Session 11 Flashcards
Imaging techniques used to view reproductive tract and which is best.
Ultrasound MRI Fluoroscopy CT in order of most used to least.
CT only really used for cancer as it doesnt give much tissue detail. Radiation exposure to rapidly dividing cells also a malignancy risk.
MRI also good but takes too long so ultrasound used more.
HSG?
Hysterosalpingography (HSG) is an X-ray procedure that is used to view the inside of the uterus and fallopian tubes. It often is used to see if the test the patency of the fallopian tubes. Will leak into the peritoneal cavity, non patent tubes will not have the leakage.
Ovarian cysts
Describe ovulation and what happens after
- The normal ovary contains over two million primary oocytes at birth
- 10 of which mature each menstrual cycle
- Of the 10 Graafian follicles that begin to mature, only one becomes the dominant follicle and grows to a size of 18-20 mm by mid-cycle, when it ruptures to release the oocyte.
- After release of the oocyte, the dominant follicle collapses, and the granulosa cells in the inner lining proliferate and swell to form the corpus luteum of menstruation
- Over the course of 14 days the corpus luteum degenerates, leaving the small scarred corpus albicans
Functional cysts
Two types:
Follicular cyst
Corpus luteum cyst
Follicular cyst
- A dominant Graafian follicle sometimes fails to ovulate and does not involute
- When it becomes larger than 3 cm, it is called a follicular cyst
- Follicular cysts are usually 3-8 cm, but may become much larger
- On ultrasound follicular cysts present as simple unilocular, anechoic cysts with a thin, smooth wall.
- Follicular cysts will usually resolve spontaneously on follow-up.
Corpus luteal cyst
- A corpus luteum may seal and fill with fluid or blood, forming a corpus luteum cyst.
- The characteristic circular Doppler appearance is called the ‘ring of fire’.
- Remember that women who are on birth control pills usually won’t form a corpus luteum, as birth control pills prevent ovulation.
- Use of fertility drugs that induce ovulation, increases the chance of developing corpus luteum cysts
Haemorrhagic cysts
Occur when you get bleeding into a functional cyst. Should resolve by themselves. Checked with a follow up.
Polycystic Ovarian Syndrome / Hyperandrogenic anovulation
Chronic anovulation syndrome associated with androgen excess
- ovulatory dysfunction (oligo- or anovulation)
- clinical and/or biochemical hyperandrogenism
- polycystic ovarian morphology on ultrasound
Need to see roughly 20
Mature cystic ovarian teratoma
- Encapsulated tumours with mature tissue or organ components.
- They are composed of well-differentiated derivations from at least two of the three germ cell layers (i.e. ectoderm, mesoderm, and endoderm).
- Contain developmentally mature skin complete with hair follicles and sweat glands
- Sometimes luxuriant clumps of long hair, and often pockets of sebum, blood, fat (93%), bone, nails, teeth, eyes, cartilage, and thyroid tissue
Ovarian hyperstimulation
- Ovarian hyperstimulation syndrome is a relatively rare condition
- It is caused by hormonal overstimulation by hCG, and is therefore usually bilateral
- Hormonal overstimulation can occur in gestational throphoblastic disease, PCOS or in patients receiving hormonal therapy.
Pelvic inflammatory disease
- PID is defined as an acute clinical syndrome associated with ascending spread of micro-organisms, unrelated to pregnancy or surgery.
- The infection generally ascends from the vagina or cervix to endometrium (endometritis)
- Then to the fallopian tubes (salpingitis)
- Then to and/or contiguous structures (tubo-ovarian abscess).
Malignant ovarian lesions
- Lesion assessment - US and MRI - Plus CA125 (contrast)
- Cancer staging
- Contrast enhanced CT Risk:
Low: premenopausal and no risk factors
High risk: postmenopausal, person of familial history of breast or ovarian cancer, BRCA-1 or 2 carriers, Ashkenazi descent, Lynch-II HNPCC
A Krukenberg tumor refers to a malignancy in the ovary that metastasized from a primary site, classically the gastrointestinal tract, although it can arise in other tissues such as the breast
Endometriosis
- Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. It is mainly found in the abdominal cavity, most commonly on the surface of the ovaries.
- It is an estrogen-dependent disease and is estimated to occur in 10% of the female population, almost exclusively in women of reproductive age.
- The most common symptoms are dysmenorrhea, dyspareunia, pelvic pain, and infertility - although it may also be asymptomatic
Can be divided into superficial and deep infiltrative.
Superficial difficult to find as resolution is good enough, deep infiltrative (involves other organs in peritoneum) iseasier as we have the resolution to see it.
Bimanual transvaginal ultrasound with palpation to check for adhesions. Assessmentwith ultrasoud for endometriosis is very user independent. MRI is much better as the image is better and the image is reproducable so not user dependent.
