Tumors Of The Reproductive System

Question 1

List the common breast diseases

Answer 1

Infection/Inflammation (Mastitis)

Benign lesions

Adenocarcinoma

Question 2

Describe the clinical presentation of breast conditions

Answer 2

Pain - diffuse cyclic pain is non-pathologic, non-cyclic tends to be localised

Palpable mass

Nipple discharge

Skin changes

Lumpy tissue

Question 3

What is the relationship between age and breast tumours?

Answer 3

Benign tumours tend to be in younger women (pre-menopausal) whereas older women tend to have malignant changes.

The majority of breast lumps are due to fibrocystic changes or have no underlying pathology. 10% are actually cancer

Question 4

How are breast lesions investigated and diagnosed?

Answer 4

Triple approach

Clinical - history and examination
Radiological - mammography, ultrasound
Pathology - cytology, cor biopsy

Question 5

Describe the features of benign breast changes

Answer 5

Benign changes in ducts and lobules classified as:

non-proliferative - fibrocystic changes, dense breast with cysts or fibrosis from chronic inflammation

proliferative: epithelial hyperplasia, papillomas,

atypical hyperplasia. cell hyperplasia however lack defining features of DCIS/LCIS e.g. do not fully distend the duct or lobule.

Question 6

Describe the features of benign breast tumours

Answer 6

Fibroademona:
Occurs in young women, multiple and bilateral
Spherical nodules, clearly circumscribed and freely moveable. Bulge into the surrounding tissue Proliferation of interlobular stroma distorts epithelium.

Question 7

What are the risk factors for breast cancer

Answer 7

Increasing age
Family history
Hormonal factors - early menarche, late menopause
Proliferative breast disease
Diet - High levels of fat, moderate to heavy alcohol consumption
Obesity
Ethnicity
Radiation

Question 8

Patterns of metastasis for breast cancer

Answer 8

Local: skin/muscle
Lymph nodes: axilla
Blood:bone, brain, liver, lung
Trans coelomic: pleura, peritoneal

Question 9

Briefly describe the epidemiology of breast cancer

Answer 9

Commonest tumor in women
More common in developed world (lifestyle factors)
More common in women over 50 (post menopause

Question 10

Describe the pathobiology of breast cancer

Answer 10

Earliest detectable change - loss of normal regulation of cell number resulting in epithelial hyperplasia, sclerosing adenosis and proliferative changes

Genetic instability in multiple small clonal populations (atypical hyperplasia)

Carcinoma in situ: Multiple other changes in malignancy - increased expression of oncogenes; decreased expression of tumor suppressors; alteration in cell structure

Invasive carcinoma:loss of cell-adhesion; increase in cell cycle proteins; increased angiogenesis

Question 11

Mammographic screening

Answer 11

used to detect small non-palpable asymptomatic breast cancers, effectiveness increases with age as there is atrophy of the breast tissue, ulrasound tends to be used in younger women

Question 12

Significance of the presence of oestrogen receptors in breast carcinomas?

Answer 12

Differences in patient characteristics, pathology, treatment and outcome.

Question 13

Difference betwen invasive carcinoma and carcinoma in situ (breast)

Answer 13

Carcinoma in situ refers to a neoplastic proliferation that is limited to ducts and lobules by the basement membrane.

Invasive carcinoma has penetrated through the basement membrane into the stroma

Question 14

Types of malignant breast tumours

Answer 14

Adenocarcinoma

Ductal carcinoma - hard, irregular border (spiculate mass), tubule formation, solid clusters of infiltrating cells

Lobular carcinoma - diffusely infiltrates the tissue causing a stromal reaction. Difficult to detect by palpation. Cells ararnged in single file/sheets. No tubule formation. Metastasis to GIT and peritoneumaa

Question 15

Axillary node clearance in breast cancer

Answer 15

70% of breast cancer have no metastasis

Assess the sentinel node - the first node in the tumour drainage path. If clear it is unlikely the cancer has metastasised.

Remove sentinel node it metastasis and then treat with chemotherapy.

Question 16

Management of invasive breast cancer

Answer 16

Surgery - mastectomy, breast conservation
Hormonal
Radiotherapy
Chemotherapy

Question 17

Paget’s disease of the nipple

Answer 17

Rare manifestation of breast cancer

Unilateral erythematous eruption with a scale crust. Pruritis is common, may be mistaken for eczema.
Malignant cells extend from DCIS in the ductal system into tthe nipple. Disrput epithelial barrier and fluid seeps out onto nipple surface.

Question 18

Prognostic factors for breast cancer

Answer 18

Hormone receptor status (HER-2/oestrogen receptor)
TNM staging
Grade of tumour
Histological type

Question 19

Cervical cancer

Answer 19

Presents in women aged 45-65 (bleeding or aymptomatic). 90% squamous cell at transformation zone between ecto and endocervix, 10% adenocarcinoma.

Affected by age of first sex, HPV infection, smoking.

Key prognostic factors: size, depth of invasion, node involvement

Preinvasive cancer detected by cytology (25-64).

Question 20

Endometrial cancer

Answer 20

Mean age of presentation 55 years (most postmenopausal)

Adenocarcinoma that spreads to myometrium. Caused by excessive oestrogen stimulation (obesity, PCOS, HRT, tamoxifen) or endometrial atrophy

Present with abnormal bleeding

Older patients have a worse prognosis

Question 21

Uterine fibroids

Answer 21

Benign smooth muscle leiomyoma

Causes infertility, abnormal bleeding, ectopic pregnancy, abdominal mass, urinary frequency

Sharply circumscribed, discrete, firm white tumours

Question 22

Ovarian neoplasms

Answer 22

Epithelial - arise from the surface mesothelium. Serous tumour, cystadenofibroma

Germ cell - teratoma, choriocarcinoma

Stromal - fibroma

Ovarian cancers are usually solid or papillary adenocarciomas. Spreads to peritoneum and adjacent organs, late presentation.

Question 23

Testicular neoplasms

Answer 23

Rare, 90% germ cell tumours
Occur in young-middle aged men.
Present as painlessly enlarged tetis

Seminoma - resemble primordial germ cells. prognosis related to differentiation

Teratoma - tissues of the three germ layers represented, more aggressive, prognosis related to differentiation

Question 24

Fibroadenoma

Answer 24

Benign, localised proliferation of the breast ducts and stroma

Firm, rubbery, well circumscribed

Presents as mobile lump of the breast in young women (25-30)

Question 25

Grading of breast cancer

Answer 25

Describes cytological changes

Grade 1 - tubular structure

Grade 2: disorganised glandular structure, mitoses

Grade 3: no glands, mitoses, poorly differentiated tissue, pleimorphic nuclei

Question 26

Presentation of breast tumours on examination

Answer 26

Malignant cancer - hard, irregular surface and diffuse edges

Benign - soft and flat

Depressed nipple

Eczematic change in the nipple (Pagets)

Dimple (if cancer is tethered to skin)

Oedema and orange peel appearance

Question 27

Benign breast diseases

Answer 27

Fibrocystic disease
Papilloma
Sclerosing lesions
Epithelial hyperplasia
Inflammation
Benign tumours
Developmental

Question 28

Breast carcinoma in situ

Answer 28

Ductal CIS - duct lined by large tumour cells and fibrosis, distorted acini (appear like ducts), necrosis and calcification. 1/3 become malignant

Lobular CIS - normal lobular architecture, increased size, packed with atypical cells. Risk of invasive cancer in both breasts