Reproductive Pathology: Female 2 Flashcards
What percentage of women have some form of congenital uterine abnormalities?
5%
What are mullerian malformations?
- Anomalies caused by errors in müllerian-duct development during embryonic morphogenesis
- Abnormalities of the renal and axial skeletal systems present
- Most problems occur after puberty
- Can be infertile
What is a hysterscopy?
Procedure which uses an endoscope to see insode the uterus
What type of cancers are vulval cancers usually?
90% are squamous cell
Where do vulval cancers usually develop?
Edges of labia majora/minora or in vagina
What do vulval squamous cell cancers develop from?
“Precancerous” pre-invasive areas called VUlval intraepithelial neoplasia
What are the 2 subtypes of sq vulval cancer?
- HPV associated (younger women)
- Older women associated with chronic vulval skin changes called vulval dystrophy, including lichen sclerosus
What does squamous hyperplasia show histologically?
- Hyperkeratosis
- Irregular thickening of ridges
- Some neoplastic potential
What does lichen sclerosus show?
- Hyperkeratosis
- Flattening of ridges
- Oedema in connective tissue with chronic inflammation
- Some neoplastic potential
- Sometimes white patches ‘leukoplakia’
What does lichen sclerosis cause?
Pruritis
What is lichen sclerosis treated with?
- Potent topical corticosteroids
What percentage of cancers are endometrial?
5% of cancers in women
How common is endometrial cancer in relation to other cancers?
- 4th most common
- Causes around 2.5% of cancer deaths
WHat is the lifetime risk of endometrial cancer in women in the UK?
2.35%
What is the most common gynaecological cancer?
- Endometrial (UK)
- CErvical (developing)
What are the 2 clinico-pathologicaltypes of endometrial adenocarcinoma?
Endometriod - Related to unopposed estrogen - Associated with atypical hyperplasia - Associated with polycystic ovary syndrome Non-endometroid - not associated with unopposed estrogen - Affects elderly post-menopausal women - p53 often mutated
What are the stages of endometrial adenocarcinoma?
1 - confined to uterine body
2 - involvement of cervix
3 - Involvement of ovaries/tubes or extension beyond serosa
4 - Spread to other organs
What does endometrial cancer typically present with?
Post-menopausal bleeding (post-menopausal bleeding is due to malignancy until proven otherwise)
What are other endometrial tumours other than adenocarcinoma?
- Endometrial stromal sarcoma
- Malignant mixed Mullerian tumour
What are the abnormalities of the myometrium?
- Adenomyosis
Smooth muscle tumours - Leiomyoma (fibroid)
- Leiomyosarcoma
What is ademyosis?
- Benign disease of uterus due to ectopic endometrial glands and stroma within the myometrium with adjacent reactive myometrial hyperplasia (disease can be diffuse or focal)
- Causes menorrhagia / dysmenorrhoea
What is leiomyoma?
- Benign SM tumour within the uterus
- V. common cause of uterine enlargement
- May undergo degeneration
- Can be: intramural, submucosal or subserosal
How are fibroids treated?
- Uterine Artery Embolism
- Hysterectomy
What is endometriosis?
Endometrial glands and stroma outside the uterine body
What are the sites of endometriosis?
- Ovary ‘chocolate cyst’
- Pouch of Douglas
- Peritoneal surfaces, including uterus
- Cervix, vulva, vagina
- Bladder, bowel etc
What can endometriosis cause?
- Pelvic inflammation
- Infertility
- Pain
How common are ovarian cysts and when would they be concerning?
- Very common in post-pubertal women
- Would be cause for concern in post-menopausal, pre-pubertal, pregnant or if mean diameter is >3cm
What is polycystic ovary syndrome?
- One of the most common endocrine disorders for women of reproductive age
- May present with hyperandrogenism
- Can cause type 2 diabetes mellitus, dyslipidaemia, hypertension, CV disease and endometrial carcinoma
- Not having normal periods
- Familial
- Weight gain common
What is the treatment for Polycystic Ovary Syndrome (PCOS)?
- Combined oral contraceptive pill - can protect against development of endometrial hyperplasia and cancer and to suppress excessive androgen secretion to control acne and hirsutism
- Mirena intrauterine system (IUS) - progesterone released very slowly can be good alternative
What are women with Polycystic ovary syndrome at higher risk of?
- Endometrial hypeplasia
- Adenocarcinoma
- 3 fold increased risk for endometrial cancer
What type of imaging technique should be considered for PCOS? (or in presence of abnormal uterine bleeding e.g absence of withdrawal bleeds)
Transvaginal US (endometrial thickness of more than 7mm should be biopsied, often with hystoscope)
How can ovarian neoplasms be classified?