Kissing ovary sign - strong pelvic adhesions pull ovaries together
Define tumour
A tumour is any clinically detectable lump or swelling. A neoplasm is just one type of tumour
Define neoplasm
A neoplasm is, “an abnormal growth of cells that persists after the initial stimulus is removed”. For malignant neoplasms the definition needs the following extending: an abnormal growth of cells that persists after the initial stimulus is removed and invades surrounding tissue with potential spread to distant sites.
Vulval cancer? How does vulval cancer spread?
Uncommon - only 3% of female cancers
More common in older patients.
Clinical Features:
Lumps, Ulceration, Skin changes
Most common to least - Squamous Cell Carcinoma, Basal Cell Carcinoma, Melanoma, Soft tissue tumours
90% are squamous cell carcinoma - seen wih keratin formation
Vulval Intraepithelial Neoplasia (VIN) = IN SITU - Precursor of vulval squamous cell carcinoma
Atypical cells (no invasion through basement membrane) - big nuclei, pleomorphic, mitotic figure, nucleoli
May or may not develop into SCC
If basement membrane still intact then not SCC
Vulval cancer spread
Direct extension - Anus, Vagina, Bladder
Lymph Nodes - Inguinal, Iliac, Para-aortic
Distant Metastases - Lungs and Liver
Are VIN and Vulval SCC related to HPV?
YES and NO
YES: 30% of cases, Usually HPV 16, Peak age of onset = 60s, Risk factors as per cervical carcinoma
NO: 70% of cases, Usually associated with longstanding inflammatory conditions (e.g. lichen sclerosus), Peak age of onset = 80s
Draw cervix
Endocervix and ectocervix
Ectocervix is stratified squamous epithelium as its best evolved to deal with environment of vagina.
Endocervix is not exposed and is simple columnar.
After menarche we have more oestrogen, one of its functions is to change the anatomical structure of the cervix by causing it to evert, exposing the coumnar epithelium to the acidic environment causing inflammation forming the ectropian . In response to this we see metaplasia in the cervix so columnar changes to stratified squamous epithelium in the transformation zone.This gives more risk for dysplasia
Define dysplasia
Dysplasia is a pre-neoplastic alteration in which cells show disordered tissue organisation. It is not neoplastic because the change is reversible. Still see enlarged nuclei, mitotic figures, pleomorphism etc but it may be reversible
Human Papilloma Virus (HPV)
DNA Virus
Sexually transmitted
Many subtypes:
Low risk (egHPV 6 and 11) -> warts on hands, mouth, genitalia, anus
High risk (egHPV 16 and 18) - Infect transformation zone, Produce viral proteins (E6 and E7) which inactivate tumour suppressor genes p53 and retinoblastoma gene resuting in uncontrolled cellular proliferation
Cervical Intraepithelial Neoplasia (CIN)
Risk factors for CIN and Cervical Carcinoma
Dysplasia
Confined to Cervical epithelium (in situ)
Caused by HPV infection
Divided into CIN 1 / 2 / 3
Risk of progression to squamous cell carcinoma higher with each stage
Risk factors for CIN and Cervical Carcinoma
•Increased risk of exposure to HPV:
Sexual partner with HPV
Multiple partners
Early age of first intercourse
- Early first pregnancy
- Multiple births
- Smoking
- Low socio-economic status
- Immunosuppression
Treatment for CIN :
CIN1
- Often regresses spontaneously
- Follow up cervical smear in 1 year
CIN 2 and 3
- Needs treatment
- Large Loop Excision of Transformation zone (LLETZ)
Cervical Cancer Screening Programme
Brush used to scrape cells from transformation zone:
Tested for HPV - If positive –cells looked at under microscope
- Aged 25 –49 = every 3 years
- Aged 50 –64 = every 5 years
- Over 65 –only if recent abnormality
Vaccination against HPV
- Gardasil
- Recombinant vaccination
- Against HPV (subtypes 6/11/16/18)
- Given aged 12-13
- Protects from cervical, vulval, oral, anal cancers
Invasive Cervical Cancer
Squamous Cell Carcinoma - Most common / CIN = precursor
Adenocarcinoma - Less common / arises from endocervical glandular cells
Presentation: Bleeding (Post coital, Inter menstrual, Post menopausal)
Mass Screening
Spread of Invasive Cervical Cancer - spreads to involve bladder, pelvic wall, rectum, vagina
Staging for cervical cancer is called figo staging
Treatment of Invasive Cervical Cancer:
If advanced: Hysterectomy, Lymph Node Dissection, +/-Chemoradiotherapy
Endometrial Hyperplasia
Thickened endometrium >11mm
Can be a precursor to endometrial cancer
Presents with inter-menstrual/postmenopausal bleeding
Caused by excessive oestrogen:
Endogenous -Obesity (androgens -> oestrogens via aromatisation) -Early menarche/late menopause -Oestrogen secreting tumours
Exogenous -Unopposed oestrogen hormone replacement therapy -Tamoxifen
Irregular Cycle - most often caused by Polycystic Ovary Syndrome
Endometrial Cancer
Most common gynaecological tract cancer
Most common at age 70
Presentation: Bleeding (Post menopausal, Inter menstrual) and Mass
Types of endometrial cancer
Endometrioid Adenocarcinoma - Most common
Resembles normal endometrial glands
Commonly arises from hyperplasia
Serous Adenocarcinoma - Less common
More aggressive
Poorly differentiated cells
Spread of endometrial cancer
Method of spread also helps to detrmine type of endometrial cancer.
