1,2,3,4 Cancer--cervical, endometrial, ovarian Flashcards
Teratoma:
- difference between male and female
- Tx for female
- Male: malignant
Female: usu benign
- Cystectomy. Don’t remove an ovary since it can recur on the other side, and removing 2 ovaries does not allow girl to undergo puberty and have kids.
Your postmenopausal patient comes to clinic with vaginal bleeding. What are next steps/possible results/tx?
Suspect endometrial CA, although vaginal atrophy more likely.
Do endometrial sampling or D&C to get endometrial bx.
Possible results:
- Negative: vaginal atrophy. Tx with creams.
- Simple hyperplasia (not atypical): Precancer. Use Progesterone to protect from estrogen.
- Adenocarcinoma or Atypical hyperplasia: Cancer/advanced precancer. Do TAH/BSO. BSO removes estrogen source.
If there are Mets, add chemo.
cancer Screening main guidelines:
- colonoscopy
- mammograms
- pap smears
- age 50, then q10 y
- age 40, then q1 y
- age 21, then q3 (if all normal, stop screening at 65)
How does endometrial CA present in a reproductive-aged female?
Dysmenorrhea, menometrorrhagia
Cervical CA
What do stages mean?
1, 2a, 2b, 3a, 3b, 4a, 4b
stage 1: cervix only
2a: upper 1/3 vagina
3a: all of vagina
2b: spread to cardinal ligament
3b: spread to cardinal lig and pelvic sidewall
4a: bowel/bladder
4b: distant mets
- A pregnant woman is discovered to have cervical dysplasia after a routine Pap smear. Do/don’t do what?
Don’t do a cone biopsy during the pregnancy (can cause cervical insufficiency). You can wait until after pregnancy since it takes 3-7 years for precancer to become cancer.
You can still do a LEEP/cryo during pregnancy.
Ovarian CA, epithelial
- presenting symptoms to be aware of (3)
- what stage does it normally present
Remains asx while seeding peritoneally. Eventually, can present at Stage 3 with:
- Renal failure
- SBO
- Ascites
Ovarian CA:
3 main categories
- Epithelial–postmenopausal female
- Germ cell–teenage girl
- Stromal tumors–sertoli leydig, granulosa-theca
Describe Cervical CA screening.
- what changes at what years?
- what if pt is immunocompromised?
Start at age 21, then q3 years.
Age 21-29: q3 y
30-65: q3 or q5 Pap+ HPV testing
>65: can stop if no abnormal screens before
Immunocompromised: start Paps at onset of sex, even if <21
Why would a cervical cancer lesion be missed on pelvic exam?
The lesion may be an endocervical carcinoma (vs ectocervical carcinoma that can be seen).
Endometrial CA:
3 main risk factors
increased estrogen exposure
- nulliparity (estrogen shuts off during pregnancy)
- early menarche/late menopause
- obesity (peripheral conversion of estrogen)
BRCA 1/2 patients:
- increased risk of what GYN cancer? Which BRCA higher risk?
- how to screen
- how to ppx
- ovarian CA, epithelial. Increased incidence and also at younger age. Risk: BRCA 1>2
- CA-125 and transvag U/S, q1 year
- BSO at age 35.
Screening Pap smear results come back as abnormal. What does that mean, and what are the next steps and final treatments?
- Abnormal means any result that is not normal or ASCUS (atypical squamous cells of undetermined significance)
- Do Colposcopy to get 2 samples: ectocervical bx and endocervical curettage.
If ecto + and endo -, problem is on the outside. Do local destruction (LEEP, Cryo)
If ecto - and endo +, problem is in endocervix. Do cone biopsy (curative).
Endometrial CA:
-4 patient types/presentations to know:
- Fat and old (obese, postmenopausal), presenting with postmenopausal bleeding–most common pt. She now has loss of progesterone after menopause, but still estrogen from fat
- Thin and old, on hormone replacement. She’s taking SERM (eg Tamoxifen for breast CA), increasing risk for endometrial CA
- Young, with PCOS. Anovulation increases estrogen and prevents progesterone secretion.
- Granulosa-thecal cell tumor (secretes estrogen)–Rare
HPV types:
- high risk
- genital warts
- Which ones does Gardasil cover
- How about the new FDA approved Gardasil 9?
16,18,31,33
6,11
Gardasil: 6,11,16,18
New Gardasil 9: 6,11,16,18,31,33,45,52,58
Cervical cancer:
- classic presentation
- Mass is identified on exam and confirmed by bx to be cervical CA. How to stage?
- post coital bleeding, in repro aged female
- Cervical CA is the only cancer that is clinically staged rather than surgically. The further down the mass is on the vagina, the higher the grade.
(Stage 2a is upper 1/3 of vagina, stage 3a is all of vagina)
You can also use CT to stage.
Markers of what cancers?
AFP, B-HCG, LDH
Germ cell ovarian CAs:
AFP: yolk sac
B-HCG: choriocarcinoma
LDH: Dysgerminoma
Screening Pap smear comes back as “ASCUS”
what does that mean, and do what next?
“atypical squamous cells of undetermined significance”
-So, results not ‘normal’ but not ‘abnormal.’ CIN I counts as ASCUS. Don’t do Colpo b/c unecessary damage to cervix with biopsies.
2 choices:
- repeat Pap in 3 months. If persistence of ASCUS, treat as abnormal Pap and do Colpo.
- Test for HPV DNA to look for high risk HPV. If high risk, treat as abnormal Pap (do Colpo)
Cancer epidemiology: What are the top 3 of:
- mortality of GYN cancers
- incidence of GYN cancers
- mortality of all cancers for women
- incidence of all cancers for women
Descending order:
- Ovarian, Endometrial, Cervical
- Endometrial, Cervical, Ovarian
- Lung, Breast, Colon
- Breast, Lung, Colon
Ovarian CA, germ cell
Name subtypes (4) and their markers
- Dysgerminoma (analogous to seminoma)–LDH
- Yolk sac (endodermal sinus)–AFP
- Choriocarcinoma–B-HCG
- Choriocarcinoma– no marker
Your pt presents with an adnexal mass on palpation, and no symptoms. What are next steps?
Transvaginal U/S: you’ll see simple vs complex cyst.
If simple cyst (no septations, smooth), conservative tx. Not cancer.
If complex cyst (septations, cystic), suspect CA. If young, suspect germ cell CA, do cystectomy.
Ovarian CA, epithelial
Risk factors, genetic and nongenetic
Increased ovulations over lifetime.
- low parity/nulliparity
- early menarche/late menopause
Genetic: HNPCC, BRCA 1/2
Stage 3 Ovarian CA, epithelial
- how to confirm and stage?
- Tx
- Use U/S and CT to confirm dx and stage.
- Tx: Debulking surgery (TAH-BSO) + chemo (paclitaxel)
Your postmenopausal female patient presents with ascites, but has no liver disease. Think what?
Think ovarian CA
