Cancro gineco

Question 1

Hiperplasia endometrio

Answer 1

• Proliferation of endometrial glands resulting in a greater gland-to-stroma ratio (>50%) than observed in normal proliferative endometrium.
• Results from chronic estrogen stimulation unopposed by the counterbalancing effects of progesterone

Question 2

Class hiperplasia

Answer 2

• Two main classification systems for endometrial hyperplasia (EH): the 2015 World Health Organization (WHO) system and the endometrial intraepithelial neoplasia system
• The 2015 WHO endometrial hyperplasia classification system is more widely used and has only two categories
  o Hyperplasia without atypia (non-neoplastic change)
  o Atypical hyperplasia (endometrial intraepithelial neoplasm)
• Endometrial intraepithelial neoplasia (EIN) classification: was proposed in 2000 but has not gained widespread acceptance, most likely due to cost and/or lack of experience with the computerized D-scoring component (measure of stromal volume as a proportion of total tissue volume).
  o Defines two classes of endometrial changes: benign and intraepithelial neoplasia.

Question 3

Epidemio hiperplasia endometrio

Answer 3

• incidence: 133 / 100 000 ♀/year.
• Rare in ♀ under 30 y. Diagnosis is most frequent in ♀ages 50-65y
• The rate of atypical hyperplasia is highest in ♀ages 60 to 64y.
• Risk of endometrial carcinoma: ♀with neoplastic (or atypical) EH may have coexistent endometrial carcinoma or may progress to carcinoma
• Coexistent carcinoma: A literature review including 2572 patients reported that 37% of women with a diagnosis of atypical EH had carcinoma
• Risk factors for EH are similar to those for endometrial carcinoma

Question 4

Dx hiperplasia endometrio

Answer 4

• Clinica:
  o typically presents with abnormal uterine bleeding (AUB). Occasionally, ♀with no AUB present with abnormal findings on cervical cytology or pelvic ultrasound
  o astenia, fatige, palpitations…
  o Physical examination: pallor, tachycardia…
  o Lab.: anemia (iron deficiency)

o Assintomatico: abnormal CitologiaCervical: adenocarcinoma, AGC, presence of endometrial cells in simptomatic or high risk ♀; Eco anormal

• Avaliação endométrio -> Is the key component in the diagnostic evaluation of women with suspicion of any endometrial pathology so we can exclude or diagnose cancer or a premalignant endometrial lesion.
  o Método invasivo- Biopsia endometrio, Dilatação e curetagem, Histeroscopia (An endometrial sampling procedure is the gold standard for diagnostic evaluation of ♀ with AUB in whom endometrial hyperplasia or carcinoma is a possibility)

o Método não invasivo - Eco pelvica/ Histerosonografia (For ♀ with suspected endometrial pathology, pelvic sonography is the first-line imaging study. It may be complemented by sonohysterography; evaluates endometrial features and other possible etiologies of abnormal uterine bleeding (eg, uterine leiomyomas).

Nota: Eco -> (Asymptomatic) Abnormal endometrial thickening post-menopausal: > 4mm -
pre-menopausal: no established cut-off

Question 5

TX hiperplasia endometrio

Answer 5

• The choice of treatment is based primarily upon two factors:
  o atipia nuclear
  o Desejo de fertilidade
• Hysterectomy / Hormonal therapy / Surveillance with serial endometrial sampling
• HYPERPLASIA WITHOUT ATYPIA: low dose progestin. The goal of treatment is to prevent progression to cancer in a small number of women and to control abnormal uterine bleeding
• ATYPICAL HYPERPLASIA: hysterectomy is the treatment of choice for women who are not planning future pregnancy. Progestin therapy with repeated endometrial biopsy is an option only for women who wish to preserve fertility or who cannot tolerate surgery

Question 6

Epidemio cancro

Answer 6

• Cancer mortality has increased in the last years; 2010 mortality rate: 182,6/100 000 women
• According to WHO, it is estimated an increase of 12,6% new cases in the present decade.
• Cancro é a 2ª causa de morte na mulher (CV 1º)
• Aum mortalidade do cancro
• Cancro endometrio + freq
• Cancro ovario + mortifero
• Prevenção do cancro colo

