Malignancy Flashcards
What masses can be in the anterior compartment of the pelvis?
- bladder tumours
- bladder distension
What masses can be in the middle compartment of the pelvis?
- 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
What masses can be in the lateral compartment of the pelvis?
- PID; tubal swelling, hydrosalpinx
- TO abscess
- ectopic pregnancy
What masses can be found in the posterior compartment of the pelvis?
- bowel tumours
- appendiceal mass
- hernias
- diverticular abscess
Masses originating from the surface epithelium of the ovary can be what?
- serous
- mucinous
- endometrioid
- clear cell
- or transitional cells
Masses originating from germ cells in the ovary can be what?
- dysgerminoma
- yolk sac
- embryonal carcinoma
- choriocarcinoma
- teratoma
Masses originating from the sex cord stroma in the ovary can be what?
- granulosa cell
- thecoma
- fibroma
What type of ovarian mass is commonest in younger woman than post-menopausal women?
Germ cell tumours
What type of ovarian mass is the commonest?
Surface epithelial masses
What investigations are undertaken for ovarian masses?
- tumour markers; e.g. CA-125, CEA
- USS
- MRI (premenopausal)
- CT (postmenopausal)
What is CA-125?
- 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
Name conditions in which CA-125 can be elevated
- 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
What is CEA?
- 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
How is the CA-125/CEA ration helpful?
- 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
Name other tumour markers that are looked art in women under the age of 40
- alpha fetoprotein; raised in embryonal carcinom a
- HCG; raised in choriocarcinoma
- LDH; raised in dysgerminoma
Describe the benign features on ultrasound of ovarian masses
- 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
Describe the malignant features on ultrasound of ovarian masses
- 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
Describe the risk of malignancy index
- 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
What are the most common benign ovarian masses?
Functional ovarian cysts, endometriotic cysts and dermoid cysts
Describe functional cysts
- 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
Endometriotic cysts present with what?
- 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)
Describe the features of a dermoid cysts
- common
- originate from totipotent cells so the contents can be teeth, hair, thyroid tissue etc
- surgery when symptomatic
Describe the management of benign ovarian tumours
- conservative
- medical; basically ovarian suppression, GnRH analogues, OCP
- surgical; laparoscopic/ laparotomy, cystectomy, oophorectomy, pelvic clearance
What is the management of borderline ovarian tumours?
- young women; unilateral cystectomy / oophrectomy with close follow up
- postmenopausal women; pelvic clearance
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?
CA-125 and USS pelvis - think ovarian cancer
Describe the managment of ovarian cancer
- 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
What is cytoreductive surgery?
To remove as many cancerous cells as possible
Describe surgery in early ovarian cancer disease
- 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
Describe treatment of advanced ovarian cancer
- 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
Describe neoadjuvant chemotherapy in ovarian cancer
- 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
Metastases on the ovary most commonly come from where?
- breast
- pancreas
- stomach
GI primaries
Which tumour has a characteristic signet ring histology?
- krukenburg tumour
- usually metastatic from stomch
- suspect when the ratio of CA125/CEA <25
Describe follicular cysts
- 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
Name complications of endometriosis
- pain
- cyst formation
- adhesions
- infertility
- ectopic pregnancy
- malignancy (endometrioid carcinoma)
What can be seen pathologically for epithelial ovarian masses to classify it as malignant?
Stromal invasion
What are the two forms of serous carcinoma?
- high grade; serous tubal intraepithelial carcinoma, most cases are essentially tubal in origin
- low grade; serous borderline tumour
Endometriosis has associations with what malignancies?
Endometrioid and clear cell carcinomas
note also associated with lynch syndrome
The primary diagnosis of clear cell or endometrioid carcinomas is made on what?
Ascitic fluid (as the tumour itself produces fluid so ascites will occur containing the abnormal cells)
What is a brenner tumour?
A tumour of transitional type epithelium, almost always benign
Describe dysgerminoma
- most common malignant primitive germ cell tumour
- 1-2% of all malignant ovarian tumours
- almost exclusively children and young women
Describe fibromas / thecomas
- benign
- may produce oestrogen causing uterine bleeding
Describe granulosa cell tumours
- all are potentially malignant
- may be associated with oestrogenic manifestations
Describe sertoli-leydig cell tumours
- rare
- may produce androgens
Describe the FIGO staging of ovarian cancer
- 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
What are the three forms of endometrial hyperplasia?
