Repro: Cancer Flashcards
Where can gynaecological tumours arise?
- Vulva
- Cervix
- Endometrium
- Myometrium
- Ovary
What are the clinical features of vulval tumours?
- Uncommon
- Women over 60 makes 2/3 of patient
- Usually Squamous cell carcinoma
How are vulval squamous neoplastic lesions related to HPV infection?
- 30% related to HPV infection and it usually HPV 16
- 70% are unrelated to HPV. Most occur due to longstanding inflammation and hyper plastic conditions of the vulva
What is VIN?
- Vulvar intraepithelial neoplasia
- Atypical squamous cells in the epidermis
- In situ precursor of vulval squamous cell carcinoma
How does Vulval squamous cell carcinoma spread?
- Spreads initially to inguinal, pelvic, iliac and para-aortic lymph nodes
- Also spreads to lungs and liver
What are the treatment options for vulval squamous cell carcinoma?
Less than 2cm
-Vulvectomy and lymphadenectomy
What is the likely causes of CIN or cervical carcinoma?
-Almost all cases related to High risk HPVs
What are the most important high risk HPV in the pathogenesis of cervical carcinoma?
- HPV 16
- HPV 18
What is the pathogenesis of HPV in CIN or cervical carcinoma?
- Infection of immature metaplastic squamous cells in transformation zone
- Production of viral proteins E6 and E7
- These interfere with tumour suppressor proteins (p53 and RB) to cause inability of repair damaged DNA and increased proliferation of cells
- Most genital HPV infectious transient and eliminated by immune response in months
What are the risk factors of Vulval squamous cell carcinoma, CIN, and Cervical Carcinoma?
- Sexual intercourse
- Early first marriage
- Early first pregnancy
- Multiple births
- Many partners
- Promiscuous partner
- Long term use of OCP
- Partner with carcinoma of the penis
- Low socio-economic class
- Smoking
- Immunosuppression
What does cervical screening involve?
- Cells from the transformation zone are scraped off
- Stained with Papanicolaou stain
- Examined microscopically
-Can also test for HPV DNA in cervical cels through molecular method of screening
Start at age 25 and do it every 3 years till 50
Then every 5 years 50-65
What is done if an abnormal cervical screening is observed?
- Coloscopy
- Biopsy
What is cervical intraepithelial neoplasia?
-Dysplasia of squamous cells within the cervical epithelium, induced by infection with high risk HPVs
What is the grading of cervical intraepithelial neoplasia?
CIN 1 - most regress spontaneously. Few progress
CIN 2 - proportion progresses to
CIN 3 - Carcinoma in situ. 10% Progresses to invasive carcinoma in 2-10 yrs and 30% regress
CIN 1 to CIN 3 takes 7 years
What is the treatment for CIN?
- CIN 1: Follow up or cryotherapy
- CIN 2 and CIN 3: Superficial excision of transformation zone
What are the types of invasive cervical carcinoma?
- Squamous cell carcinoma (80%)
- Adenocarcinoma (15%)
Average Age - 45 years
May be exophytic or infiltrative
How does cervical carcinoma spread?
- Locally to para-cervical soft tissues, bladder, ureters, rectum, vagina
- Lymph nodes (para-cervical, pelvic, para-aortic)
- Distally
How does cervical carcinoma present?
- Screening abnormality
- Post-coital, intermenstrual or post-menopausal vaginal bleeding
How is invasive cervical carcinoma treated?
Microinvasive (5 yr survival = 100%)
-Treated with cervical cone excision
Invasive carcinoma (62% ten year survival) -Treated with hysterectomy, lymph node dissection and if advanced, radiation and chemotherapy
What is endometrial hyperplasia?
- Increased gland to stroma ratio
- Frequent precursor to endometrial carcinoma
- Endometrium line the internal cavity of uterus
What is associated with endometrial hyperplasia?
- Annouvulation
- Increased oestrogen from endogenous sources
- Exogenous oestrogen
How is endometrial hyperplasia treated if complex and atypical?
Hysterectomy
What are the clinical features of endometrial adenocarcinoma?
- Common invasive cancer of the genital tract
- Usually 55-75
What is the presentation of endometrial adenocarcinoma?
-Irregular or post menopausal vaginal bleeding
Early detection and cure often possible.
What are the macroscopic features of endometrial adenocarcinoma?
-Can be polyploid or infiltrative
What types of endometrial adenocarcinoma are there?
- Endometrioid (more common)
- Serous carcinoma
What are the features of endometrioid adenocarcinoma?
- Mimics proliferative glands
- Arises from endometrial hyperplasia
- Associated with unopposed oestrogen ad obesity
- Spread by myometrial invasion and direct extension to adjacent structures, to local lymph nodes and distant sites
What are features of Serous Carcinoma?
- Poorly differentiated, aggressive, worse prognosis
- Exfoliates, travels through Fallopian tubes and implants on peritoneal surfaces
What is the commonest tumour of the myometrium?
- Leiomyoid = fibroid
- Benign tumour of myometrium
- Often multiple
- Tiny to massive, filling the pelvis
What is the presentation of leiomyoma?