Question 7

Cancro colo útero epidemio

Answer 7

• The most frequent gynecological cancer worldwide (HPV em quase todos os casos)
• The fourth most common cancer in women worldwide
• High geographical variation
• Baixa incidência e mortalidade -> rastreio e vacina
• Em PT maior incidência sul e menor no Norte

Question 8

• FPat Cancro colo

Answer 8

• HPV is virtually the cause of all cases of cervical neoplasia and it has been detected in 99.7% of cervical cancers.
• Of over 100 HPV genotypes, >40 can infect the anogenital epithelium and between 15 to 20 are oncogenic.
• Afeta cervix, orofaringe, anus, vulva, vagina,pénis -> em paises desenvolvidos cervix 65%, nos menos desenvolvidos cervix 93%
• High-risk (oncogenic or cancer associated) types:
  o 16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 73, 82
• Low-risk (non-oncogenic) types (condilomas e verrugas):
  o Common types: 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81
• Genital tract HPV infection is extremely common but results in cervical cancer in only a small proportion of infected women. HPV = STD; ~ 75-80% of sexually active adults will acquire genital tract HPV before the age of 50.
• Most HPV infections are transient, and the virus alone is not sufficient to cause cervical neoplasia -> When HPV infection persists, the time from initial infection to development of high grade cervical intraepithelial neoplasia and, finally, invasive cancer takes an average of 15 years, although more rapid courses have been reported.
• Ectocervix - surface of the cervix that protrudes into the vagina; squamous epithelium.
• Endocervix - cervical canal; columnar (glandular) epithelium
• Transformation zone - area of immature metaplasia between the original and the current squamocolumnar junction -> Physiologic metaplasia - Celular instability

Question 9

Fases desenvolvimento cancro colo

Answer 9

1. Oncogenic HPV infection of the metaplastic epithelium at the cervical transformation zone.
2. Persistence of the HPV infection.
3. Progression of a clone of epithelial cells from persistent viral infection to a precancerous lesion.
4. Development of carcinoma and invasion through the basement membrane.

• ONCOPROTEINS E6 and E7 prod pelo virus- HPV e co-carcinogenese (The two most important HPV proteins in the pathogenesis of cervical cancer are E6 and E7. They interact with p53 and retinoblastoma (Rb), respectively, in a cooperative manner in order to immortalize epithelial cells.)

Question 10

FR Cancro colo

Answer 10

1. Early onset of sexual activity.
2. Multiple sexual partners – Compared with one partner, the risk is approximately 2x with two partners and 3x with six or more partners.
3. A high-risk sexual partner (eg, a partner with multiple sexual partners or known HPV infection).
4. History of sexually transmitted infections (eg, Chlamydia trachomatis, genital herpes).
5. Immunosuppression (eg, human immunodeficiency virus infection or therapeutic).
6. Multiple pregnancies.
7. Smoking is an important cofactor. 2x the risk in women with chronic HPV infections.

Question 11

Prevenção cancro cervical

Answer 11

• Primaria e secundaria
• Vacina e rastreio
• The incidence and mortality rates are related to the presence of screening and HPV vaccination programs
• Cervical cancer screening detects precancerous lesions and early stage desease which treatment decreases the incidence of cervical cancer and cervical cancer mortality, respectively.
• HPV vaccination is effective in preventing cervical disease, including cervical intraepithelial neoplasia (CIN2 or 3) and adenocarcinoma in situ
• Vacina-
  o 9-valente - targets HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58 (National Vaccination Program)
  o bivalente - HPV types 16 and 18
• Raparigas entre 10-13, <18 tem de começar o programa, <25 podem completar o programa (2ª e/ou 3ª dose)
• se começou 10-13 (2 doses 0,6M), se começou apos 13 anos (3 doses, 0,2,6M ou 0,1,4 M)
• Rastreio
  o Cervical cytology (Pap test)/HPV test/Cervical cytology + HPV test
  o ♀< 30y: Cervical cytology alone at intervals of every three years (Women age <30 years should not be screened with HPV testing (primary or co-testing). In such women, who are more likely to have transient HPV infections, the poor specificity and correspondingly poor positive predictive value limits the usefulness of HPV testing as a screening modality.)
  o ♀≥ 30A: HPV test followed by reflex cytology testing (HPV infection in women ≥30 years is more likely to be persistent and, therefore, has a greater likelihood of clinical significance. NEGATIVE PREDICTIVE VALUE ~100%.)
• It is very unlikely that a woman with a negative HPV test and cytology develop high grade lesion or cancer in the next 5 to 10 years; this may justify widening the screening interval
• Recomendações:
  o Rastreio Organizado: Mulheres 25-30: so papa a cada 3 anos; 30-65: teste HOV com papa reflexo a cada 5 anos
  o Rastreio oportunista: começar 21 anos e/ou 3 anos apos começar vida sexual
  o População especial:
  1. ♀with HPV vaccine: no alterations
  2. Immunocompromised ♀(HIV positive or Immunosuppressed): anual screening
  3. Pregnancy: only if no previous negative screening in the previous 5y
  4. . After hysterectomy:
  a) CIN2/3: continue screening every 3y

