What are vulval cancers?
Uncommon
Over 80yrs old
Over 90% are squamous cell carcinoma
Also melanoma and Basal cell carcinoma
Present as: Lumps, ulcers, skin changes
What is VIN?
Vulval Intraepithelial Neoplasia
- In situ precursor of vulval squamous cell carcinoma
- -May or may not develop into SCC (squamous cell carcinoma)
- Atypical squamous cells
- Confined to epidermis
- No invasions of basement membrane
Are VIN and vulval SCC related to HPV?
Depends on case
30% cases - YES
- Usually HPV 16
- 60s -onset
- Risk factors same as cervical carcinoma
- Expose to HPV
- Ealry first pregnancy
- Multiple births
- Smoking
70% cases - NO
- Usually associated with longstanding inflammatory conditions (e.g. Lichen sclerosus)
- 80s -onset
How does vulval cancer spread?
Direct extension
- Anus
- Vagina
- Bladder
Lymph nodes
- Inguinal
- Iliac
- Para-aortic
Distant metastases
- Lungs
- Liver
What cells line the cervix and how does this change?
Transformation Zone:
Premenarchal: Endocervix (between internal and external os) is made from columnar epithelium and ectocervix is made from squamous epithelium.
Early reproductive age: Cervix everts under the influence of oestrogen (so the simple squamous becomes simple columnar). This means that the simple columnaris exposed to low vaginal pH. The low pH causes inflammation = ectropian.
Women in her 30s: Simple columnar epithelium undergoes metaplasia into stratified squamous to adapt to low pH. This metaplasia means there is an increases risk of dysplasia.
What is HPV?
DNA virus that can be sexually transmitted.
Many subtypes
- HPV 6&11 = anogenital warts
- HPV 16&18 = high risk subtypes
- Infects trnasformation zone
- Produces viral proteins E6 and E7
- These inactivate tumour suppressor genes (P53 and Rb)
- Results in uncontrolled cell growth and proliferation
What is CIN?
Cervical intraepithelial neoplasia
- Dysplasia
- Confined to cervical epithelium (in situ)
- Caused by HPV infection (95%)
- Divided into CIN 1,2,3
- Increasing thickness of dysplasia
- Increasing risk of progression to invasive squamous cell carcinoma.
What are the risk factors for CIN and 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 class
- Immunosuppression
How does the cervical cancer screeing program work?
Brush used to scrape cells from the transformation zone - send for cytological assessment.
Significant reduction in rates of cervical caner
- Aged 25-49 = every 3 years
- Aged 50-64 = eveyr 5 yeats
- 65+ - Only if recent abnormality
Discuss the HPV vaccine
Gardasil
- Vaccination against high risk HPV subtypes (6,11,16,18)
- Given aged 12-13
- Pretection from - cervical, vulval, oral and anal cancer
- Not given to men (controvercial)
- HPV> in penile, anal and oral cancers
- Men are carriers for HPV
- Screening has reduced rates of invasive cervical cancer
WHat is invasive cervical cancer and how do patients present?
- Most commonly invasive squamous cell carcinoma (Precursor = CIN)
- Also adenocarcinoma (arise from endocervical glandular mucosa)
- Presentation:
- Post-coital, inter-menstrual, post-monopausal bleeding
- Mass - exophytic and infiltrative
- Screening
How does cervical cancer spread?
..
How do you treat cervical cancer?
If advanced:
- Hysterectomy
- Lymph node dissection
- Chemoradiotherapy
What is Endometrial hyperplasia and what causes it?
Thickened endometrium - >11cm
Can be a precursor to endometrial cancer
Inter-menstrual / post-menopausal bleeding.
Caused by excessive oestrogen:
- Endogenous
- Obeisity
- Early Menarchy / late menopause
- Oestrogen secreting tumours (granulosa cell tumours)
- Exogenous
- Unopposed oestrogen - HRT
- Tamoxifen (partial agonist in endometrium)
- Irregular cycles
- PCOS
Hw does endometrial cancer present?
- Intermenstrual bleeding
- Postmenopausal bleeding
- Mass
What are the types of endometrial cancer?
- Endometrioid adenoarcinoma
- Mostcommon
- Resemble normal endometrial glands
- Commonly arises from endometrial hyperplasia
- Serous Carcinoma
- Less common
- More aggressive
- Poorly differentiated cells
How do endometrioid cancers spread?
..
How do serous carcinoma’s spread?
