3: Gynecologic Cancers

Question 1

What are common distal sites for endometrial cancer?

Answer 1

1. Lungs
2. Inguinal and supraclavicular nodes
3. Liver
4. Bones
5. Brain
6. Vagina

Question 2

• Related to human papillomavirus (HPV) infection in most cases, and tends to occur in younger women.
• It may be associated with similar lesions of the cervix and vagina.

Answer 2

Usual-type Vulvar Intraepithelial Neoplasia (VIN)

Question 3

Risk factors for endometrial cancer.

Answer 3

1. Estrogen therapy (unopposed estrogen is a risk factor)
2. Tamoxifen use in breast cancer
3. Early menarche (<12)
4. Late menopause (52+)
5. History of infertility or nulliparity
6. Obesity
7. Chronic anovulation
8. Diabetes
9. High fat diet
10. Ovarian cancer
11. Increased age
12. Smoking (Type 2)
13. Sedentary lifestyle
14. Hx of pelvic radiation
15. Endometrial hyperplasia

Question 4

Why might high-resource countries have higher rates of endometrial cancer?

Answer 4

Higher rates of obesity and inactivity.

Question 5

T/F Once vulvar cancer spreads, in late stages, it often invades all lymph nodes.

Answer 5

False. Lymphatic spread usually occurs first in the inguinal lymph nodes, then involves the femoral lymph nodes, and finally spreads to the external iliac chain of the pelvic lymph nodes. The incidence of lymph node involvement is approximately 30%. Hematogenous spread to distant sites appears to be uncommon.

Question 6

Which 2 genetic mutations have been linked to endometrial cancer?

Answer 6

1. As many as 10% of the cases occur in women diagnosed prior to age 50 years who have the autosomal dominant syndrome known as Lynch syndrome (also called hereditary nonpolyposis colorectal cancer). Also increases risk of ovarian and colon cancers.
2. Cowden disease (also known as multiple hamartoma syndrome) is another autosomal dominant disorder and is associated with increased risk for endometrial, breast, and thyroid cancers.

Question 7

Commonly diagnosed in late stages due to vague symptoms.

Answer 7

Ovarian cancer

Question 8

This type of ovarian cancer is linked with BRCA mutations.

Answer 8

Type 2 epithelial ovarian cancer (less common than Type 1)

Question 9

• The majority are squamous cell carcinomas.
• Less common forms include malignant melanomas, adenocarcinomas, and basal cell carcinomas.

Answer 9

Vulvar cancer

Question 10

T/F Bartholin’s cysts increase risk for vulvar cancer.

Answer 10

True

Question 11

Genetic research indicates that women with differentiated-type VIN often have a genetic mutation involving the _____, which plays a key role in the carcinogenesis of vulvar cancer.

Answer 11

Genetic research indicates that women with differentiated-type VIN often have a genetic mutation involving the p53 tumor suppressor gene, which plays a key role in the carcinogenesis of vulvar cancer.

Question 12

Which ethnicities are more likely to be both diagnosed and die from cervical cancer?

Answer 12

1. African American
2. Hispanic

Question 13

Kinds include:

1. Warty
2. Basaloid
3. Mixed

Answer 13

Usual-type Vulvar Intraepithelial Neoplasia (VIN)

Question 14

Has the highest mortality rate of all gynecologic cancers.

Answer 14

Ovarian cancer

Question 15

Which type of endometrial cancer usually presents with higher grade tumors and are more aggressive?

Answer 15

Type 2 (less common than Type 1)

Question 16

What is follow up for endometrial cancer after treatment?

Answer 16

• Every 3-6 months for 2 years.
• Every 6 months for 3 years.
• Annually after that (most recurrences are found within the 1st 3 years).

Question 17

T/F Endometrial carcinoma has been linked to a genetic predisposition to develop this disease.

Answer 17

True.

Question 18

The incidence of _____ is higher in white women than in black women, but the mortality rate in black women is nearly twice as high as that in white women.

Answer 18

The incidence of endometrial cancer is higher in white women than in black women, but the mortality rate in black women is nearly twice as high as that in white women.

Question 19

Why would breastfeeding decrease the risk of ovarian cancer?

Answer 19

Suppression of the pituitary gonadotropins and ovary production of estradiol that occurs during lactation.

Question 20

It is thought that women with this condition end up with vulvar cancer because the itch-scratch cycle leads to squamous cell hyperplasia when progresses to cellular atypia and finally to invasive squamous cell carcinoma.

Answer 20

Lichen sclerosus (develops 10 years after onset of lichen sclerosus in affected women)

Question 21

This cancer has 2 types of pathology:

1. Type 1 (estrogen-dependent)
2. Type 2 (previously thought to be estrogen-independent).

Answer 21

Endometrial cancer

Question 22

• Both genetic and epigenetic changes are associated with the pathogenesis and mutations are detected more often with increasing tumor stage.
• DNA mutations are acquired over the course of an individual’s life; consequently, the risk is not inheritable.

