Reproductive Tract Cancers Flashcards
Define a tumour
Any clinically detectable lump or swelling
Define neoplasm
An abnormal growth of cells that persists after the initial stimulus is removed
What is a malignant neoplasm?
An abnormal growth of cells that persists after the initial stimulus is removed and invades surrounding tissue with potential to spread to distant sites
In what demographic are vulval cancers most common?
Tend to arise in older patients
What is the most common type of vulval cancer?
Squamous Cell Carcinoma (90%)
Note Atypical squamous cells - large nuclei, mitotic bodies, irregular borders and keratin formation (whirls and swirls)
Others are Basal Cell Carcinoma, Melanoma and Soft tissue tumours
What is the main causative factor for vulval tumours in pre-menopausal women?
HPV (human papilloma virus)
Which lymph nodes would vulval cancers predominantly metastasis to?
Inguinal lymph nodes
What is vulval intraepithelial neoplasia?
An in situ precursor of vulval squamous cell carcinoma
Has not invaded through the basement membrane. May or may not develop into SCC
Are VIN and Vulval SCC related to HPV?
Yes and No!
Yes:
- 30% of cases, usually HPV 16
- Peak onset age 60s
No:
- 70% of cases
- Usually associated with long term inflammatory conditions e.g. lichen scleosus
- Peak onset age 80s
Which direct extensions sites can vulval cancer spread to?
- Anus
- Bladder
- Vagina
Explain how the cell types of the cervix change in normal anatomy
The Transformation Zone is the area where the epithelium changes from columnar epithelium in the endocervix to squamous epithelium in the ectocervix
How does the transformation zone change throughout the womans life?
Premenarche: Well defined ecto and endo cervix
Early reproductive age: Rises in oestrogen cause the endocervix to evert so columnar epithelium is exposed to the acidic environement of the vagina
In their 30s: Metaplasia from simple columnar to stratified squamous columnar in the transformation zone
Which HPV strains are high risk?
HPV 16 & 18
How does the HPV virus cause uncontrolled cellular proliferation?
- HPV strains 16 &17 infect the transformation zone which is already at risk of dysplasia
- Produces viral proteins E6 and E7
- Viral proteins inactivate tumour suppressor genes p53 and Rb
- Causes uncontrolled cellular proliferation
What is cervical intraepithelial neoplasia?
Dysplasia of cells of the cervix confined to the cervical epithelium. Does not break through the basement membrane. Caused by HPV infection
What are the main types of cancer of the cervix?
- Squamous cell carinoma (80%)
- Adenocarcinoma (15%)
What factors increase risk of exposure to HPV?
- Sexual partner with HPV
- Multiple sexual partners
- Early age of first intercourse
What are some of the risk factors for CIN and Cervical Carcinoma?
- Increased risk of exposure to HPV
- Early 1st pregnancy
- Multiple births
- Smoking
- Low socio-economic status
- Immunosuppression
How would you target the treatment of the different types of CIN?
CIN 1: often regresses spontaneously, follow up with smear 1 year later
CIN 2&3: need treatments, large loop excision of transformation zone
Explain the principles of the cervical cancer screening programme
Brush used to scrape cells from the transformation zone and tested for HPV
If positive for HPV cells are looked at under microscope
Age 25-49: done every 3 years
Age 50-64: every 6 years
Over 65: only if recent abnormality
What features of this histology slide indicate neoplasia?
- Pleomorphism
- Large nucleus size
- Presence of nucleoli
Explain the basics of the HPV vaccination programme
- Girls aged 12-13 offered vaccination against high risk HPV subtypes HPV 6/11/16/18
- Protects aginst HPV infection for up to 10 years
- Protects against cervical, vulval, oral and anal cancers
How would invasive cervical cancer present?
-
Bleeding
- Post coital
- Inter menstrual
- Post menopausal
- Mass
- Detected on screening
Which lymph nodes would carcinoma of the cervix spread to?
Iliac and then aortic lymph nodes
How can you treat invasive cervical cancer?
- Hysterectomy if advanced
- Lymph node dissection
- +/- Chemoradiotherapy
What is the main type of tumour of the endometrium and the two histological types?
