  • very common
  • can form when ovulation doesnt occur (polycystic ovaries)
  • follicle doesnt rupture but grows until it becomes a cysts
  • can grow up to several cm in size
  • thin walled, lined by granulosa cells
  • usually resolve over a few months
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34
Q

Name complications of endometriosis

A
  • pain
  • cyst formation
  • adhesions
  • infertility
  • ectopic pregnancy
  • malignancy (endometrioid carcinoma)
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35
Q

What can be seen pathologically for epithelial ovarian masses to classify it as malignant?

A

Stromal invasion

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36
Q

What are the two forms of serous carcinoma?

A
  • high grade; serous tubal intraepithelial carcinoma, most cases are essentially tubal in origin
  • low grade; serous borderline tumour
37
Q

Endometriosis has associations with what malignancies?

A

Endometrioid and clear cell carcinomas

note also associated with lynch syndrome

38
Q

The primary diagnosis of clear cell or endometrioid carcinomas is made on what?

A

Ascitic fluid (as the tumour itself produces fluid so ascites will occur containing the abnormal cells)

39
Q

What is a brenner tumour?

A

A tumour of transitional type epithelium, almost always benign

40
Q

Describe dysgerminoma

A
  • most common malignant primitive germ cell tumour
  • 1-2% of all malignant ovarian tumours
  • almost exclusively children and young women
41
Q

Describe fibromas / thecomas

A
  • benign

- may produce oestrogen causing uterine bleeding

42
Q

Describe granulosa cell tumours

A
  • all are potentially malignant

- may be associated with oestrogenic manifestations

43
Q

Describe sertoli-leydig cell tumours

A
  • rare

- may produce androgens

44
Q

Describe the FIGO staging of ovarian cancer

A
  • 1a; tumour limited to one ovary
  • 1b; tumour limited to both ovaries
  • 1c; cancer involving ovarian surface / rupture / surgical spill / tumour in washings
  • 2a; extension or implants on uterus / fallopian tube
  • 2b; extension to other pelvic intraperitoneal organs
  • 3a; retroperitoneal lymph node metastasis or microscopic extrapelvic peritoneal involvement
  • 3b; macroscopic peritoneal metastasis beyond pelvis up to 2cm in dimension
  • 3c; macroscopic peritoneal metastasis >2cm in dimension
    4; distant metastasis
45
Q

What are the three forms of endometrial hyperplasia?

A
  • simple
  • complex
  • atypical (precursor of carcinoma)
46
Q

What is the cause and presentation of endometrial hyperplasia?

A
  • cause; often unknown, may be persistent oestrogen stimulation
  • presents with abnormal bleeding (dysfunctional uterine bleeding or postmenopausal bleeding)
47
Q

Who usually gets endometrial carcinoma?

A
  • peak incidence; 50-60 years, uncommon under 40

- in young women, consider predispostion e.g. PCOS or lynch syndrome

48
Q

What are the precursor lesions for endometrial carcinoma?

A
  • endometrioid carcinoma; precursor atypical hyperplasia

- serous carcinoma; precursor serous intraepithelial carcinoma

49
Q

Most endometrial carcinomas are what?

A

Adenocarcinomas

50
Q

What are the two clinico-pathological types of endometrial carcinoma?

A

Endometrioid (and mucinous) type 1 tumours (80%);
- related to unopposed oestrogen
- associated with atypical hyperplasia
Serous (and clear cell) type 2 tumours;
- not associated with unopposed oestrogen
- affect elderly post menopausal women
- TP53 often mutated

51
Q

Describe lynch syndrome

A
  • hereditary non-polyposis colorectal cancer is a cancer predisposition syndrome
  • high risk of colorectal and endometrial cancer, increased also is ovarian cancer e
  • due to the inheritance of a defective DNA mismatch repair gene
  • autosomal dominant inheritance
  • show microsatellite instability
52
Q

Serous carcinoma is characterised by what pathologically?

A

Complex papillary and r glandular architecture with diffuse, marked nuclear pleomorphism

53
Q

Endometrial carcinoma typically infiltrates where?