Answer 22

Vulvar cancer

Question 23

This cancer is more prevalent in high-resource countries than low, but death is more common in low.

Answer 23

Endometrial cancer

Question 24

T/F Late age for a last pregnancy (40 years or older) has a protective effect for carcinoma of corpus uteri by further decreasing estrogen exposure just prior to menopause.

Answer 24

False. Late age for a last pregnancy (40 years or older) has a protective effect for endometrial cancer by further decreasing estrogen exposure just prior to menopause.

Question 25

If endometrial biopsy findings are inadequate or negative with ongoing symptoms of bleeding, or if the endometrial thickness as assessed by transvaginal ultrasound is greater than ____, or if a high degree of suspicion exists, the patient needs a D and C under anesthesia to exclude malignancy

Answer 25

If endometrial biopsy findings are inadequate or negative with ongoing symptoms of bleeding, or if the endometrial thickness as assessed by transvaginal ultrasound is greater than 4 mm, or if a high degree of suspicion exists, the patient needs a D and C under anesthesia to exclude malignancy.

Question 26

Usual-type VIN and differentiated-type VIN lead to this type of cancer.

Answer 26

Squamous cell vulvar cancer

Question 27

• This cancer is primarily a disease of postmenopausal women.
• 2/3 occur in women 60+.
• Older age is associated with an almost 4-fold risk for death from this cancer.

Answer 27

Vulva cancer

Question 28

Differentiated-type VIN is considered a high-grade precursor lesion for _____ and occurs primarily in older women (older than age 60).

Answer 28

Differentiated-type VIN is considered a high-grade precursor lesion for vulvar squamous cell carcinoma and occurs primarily in older women (older than age 60).

Question 29

How do you prevent vulvar cancers?

Answer 29

1. HPV vaccine
2. Smoking cessation
3. Safe sex
4. Vulvar self-exam
5. Routine gynecologic visits

Question 30

Name the 4 categories of ovarian cancer. Which is most common?

Answer 30

1. Epithelial ovarian carcinomas (most common)
2. Germ cell tumors
3. Stromal cell tumors
4. Metastatic neoplasms (most originate in GI tract)

Question 31

When should follow up occur after treatment for ovarian cancer?

Answer 31

• Every 2-4 months for 2 years.
• Every 4-6 months for 3 years.
• Annually for 5 years.

Question 32

Vulvar cancer associated with high-risk HPV types initially presents as a premalignant, usual-type VIN that is either _____ or _____ in tissue histology. The presence of usual-type VIN confers an increased risk of vulvar cancer, even though most cases do not progress to squamous cell cancer. An estimated 9% to 16% of women with untreated usual-type VIN develop invasive disease.

Answer 32

Vulvar cancer associated with high-risk HPV types initially presents as a premalignant, usual-type VIN that is either basaloid** or **warty in tissue histology. The presence of usual-type VIN confers an increased risk of vulvar cancer, even though most cases do not progress to squamous cell cancer. An estimated 9% to 16% of women with untreated usual-type VIN develop invasive disease.

Question 33

Risk factors for ovarian cancer.

Answer 33

1. Family history (1st degree relative)
2. BRCA gene mutation
3. Older age
4. Nulliparity (more ovulation cycles)
5. Short or irregular cycles
6. Late menopause
7. Lynch syndrome
8. Obesity
9. Talcum powder use
10. Smoking
11. Clomid (may increase risk of Type 1)

Question 34

• Usually diagnosed in women 65 to 75 years of age.
• Associated with vulvar dermatologic conditions such as:
  
  • Lichen sclerosus
  • Squamous cell hyperplasia
  • Paget’s disease of the vulva

Answer 34

Differentiated-type Vulvar Intraepithelial Neoplasia (VIN)

Question 35

Vulvar cancer lesions that are _____ tend to be minimally invasive, whereas _____, anaplastic lesions are more likely to be deeply invasive.

Answer 35

Vulvar cancer lesions that are well differentiated** tend to be minimally invasive, whereas **poorly differentiated, anaplastic lesions are more likely to be deeply invasive.

Question 36

Which type of VIN more commonly leads to squamous cell vulvar cancer?

Answer 36

Differentiated-type VIN

Question 37

After vulvar cancer, when should follow up occur?

Answer 37

6 and 12 months. Due to slow progression, can become annual after that if no new lesions appear.

Question 38

These strains of HPV infection confer a high risk of developing vulvar cancer.

Answer 38

1. 16
2. 18
3. 31 (and others)

Question 39

What is the characteristic metastatic spread pattern of endometrial cancer?

Answer 39

Commonly to the pelvic and para-aortic nodes.

Question 40

How does vulvar cancer differ in the presence of HPV infection?

Answer 40

They tend to be younger and present with multiple lesions.