Adenocarcinoma
2 main histological types: endometroid and serous
What are the causes of endometrial hyperplasia?
Caused by excessive oestrogen
-
Endogenous
- Obesity (androgens → oestrogens)
- Early menarche/ late menopause
- Oestrogen secreting tumours
-
Exogenous
- Unopposed oestrogen hormone replacement therapy
- Tamoxifen (breast cancer treatment)
-
Irregular Cycles
- PCOS
What is the most common type of endometrial cancer?
Endometrioid Adenocaricoma
Resembles normal endometrial glands just very close together with no stroma
Commonly arises from hyperplasia
What is the less common form of endometrial cancer?
Serous Adenocarcinoma
Less common but more aggressive
Poorly differentiated cells, look nothing like normal endometrium
Where can serous adenocarcinoma spread to?
- Cervix
- Bladder
- Rectum
- Desposits in the peritoneal cavity by transcolaemic spread
What histological feature is associated with exfoliates of serous adenocarcinoma?
Collections of Calcium - Psammoma bodies
How do you manage endometrial cancer?
- Hysterectomy
- Bilateral salpingo-oophorectomy
- +/- lymph node dissection
- +/- chemo radiotherapy
What are fibroids?
Benign tumours of uterine smooth muscle
Proper name = leiomyomas
Pale, homogenous and well circimscribed mass
How may leiomyoma present?
- asymptomatic
- pelvic pain
- heavy periods
- urinary frequency (if bladder compressed)
How does leiomyoma look histologically?
Whorled intersecting fasciles of beign smooth muscle cells
What is leiomyosarcoma?
- Malignant tumour of smooth muscle
- Atypical cells
- Doesn’t arise from leiomyoma
- Can metastsise to lung
What 3 types of tumour can develop in the ovary?
- epithelial tumours
- germ cell tumours
- sex cord stromal tumours
What are the histological subtypes of ovarian epithelial tumours?
- Serous
- Mucinous
- Endometrioid
- All are types of adenocarcinoma
Can all be further classified as benign, borderline or malignant
How do ovarian serous adenocarcinomas look histologically?
- highly atypical cells
- Often show Psammoma bodies
How does ovarian mucinous adenocarcinoma look histologically?
How does ovarian endometroid adenocarinoma look histologically?
- glands resembling endometrium
- may arise from endometriosis
Which markers exist for ovarian cancer?
Ca-125
- Serum marker
- For diagnosis / monitoring
BRCA 1/2
- tumour suppressor genes
- assoicated with high grade serous cancers
- would do a prophylactic salpingo-oophrectomy
What is a teratoma?
Most common germ cell tumour in women, also called a dermoid cyst. Can contai tissue from any of the 3 germ layers; skin, hair, teeth, muscle, cartilage etc
3 subtypes
- mature (benign)
- immature (malignant)
- monodermal (highly specialised)
Other than teratoma, name some other germ cell tumours
- Dysgerminoma (seminoma of the testes)
- Choriocarcinoma
- Embryonal Carcinoma
- Yolk Sac Tumour
- All are malignant
What are the 2 types of sex cord stromal tumours that can arise in the ovary?
- Granulosa Cell Tumours - resemble lining of ovary follicle, commonly produce oestrogen, from granulosa and theca cells
- Sertoli-Leydig cell tumours- rare sex cord tumours that may produce androgen and cause defeminisation, masculation and amenorrhoea or infertility
What is a Krukenberg Tumour?
Metastatic spead of GI tumour
Often gastric origin with signet cell sign
Which tumours commonly metastasise to the ovary?
- Breast cancer
- Other gynae tumours
- GI cancers
What is a key risk factor for testicular cancer?
Cryptorchidism
i.e. maldescended testicle
What are some useful tumour markers for testicular cancer?
- Beta hCG - choriocarcinoma a type of germ cell tumour
- Alpha fetoprotein (AFP) yolk sac tumours
What is a seminoma?
- Approx 50% of germ cell tumours are seminomas
- Common in young men
- Fried egg appearance on histology
- Cancer confined to the testis for a long period
- Common metastasis to iliac and paraortic lymph nodes
In which age group do yolk sac tumours usually present?
In young children
Have good prognosis
