week 3 part 1

Question 1

What are the sub-types of Epithelial cell tumours (ovarian cancer)

Answer 1

	Serous tumours (the most common)
	Endometrioid carcinomas
	Clear cell tumours
	Mucinous tumours
	Undifferentiated tumours

Question 2

Serous cystadenoma

Answer 2

Most common benign ovarian tumour, often bilateral

Cyst lined by ciliated cells (similar to Fallopian tube)

Question 3

Serous cystadenocarcinoma

Answer 3

Malignant - Often bilateral

Psammoma bodies seen (collection of calcium)

Question 4

Mucinous cystadenoma

Answer 4

Benign - Cyst lined by mucous-secreting epithelium (similar to endocervix)

Question 5

Mucinous cystadenocarcinoma

Answer 5

Malignant - May be associated with pseudomyxoma peritonei (although mucinous tumour of appendix is the more common cause)

Question 6

Brenner tumour

Answer 6

Benign ovarian growth - Contain Walthard cell rests (benign cluster of epithelial cells), similar to transitional cell epithelium. Typically have ‘coffee bean’ nuclei.

Question 7

Dermoid Cysts / Germ Cell Tumours

Answer 7

These are benign ovarian tumours. They are teratomas, meaning they come from the germ cells. They may contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion. Germ cell tumours may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG).

Question 8

Teratoma

Answer 8

Mature teratoma (dermoid cyst) - most common: benign
Immature teratoma: malignant

Question 9

Dysgerminoma

Answer 9

Most common malignant germ cell tumour
Histological appearance similar to that of testicular seminoma
Associated with Turner’s syndrome
Typically secrete hCG and LDH

Question 10

Yolk sac tumour

Answer 10

Malignant
Typically secrete AFP
Schiller-Duval bodies on histology are pathognomonic

Question 11

Granulosa cell tumour

Answer 11

Malignant
Produces oestrogen leading to precocious puberty if in children or endometrial hyperplasia in adults.
Contains Call-Exner bodies (small eosinophilic fluid-filled spaces between granulosa cells)

Question 12

Sertoli-Leydig cell tumour

Answer 12

Benign
Produces androgens → masculinizing effects
Associated with Peutz-Jegher syndrome

Question 13

Fibroma

Answer 13

Benign
Associated with Meigs’ syndrome (ascites, pleural effusion)
Solid tumour consisting of bundles of spindle-shaped fibroblasts
Typically occur around the menopause, classically causing a pulling sensation in the pelvis

Question 14

Kruckenberg tumour

Answer 14

A Kruckenberg tumour refers to a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach. Kruckenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.

Question 15

Risk factors for ovarian cancer

Answer 15

	Age (peaks age 60)
	BRCA1 and BRCA2 genes 
	Increased number of ovulations
	Obesity
	Smoking
	Recurrent use of clomiphene

Question 16

Protective factors for ovarian cancer

Answer 16

Having a higher number of lifetime ovulations increases the risk of ovarian cancer. Factors that stop ovulation or reduce the number of lifetime ovulations, reduce the risk:

1. Combined contraceptive pill
2. Breastfeeding
3. Pregnancy

Question 17

Presenting features of ovarian cancer

Answer 17

	Abdominal bloating
	Early satiety (feeling full after eating)
	Loss of appetite
	Pelvic pain
	Urinary symptoms (frequency / urgency)
	Weight loss
	Abdominal or pelvic mass
	Ascites

Question 18

Why is there hip or groin pain in some ovarian cancers?

Answer 18

An ovarian mass may press on the obturator nerve and cause referred hip or groin pain.

Question 19

The two-week referral criteria for ovarian cancer

Answer 19

1. Ascites
2. Pelvic mass (unless clearly due to fibroids)
3. Abdominal mass

Question 20

Investigations for ovarian cancer

Answer 20

1. CA125 blood test (>35 IU/mL is significant)

2. Pelvic ultrasound

Question 21

The risk of malignancy index (RMI)

Answer 21

Estimates the risk of an ovarian mass being malignant, taking account of three things:

1. Menopausal status
2. Ultrasound findings
3. CA125 level

Question 22

Women under 40 years with a complex ovarian mass require tumour markers for a possible germ cell tumour: what are those markers?

Answer 22

 Alpha-fetoprotein (α-FP)

 Human chorionic gonadotropin (HCG)

Question 23

CA125

Answer 23

CA125 is a tumour marker for epithelial cell ovarian cancer. It is not very specific, and there are many non-malignant causes of a raised CA125

Question 24

Causes of raised CA125 tumour markers

Answer 24

1. Endometriosis
2. Fibroids
3. Adenomyosis
4. Pelvic infection
5. Liver disease
6. Pregnancy

Question 25

The International Federation of Gynaecology and Obstetrics (FIGO) staging system

Answer 25

Staging system for ovarian cancers Stage 1: Confined to the ovary Stage 2: Spread past the ovary but inside the pelvis Stage 3: Spread past the pelvis but inside the abdomen Stage 4: Spread outside the abdomen (distant metastasis)

Question 26

Benign ovarian cysts

Answer 26

Benign ovarian cysts are extremely common. They may be divided into physiological cysts, benign germ cell tumours, benign epithelial tumours and benign sex cord stromal tumours. Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.