b) No history of CIN2/3: no need for further screening

Question 12

Papanico

Answer 12

• The Papanicolaou (Pap smear) test consists of cells sampled from the cervix and vagina.
• It can identify abnormal cells from the transformation zone and the squamocolumnar junction, where cervical dysplasia and cancers arise.
• It yields cytologic results, permitting examination of cells but not tissue structure.
• Resultado com class de Bethesda

Question 13

Follow up de testes anormais

Answer 13

• ASC-US: The risk of invasive cervical cancer in ♀ with ASC-US is low,>2/3 of cases are not associated with high-risk HPV infection;The majority corresponds to inflammation or atrophy. -> repetir no prazo de um ano e se continuar -> colposcopia
• LSIL, ASC-H, HSIL, AGC: Colposcopia+ biopsia

Question 14

Colposcopia

Answer 14

• diagnostic procedure in which a colposcope (a dissecting microscope with various magnification lenses) is used to provide an illuminated, magnified view of the cervix, vagina, vulva, or anus.
  It’s primary goal is to identify precancerous and cancerous lesions so that they may be treated early
• Indicações
  1. Follow-up test to evaluate abnormal cervical cancer screening tests.
  2. Abnormal findings on gross examination of the cervix, vagina, or vulva.
  3. Postcoital bleeding.
  4. Persistent vaginal discharge with no evident cause.
  5. Neoplasia da vulva ou vagina.
  6. CIN post terapeutic follow up.

Question 15

Lesões precancerosas colo

Answer 15

• Cervical intraepithelial neoplasia (CIN)
• CIN may be low grade (CIN 1) or high grade (CIN 2,3)
  o CIN refers to squamous abnormalities. Glandular cervical neoplasia includes adenocarcinoma in situ and adenocarcinoma

Question 16

Gestão de lesões precancersas do colo

Answer 16

• Goal: prevent progression to invasive cancer while avoiding overtreatment of lesions that are likely to regress
• Decisions regarding management of CIN depend upon the risk of cervical cancer, risks associated with treatment, and the likelihood of compliance with a management plan
• Two management approaches to CIN: continued observation (with cervical cytology, HPV testing, and colposcopy) and treatment with an excision or ablation of the cervical transformation zone.
• Tx excisional: Cervical conization or exeresis of the transformation zone
  o Excision of a cone-shaped portion of the cervix surrounding the endocervical canal and including the entire transformation zone.
  o Diagnostic and potentially therapeutic procedure for women with cervical neoplasia
  o It can be done by: CO2 LASER - Electrosurgical loop - Surgical scalp
• Destructive or ablative procedures cryosurgery, electrofulguration or laser are an alternative to CONIZATION
  o However, no pathologic specimen is obtained since the cervical tissue is destroyed. These procedures are purely therapeutic and have no diagnostic value
  o Appropriated for selected patients with previously well characterized lesions histologically and colposcopically, in whom invasive cancer has been excluded

Question 17

Histopatologia cancro cervical

Answer 17

• Squamous cell carcinoma – 69%
• Adenocarcinoma (including adenosquamous) – 25%
• Other histologies – 6%
• Squamous cell carcinoma – HPV 16 (59%) / Adenocarcinoma – HPV 16 (36%), 18 (37%)
• Vias de metastase: direct extension - lymphatic - hematogenous -> Direct extension may involve the uterine corpus, vagina, parametria, peritoneal cavity, bladder or rectum. Ovarian involvement by direct extension of cervical cancer is rare.
  o Hematogenous spread: are the lungs, liver, and bone.