- simple
- complex
- atypical (precursor of carcinoma)
What is the cause and presentation of endometrial hyperplasia?
- cause; often unknown, may be persistent oestrogen stimulation
- presents with abnormal bleeding (dysfunctional uterine bleeding or postmenopausal bleeding)
Who usually gets endometrial carcinoma?
- peak incidence; 50-60 years, uncommon under 40
- in young women, consider predispostion e.g. PCOS or lynch syndrome
What are the precursor lesions for endometrial carcinoma?
- endometrioid carcinoma; precursor atypical hyperplasia
- serous carcinoma; precursor serous intraepithelial carcinoma
Most endometrial carcinomas are what?
Adenocarcinomas
What are the two clinico-pathological types of endometrial carcinoma?
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
Describe lynch syndrome
- 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
Serous carcinoma is characterised by what pathologically?
Complex papillary and r glandular architecture with diffuse, marked nuclear pleomorphism
Endometrial carcinoma typically infiltrates where?
The myometrium
Describe the staging of endometrial cancer
- 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
Describe the grading of endometria carcinoma
- grade 1; 5% or less solid growth
- grade 2; 6-50% solid growth
- grade 3; >50% solid growth
Carcinosarcoma was previously referred to as what?
Mullerian tumour
Describe endometrial stromal sarcomas
- 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
Describe the features of carcinosarcoma
- <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
Fibroids are what type of tumour?
Leiomyoma - smooth muscle tumour (benign)
Describe leiomyosarcomas
- 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
What cells are captured during a smear test?
- exfoliating cells on the surface
- squamous epithelium similar to that of skin but not keratinised
Describe cervicitis
- 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
What is a cervical polyp?
- localised inflammatory outgrowth
- cause of bleeding, if ulcerated
Name risk factors for CIN/ cervical cancer
- 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
What occurs when HPV integrates itself into host DNA?
Cervical cancer
What is CIN?
- cervical intraepithelial neoplasia
- pre-invasive stage of cervical cancer
- occurs at the transformation zone
- dysplasia of squamous cells
- asymptomatic
Describe the grading of CIN
- 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
What is the earliest form of squamous cell carcinoma in the cervix?
When there is breach of the basement membrane with invasion of the stroma
Describe invasive squamous carcinoma
- 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
Describe the symptoms of invasive carcinoma
- 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
What is CGIN?
- 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
High grade CGIN is a precursor to what?
Adenocarcinoma
Describe the epidemiology of adenocarcinoma
- higher socioeconomic class
- later onset of sexual activity
- smoking
- HPV again incriminated
- particualrly in HPV18
What is VIN?
- vulval intraepithelial neoplasia
- precursor of HPV driven SCC
- differentiated VIN often background of inflammatory dermatoses such as lichen sclerosus
Describe vulvar invasive squamous carcinoma
- 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
Describe vulvar pagets disease
- 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
What is VaIN?
- vaginal intraepithelial neoplasia
- may also have cervical and vulval lesions
Describe the HPV vaccination programme
- offered to 12-13 year olds in the UK
- 2 dose regimen, separated by 6 months
- quadrivalent vaccine (gardsail)
How is cervical screening undertaken?
- 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
What is the impact of obesity in O&G?
- increased subfecundity
- increased infertility
- decreased effectiveness of IVF
- increased risk of miscarriage
- increased risk of pregnancy complications
- increased incidence of cancer
What are the modes of hysterectomy and what does it entail?
- 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
Describe the surgical treatment of cervical cancers
- 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
Which is trachelectomy?
Removal of cervix, parametrium, and cuff of vagina
Describe the surgical management of ovarian cancer
- early stages; open hysterectomy, BSO and infracolic omentectomy
- late stages; radical debulking (bring down disease burden to nil residual disease)
Describe the surgical management of vulval cancer
- 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)
Describe colopscopy
- 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
What is the management of CIN 1?
Conservative management for 2 years
What is the management of CIN2?
- LLETZ
- cold coagulation
