Neoplasms of the Reproductive System

Question 1

State the type of cancer found in vulva

Answer 1

Squamous cell carcinoma

Question 2

Describe the epidemiology of vulva tumours

Answer 2

• More commonly found in older women

- 30% of cancers are related to HPV infections

Question 3

Describe the possible causes of tumours of the vulva

Answer 3

• Vulvar intraepithelial neoplasia (VIN)
  
  • Atypical squamous cells within the epidermis - no invasion
  • Precursor for vulval squamous cell carcinoma
• Vulval squamous cell carcinoma
  
  • Involve invasion of the epidermis
  • Spreads initially to inguinal, pelvic, iliac and para-aortic lymph nodes
  • Can also spread to lungs and liver

Question 4

Describe the epithelium at the cervix

Answer 4

• Endocervix covered by glandular epithelium
• Exocervix coveted by squamous cell epithelium
• Transformation zone is area between glandular and squamous cell epithelium and where cell proliferation takes place

Question 5

Describe how HPV can cause cervical cancer

Answer 5

• Infect immature metaplastic squamous cells in transformation zone
• Produce viral proteins E6 and E7
  
  • E6 inhibits p53 and E7 inhibits RB
  • Causes inability to repair damaged DNA and increased proliferation of cells

Question 6

List the risk factors of cervical cancer

Answer 6

• Sexual intercourse
• Early first marriage
• Early first pregnancy
• Multiple births
• Many partners
• Partner with carcinoma of the penis
• Long term use of oral contraceptive pills
• Immunosuppression - susceptible to HPV infections
• Smoking

Question 7

State the pathology related to cervical tumours

Answer 7

• Cervical intraepithelial neoplasia (CIN)

- Invasive cervical carcinoma

Question 8

Describe cervical intraepithelial neoplasia and its treatment

Answer 8

• Dysplasia of squamous cells within the cervical epithelium, induced by infection with high risk HPV
• A small proportion of CIN I progress to CIN II and then CIN III
  
  • CIN III is a carcinoma in situ - with 10% progressing to invasive carcinoma
• Treatment - progression of CIN identified through cryoscopy and treatment based on progression
  
  • CIN I treated through follow-up or cryotherapy
  • CIN II and CIN III treated by superficial excision - large loop excision of the transformation zone

Question 9

Describe invasive cervical carcinoma presentation and treatment

Answer 9

• 80% squamous cell carcinoma and 15% adenocarcinoma
• May be exophytic (localise on surfaces) or infiltrative
• Spreads to para-cervical soft tissue, bladder, ureters, rectum and vagina
  
  • Spread to lymph nodes and can spread distally
• Present with post-coital, intermenstrual or postmenopausal vaginal bleeding
• Treatment - micro-invasive carcinomas treated with cervical cone excision
  
  • Invasive carcinomas require hysterectomy, lymph node dissection and chemotherapy

Question 10

Explain the principles of HPV vaccination

Answer 10

• Given to girls 12-13 and protects for 10 years (period highest risk to infection)
• Doesn’t protect against all high risk infections - screening still needed
• Currently boys not vaccinated, but vaccination can protect against penile cancer and decrease risk of spread

Question 11

Explain the principles of cervical screening

Answer 11

• Cervix accessible to visual examination (colposcopy) and sampling
• Slow progression from precursor lesions to invasive cancers - have time to screen and detect
  
  • Early detection and treatment
• Cells from the transformation zone are scraped off and stained (smear test)
• Can also test for HPV DNA in cervical cells
• Starts age 25, then every 3 years until 50, when it becomes every 5 years

Question 12

Explain endometrial hyperplasia link to endometrial adenocarcinoma

Answer 12

• Endometrial hyperplasia common precursor to endometrial carcinoma
• Increased gland to stroma ratio
• Associated with prolonged oestrogen stimulation (causes proliferation of endometrium)

Question 13

Explain endometrial adenocarcinoma epidemiology and presentation

Answer 13

• Most common invasive cancer of the female genital tract
• Common in older women
• Present with irregular or postmenopausal vaginal bleeding - early detection and good survival rate
• Can be polypoid or infiltrative

Question 14

Describe the 2 types of endometrial adenocarcinomas

Answer 14

• Endometrioid
  
  • More common
  • Mimics proliferative glands - many glands seen microscopically
  • Arises after endometrial hyperplasia
  • Associated with unopposed oestrogen and obesity (increased adipose tissue and therefore oestrogen)
  • Spreads by myometrial invasion and direct extension to adjacent structures, to local lymph nodes and distant sites
• Serous carcinoma
  