Question 27

Physiological cysts (functional cysts)

Answer 27

1. Follicular cysts | 2. Corpus luteum cyst

Question 28

Follicular cysts

Answer 28

o commonest type of ovarian cyst o due to non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle o commonly regress after several menstrual cycles

Question 29

Corpus luteum cyst

Answer 29

o during the menstrual cycle if pregnancy doesn't occur the corpus luteum usually breaks down and disappears. If this doesn't occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst o more likely to present with intraperitoneal bleeding than follicular cysts

Question 30

Dermoid cyst

Answer 30

1. also called mature cystic teratomas. Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth 2. most common benign ovarian tumour in woman under the age of 30 years 3. median age of diagnosis is 30 years old 4. bilateral in 10-20% 5. usually asymptomatic. Torsion is more likely than with other ovarian tumours

Question 31

Serous cystadenoma

Answer 31

i. the most common benign epithelial tumour which bears a resemblance to the most common type of ovarian cancer (serous carcinoma) ii. bilateral in around 20%

Question 32

Mucinous cystadenoma

Answer 32

i. second most common benign epithelial tumour ii. they are typically large and may become massive iii. if ruptures may cause pseudomyxoma peritonei

Question 33

Benign epithelial tumours

Answer 33

Arise from the ovarian surface epithelium 1. Serous cystadenoma 2. Mucinous cystadenoma

Question 34

Risk of Malignancy Index (RMI)

Answer 34

The RMI I is the most effective for women with suspected ovarian cancer. This is also recommended by the National Institute for Health and Care Excellence (NICE) guideline on ovarian cancer[8]. It should not be used for premenopausal women though. RMI I combines three pre-surgical features: serum CA 125 (CA 125); menopausal status (M); and ultrasound score (U).

Question 35

Simple ovarian cysts management

Answer 35

do not require treatment

Question 36

Women with small (less than 50 mm in diameter) simple ovarian cysts management

Answer 36

No treatment

Question 37

Women with simple ovarian cysts of 50-70 mm management

Answer 37

should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention

Question 38

Complications of ovarian cancer and cysts

Answer 38

1. Torsion of an ovarian cyst can occur. 2. Haemorrhage is more common for tumours of the right ovary. 3. Rupture of an ovarian cyst can occur. 4. Infertility can occur as a result of ovarian tumours or their treatment

Question 39

Uterine fibroid

Answer 39

Fibroids are benign smooth muscle tumours of the uterus. They are thought to occur in around 20% of white and around 50% of black women in the later reproductive years

Question 40

Uterine fibroid associations

Answer 40

more common in Afro-Caribbean women rare before puberty, develop in response to oestrogen