- Exfoliates
- Travels through Fallopian tubes
- Deposits on peritoneal surface
- Associated with collections of calcium (Psammoma bodies)
How do you manage invasive endometrial cancer?
- Hysterectomy
- Bilateral salpingo-oophrectomy
- +/- lymph node dissection
- +/- chemoradiotherapy
What tumours can o get in myometrium?
Leiomyoma
Leiomyosarcoma
What is a leiomyoma?
- Most common tumour of myometrium
- Benign
- Pale, homogenous, well circumscribed mass
How does a leiomyoma present?
- Asymptomatic
- Pelvic pain
- Heavy periods
- Urinary frequency (bladder compression)
What is a leiomyosarcoma?
- Malignant tumour of smooth muscle
- Cellsare bizarre and atypical
- Doesn’t arise from a leiomyoma
- Metastases to lung common
How does an ovarian cancer present?
Early - vague, non-specific symptoms (leads to a delayed diagnosis)
Later - Abdominal pain, abdominal distention, urinary symptoms, GI symptoms, hormonal disturbances
How can you hep diagnose ovarian cancer?
Ca-125 - a serum marker used in diagnosis and monitoring for recurrence
BRACA1/2 - High grade serous cancers, prophylactic salpingo-oophrectomy
What are the normal places in ovaries cancer comes from?
Epithelial lining on outside
Follicles - germ cells
Stromal cells
Also metastasis to the ovary
What are the subtypes of ovarian tumours?
Often presetn as cystic masses
Histological subtypes:
- Serous
- Mucinous
- Endometrioid
Can all be:
- Benign
- Borderline (increased atypia, no stromal invasion)
- Malignant
What are ovarian serous tumours?
Highly atypical. pleomorphic cells.
Often show psammoma bodes (Ca collections)
Often spread to the peritoneal surface
What are ovarian mucinous tumours?
Secrete mucin
Atypical epithelial cells
What are ovarain endometrioid tumours?
- Glands resembling endometrium
- May arise in endometriosis
- May have synchronous endometrial endometrioid adenocarcinoma
What are the subtypes of a teratoma?
Teratoma is the most common germ cell tumour:
- Mature (benign)
- Immature (malignant)
- Monodermal (highly specialised)
What is a mature teratoma?
Dermoid cyst
Contain fully, mature, differentiate tissue from all germ cell layers
Can be bilateral
Often contains skin and hair structures
What is an immature teratoma?
- Contains immature, embryonic tissue
- Malignant
What is a monodermal teratoma?
A teratoma comprised entirely of one fully differentiated tissue type.
Most common = thyroid tissue (Struma Ovarii)
Benign
Can also cause hypo/hyperthyroidism
What other germ cell tumours are there?
- Dysgerminoma (equivalent of seminoma in testes)
- Choriocarcinoma
- Embryonal carcinoma
- Yolk sac tumour
What are sex cord stromal tumours?
From ovarian derived stroma
- Stroma derived from sex cord of embryonic gonad
- Sex cord produces:
- Sertoli and Leydig cells in the testes
- Granlosa and Theca cells in the ovaries
- Tumours resembling all these cell types can arise in the ovary.
What hormone do theca and granulosa cell tumours produce, therefore what does this predispose to?
Produce oestrogen
- Pre puberty
- Precocious puberty
- Adult
- Breast cancer
- Endometrial hyperplasia
- Endometrial carcinoma
What hormone do sertoli-Leydig tumours produce, what can this lead to?
Prodice testosterone
- Pre-puberty
- Prevent normal, female pubertal changes
- Adult
- Sterility
- Amenorrhoea
- Hirsuitism
- Male pattern baldness
- Breast atrophy
What cancers commonly metastasis to the ovary?
- Breast Cancer
- Gastro-intestinal cancers
- Colon
- Stomach
- Biliary tract
- Appendix
- Krukenberg tumour
- Metastatis GI tumour
- Often gastric
- Signet cells
- Other gynae tumours
- Endometrial
- Other ovary
- Fallopiaan tube
What are the risk factors, presentation and investigations done for testicular cancer?
Risk factor: Cryptorchidism
Presentation: Mass +/- pain
Investigations: Scans (USS), Tumour markers
What are the subtypes of testicular cancer?
Different histological subtypes are often mixed in the same tumour
What are the testicular cancer tumour markers?
Germ cell tumours
B hCG -Choriocarcinoma
AFP -Yolk Sac tumours
Tumours may be benign / malignant depending on age of patient.