Where can gynaecological tumours arise?
- Cervix (neck of uterus)
- Endometrium (lining of uterus)
- Myometrium (body of uterus)
What are the clinical features of vulval tumours?
- Approx. 2/3rds occur > 60 years of age
- Usually squamous cell carcinoma
How many vulval squamous neoplastic lesions are related to HPV infection?
- 30% HPV-related (6th decade) – risk factors the same as for cervical carcinoma
- 70% HPV-related (8th decade) – often occur in longstanding inflammatory and hyperplastic conditions of the vulva e.g. lichen sclerosis
What is vulvar intraepithelial neoplasia?
- Vulvar intraepithelial neoplasia involves atypical squamous cells within the epidermis (no invasion)
- It is an in situ precursor of vulval squamous cell carcinoma
How does vulval squamous cell carcinoma spread?
- Spreads initially to inguinal, pelvic, iliac and para-aortic lymph nodes
- Thereafter spreads to lungs and liver
Almost all cases of CIN and cervical carcinoma are related to high risk HPVs.
How does an HPV infection lead to these conditions?
⇒ Infects immature metaplastic squamous cells in transformation zone
⇒ Produces viral proteins E6 & E7 which interfere with activity of TSGs to cause inability to repair damaged DNA and increase cell proliferation
What are the risk factors for CIN and cervical carcinoma?
- Early first sexual intercourse
- Early first marriage/pregnancy
- Multiple births
- Sexual promiscuity
- Immunosuppression (cannot clear HPV infection)
Why is cervical screening successful?
- Cervix accessible to visual examination (colposcopy) and sampling
- Slow progression from precursor lesions → invasive cancers (years)
- Pap test detects precursor lesions and low stage cancers
- Allows early diagnosis and curative therapy
What does cervical screening involve?
- Cells from the transformation zone are scraped off
- Cells are stained with Pap stain
- Cells are examined microscopically
- Cervical cells can be tested for HPV DNA
In cervical screening, abnormalities are referred for colposcopy and biopsy.
What sort of abnormalities could be seen?
- Increased nuclear:cytoplasmic
- Irregular nuclear outlines
- Hyperchromatic nuclei
What are the advantages of vaccinating men against HPV too?
- Reduce risk of oral and penile cancer
- Reduce risk of transmission of HPV
- Protect girls who cannot be vaccinated (herd immunity)
What is Cervical Intraepithelial Neoplasia?
- CIN is a dysplasia of squamous cells within the cervical epithelium, induced by infection with high risk HPVs
- Three stages: CN I mostly regresses spontaneously, some progress to CN II (in situ carcinoma) and 10% may progress to an invasive carcinoma (CN III – 2-10 years)
What is the treatment for CIN?
- CIN I – follow-up or cryotherapy
- CIN II & CIN III – superficial excision (LLETZ – large loop excision of transformation zone)
What are the different types of invasive cervical carcinomas?
- 80% – squamous cell carcinomas
- 15% – adenocarcinomas (also caused by high risk HPVs)
Which age group is usually affected by invasive cervical carcinoma?
Average age = 45 years
What do invasive cervical carcinomas look like?
Exophytic (external) or infiltrative (stromal invasion through basement membrane)
Identify the three ways in which invasive cervical carcinomas spread
- Locally to para-cervical soft tissues, bladder, ureters, rectum, vagina
- Lymphatic system to para-cervical, pelvic, para-aortic nodes
How does cervical carcinoma present?
- Screening abnormality
- Postcoital, intermenstrual or postmenopausal vaginal bleeding
How are cervical carcinomas treated?
- Microinvasive carcinomas: cervical cone excision
- Invasive carcinomas: hysterectomy, lymph node dissection and radiation and chemotherapy (if advanced)
Describe the structure and location of the endometrium
- Location: lines internal cavity of uterus
- Structure: glands are within a cellular stroma
Why is endometrial hyperplasia a frequent precursor to endometrial carcinoma?
- Increased gland:stroma ratio
- Associated with prolonged oestrogenic stimulation:
II. Increased oestrogen from endogenous sources (e.g. adipose tissue)
III. Exogenous oestrogen
What are the clinical features of endometrial adenocarcinoma?
- Most common invasive cancer of the female genital tract
- Usual age: 55-75 years
- Presents with irregular or postmenopausal vaginal bleeding
What do endometrial adenocarcinomas look like?
Polypoid or infiltrative
Identify the two types of endometrial adenocarcinoma
- Endometrioid endometrial adenocarcinoma
- Serous carcinoma
What are the clinical features of endometrioid endometrial adenocarcinoma?
- More common
- Mimics proliferative glands
- Arises due to endometrial hyperplasia
- Spreads by myometrial invasion to local lymph nodes and distant sites
- Associated with unopposed oestrogen and obesity
How do endometrioid endometrial adenocarcinoma look?
What are the clinical features of serous carcinoma (endometrial adenocarcinoma)?
- Poorly differentiated
- Exfoliates, travels through oviducts and implants on peritoneal surfaces
What is the commonest tumour of the myometrium?
- Leiomyoma – benign tumour of myometrium (fibroid)
- Probably most common tumour in women
What are the clinical features of a leiomyoma?
- Often multiple
- Range from tiny → massive
- Asymptomatic or heavy/painful periods, urinary frequency, infertility
- Malignant transformation rare
What does a uterine leiomyoma look like?
- Well circumscribed, round, firm and whitish in colour
- Bundles of smooth muscle (resembles normal myometrium)