Question 41

Uterine fibroid presentation

Answer 41

``` > may be asymptomatic > menorrhagia > lower abdominal pain: cramping pains, > bloating > urinary symptoms, e.g. frequency > subfertility ```

Question 42

Uterine fibroid diagnosis

Answer 42

Transvaginal ultrasound

Question 43

Asymptomatic fibroids treatment

Answer 43

No treatment is needed other than periodic review to monitor size and growth

Question 44

Medical Treatment to shrink/remove fibroids

Answer 44

GnRH agonists may reduce the size of the fibroid but are typically useful for short-term treatment

Question 45

Surgical treatment to shrink/remove fibroids

Answer 45

1. myomectomy 2. hysteroscopic endometrial ablation 3. hysterectomy 4. uterine artery embolization

Question 46

Endometrial cancer

Answer 46

Endometrial cancer is a common oestrogen-dependent gynaecological cancer which tends to affect older women. Unlike cervical cancer, it is not currently screened for in the UK.

Question 47

Myometrium

Answer 47

the thick layer of smooth muscle and connective tissue lying beneath the endometrium. It contracts during a period to reduce blood loss (causing cramps) and during labour to expel the foetus. It often gives rise to benign growths called fibroids (leiomyomas) but rarely undergoes malignant change.

Question 48

Parametrium

Answer 48

the parametrium is a fibrous fascial layer which lines the outer surface of the upper part of the cervix and separates it from the bladder. It contains the uterine artery and the ovarian ligament. The parametrium is important, as cervical cancers often spread out to invade it as they grow.

Question 49

Perimetrium

Answer 49

The perimetrium is the membranous layer of visceral peritoneum which lines the outer surface of the whole uterus, apart from a small area anteriorly where it deflects forwards to cover the bladder.

Question 50

Endometrium

Answer 50

The endometrium is the thin inner mucous membrane which lines the cavity of the uterus and is shed during the monthly menstrual period. Its high cell turnover makes it the most common site for cancers of the uterus to develop.

Question 51

The wall of the uterus has four distinct layers: what are they?

Answer 51

the endometrium, myometrium, parametrium and perimetrium (peritoneum)

Question 52

Postmenopausal bleeding (PMB)

Answer 52

is vaginal bleeding occurring after 12 months of amenorrhoea in a woman of menopausal age or who has experienced the menopause – this affects 4-11% of postmenopausal women and accounts for 5% of all gynaecology outpatient referrals

Question 53

Uterine sarcomas

Answer 53

 these are tumours arising from the myometrium and connective tissues of the uterus  this is a rare diagnosis with an aggressive clinical course and a poor prognosis  2% leiomyosarcoma  1% carcinosarcoma (aka mixed mesodermal Mullerian tumour)  <1% endometrial stromal carcinoma

Question 54

Symptoms of endometrial cancer

Answer 54

1. postmenopausal bleeding 2. in pre- or perimenopausal women (20-25% of cases), symptoms can include intermenstrual bleeding or menorrhagia 3. increased vaginal discharge 4. pyometra (a collection of pus in the uterine cavity) 5. symptoms of advanced disease include pelvic pain, pelvic mass, leg swelling, haematuria, PR bleeding, weight loss and fatigue 6. symptoms of metastatic disease

Question 55

Cervical cancer

Answer 55

Cancer of the cervix tends to affect younger women, peaking in the reproductive years. 80% of cervical cancers are squamous cell carcinoma. Adenocarcinoma is the next most common type. Very rarely there are other types, such as small cell cancer.

Question 56

Cervical cancer associations

Answer 56

Cervical cancer is strongly associated with human papillomavirus. Children aged 12 – 13 years are vaccinated against certain strains of HPV to reduce the risk of cervical cancer.

Question 57

What strains of HPV are associated with cervical cancer?

Answer 57

type 16 and 18, as they are responsible for around 70% of cervical cancers and also the strains targeted with the HPV vaccine. There is no treatment for infection with HPV. Most cases resolve spontaneously within two years, while some will persist.

Question 58

Risk factors for cervical cancer

Answer 58

> Increased risk of catching HPV > Later detection of precancerous and cancerous changes (non-engagement with screening) • Early sexual activity • Increased number of sexual partners • Sexual partners who have had more partners • Not using condoms • Smoking • HIV • Combined contraceptive pill use for more than five years • Family history

Question 59

Appearances that may suggest cervical cancer need urgent referral; what are they?

Answer 59

``` Appearances that may suggest cervical cancer are: • Ulceration • Inflammation • Bleeding • Visible tumour ```

Question 60

Cervical Intraepithelial Neoplasia

Answer 60

A grading system for the level of dysplasia (premalignant change) in the cells of the cervix. CIN is diagnosed at colposcopy (not with cervical screening)

Question 61

Cervical Intraepithelial Neoplasia grading criteria

Answer 61

1. CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment 2. CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated 3. CIN III: severe dysplasia, very likely to progress to cancer if untreated CIN III is sometimes called cervical carcinoma in situ.

Question 62

dyskaryosis

Answer 62

Dyskaryosis refers to the change of appearance in cells that cover the surface of the cervix. A smear test or cervical screening test is used to detect abnormal cells in your cervix (the entrance to your womb). Regular screening monitors changes in the cells.

Question 63

The cervical screening program involves performing a smear for women (and transgender men that still have a cervix): how often is a smear test carried out?

Answer 63

* Every three years aged 25 – 49 | * Every five years aged 50 – 64

Question 64

Vulval cancer

Answer 64

Vulval cancer is rare compared with other gynaecological cancers. Around 90% are squamous cell carcinomas. Less commonly, they can be malignant melanomas.

Question 65

Risk factors for vulval cancer

Answer 65

 Advanced age (particularly over 75 years)  Immunosuppression  Human papillomavirus (HPV) infection  Lichen sclerosis

Question 66

Vulval intraepithelial neoplasia (VIN)

Answer 66

Vulval intraepithelial neoplasia (VIN) is a premalignant condition affecting the squamous epithelium of the skin that can precede vulval cancer. VIN is similar to the premalignant condition that comes before cervical cancer (cervical intraepithelial neoplasia).

Question 67

High grade squamous intraepithelial lesion

Answer 67

High grade squamous intraepithelial lesion is a type of VIN associated with HPV infection that typically occurs in younger women aged 35 – 50 years.

Question 68

Symptoms of vulval cancer

Answer 68

```  Vulval lump  Ulceration  Bleeding  Pain  Itching  Lymphadenopathy in the groin ```