ovarian tumours + vulval cancer

Question 1

classification of ovarian tumours

Answer 1

epithelial - commonest
germ cell
sex cord/stroma
metastatic

Question 2

how are ovarian tumours often diagnosed?

Answer 2

asitic fluid

Question 3

Figo staging of ovarian cancer

Answer 3

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

Question 4

epithelial ovarian tumours

Answer 4

cell of origin not clear
65-70% of ovarian tumours

types
- serous - commonest
- mucinous
- endometriod
- clear cell
- brenner
- undifferentiated carcinoma

Question 5

serous carcinoma

Answer 5

high grade = serous tubal intrapithelial carcinoma (STIC)
- most cases are essentially tubal in origin

low grade = serous borderline tumour

Question 6

endometriod + clear cell carcinoma

Answer 6

both have strong assoc with endometriosis of ovary
most endometriod are low grade + early stage

assoc with Lynch syndrome - esp clear cell

Question 7

Brenner tumour

Answer 7

tumour of transitional type epithelium
usually benign - borderline + malignant variants rare

Question 8

germ cell tumours - teratomas

Answer 8

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

Question 9

sex cord stomal tumours

Answer 9

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

Question 10

krukenberg tumour

Answer 10

metastasis in overy, usually from GI tract cancer

characteristic “signet ring” cell on histology

(CEA tumour marker)

Question 11

ovarian cancer

Answer 11

often presents late due to non-specific symptoms - worse prognosis
70% after has spread beyond pelvis
peak incidence = 60yrs

epithelial - serous = commonest

Question 12

ovarian cancer risk factors

Answer 12

FH - mutations of BRCA1, BRCA2 gene
many ovulations - early menarche, late menopause, nulliparity
obesity
smoking
recurrent use of clomifene

Question 13

protective factors of ovarian cancer

Answer 13

factors that stop ovulation or reduce the number of lifetime ovulations
- combined contraceptive pill
- breastfeeding
- pregnancy

Question 14

ovarian cancer presentation

Answer 14

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

Question 15

referral criteria for ovarian cancer

Answer 15

2 week wait referral
- ascites
- pelvic mass - unless due to fibroids
- abdominal mass

Question 16

ovarian cysts

Answer 16

arise from any element of ovary, innate or acquired
- follicular - polycyctic ovaries
- luteal - corpus luteum
- endometriotic - from endometriosis
-epithelial - lined by epithelial cells

Question 17

follicular cysts

Answer 17

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

Question 18

ovarian cancer investigations

Answer 18

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

Question 19

granulosa cell (sex cord) tumour on histology

Answer 19

coffee been nuclei + gland-like spaces (call-exner bodies)

Question 20

ovarian cancer staging

Answer 20

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

Question 21

management of ovarian cancer

Answer 21

Management
- pelvic clearance (hysterectomy + BSO + infracolic omentectomy)
- Radical debulking
- Followed up for 5yrs, CA125 continously monitored

Question 22

vulval cancer

Answer 22

rare
90% squamous cell carcinoma

RF
- old age
- immunosuppressed
- HPV
- lichen sclerosis - 5% get vulval cancer

Question 23

vulval intraepithelial neoplasia (VIN)

Answer 23

premalignant condition affecting squamous epithelium of skin that can precede vulval cancer

mx
- watch + wait
- wide local excision
- imiquimod cream
- laser ablation

Question 24

different types of vulval intraepithelial neoplaia (VIN)

Answer 24

• high grade squamous intraepithelial lesion - assoc with HPV, younger women aged 35-50
• differentiated VIN - assoc with lichensclerosis, older women age 50-60yrs

Question 25

vulval cancer mx

Answer 25

Management
- Depends on stage
- Wide local excision
- Groin node dissection
- Chemo, radio