Squamous cell carcinoma of the cervix

The common presenting symptom is vaginal bleeding in the early stages, but advanced neglected tumours may cause urinary obstruction due to bladder involvement.

The histological type of the tumour is less important for prognosis than is the staging at diagnosis. Microinvasive carcinomas show minute foci of very

superficial invasion, only detected histologically, and have a very good prognosis after local excision. Invasive carcinomas are staged according to the degree of local invasion, and survival is related to stage. Invasion of paracervical and external iliac nodes occurs early.

Invasive carcinoma of the cervix is most commonly squamous-cell carcinoma. Invasive carcinoma of the cervix may occur at any time during the reproductive and post-menopausal years, but the average age of development is about 50 years. It accounts for 3-5% of cases of carcinoma in females.

Macroscopically, early lesions appear as areas of granular irregularity of the cervical epithelium, progressive invasion of the stroma causing abnormal hardness of the cervix. Late lesions appear as fungating, ulcerated areas, which destroy the cervix.

The vast majority of carcinomas of the cervix are squamous-cell carcinomas, arising from the transformation zone or ectocervix. Lesions fall into three histological patterns: keratinising squamous cell carcinoma, non-keratinising large-cell squamous carcinoma, and non-keratinising small-cell squamous carcinoma.

DISEASES OF THE OVARIES

Non-neoplastic cystic lesions in ovaries are extremely common, the majority arising from development of Graafian follicles, others being derived

from surface epithelium. Among the main types are mesothelial-lined inclusion cysts, which are small lesions ranging from microscopic up to 3-4 cm in diameter. They are lined by cells that are the same as those of the ovarian surface epithelium, and are filled with clear fluid.

Follicular cysts are derived from ovarian follicles and are lined by granulosa cells, with an outer coat of thecal cells. Cysts are, by definition, over 2 cm in diameter. In some cysts the thecal coat becomes luteinized.

Corpus luteum cysts are caused by failure of involution of the corpus luteum. Cysts are typically 2-3 cm in diameter, with a thick, yellow lining of luteinized granulosa cells. There is continued production of progesterone, resulting in menstrual irregularity.

Theca-lutein cysts are usually seen as multiple bilateral cysts, up to 1 cm in diameter, filled with clear fluid. They are caused by high levels of gonadotrophin, which precipitates follicle development (e.g. in hydatidiform mole and drug treatment).

Polycystic ovary syndrome (Stein-Leventhal syndrome) is a common cause of infertility.

Patients are obese, hirsute, and have acne and menstrual abnormalities (amenorrhea or irregular periods). The ovaries show thickening of the capsule, and multiple follicular cysts with stromal hyperplasia.

The pathogenesis of this syndrome is still uncertain. Patients have a persistent anovulatory state, high levels of estrogen, low levels of FSH with high levels of circulating androgen produced by the ovary. There is insulin resistance and hyperinsulinism. The high estrogen levels may cause endometrial hyperplasia and increase the risk of development of endometrial carcinoma.

It is not uncommon to see luteinizing hormone-driven ovarian hyperandrogenism, acne, anovulation, oligomenorrhea, and large, multifollicular ovaries in early to mid-puberty, arising as a self-limited maturational stage in development. However, it is not possible to tell if this is a precursor of polycystic ovary syndrome in a proportion of cases.

Tumours of the ovaries

Primary tumours of the ovary are divided into those derived from surface epithelium, those from sex-cord and stromal cells, and those from germ cells. In addition to primary tumours, the ovary is frequently involved in metastatic disease from other sites. Malignant tumours of ovary spread locally and particularly seed to peritoneum, when ascites is an important complication.

Epithelial tumours of the ovary can differentiate into several types.

1. Endocervical differentiation: mucinous ovarian tumours.

2. Tubal differentiation: serous ovarian tumours.

3. Endometrial differentiation: endometrioid and clear-cell ovarian tumours.

4. Transitional differentiation: Brenner tumours. In histological assessment of epithelial tumours

of the ovary, it can be difficult to decide which lesions are benign and which are malignant. In between those tumours that are obviously benign or malignant are some cases in which there are histological features of atypical cells and abnormal tissue architecture, but no evidence of invasion. Such lesions are termed «tumours of borderline malignant potential)). Most borderline tumours behave in a benign fashion, the remainder behaving as low-grade malignant tumours.

Serous tumours of the ovary contain watery fluid and are often bilateral.

Benign serous tumours of the ovary are termed «serous cystadenomas». These thin-walled, unilocular cysts contain watery fluid and are bilateral in about 10% of cases. Microscopically, they are lined by a cuboidal, regular epithelium in which small papillary projections may be seen. A related tumour, termed an adenofibroma, is a benign, sometimes solid and sometimes cystic (cystadenofibroma) tumour, composed of benign serous epithelium and spindle-cell stroma.

Malignant serous tumours of the ovary are termed «serous cystadenocarcinomas». These are the most common form of ovarian carcinoma and are bilateral in about half of all cases. Macroscopically, tumours may be cystic, mixed solid and cystic, or largely solid in appearance. Histologically they are composed of cystic cavities lined by columnar and cuboidal cells, with papillary proliferations of cells and solid areas. Cells are pleomorphic and mitoses are seen. Importantly, invasion of the ovarian stroma does occur, confirming the malignant character. These lesions are associated with an overall 20% five-year survival.

Borderline serous tumours of the ovary are bilateral in about 30% of cases. Macroscopically, tumours may be cystic, or mixed solid and cystic. Histologically they are composed of cystic cavities lined by columnar and cuboidal cells, with papillary proliferation of cells and solid areas. Cells are pleomorphic and mitoses are seen. However, invasion of the ovarian stroma does not occur, despite the presence of cellular atypia. These lesions are associated with an overall 75% ten-year survival.