Question 18

Clinica cancro cervical

Answer 18

o Early stages are frequently asymptomatic, emphasizing the importance of screening
o Most common symptoms at presentation: abnormal vaginal bleeding (including postcoital bleeding) and vaginal discharge.
o Advanced disease may present with pelvic or lower back pain, which may radiate along the posterior side of the lower extremities. Bowel or urinary symptoms are uncommon and suggest advanced disease.

• EO:
  o A lesion may not be visible or palpable on physical examination or manifest as superficial ulceration, exophytic tumor in the exocervix, or infiltration of the endocervix
  o A thorough pelvic examination including rectovaginal examination with assessment of tumor size and vaginal or parametrial involvement is required for staging cervical cancer
• Estadiamento CLINICO -> Tumor stage is determined at the time of primary diagnosis of cervical cancer and is not altered, even upon recurrence -> FIGO 2009

Question 19

TX cancro cervical

Answer 19

• Histologia, Invasão linfovascular, volume tumor, estadio e preferência do doente
• Doença precoce (Cervical cancer limited to the uterus: FIGO stage IA or IB1)
  o definitive surgery (modified radical hysterectomy),

o fertility-sparing surgery -> Stage IA1 without lymphovascular space involvement (LVSI) - cervical cold knife conization
. Early-stage disease (stage IA1 with LVSI or stage IA2 to IB1) at low risk of cancer recurrence (ie, lesion size <2 cm; no lymph node metastases) - radical trachelectomy.

o primary radiation therapy (Rt with or without Qt).

• Cancro cervical avançado local
  o : primary chemoradiation (RT: external + brachytherapy)

Question 20

Epidemio cancro endometrial

Answer 20

• Endometrial carcinoma (EC) is most common gynecologic malignancy in developed countries and is the second most common in developing countries
• Adenocarcinoma is the most common histologic type
• > 90% cases are diagnosed in ♀over 50y, however, 4% are diagnosed in ♀under 40y.
• 75-90% of ♀with EC present with AUB. The majority is diagnosed with disease confined to the uterus and has a 5year survival rate > 90%.
• PT: Incidence 10.2/100 000 (RON 2005) 10.4/100 000 (RON 2010)
  Mortalidade: 1.8/100 000/year (2012)

Question 21

Histopatologia carcinoma endometrio

Answer 21

• Endometrioid adenocarcinomas (type 1): 80-85%
  o Associated with prolonged exposure to endogenous or exogenous estrogen, unopposed by progesterone. Obesity is a risk factor.
  o Usually well (G1) or moderately (G2) differenciated.
• Nonendometrioid carcinomas (type 2): 10-15%
  o Includes mucinous, and serous carcinomas, clear cell carcinomas, mixed cells tumors and carcinosarcomas.
  o Serous and clear cell ECs are not stimulated by estrogen and usually do not express estrogen or progesterone receptors.
  o They typically arise in atrophic endometrium or an endometrial polyp in older adult women, and are not associated with obesity.
  o More aggressive and with poorer prognosis. Undifferenciated (G3).
• Hereditary carcinomas (type 3): 5-10%
  o Hereditary cancer syndromes that predispose to an increased risk of EC: Lynch (40-60% lifetime risk of EC) and Cowden syndromes (autosomal-dominant; lifetime risk of 5-10% of EC).