A

The myometrium

54
Q

Describe the staging of endometrial cancer

A
  • 1a; inner half of myometrium
  • 1b; outer half of myometrium
  • 2; down into cervix
  • 3a ; tumour invades serosa of uterus and or adnexae
  • 3b; vaginal or or parametrial involvement
  • 3c; metastases to pelvic and or para-aortic lymph nodes
  • 4; distant spread
55
Q

Describe the grading of endometria carcinoma

A
  • grade 1; 5% or less solid growth
  • grade 2; 6-50% solid growth
  • grade 3; >50% solid growth
56
Q

Carcinosarcoma was previously referred to as what?

A

Mullerian tumour

57
Q

Describe endometrial stromal sarcomas

A
  • low grade endometrial stromal sarcoma
  • high grade endometrial stromal sarcoma (increased atypia, proliferative activity)
  • rare, cells resemble endometrial stoma, infiltrate myometrium and often lymphovascular spaces
  • high grade more likely to die of disease
  • typically presents with abnormal uterine bleeding but initial presentation may be as metastasis
  • stage is the most important prognostic factor
58
Q

Describe the features of carcinosarcoma

A
  • <5% of uterine malignancies
  • high grade carcinomatous and sarcomatous elements
  • heterologous elements commonly seen in about 50% cases (rhabdomyosarcoma, chrondrosarcoma, osteosarcoma)
  • the presence of a rhabdomyosarcomatous component and has the worst prognosis
59
Q

Fibroids are what type of tumour?

A

Leiomyoma - smooth muscle tumour (benign)

60
Q

Describe leiomyosarcomas

A
  • a malignant smooth muscle tumour commonly displaying a spindle cell morphology
  • most common uterine sarcoma
  • most occur in women >50 years
  • commonest symptoms abnormal vaginal bleeding, palpable pelvic mass and pelvic pain
  • coagulative tumour necrosis
61
Q

What cells are captured during a smear test?

A
  • exfoliating cells on the surface

- squamous epithelium similar to that of skin but not keratinised

62
Q

Describe cervicitis

A
  • often asymptomatic; can lead to infertility due to simultaneous silent fallopian tube damage
  • non specific acute / chronic inflammation
  • follicular cervicitis; sub epithelial reactive lymphoid follicles present in cervix
  • chlamydia trachomatis; sexually transmitted
  • herpes simplex viral infection
63
Q

What is a cervical polyp?

A
  • localised inflammatory outgrowth

- cause of bleeding, if ulcerated

64
Q

Name risk factors for CIN/ cervical cancer

A
  • persistence of high risk HPV, mostly types 16,18, 31, 33, 35, 45, 48
  • vulnerability of SC junction in early reproductive life; age at first intercourse, long term use of oral contraceptives, non use of barrier contraception
  • smoking 3x risk
  • immunosuppression
65
Q

What occurs when HPV integrates itself into host DNA?

A

Cervical cancer

66
Q

What is CIN?

A
  • cervical intraepithelial neoplasia
  • pre-invasive stage of cervical cancer
  • occurs at the transformation zone
  • dysplasia of squamous cells
  • asymptomatic
67
Q

Describe the grading of CIN

A
  • CIN1; basal, 1/3 epithelial occupied by abnormal cells, raised numbers of mitotic figures in lower 1/3, surface cells quite mature, but nuclei slightly abnormal
  • CIN2; abnormal cells extend to middle 1/3, abnormal mitotic figures
  • CIN3; abnormal cells occupy full thickness of epithelium, mitoses, often abnormal in upper 1/3
68
Q

What is the earliest form of squamous cell carcinoma in the cervix?

A

When there is breach of the basement membrane with invasion of the stroma

69
Q

Describe invasive squamous carcinoma

A
  • 75-95% of malignant cervical tumours
  • 2nd commonest female cancer worldwide
  • increasingly detected in younger women, often found in early stage, some are rapidly progressive tumours
  • develops from pre-existing CIN, therefore most cases should be preventable by screening
70
Q

Describe the symptoms of invasive carcinoma

A
  • usually none at microinvasive and early invasive stages
  • abnormal bleeding; postcoital, postmenopausal, brownish or blood stained vaginal discharge, contact bleeding - friable epithelium
  • pelvic pain
  • haematuria / urinary infection
  • ureteric obstruction / renal failure
71
Q

What is CGIN?

