Session 11: Tumours of the Reproductive Tracts NOT FINISHED

Question 1

Where might you find tumours in the female reproductive tracts?

Answer 1

Vulva

Cervix

Endometrium

Myometrium

Ovaries

Question 2

What is a tumour?

Answer 2

Any clinically detectable lump or swelling. A neoplasm is just one type of tumour.

Question 3

What is a neoplasm?

Answer 3

An abnormal growth of cells that persists after the initial stimulus is removed.

Question 4

What is a malignant neoplasm?

Answer 4

An abnormal gorwth of cells that persists after the initial stimulus is removed and invades surrounding tissue with potential to spread to distant sites.

Question 5

Most common vulval cancers.

Answer 5

Squamous cell carcinoma (90%)

Basal cell carcinoma

Melanoma

Soft tissue tumours

Question 6

Clinical features of vulval cancers.

Answer 6

Lumps

Ulceration

Skin changes

Question 7

What might you find upon histological investigation of squamous cell carcinoma of vulva?

Answer 7

Atypical squamous cells and keratin formation

Question 8

What is vulval intraepithelial neoplasia a potential precursor of?

Answer 8

Squamous cell carcinoma

Question 9

What is the main causative factor of squamous cell carcinoma of the vulva in pre-menopausal women?

Answer 9

HPV

Question 10

Where does the SCC spread?

Answer 10

Direct to anus, vagina and bladder

Lymph nodes such as inguinal, iliac and para-aortic

Distant metastases to lung and liver

Question 11

What is the causative agent of vulval squamous cell carcinoma in older women?

Answer 11

Not known but probably related to chronic irritation and long standing dermatoses such as lichen sclerosus.

Question 12

What is dysplasia?

Answer 12

A pre-neoplastic alteration in which cells show disordered tissue organisation.

It is not neoplastic because the change is reversible.

Question 13

What type of cancer is most common of the cervix?

Answer 13

Squamous cell carcinomas (80%)

15% are adenocarcinomas

Question 14

Most common causative agent of cervical cancer.

Answer 14

Almost exclusively HPV (99.5%)

Question 15

What does squamous cell carcinoma develop from?

Answer 15

Cervical intraepithelial neoplasia (CIN)

Question 16

Explain how HPV causes cancer of the cervix.

Answer 16

Infect the transformation zone

Produce viral proteins E6 and E7 that inactivate TSGs p53 and Rb.

This leads to uncontrolled cellular proliferation.

Question 17

Risk factors for CIN and cervical carcinoma

Answer 17

Increased risk of exposure to HPV such as sexual partner with HPV, multiple partners or early age of first intercourse.

Early first pregnancy

Multiple births

Smoking

Low socio-economic status

Immunosuppression

Question 18

Treatment for CIN

Answer 18

Depends on which stage of CIN.

Question 19

Treatment of CIN1.

Answer 19

Most commonly regress spontaneously but is followed up by a cervical smear in 1 year time.

Question 20

Treatment of CIN 2&3.

Answer 20

Needs treatment and is done by large loop excision of transformation zone.

Question 21

What is the cervical screening programme?

Answer 21

Brush is used to scrape cells from the transformation zone to detect abnormally enlarged nuclei possessing abnormal chromatin. If this is positive there is referral to colposcopy.

You also test for HPV.

Aged 25-49 = every 3 years

Aged 50-64 = every 5 years

Over 65 = only if recent abnormality

Question 22

What is vaccination against HPV?

Answer 22

Given in girls aged 12-13 and becomes more common in boys as well.

Protects from cervical, vulval, oral and anal cancers.

Question 23

How do carcinomas of cervix spread?

Answer 23

Spreads initially to iliac and aortic lymph nodes before wider systemic dissemination.

Spread locally to ureters, bladder, and rectum.

Can be extremely distressing with pain and fistula formation

Question 24

Clinical presentation of invasive cervical cancer.

Answer 24

Bleeding post coital, intermenstrual and post menopausal.

Mass felt

Question 25

Treatment of invasive cervical cancer.

Answer 25

Hysterectomy Lymph node dissection +/- chemoradiation

Question 26

What types of endometrial cancers are there?

Answer 26

Endometrioid adenocarcinoma Serous adenocarcinoma

Question 27

What does endometrioid adenocarcinoma commonly arise from?

Answer 27

Endometrial hyperplasia

Question 28

Which age group is generally affected by endometrioid adenocarcinoma?