  • Poorly differentiated, aggressive worse prognosis
  • Can spread very easily - to Fallopian tubes, peritoneal surfaces

Question 15

Describe the presentation and prognosis of leiomyoma

Answer 15

• Leiomyoma (fibroids) - most common tumour in women
• Benign tumour of myometrium (uterine smooth muscle)
• May be asymptomatic but can cause heavy periods, urinary frequency, infertility
• Very rarely becomes malignant
• Growth is oestrogen dependent and usually regress after menopause
• Well circumscribed, round, firm and white tumours
• Bundles of smooth muscle - resembles normal myometrium

Question 16

Describe a cancerous tumour of the myometrium

Answer 16

• Uterine leiomyosarcoma
• Highly malignant
• Doesn’t arise from leiomyomas
• Commonly metastasize to the lung

Question 17

Describe the epidemiology of ovarian tumours

Answer 17

• Most are benign and occur in younger women
• Malignant tumours occur in older women
• Tend to spread beyond ovaries before time of presentation so poor prognosis
• Commonly bilateral
• Some associated with BRCA mutations - possible breast cancer or family history of breast cancer

Question 18

Describe the presentation of ovarian tumours

Answer 18

• Most non-functional - do not produce hormones
  
  • Produce symptoms when they become large, invade adjacent structures or metastasize
  • Abdominal pain, abdominal distension, ascites
• Can be functional - produce hormones (high oestrogen in blood)
  
  • Menstrual disturbances, inappropriate sex hormones

Question 19

Describe the spread of ovarian cancer and how its monitored

Answer 19

• Commonly spread to other ovary and through peritoneal cavity
• Spread to regional nodes as well as liver and lungs
• Serum CA-125 used in diagnosis and to monitor disease recurrence and progression

Question 20

State the classification of ovarian cancer

Answer 20

• Epithelium tumours (Mullerian)
• Germ cell ovarian tumours
• Sex cord-stromal tumours
• Metastases

Question 21

Describe the risk factors associated with epithelial ovarian tumours

Answer 21

• Risk factors include BRCA mutations, smoking, endometriosis
• More ovulations (such as no OCP, early menarche, late menopause) means more damage and healing to ovaries and thus higher chance of mutations

Question 22

Describe the types of epithelial ovarian tumours

Answer 22

• Serous ovarian tumour - often spread to peritoneal surfaces and omentum
  
  • Commonly associated with ascites
  • Cells can fall off ovary and spread around the body
• Mucinous ovarian tumour - large cystic masses filled with sticky, thick fluid
  
  • Usually benign or borderline
  • Pseudomyxoma peritonei - extensive mucinous ascites
    
    • Epithelial implants on peritoneal surfaces
• Endometrioid ovarian tumour - contain tubular glands resembling endometrial glands
  
  • Can arise in endometriosis
  • Some associated with endometrial endometrioid adenocarcinoma

Question 23

Describe germ cell ovarian tumours

Answer 23

• Pluripotent
• Most are teratomas - usually benign
• Mature teratomas / dermoid cysts
  
  • Benign and most common
  • Most are cystic
  • Contain hair, sebaceous material, tooth structures , skin like structures
  • Often tissue from other germ layers
• Monodermal teratomas - struma ovarii benign but composed of mature thyroid tissue and produces thyroid hormones

Question 24

Describe sex cord-stromal tumours

Answer 24

• Functional tumours as derived from endocrine apparatus of the ovary
• Most occur in post-menopausal women
• Sex cord produces Sertoli and Leydig cells in testes and granulosa and theca cells in ovaries
• Tumours resembling all of these four cell types can be found in the ovary
• May produce large amounts of oestrogen - precocious puberty in children, breast disease, endometrial hyperplasia in adults
• May produce masculine features if testosterone levels are high

Question 25

Describe the cause of ovarian metastases

Answer 25

• Most commonly Mullerian tumours - uterus, fallopian tubes, contralateral ovary, pelvic peritoneum
• GI tumours and breast tumours

Question 26

Describe the classification of testicular tumours

Answer 26

• Germ cell tumours
  
  • Seminomas
    
    • Treatment is radiotherapy and radical orchiectomy
  • Non-seminomatous germ cell tumours (NSGCT)
    
    • Have high hCG and alpha fetoprotein levels in blood
    • Treatment is chemotherapy and surgery (radical orchiectomy)
• Sex cord-stromal tumours
  
  • Sertoli and Leydig cell tumours
• Lymphomas