Other Cancers - Gynaecology

Other Cancers

Ovarian cancer

·        Risk factors: nulliparity, infertility, early menarche, family history, no past pill use

·        Presentation:

o   75% asymptomatic until advanced

o   Swelling with palpable mass

o   Pressure effects (eg on bladder)

o   Infarction, haemorrhage, peritonism

o   Ascites

o   Torsion

o   Endocrine: virilisation, menstrual irregularity, PMB

·        Lower incidence than endometrial cancer, but higher death rate due to late presentation

·        5 Yearly survival ~ 30 – 35% (varies from 80 – 100% for FIGO I to 5 – 10% for FIGO IIIC/IV)

·        Types:

o   Epithelium: 70% 

§  Benign (60%): younger – serous cystadenoma, mucinous cystadenoma. If cysts have smooth internal epithelium likely to be benign 

§  Borderline (20%): mucinous tumour of borderline malignancy. 6% recurrence (but still treatable) so need long term follow-up

§  Malignant (20%): serous cystadenocarcinoma

o   Ovum:  20%

§  Dermoid cyst (teratoma)

§  Occur in children and young women, in contrast to epithelial tumours

§  Commonest is benign, but in young children they are often malignant

§  Micro: variety of mature cell types: skin, gut, neural tissue, etc

o   Others: 5%

§  Stroma: lymphoma, fibroma 

§  Granulosa cell tumour ® ­oestrogen ® amenorrhoea and breakthrough bleeding

§  Thecal cell tumour ® ­androgen ® infertile, hirsutism, amenorrhoea

·        Investigations: Ca125, FBC, electrolytes, LFTs, US + CT (for mets or possible primary elsewhere) 

·        Should identify and screen those with high risk – those with genetic tendency (ie BRAC1, BRAC2, HPNNC). If family history then screen with US plus CA125 – more informative together. NB ­ lead time bias 

·        Treatment: Surgery for staging +/- debulking, chemo (usually platinum)

·        Other ovarian cysts:

o   Present with mass effects of torsion:

§  Follicular cyst

§  Corpus luteum cyst

o   Polycystic ovaries

o   Endometriosis

Endometrial Neoplasia

·        Most common gynaecological cancer, but early presentation ® better prognosis

·        Endometrial hyperplasia: 

o   Simple hyperplasia: cystic glands with pseudostratified mitotically active cells. No atypia, minimal risk of carcinoma 

o   Complex hyperplasia: More crowded gland with budding and infolding. With atypia, 5% progress to carcinoma

o   Complex hyperplasia with atypia: crowded, folded gland in which the lining cells are pleomorphic with loss of polarity and increased nuclear cytoplasmic ratio. > 25% progress to carcinoma

·        Endometrial polyps:

o  Most are hyperplastic polyps

o  Often seen with generalised hyperplasia

o  Due to an area responding to oestrogen but resistant to progesterone

o  Micro: a polypoid collection of cystic hyperplastic glands in a fibrotic stroma

·        Endometrial Cancer:

o  Presentation: irregular PV bleeding, often post menopausal 

o  Risk factors: obesity, nulliparity, diabetes, unopposed oestrogen therapy, pelvic irradiation, endogenous unopposed oestrogen (functioning ovarian tumour, anovulatory cycles, fat), family history for breast, ovarian or colon cancer 

o  Peak age 55 - 60

o  Investigate endometrial thickness with trans-cervical ultrasound:

§  Reproductive endometrium: 0.5 – 1.5 cm 

§  Menopausal endometrium: < 5 mm. If bleeding, repeat US in 4 – 6 months and look for change 

§  If menopausal and 5 – 9mm, do endometrial sample. 90% are normal proliferative endometrium. 5% are atypical (pre-cancerous), 5% are carcinoma 

§  If > 9 mm, straight to D&C to get good endometrial sample (high suspicion of cancer). Not hysteroscopy (can force malignant cells into the peritoneum)

o  Macro: fungating mass in the fundus

o  Micro: adenocarcinoma

o  Treatment: hysterectomy and oophorectomy + chemo and radiotherapy

o  Prognosis:

§  Stage 1: invade wall, 90% 5 year survival

§  Stage 2: invade cervix, 50% 5 year survival

§  Stage 3: lymph nodes, 20% 5 year survival