ovarian tumours + vulval cancer Flashcards
classification of ovarian tumours
epithelial - commonest
germ cell
sex cord/stroma
metastatic
how are ovarian tumours often diagnosed?
asitic fluid
Figo staging of ovarian cancer
1A - limited to one ovary
1B – limited to both
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
3A – retroperitoneal lymph node metastasis or microscopic extra pelvic peritoneal involvement
3B – macroscopic peritoneal metastasis beyond pelvis up to 2cm in dimension
3C – macroscopic peritoneal metastasis >2cm in dimension
4 – distant metastasis
epithelial ovarian tumours
cell of origin not clear
65-70% of ovarian tumours
types
- serous - commonest
- mucinous
- endometriod
- clear cell
- brenner
- undifferentiated carcinoma
serous carcinoma
high grade = serous tubal intrapithelial carcinoma (STIC)
- most cases are essentially tubal in origin
low grade = serous borderline tumour
endometriod + clear cell carcinoma
both have strong assoc with endometriosis of ovary
most endometriod are low grade + early stage
assoc with Lynch syndrome - esp clear cell
Brenner tumour
tumour of transitional type epithelium
usually benign - borderline + malignant variants rare
germ cell tumours - teratomas
15-20% of all ovarian tumours
assoc with ovarian torsion
may raise alpha-fetoprotein + hCG
dermoid cysts = 95%
- can rarely become malignant
others = dysgerminoma, yolk sac, choriocarcinoma
sex cord stomal tumours
rare, benign or malignant
arise from stroma (connective tissue) or sex cords (embryonic structures assoc with follicles)
types
- fibroma/thecoma
- sertoli-Leydig tumours
- granulosa cell tumours (all potentially malignant), 75% secrete sex hormones, pseudopuberty
krukenberg tumour
metastasis in overy, usually from GI tract cancer
characteristic “signet ring” cell on histology
(CEA tumour marker)
ovarian cancer
often presents late due to non-specific symptoms - worse prognosis
70% after has spread beyond pelvis
peak incidence = 60yrs
epithelial - serous = commonest
ovarian cancer risk factors
FH - mutations of BRCA1, BRCA2 gene
many ovulations - early menarche, late menopause, nulliparity
obesity
smoking
recurrent use of clomifene
protective factors of ovarian cancer
factors that stop ovulation or reduce the number of lifetime ovulations
- combined contraceptive pill
- breastfeeding
- pregnancy
ovarian cancer presentation
non-specific
abdo bloating
early satiety
loss of appetite
pelvic pain
urinary symptoms - frequency/urgency
weight loss
abdominal or pelvic mass
ascites *
**mass may press on obturator nerve + cause hip or groin pain
- passes along inside of pelvic, lateral to ovaries
referral criteria for ovarian cancer
2 week wait referral
- ascites
- pelvic mass - unless due to fibroids
- abdominal mass
ovarian cysts
arise from any element of ovary, innate or acquired
- follicular - polycyctic ovaries
- luteal - corpus luteum
- endometriotic - from endometriosis
-epithelial - lined by epithelial cells
follicular cysts
v common
can form when ovulation doesnt occur - polycyctic ovaries
follicle doesnt rupture, grows until it becomes a cyst
thin wall lined by granulosa cells
usually resolves over a few months
ovarian cancer investigations
Ca125 - esp in women over 50with symptoms
pelvic US
risk of malignancy index
CEA may be raised, esp in mucinous (used to eclude mets from GI cancer)
women <40yrs require tumour markers for possible germ cell tumour
- alpha feto protein
- HCG
granulosa cell (sex cord) tumour on histology
coffee been nuclei + gland-like spaces (call-exner bodies)
ovarian cancer staging
Staging
- Stage 1 – confined to ovary
- Stage 2 – spread past ovary but inside pelvis
- Stage 3 – spread past pelvic but inside abdomen
- Stage 4 – spread outside the abdomen – distant mets
management of ovarian cancer
Management
- pelvic clearance (hysterectomy + BSO + infracolic omentectomy)
- Radical debulking
- Followed up for 5yrs, CA125 continously monitored
vulval cancer
rare
90% squamous cell carcinoma
RF
- old age
- immunosuppressed
- HPV
- lichen sclerosis - 5% get vulval cancer
vulval intraepithelial neoplasia (VIN)
premalignant condition affecting squamous epithelium of skin that can precede vulval cancer
mx
- watch + wait
- wide local excision
- imiquimod cream
- laser ablation
different types of vulval intraepithelial neoplaia (VIN)
- high grade squamous intraepithelial lesion - assoc with HPV, younger women aged 35-50
- differentiated VIN - assoc with lichensclerosis, older women age 50-60yrs
vulval cancer mx
Management
- Depends on stage
- Wide local excision
- Groin node dissection
- Chemo, radio