Question 22

Genetica carcinoma endometrio

Answer 22

- Endometrioid carcinomas (type 1):
o microsatellite instability 
o PTEN
o K-ras
o β-catenina CTNNB1
o PI3KCA

• Tipo 2:
  o p 53
  o erbB2

Question 23

Carcinoma endometrioide

Answer 23

• Usually grade 1 (G1) or grade 2 (G2) in cell differentiation.
• These tumors typically have a favorable prognosis, are estrogen-responsive.
• FR: excess of endogenous (obesity) or exogenous estrogen without adequate opposition by a progestin (eg, postmenopausal estrogen therapy without a progestin).
• Prevenção secundária: To date, there is no evidence supporting screening in general population; Routine screening with ECO in ♀ with risk factors for EC is not recomended.
• Rastreio recommended in
  ♀carring Lynch syndrome mutations: Gynecological exam, transvaginal ECO and hysteroscopy with biopsy (once a year, after 35y and until TH+BA).
• Outros FR: idd avançada, tx estrogenica sem progesterona, menopausa >55, nuliparidade, SOPoliquistico, obseidade, DM, Tamoxifeno
• Clinica:
  o AUB is present in ~75-90% of ♀with EC; the amount of bleeding does not correlate with the risk of cancer -> Posmenopausa: 3-20% tem carcinoma endometrio e 5-15% tem hiperplasia; dos 45 à menopausa incluindo hemorragia intermentrual, freq (<21 dias), elevada (>80 ml) ou prolongada (>7 d); <45 anos hemorragia persistente com hx de estrogenio sem progesterona (obesidade), oligo ou amenorreia ou falência tx na hemorragia, ou Fatores genéticos como Lynch

o Cervical cytology findings adenocarcinoma, atypical glandular cells, endometrial cells
o Incidental findings on imaging thickened endometrium
o Incidental finding at hysterectomy

Question 24

Causas de HUA em posmenopausa

Answer 24

• Atrofia 60-80%
• Tx hormonal - 15-25%
• Hiperplasia - 5-15%
• Carcinoma - 7-12%
• Polipos - 2-12%

Question 25

AValiação de possivel Neo endometrio

Answer 25

• Physical examination
• Laboratory
• Pelvic sonography
• Endometrial sampling
• DX: a histologic diagnosis upon evaluation of an endometrial biopsy/curettage sample, or hysterectomy specimen.
• Avaliação pre tx:
  o Assessment for hereditary cancer syndromes - Lynch syndrome (history suggestive of Lynch syndrome should be referred for genetic
  counseling and testing, and also have testing of their tumor specimen for the mismatch repair proteins which characterize this syndrome.)
  o Marcadores tumor -
  CA 125 high values favor extrauterine spread of EC; useful for follow up after treatment (if elevated). Total blood count, Renal and Hepatic function.
  o Imagem - RX TX, Abdominal and pelvic CTscan or MRI – for the evaluation of the extension of EC; indicated for planning surgical approach or when surgery is contraindicated.
• Estadiamento- FIGO 2010/TNM - SÓ APOS CIRURGIA

Question 26

Cirurgia carcinoma endometrio

Answer 26

• Total extrafascial hysterectomy with bilateral salpingo-oophorectomy with pelvic and paraaortic lymph node dissection is the standard staging procedure for EC
  o Peritoneal cytology (although not part of FIGO staging).
  Gross inspection with biopsy of any areas where metastases are suspected
  o Total extrafascial hysterectomy with bilateral salpingo-oophorectomy (Intra-operative inspection of the surgical specimen to evaluate the extent of uterine disease in G1 or G2 EC will determine whether lymph node evaluation is needed, which, in turn, may impact on recommendations for adjuvant treatment.)
  o Pelvic and lomboaortic linphadenectomy: Invasive disease or poorly differentiated cancer
• Cirurgia é curativa de CE nos estadios 1A G1 e G2
• Tx adjuvante:
  o Radiotherapy Vaginal brachytherapy and/or external beam radiation
  o Chemotherapy Adjuvant treatment or Palliative care

Question 27

Vigilância pos tx de CEndometrio

Answer 27

• Monitoring symptoms and physical examination.
  (4-4M (1st and 2nd year), 6-6M (3rd,4th and 5th year), once a year (> 5th year))
• CA 125 or imaging studies only if clinically indicated

- Preservação fertilidade
o Atypical EH or EC endometrioid, G1, with negative MRI for miometrial invasion
o Hormonotherapy (progestins)
o Monitoring efficacy at 3 to 6M (transvaginal ECO and endometrial biopsy):  no response <> surgery; response <> monitoring every 3M until pregnancy.