- Epithelial (90%), derived from surface coelomic epithelium
- Germ cell
- Sex-cord / stromal
- Metastatic
- Miscellaneous
How do epithelial ovarian tumour progress?
- Benign
- Borderline (cytological abnormalities with no stromal invasion)
- Amilgnant with stromal invasion
What are the symptoms of ovarian cancer and what makes it hard to diagnose?
- Insidious onset means that up to 75% of patients present with synmptoms of advanced disease due to mass effects of the tumour
- Non-specific GI symptoms such as bloating or indigestion (often misdiagnosed as IBS)
- Gradually increasing abdo distension
- Pressing on other things -> pelvic + back pain, urinary frequency, constipation, leg sweeling, DVT
- Symptoms of metastatic disease include pleural efusion, ascites, weigt loss and fatigue
- Sudden torision, rupture or infection (Less common)
What percentage of ovarian neoplasms are serous adenocarcinoma?
50 - 80%
How is ovarian cancer treated?
- Surgical management: Exploratory laparotomy for tumour debulking and formal surgical staging
- MAjor procedure which comprises total abdominal hysterectomy and bilateral salpingo-oopherectomy (BSO), infracolic omentectomy, pelvic and para-aortic lymph node sampling, peritoneal biopsies, multiple pelvic washings, sampling of ascites
- Adjuvant chemotherapy (>stage1c), often intraperitoneal
How can response to ovarian cancer treatment be managed?
Monitored using CA-125 levels, decrease if treatment is effective and increase if there is relapse
What common cancer treatment is not used in ovarian cancer?
Radiotherapy as tumours tend to be very radioresistant
What are the types of germ cell tumours?
- Dysgerminoma (undifferentiated)
- Teratoma (contains all 3 embryonic germ cell layers) (mature cystic teratoma = dermoid cyst)
- Extraembryonic (yolk sac tumour)
- Choriocarcinoma
What can arise as a result of gestational trophoblastic disease?
Choriocarcinoma
What is the most common monodermal teratoma?
Struma ovarii (thyroid tissue)
What feature in ovarian teratomas is different to testicular ones usually?
Ovarian are usually benign
What are different types of sex cord/stromal tumours?
- Fibroma / Thecoma
- Granulosa cell tumour
- Sertoli-Leydig cell tumours
Where can metastases on the ovary come from?
- Stomach
- Colon
- Breast
- Pancreas
(always to be considered especially if bilateral)
What are different gestational trophoblastic diseases?
- Hyadiform mole
- Invasive mole
- Choriocarcinoma
- Placental-site trophoblastic tumour
- Epithelioid trophoblastic tumour
How common are molar pregnancies?
1 for every 714 live births
What are the 2 types of Hydatidiform mole?
- Complete hydatidiform mole - sperm cells fertilise empty egg cell
- Partial hydatidiform mole - 2 sperms fertilise normal egg (non-viable fetus)
What is an invasive mole?
Hydatidiform mole that has grown into the myometrium
What type of Hydatidiform mole is more liekly to become invasive?
- Complete moles more often become invasive than partial
How often do invasive moles develop in those who have had a complete mole removed?
1 out of 5
Women with hydatidiform moles will have higher levels of what hormone compared with normal pregnancy?
hCG (can cause extreme morning sickness)
- Test can tell whether it has been completely removed
What tissue produces hCG?
Trophoblastic tissue
What does a hydatidiform mole look like on US?
Grapes
What is the malignant form of gestational trophoblastic disease called?
Choriocarcinoma
What percentage of choriocarcinomas start off as molar pregnancies?
50%
What can increase the risk of choriocarcinoma?
Miscarriage, abortion, normal pregnancy (around 50% develop from this)
What type of cancer can non-gestational choriocarcinoma develop into?
May develop in ovaries, testes, chest or abdomen -> mixed germ cell tumor
What is an ectopic pregnancy?
- Implantation of a conceptus outside the endometrial cavity
- Often ruptures causing fatal intra-abdominal haemorrhage
Where is the site of an ectopic pregnancy?
- Commonest site is ampulla of fallopian tube
- May occur in ovary or peritoneum
When should ectopic pregancy be considered?
Any female of reproductive age with amenorrhoea and acute hypotension or an acute abdomen
How is ectopic pregancy treated?
- Methotrexate
- Laparascopic surgical extraction