Answer 28

Perimenopausal and older women.

Question 29

Aetiology of endometrial adenocarcinoma in perimenopausal women.

Answer 29

Unopposed oestrogen from obesity, exogenous oestrogen administration like HRT. Tamoxifen Hormone-secreting tumour Polycystic ovarian syndrome Early menarche/late menopause (longer exposure to oestrogen)

Question 30

How can obesity cause a higher risk of endometrial hyperplasia and endometrial adenocarcinoma?

Answer 30

Peripheral adipocytes cause conversion of androgen to oestrogen leading to higher oestrogen levels.

Question 31

Clinical presentation of endometrial cancer.

Answer 31

Bleeding that is post menopausal. Intermenstrual bleeding Mass

Question 32

How do serous adenocarcinomas differ to endometrioid carcinoma?

Answer 32

Serous are less common and more aggressive.

Question 33

What is the spread of endometrioid adenocarcinoma?

Answer 33

Cervix, bladder and rectum. Through the peritoneal cavity and to the regional lymph nodes.

Question 34

Spread of serous adenocarcinoma.

Answer 34

Travels through fallopian tubes. Deposits on peritoneal surface via transcoelomic spread. Associated with collections of calcium called psammoma bodies.

Question 35

Management of endometrial cancer.

Answer 35

Hysterectomy Bilateral salpingo-oophorectomy +/- lymph node dissection +/- chemoradiotherapy

Question 36

What are fibroids?

Answer 36

Leiomyoma which are the most common of the myometrium and benign.

Question 37

Symptoms of fibroids

Answer 37

Heavy menstrual loss, menorrhagia and infertility

Question 38

Appearance of fibroids.

Answer 38

Pale, homogenous, well circumscribed mass

Question 39

What can fibroids cause?

Answer 39

Massive uterine enlargement and this results in pressure symptoms in the pelvis. The growth is oestrogen dependent and they usually regress after the menopause.

Question 40

What is a malignant tumour of the myometrium?

Answer 40

Leiomyosarcoma

Question 41

Do leiomyosarcomas arise from leiomyomas?

Answer 41

No

Question 42

Metastases of leiomyosarcoma.

Answer 42

Spread via blood stream to the **lungs**

Question 43

Presentation of ovarian cancer.

Answer 43

Vague and non-specific. Later symptoms like abdo pain, abdo distension, urinary symptoms and GI symptoms due to mass effect. Hormonal disturbances

Question 44

Give types of ovarian tumours.

Answer 44

Surface epithelium (epithelial tumours) Germ cell tumours Sex-cord stromal tumours

Question 45

What are the majority of ovarian tumours?

Answer 45

Epithelial tumours

Question 46

Serum marker of ovarian cancer.

Answer 46

Ca-125

Question 47

Cause of ovarian epithelial carcinoma.

Answer 47

BRCA1/2 which are TSGs associated with high grade serous cancers.

Question 48

What are the histological subtypes of ovarian epithelial tumours.

Answer 48

Serous Mucinous Endometroid All adenocarcinomas All can be benign, borderline or malignant

Question 49

Answer 49

Ovarian serous adenocarcinoma with highly atypical cells often show **psammoma bodies**. Often spreads to the peritoneal cavity

Question 50

Answer 50

Ovarian mucous adenocarcinoma showing atypical cells secreting mucin.

Question 51

Answer 51

Ovarian endometrioid adenocarcinoma Glands resembling **endometrium** and may arise in endometriosis.

Question 52

Most common female germ cell tumour.

Answer 52

Teratoma

Question 53

Three subtypes of teratoma

Answer 53

Mature Immature Monodermal

Question 54

What do mature teratomas (dermoid cyst) look like on histology?

Answer 54

Contain fully mature differentiated tissue from all germ cells layers. Often contains skin + hair

Question 55

What does the presence of immature tissue such as primitve neuroepithelium indicate?

Answer 55

Malignancy and a risk for intra-abdominal spread.

Question 56

Give other malignant germ cell tumours.

Answer 56

Dysgerminomas which are the equivalent of seminoma in testis. Choriocarcinoma Embryonal carcinoma Yolk sac tumour

Question 57

Useful tumour markes in malignant germ cell tumours.