Question 28

PGX CEndometrio

Answer 28

• is determined primarily by disease stage and histology (including both grade and histologic subtype).
• Fortunately, most women with endometrial carcinoma have a favorable prognosis, since the majority has endometrioid type histology and present with early-stage disease.

- FIGO
Estadio1: 88% sobrevivência 5 anos
2: 77%
3: 61%
4: 21%

Question 29

Cancro Ovarico Epidemio

Answer 29

• Ovarian cancer is the second most common gynecologic malignancy in developed countries and the third in developing countries (cervical cancer is the most common).
• In western countries is the leading cause of death from gynecologic cancer
• Worldwide, ovarian cancer is the eighth most common form of cancer in women
• The majority of ovarian malignancies (95%) are epithelial; the remainder arise from other ovarian cell types (germ cell tumors, sex cord-stromal tumors).
• Serous carcinoma, the most common histologic subtype of epithelial ovarian carcinoma (EOC), is regarded as closely related to fallopian tube and peritoneal serous carcinoma, based upon similarities in histology and clinical behavior
• The padronized incidence in Portugal is approximately 8,2 per 100.000 women (European Cancer Observatory – 2012).

Question 30

Tumores epiteliais superficiais

Answer 30

• Class por:
  o cell type: serous (cistoadenoma, borderline seroso ou adenocarcinoma seroso), mucinous (cistoadenoma, mucinoso borderline, adenocarcinoma mucinoso), endometrioid (cistoadenoma,….), etc
  o atypia: benign, borderline (atypical proliferation, low malignant potential) or malignant; malignant may be invasive or non-invasive.

- Tumores cel transitional:
o tumor de Brenner
o tumor de Brenner borderline
o Malignant Brenner tumor
o Transitional cell carcinoma (non-Brenner type)

• Epithelial-stromal
  o Adenosarcoma
  o Carcinosarcoma (formerly mixed Muellerian tumors)

Question 31

FPat de carcinoma epitelial do ovário

Answer 31

• EOC has been used to refer to a large group of malignant neoplasms that typically present as ovarian tumors with involvement of the fallopian tube and peritoneum.
• that these epithelial neoplasms can be divided into two groups in terms of probable site of origin: ovarian or tubal.

o first group of carcinomas, which have a plausible origin in the ovary, include the following histologies: endometrioid, mucinous, clear cell, borderline, and low grade serous -> an indolent behavior and appear to form part of a morphological and molecular continuum starting with cystadenoma/adenofibroma benign tumors that subsequently develop towards atypical proliferative or borderline tumors and then finally towards invasive tumors -> often confined to the ovary at the time of diagnosis, with a stable genome and without TP53 mutations.

o second group consists of extrauterine pelvic serous carcinomas, particularly those that are high grade and are associated with a poor prognosis: rapid progression, extra-ovarian disease at the time of diagnosis and genetically highly unstable; the majority have TP53 mutations, and almost half have mutation, hypermethylation, or dysfunction of BRCA 1/2. No precursor lesion known

Question 32

FR carcinoma epiltelial do ovario

Answer 32

• include increasing age, nulligravidity, infertility, endometriosis, and hereditary ovarian cancer syndromes (BRCA gene mutations, Lynch syndrome).
• Fatores protetores: include oral contraceptives, salpingo- oophorectomy, breastfeeding, tubal ligation and hysterectomy

Question 33

Rastreio carcinoma epiltelial do ovario

Answer 33

• Average-risk women for ovarian cancer: no screening
• Women with a family history of ovarian cancer who do not have a confirmed ovarian cancer syndrome: management as for women at average risk.
• Women who are carriers for hereditary and/or familial breast and ovarian cancer syndromes (BRCA1/BRCA2) and Lynch syndrome: discussion of ovarian cancer screening with the patient - transvaginal ultrasound and CA-125 every six months beginning at age 30 or 5 to 10 years before the earliest age of first diagnosis of ovarian cancer in the family.