Spread of Endometrioid Adenocarcinoma - Spreads as you would expect - through the myometrium, invades into the cervix and vagina and then other nearby organs and then break off.
Spread of Serous Adenocarcinoma
Exfoliates Travels through Fallopian tubes
Deposits on peritoneal surface (Transcoelomic spread)
Associated with collections of calcium (Psammomabodies)
Management of Endometrial Cancer
Hysterectomy
Bilateral salpingooophorectomy
+/-lymph node dissection
+/-chemo radiotherapy
Leiomyoma
Leiomyoma (fibroid)
Most common tumour of myometrium
Benign
Pale, homogenous, well circumscribed mass
Presentation: Asymptomatic, Pelvic pain, Heavy periods, Urinary frequency (bladder compression)
Whorled, intersecting fascicles of benign smooth muscle cells seen on microscope
Leiomyosarcoma
Malignant tumour of smooth muscle
Atypical cells
Doesn’t arise from a leiomyoma
Tend to metastasise to lung
Ovarian Cancer
Presentation
Early symptoms - Vague and non-specific leading to Delayed diagnosis
Later symptoms - Abdominal pain, Abdominal distension, Urinary symptoms, Gastrointestinal symptoms, Hormonal disturbances,
Ca-125 Serum marker –diagnosis/monitoring recurrence
BRCA1/2 - Tumour suppressor genes
Associated with high grade serous cancers
Prophylactic salpingo-oophrectomy often done to reduce risk
Cells that make ovaries at risk of specific tumours
Lined by epithelium • Epithelial tumours
Contains germ cells • Germ cell tumours
Contains stromal cells • Sex cord stromal tumours
Is also a site for metastatic spread
Ovarian Epithelial Tumours
Often present as cystic masses
Histological subtypes: (adenocarcinoma) -Serous -Mucinous -Endometrioid
Can all be:
- Benign
- Borderline -Increased atypia, no stromal invasion
- Malignant
Ovarian Serous Adenocarcinoma
Highly atypical cells
Often show Psammoma Bodies
Often spreads to peritoneal surface
Ovarian Mucinous Adenocarcinoma
Atypical epithelial cells
Secreting mucin
Ovarian Endometrioid Adenocarcinoma
Glands resembling endometrium
May arise in endometriosis
May have synchronous endometrial endometrioid adenocarcinoma
Teratoma
Most common germ cell tumour
Three subtypes:
- Mature(benign)
- Immature(malignant)
- Monodermal (highly specialised) - commonly thyroid tissue
Mature Teratoma (Dermoid Cyst) - Contain fully mature, differentiated tissue from all germ cell layers - Can be bilateral - Often contains skin + hair structures
Immature Teratoma - Contains immature, embryonal tissue
Malignant
Other Germ Cell Tumours
Dysgerminoma (equivalent of seminoma in testis)
Choriocarcinoma
Embryonal Carcinoma
Yolk Sac Tumour
All malignant
Sex Cord Stromal Tumours
From ovarian stroma
Sex Cord ->
Testes - Sertoli Cells and Leydig Cells
Ovaries - Granulosa Cells and Theca Cells
Tumours resembling ALL the above cell types can arise in the ovary
Theca and Granulosa Cell Tumours
Produce Oestrogen
Patient pre-puberty - Precocious puberty
Patient post-puberty - Breast cancer, Endometrial hyperplasia, Endometrial carcinoma
Sertoli-Leydig Tumours
Produce testosterone
Patient pre-puberty - Prevents normal female pubertal changes
Patient post-puberty - Sterility, Amenorrhoea, Hirsuitism, Male pattern baldness, Breast atrophy
Metastases to Ovary
Breast cancer
Krukenberg Tumour • Metastatic GI tumour • Often gastric • Signet cells
Gastrointestinal cancers
Other Gynaetumours • Endometrial • Other ovary • Fallopian Tube
Testicular Cancer
Risk factor: -Cryptorchidism (undescended testicle)
Presentation: -Mass+/-pain
Investigations: -Scans -Tumour markers
Tumour Markers:
Useful in germ cell tumours Diagnosis/response to treatment/monitoring for recurrence
β hCG - Choriocarcinoma
Alpha fetoprotein (AFP) - Yolk Sac Tumours
Subtypes of Testicular Cancer
How do we image prostate cancer?
MRI as ths reduces bipsies. PSA test used prior. PSA density looked at. Then use PI-RADS to determine likelihood of cancer.
MRI can be used in conjunction with ultrasound for biopsy guidance.