- Asymptomatic
- Can cause heavy/painful periods
- Urinary frequency
- Infertility
What is a malignant tumour of myometrium?
Uterine leimyosarcoma
- Uncommmon (40-60 yrs)
- Highly malignant
- Doesn’t arise from leiomyomas
- Metastasise to lungs
What are clinical features of ovarian tumours?
- Approximately 80% are benign and generally occur at 20-45 yrs
- Malignant tumours generally occur at 45-65 yrs
- Malignant tumours generally occur at 45-65 yrs
- Many are bilateral
How do ovarian tumours present?
- Most are non-functional. Only produce symptoms when they become large and invade adjacent structures or metastasise
- Hormonal problems
What are the symptoms of large non-functional tumours?
- Abdominal pain
- Abdominal distension
- Urinary and Gastrointestinal symptoms
- Ascites
What are the hormonal problems of ovarian tumours?
- Menstrual disturbances
- Inappropriate sex hormones
What are the clinical features of malignant ovarian tumours?
- 50% spread to other ovary
- Spread to regional nodes and elsewhere
- Some associated with BRCA mutations (carriers treated with prophylactic sapling-oophrectomy)
What is used in diagnosis of malignant ovarian tumours?
CA-125
-Monitor disease recurrence and progression
How are ovarian tumour classified?
- Mullerian (ovarian) epithelium (endometriosis)
- Germ cell
- Sex cord-stromal cells
- Metastases
What are the 3 main histological types of ovarian epithelial tumours?
- Serous
- Mucinous
- Endometrioid
Many are cystic
What are risk factors for ovarian epithelial tumours?
- Nulliparity or low parity
- OCP protective
- Heritable mutations eg BRCA1 and BRCA2
- Smoking
- Endometriosis
What are serous ovarian tumours?
-Often spread to peritoneal surfaces and omentum and commonly associated with ascites
What are mucinous ovarian tumours?
- Often large, cystic masses which can be more than 25 kg
- Filled with sticky, thick fluid
- Usually benign or borderline
What is pseudomyxoma peritonei? (thought to be from micnous but not)
- Extensive mucinous ascites
- Epithelial implants on peritoneal surfaces
- Frequent involvement f ovaries
- Can cause intestinal obstruction
- Most likely is extra-ovarian usually appendix
What is endometrioid ovarian tumour?
- Tumour has tubular gland resembling endometrial glands
- Can arise in endometriosis
- 15-30% have associated endometrial endometrial endometriod adenocarcinoma probably arising separately
What are Germ cell ovarian tumours?
- 15-20% of all ovarian neoplasms
- Most are teratomas which are usually benign
- Other types are malignant and include dysgerminoma, Yolk sac tumour, Choriocarcinoma, Embryonal carcinoma
What are the types of ovarian teratoma?
- Mature (benign) is most common
- Mono-dermal (highly specialised)
- Immature (malignant) is rare and composed to tissues that resemble immature foetal tssue
What are the clinical features of ovarian mature teratomas?
- Most are cystic
- Most contain skin lie structures
- Usually occur in young women
- Bilateral in 10-15% of cases
What is usually contain in ovarian mature teratomas?
- Contain hair and sebaceous material and can contain tooth structures
- Often also tissue from other germ laters such as cartilage, bone, thyroid and neural tissue
What is the most common mono-dermal ovarian teratoma?
Struma ovarii
- Benign
- Composed entirely of mature thyroid tissue
- May be functional and cause hyperthyroidism
What are ovarian sex cord-strumal tumours?
- Derived from ovarian stroma
- Produces Sertoli and Leydig cells leading cell in testes and Granulosa and Theca cells in the ovaries
- Tumours reselling all of these four cell types can be found in the ovary
- These tumours can be feminising or masculinising
What are the clinical features of granulosa cell tumours?
- Most occur in post-menopausal women
- May produce large amounts of oestrogen
What may be produced in pre-pubertal girls and adult women due to granulosa cell tumours?
- Precocious puberty in pre-pubertal girls
- Endometrial hyperplasia, endometrial carcinoma and breast disease in adult women
What are the clinical features of ovarian-sertoli leading cell tumours?
Often functional. Peak incidence in teens or twenties
- In children, may block normal female sexual development
- In women can cause defeminisation and masculinisation
What tumours occur in the testes?
- Germ cell tumours
- Sex cord-stromal tumors (Sertoli cell tumours, Leydig cell tumours)
- Lymphomas
What are types of germ cell tumours occurring in men?
- Seminomas
- Non-seminomatous germ cell tumours (Yolk sac tumours, Embryonal carcinomas, Choriocarcinomas, Teratomas)
Which tumours commonly metastasise to the ovaries?
Mullerian tumours from
- Uterus
- Fallopian tubes
- Contralateral ovary
- Pelvic peritoneum
What other tumours metastasise to the ovaries?
- Gastrointestinal tumour and breast
- Krukenberg tumour : metastatic gastrointestinal tumour within the ovaries which is often bilateral and from the stomach