Question 34

Clinica carcinoma epiltelial do ovario

Answer 34

• Subacute or acute
• majority of women have stage III disease at diagnosis (disease that has spread throughout the peritoneal cavity and/or that involves lymph nodes).
• historically been thought to be a silent disease; however, studies have found that symptoms occur in many women even at early stages - subacute presentation: eg, adnexal mass, pelvic or abdominal symptoms (pain, bloating, difficulty eating or feeling full quickly, urinary urgency or frequency).
• Women who present in an acute fashion are typically those with advanced disease who present with a condition that requires urgent care and evaluation; eg, pleural effusion, bowel obstruction
• Infrequently, EOC is discovered at the time of surgery performed for another indication.

Question 35

Avaliação na suspeita de cancro ovario

Answer 35

• determine the degree of clinical suspicion of malignancy; if there is a high likelihood of malignancy, the patient should be referred to a gynecologic oncologist
  o HC
  o EO
  o Imaging studies: gynecological ultrasound, MRI or CT
  o Tumor markers
• Preoperative evaluation: assess the ability to tolerate surgery, assess for metastatic disease (abdomino-pelvic CT/MRI; chest radiography), exclude metastatic disease from another primary cancer (gastrointestinal cancers and breast cancer, most frequent) or a synchronous malignancy (endometrial - 10%).
• Estadio: surgically staged according to the joint 2010 International Federation of Gynecology and Obstetrics (FIGO)/Tumor, Nodes, Metastasis (TNM) classification system. -> 1 - ovário, 2- quanto há extensão pelvica, 3- peritoneal extra pelvica, 4 - doença `distância

Question 36

TX Epithelial ovarian carcinoma

Answer 36

• Primary surgical cytoreduction followed by adjuvant chemotherapy is the preferred initial management
• Patients who are not good candidates for surgery due to the location and volume of disease involvement or medical comorbidities at the time of diagnosis, may be considered for neoadjuvant chemotherapy followed by surgery
• PGX major prognostic factors associated with improved outcome are younger age, low volume of residual disease, good performance status, and serous histology
  1: 83-90% 5 anos
  2: 66-71%
  3- 33-47%
  4- 19%

Question 37

Cancro ovario não epitelial

Answer 37

• Germ cell tumors
• Sex cord-stromal tumors

o Heterogeneous group of benign or malignant neoplasms.
o ~ 5% of malignant ovarian cancer.
o In contrast with epithelial ovarian cancer, most patients are diagnosed with early-stage disease.
o Young ♀ - fertility questions.

Question 38

Tumores cel germinativas

Answer 38

• These neoplasms comprise approximately 20 to 25% of ovarian neoplasms overall, but account for only about 5% of all malignant ovarian neoplasms.
• Ovarian germ cell (OGC) neoplasms are derived from primordial germ cells of the ovary; they may be benign or malignant.
• OGC neoplasms arise primarily in young women between 10-30y of age; they represent 70% of ovarian neoplasms in this age group.
• Often produce tumor markers (AFP, HCG, LDH) - diagnosis and follow up.
• Most common ovarian germ cell neoplasm: benign mature cystic teratoma (dermoid cyst), which can be bilateral. Approximately 1% contain a secondary malignancy arising from one of the components, usually a squamous cell carcinoma. Ovarian cystectomy or oophorectomy provides definitive diagnosis and treatment.
• Dysgerminoma is the most common malignant ovarian germ cell neoplasm. Bilateral ovarian disease is more common than with any other ovarian germ cell neoplasm. These neoplasms are less likely to produce tumor markers than other malignant germ cell neoplasms, but lactic dehydrogenase (LDH) is often elevated.

Question 39

Sex cord-stromal tumors

Answer 39

• Arise from the dividing cells that would give rise to specialized gonadal stroma surrounding the oocytes, including granulosa cells, theca cells, Sertoli and Leydig cells and fibroblasts.
• Malignant ovarian sex cord-stromal neoplasms are rare: 1.2% of all primary ovarian cancers. The average age at diagnosis is 50 y (compared with 61 y for EOC); 12% < 30 y.
• Some produce sex steroid hormones, including estrogen and androgens. These may result in symptoms and measurement of these and other tumor markers (eg. inibina) may play a role in diagnosis and follow up.
• Granulosa cell tumors - secrete estrogen - may associate with endometrial hyperplasia or carcinoma. Most patients with malignant sex cord-stromal neoplasms are diagnosed with early-stage disease.