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Gynaecological Tumours Flashcards

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1
Q

How common are vulval tumours and who do they affect the most?

A

Uncommon (approx 3% of female genital cancers)

2/3rds in women over 60

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2
Q

What are the types of vulval tumours?

A

Squamous cell carcinoma - most common
Extramammary Paget’s disease
Basal cell carcinoma
Malignant melanoma

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3
Q

Risk factors for vulval squamous cell carcinoma?

A

Same for cervical carcinomas:

  • HPV
  • intercourse
  • early marriage
  • early first pregnancy
  • multiple births
  • many partners
  • promiscuous partner
  • long term use of OCP
  • partner with carcinoma of the penis
  • low socio-economic class
  • smoking
  • immunosuppression
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4
Q

What are the usual causes of squamous cell carcinoma of the vulva in older and younger women?

A

70s - long standing inflammatory and hyperplastic conditions of the vulva eg lichen sclerosis

50s - usually HPV and risk factors same as cervical carcinoma

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5
Q

What is the precursor to squamous neoplastic lesions of the vulva?

A

Vulvar intraepithelial neoplasia (VIN)

-atypical squamous cells within the epidermis (no invasion)

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6
Q

Which lymph nodes does vulval squamous cell carcinoma spread to?

Where else?

A

Inguinal, pelvic, iliac and para-aortic lymph node

Lungs and liver

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7
Q

Survival if a lesion of vulval squamous cell carcinoma is less than 2cm?
Following which procedures?

A

90% 5 year survival

Vulvectomy and lymphadenectomy

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8
Q

Where includes gynaecological tumours?

A 
Cervix
Endometrium
Myometrium
Ovary
Vulva
Tumours of gestation
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9
Q

What are the two important viruses causing cervical carcinoma?

A

HPV 16

HPV 18

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10
Q

How do the viruses cause squamous cell carcinoma?

A

Infect immature metaplastic squamous cells in the transformation zone
Produce viral proteins which interfere with activity of tumour suppressor genes - inability to repair damaged DNA and increase proliferation of cells

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11
Q

Risk factors for CIN and cervical carcinoma?

A 
Sexual intercourse
Early first marriage
Early first pregnancy
Multiple births
Many partners
Promiscuous partner
Long term use of OCP
Partner with carcinoma of penis
Low socio-economic class
Smoking
Immunosuppression
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12
Q

Why is cervical screening so successful?

A

Cervix accessible to visual examination and sampling
Slow progression from precursor lesions to invasive cancers
Pap test detects precursor lesions and low stage cancers
Allows early diagnosis and curative therapy

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13
Q

How is the cervical screening done?

A

Cells from transformation zone are scraped off, stained with Papanicolaou stain and examined microscopically

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14
Q

When is cervical screening done?

A

Starts age 25
Every three years until 50
Every 5 years from 50-65

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15
Q

What happens if the result of cervical screening is abnormal?

A

Referred for colposcopy (visualisation of cervix) and biopsy

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16
Q

For how many years does the vaccine against HPV protect for?

A

Up to 10 years

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17
Q

What is cervical intraepithelial neoplasia?

A

Dysplasia of squamous cells within the cervical epithelium, induced by infection with high risk HPVs

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18
Q

What is dysplasia?

A

Enlargement of an organ/tissue by the proliferation of cells of an abnormal type - early stage in development of cancer

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19
Q

What are the CIN stages?

What is the outcome of each one?

A

CIN I - most regress spontaneously and a small % progress to..
CIN II
CIN III - carcinoma in situ - 10% progress to invasive carcinoma in 2-10 years, 30% regress

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20
Q

How long does it take to go from CIN I to CIN III

A

7 years

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21
Q

What is the management of each CIN stage?

A

CIN I - follow-up or cryotherapy

CIN II and III - superficial excision

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22
Q

Average age of presentation of cervical carcinoma?

A

45

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23
Q

What are the most common types of cervical carcinomas?

A

80% squamous cell carcinoma

15% adenocarcinoma

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24
Q

Where can cervical carcinoma spread to?