A
  • cervical glandular intraepithelial neoplasia
  • origin from endocervical epithelium
  • CGIN is preinvasive phase of endocervical adenocarcinoma
  • more difficult to diagnose on cervical smear than squamous
  • screening less effective
  • sometimes associate with CIN
72
Q

High grade CGIN is a precursor to what?

A

Adenocarcinoma

73
Q

Describe the epidemiology of adenocarcinoma

A
  • higher socioeconomic class
  • later onset of sexual activity
  • smoking
  • HPV again incriminated
  • particualrly in HPV18
74
Q

What is VIN?

A
  • vulval intraepithelial neoplasia
  • precursor of HPV driven SCC
  • differentiated VIN often background of inflammatory dermatoses such as lichen sclerosus
75
Q

Describe vulvar invasive squamous carcinoma

A
  • usually elderly women, ulcer or exophytic mass
  • can arise from normal epithelium or VIN
  • mostly well differentiated (verrucous are an extremely well differentiate type)
  • spread to inguinal lymph nodes, which is most important prognostic factor
  • surgical treatment; radical vulvectomy and inguinal lymphadenopathy
76
Q

Describe vulvar pagets disease

A
  • crusting rash, often sharp demarcation
  • pruritic / painful
  • tumour cells in epidermis, contain mucin
  • mostly no underlying cancer, tumour arises from intraepithelial glandular cells or pluripotent cells of folliculosebaceous or eccrine units
  • secondary; colorectal, urothelial
77
Q

What is VaIN?

A
  • vaginal intraepithelial neoplasia

- may also have cervical and vulval lesions

78
Q

Describe the HPV vaccination programme

A
  • offered to 12-13 year olds in the UK
  • 2 dose regimen, separated by 6 months
  • quadrivalent vaccine (gardsail)
79
Q

How is cervical screening undertaken?

A
  • women aged 35-64 years old
  • speculum examination; visual examination, brush sample of the cells from the transformation zone of the cervix, 5 times rotation of brush on the cervix, swirl in pot 10 times
  • the sample is initially tested for Hr-HPV using automated platform, a negative HPV means very low risk
  • positive results the have a cytology test carried out
80
Q

What is the impact of obesity in O&G?

A
  • increased subfecundity
  • increased infertility
  • decreased effectiveness of IVF
  • increased risk of miscarriage
  • increased risk of pregnancy complications
  • increased incidence of cancer
81
Q

What are the modes of hysterectomy and what does it entail?

A
  • open, laparoscopic and robotic
  • removal of uterus and cervix
  • open; traditional, elaborate incision on patients abdominal wall, midline incision or lateral along pickneys line
  • mainstay is laparoscopic hysterectomy via three to four incisions
82
Q

Describe the surgical treatment of cervical cancers

A
  • up to stage 1A2 and desiring fertility; LLETZ/ cone biopsy
  • up to stage 1a2 & completed family; hysterectomy
  • stage 1b and fertility; trachelectomy
  • stage 1b and completed family; radical hysterectomy
  • more than stage 1b; chemoradiotherapy
83
Q

Which is trachelectomy?

A

Removal of cervix, parametrium, and cuff of vagina

84
Q

Describe the surgical management of ovarian cancer

A
  • early stages; open hysterectomy, BSO and infracolic omentectomy
  • late stages; radical debulking (bring down disease burden to nil residual disease)
85
Q

Describe the surgical management of vulval cancer

A
  • involves wide local incision of vulval lesion (meaning achieving 1cm free margin beyond the cancer)
  • if the depth of invasion is >1mm, the surgery includes groin nodes removal (unilateral or bilateral depending on the site of vulval cancer)
86
Q

Describe colopscopy

A
  • magnification to look at transformation zone, speculum introduced like smear teat
  • acetic acid and iodine staining
  • directed biopsy; tissue diagnosis
  • local anaesthetic can be given if needed
87
Q

What is the management of CIN 1?

A

Conservative management for 2 years

88
Q

What is the management of CIN2?

A
  • LLETZ

- cold coagulation

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