Answer 57

Alpha-fetoprotein (AFP) beta-human chorionic gonatrophin (hCG)

Question 58

Sex cord stromal tumours in testes

Answer 58

Sertoli cell tumour Leydig cell tumour

Question 59

Sex cord stromal tumours in ovaries.

Answer 59

Granulosa cells Theca cells

Question 60

What do granulosa cell tumours produce?

Answer 60

Oestrogens that may be responsible for endometrial hyperplasia and adenocarcinoma as it can lead to endometroid adenocarcinoma.

Question 61

What do sertoli-leydig cell tumours produce?

Answer 61

Androgens that can cause defeminisation, masculinisation, amenorrhoea and infertility.

Question 62

What might theca and granulosa cell tumours cause in a patient pre-puberty?

Answer 62

Precocious puberty

Question 63

What might theca and granulosa cell tumours cause in a patient post-puberty?

Answer 63

Breast cancer Endometrial hyperplasia Endometrial carcinoma

Question 64

What might Sertoli-Leydig cell tumours cause in a patient pre-puberty?

Answer 64

Prevents normal female pubertal changes

Question 65

What might Sertoli-Leydig cell tumours cause in a patient post-puberty?

Answer 65

Sterility Amenorrhoea Hirsuitism Male pattern baldness Breast atrophy

Question 66

Common cancers metastasising **to** ovaries.

Answer 66

Breast cancer Gastrointestinal cancers Krukenberg tumour (metastatic GI tumour) Other gynae tumours endometrial, other ovary, fallopian tube

Question 67

When in men are tumours of the testis most common?

Answer 67

Aged 15-34

Question 68

What can testicular tumours be classified as?

Answer 68

Germ cell tumours Sex-cord stromal tumours

Question 69

What are the most common sex cord stromal tumours in men?

Answer 69

Sertoli or Leydig cell tumours

Question 70

Are sex cord-stromal tumours malignant or benign?

Answer 70

Benign and also very uncommon

Question 71

What are the most common testicular tumours?

Answer 71

Germ cell tumours (they are also all malignant)

Question 72

Risk factors of testicular cancer.

Answer 72

Cryptorchidism which is an undescended testicle. That's why it is important to ask for medical history

Question 73

Presentation of testicular cancer.

Answer 73

Mass Usually painless testicular mass but might be painful.

Question 74

What is the pre-invasive precursor of germ cells tumours?

Answer 74

Intratubular germ cell neoplasia

Question 75

What can germ cell tumours be divided into?

Answer 75

Seminomas Non-seminomatous germ cells tumours (NSGCTs)

Question 76

What percentage of germ cell tumours are seminomas?

Answer 76

50%

Question 77

Peak age of seminomas

Answer 77

40-50 yrs of age

Question 78

What can pure NGSCTs be classified as?

Answer 78

Yolk sac tumours Embryonal carcinomas Choriocarcinomas Teratomas However most NSGCTs are mixed

Question 79

Yolk sac tumours

Answer 79

Occur in young children and have very good prognosis

Question 80

Investigations of testicular cancers

Answer 80

Scans and tumour markers

Question 81

What do yolk sac tumours produce?

Answer 81

AFP

Question 82

Embryonal carcinomas, choriocarcinomas, and mixed NGSCTs

Answer 82

Occur in young adults

Question 83

What do choriocarcinomas produce?

Answer 83

beta-human chorionic gonadotropin (hCG)

Question 84

What do mixed NSGCTs produce?

Answer 84

AFP and hCG

Question 85

Teratomas in men

Answer 85

Occur in all ages. Arise in prepubertal then usually benign, if in postpubertal always malignant.

Question 86

Seminomas

Answer 86

10% are also associated with raised serum hCG.

Question 87

Spread of seminomas

Answer 87

Remain confined to the testis for long periods of time. However when they do metastasise it is by the lymphatics and most commonly to the **iliac** and **paraortic lymph nodes**. Further spread is rare.

Question 88

Spread of NSGCTs.

Answer 88

Tend to metastasise early and do so via both lympathics and blood. The primary tumour might even be non-palpable.

Question 89

Treatment of testicular tumours.

Answer 89

Radical orchiectomy

Question 90

Further treatment of testicular tumours

Answer 90

Depends on whether the tumour is seminoma or NSGCT.

Question 91

Further treatment of a seminoma.

Answer 91

Radiosensitive and treated therfore with radiotherapy.

Question 92

Further treatment of NSGCTs.

Answer 92

Aggressive chemotherapy