A

Para-cervical soft tissues, bladder, ureters, rectum, vagina

Lymph nodes - para-cervical, pelvic, para-aortic
Distally

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25
How does cervical carcinoma usually present?
Screening abnormality | Postcoital, intermenstrual or postmenopausal vaginal bleeding
26
Treatment of cervical carcinoma?
Microinvasive - cervical cone excision - 100% survival Invasive - hysterectomy, lymph node dissection, radiation and chemotherapy - 62% 10 year survival
27
What is the endometrium made up of?
Glands with a cellular stroma
28
What is the frequent precursor to endometrial carcinoma?
Endometrial hyperplasia | -increased gland to stroma ratio
29
What is endometrial hyperplasia associated with?
Annovulation Increased oestrogen from endogenous sources eg adipose tissue Exogenous oestrogen
30
How is endometrial carcinoma treated?
If complex and atypical, hysterectomy
31
What age does endometrial adenocarcinoma affect?
55-75, unusual before 40
32
Usual presentation of endometrial adenocarcinoma?
Irregular or postmenopausal vaginal bleeding
33
How common is endometrial adenocarcinoma?
Very common - most common invasive cancer of female genital tract 75% 10 year survival
34
What can endometrial carcinoma be classed as?
Polypoid or infiltrative
35
What are the two most common types of endometrial adenocarcinoma?
Endometrioid endometrial adenocarcinoma -associated with unopposed oestrigen and obesity Serous carinoma
36
Give pathophysiology of endometrioid endometrial adenocarcinoma and how it spreads
Mimics proliferative glands Arises in setting of endometrial hyperplasia Spreads by myometrial invasion and direct extension to adjacent structures - local lymph nodes and distal sites
37
Features of serous endometrial adenocarcinoma carcinoma?
Poorly differentiated, aggressive, worse prognosis
38
How does serous endometrial adenocarcinoma spread?
Exfoliates Travels through Fallopian tubes Implants on peritoneal surfaces and grows
39
What are fibroids?
Uterine leiomyoma Benign tumour of myometrium (uterine smooth muscle) Often multiple Range from tiny to massive
40
Symptoms of fibroids?
Asymptomatic Heavy/painful periods Urinary frequency due to bladder compression Infertility
41
What does uterine leiomyoma look like?
Well circumscribed, round, firm, whitish, well differentiated Bundles of smooth muscle - resembles normal myometrium
42
How common is leiomyosarcoma and who does it affect?
40-60 years | Uncommon
43
Where do uterine leiomyosarcomas usually metastasise to?
Lungs | -highly malignant
44
Are most ovarian tumours benign or malignant?
80% are benign
45
When do most benign ovarian tumours occur? | When do most malignant tumours occur?
Benign: 20-45 years Malignant: 45-65 years
46
Why is prognosis of ovarian tumours poor?
Usually spread beyond the ovary by the time of presentation - few symptoms
47
When do non-functional (don't produce hormones) ovarian tumours usually give symptoms? What symptoms do they produce?
When they become large, invade adjacent structures and metastasise Abdominal pain Abdominal distension Urinary and GI symptoms Ascites due to malignant spread through peritoneum
48
What hormonal problems can ovarian tumours cause?
Menstrual disturbances | Inappropriate sex hormones
49
Where do most malignant ovarian tumours spread to?
Regional nodes Liver and lungs 50% to other ovary
50
What is used to diagnose and monitor disease recurrence of ovarian cancer?
CA-125 | Possible future screening test
51
What are the general classifications of ovarian tumours?
``` Müllerian epithelium (including endometriosis) Germ cells (pluripotent) Sex-cord stromal cells (form the endocrine apparatus of the ovary) Metastases to the ovary ```
52
What are the three main histological types of ovarian Muüllerian epithelial tumours? What can each be classified as?
Serous Mucinous Endometrioid Benign, borderline or malignant
53
Risk factors for ovarian epithelial tumours?
Nulliparity or low parity Heritable mutations eg BRCA1&2 Smoking Endometriosis OCP protective (fewer ovulations)
54
Why are serous Mullerian epithelial ovarian tumours commonly associated with ascites?
Often spread to peritoneal surfaces and omentum
55
What do mucinous ovarian tumours usually look like?
Large, cystic masses Filled with sticky, thick, mucinous fluid Usually benign or borderline
56
Give features of Mullerian epithelial endometrioid ovarian tumours
Contain tubular glands resembling endometrial glands Can arise in endometriosis Sometimes have associated endometrial endometrioid adenocarcinoma, probably arising separately
57
What are the types of germ cell ovarian tumours?
Most are teratomas - benign Other types are malignant -non-gestational choriocarcinoma (aggressive and often fatal, produces human chorionic gonadotropin) -yolk sac (produces alpha-fetoprotein)
58
Three groups of ovarian teratomas?
Mature (benign) - most common Immature (malignant) - rare, composed of tissues resembling immature fetal tissue) Monodermal (highly specialised - one cell type)
59
Who do ovarian teratomas usually occur in?
Young women usually
60
What do teratomas often contain?
``` Cystic -hair -sebaceous material -teeth AKA dermoid cysts as they often have skin-like structures ``` Also tissue from other germ layers - cartilage - bone - thyroid - neural tissue
61
Common types of monodermal ovarian tumours?
Struma ovarii - benign - composed of mature thyroid tissue - hyperthyroidism Carcinoid - malignant - can be function producing 5HT (serotonin) and can cause carcinoid syndrome
62
Where are ovarian sex-cord stromal tumours derived from?
Ovarian stroma derived from sex cords of the embryonic gonad
63
What do sex cords normally give rise to?
Sertoli and Leydig cells in testes | Granulosa and theca cells in the ovaries
64
What can sex cord stromal tumours cause?
Feminising if from granulosa/theca cell | Masculinising if from Leydig cells
65
Who do granulosa cell tumours usually occur in?
Post-menopausal women
66
What are the signs and symptoms of granulosa cell tumours?
Produce lots of oestrogen - precocious puberty in pre-pubertal girls - adults - associated with endometrial hyperplasia, endometrial carcinoma, breast disease
67
What problems can Sertoli-Leydig cell tumours produce?
``` In children - block normal female sexual development Women - defeminisation and masculisation -breast atrophy -amenorrhoea -sterility -hair loss -hirsutism with male hair distribution -clitoral hypertrophy -voice changes ```
68
When is the peak incidence of Sertoli-Leydig cell tumours?
Teens/twenties
69
Where do metastases to the ovaries usually come from?
Mullerian tumours - uterus - Fallopian tubes - contralateral ovary - pelvic peritoneum Sometimes GI - colon - stomach - biliary tract - pancreas - appendix Breast Krukenberg tumour - drops down from stomach
70
What is gestational trophoblastic disease?
Tumours and tumour-like conditions which show proliferation of placental tissue
71
Types of gestational trophoblastic disease?
``` Hydatidiform mole (growing mass of tissue in the uterus due to abnormal conception) Invasive mole (tumorous growth associated with gestation) Choriocarcinoma ```
72
What is a hydatidiform mole?
Cystic swellings of chorionic villi and trophoblastic proliferation
73
Presentation of a hydatidiform mole?
Diagnosed in early pregnancy with ultrasound scan | Miscarriage
74
Highest risk group of hydatidiform mole?
Extremes of repro life - teens - 40-50 years
75
Types of hydatidiform mole?
complete | partial
76
What do hydatidiform moles look like?
Friable mass of thin-walled, translucent, grape-like structures = swollen oedematous villi
77
How is a hydatidiform mole treated?
Curettage followed by HCG monitoring - if HCG doesn't fall, may indicate an invasive mole (rarely happens)
78
What is an invasive mole?
Mole that penetrates or perforates uterine wall | Locally destructive - can cause uterine rupture requiring hysterectomy
79
Symptoms and signs of an invasive mole?
Vaginal bleeding and uterine enlargement | Persistently elevated HCG
80
How is an invasive mole treated?
Chemotherapy
81
What is a gestational choriocarcinoma?
Malignant neoplasm of trophoblastic cells derived from previously normal or abnormal pregnancy, with no villi present Rapidly invasive, metastasises widely but responds well to chemo
82
How can non-gestational choriocarcinomas arise?
From germ cells in the ovary or in the mediastinum
83
How does gestational choriocarcinoma present?
Vaginal spotting | High HCG levels
84
How is gestational choriocarcinoma treated?
Uterine excavation and chemotherapy | -high cure rate

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