Clin Med - Uterine Cervix & Corpus Flashcards
What is the MCC of cervix cancer?
HPV - human papilloma virus
What are the risk factors for HPV?
- Multiple sexual partners
- Young age at coitarche
- High parity
- -First baby before the age of 20
- Immunosuppression
- Cigarette smoking
- -Byproducts of smoking appear in the cervical mucous
- Failure to participate in regular screening
- Persistent HPV infection with high risk serotypes (HPV 16, 18)
Define koilocytosis
presence of koilocytes in a specimen
Define koilocyte
a squamous epithelial cell that has undergone morphologic changes as a result of HPV infection
What do HPV-infected cells look like under the microscope?
- Enlarged nuclei
- Darker than normal staining pattern in nucleus – hyperchromasia
- perinuclear halo – clear area around the nucleus
- irregularity of nuclear membrane
What are the screening tests for cervical cancer?
- pap test
- HPV testing
Characteristics of pap test
- most effective screening test in modern medicine
- not a screening test for CANCER
- pap tests are designed to find subclinical disease, but cancer is often found by them
Which serotype is HPV testing looking for?
High risk serotypes: 16, 18, 31, 33
Which part of the cervix are we looking for with colposcopy?
The transformation zone
Cervical Intraepithelial Neoplasm (CIN)
-etiology
- Obtained from colposcopic directed biopsy
- Premalignant lesions
- HPV infection:
- -Extremely common
- -Asymptomatic
- -Mostly transient
- -Persistence increases risk for premalignant lesion
Management of CIN
- Expectant with surveillance vs. treatment
- -Cervical cytology findings
- -Colposcopic impression
- -Cervical biopsy results
Patient characteristics
- Age
- Pregnancy
- Likelihood of compliance
- Smoking
- Immunocompromised state
Histology of cervical cancers
-list the most prevalent
- Squamous cell (80%)
- Adenocarcinoma (15%)
- Adenosquamous
- Neuroendocrine or small cell carcinoma (rare)
When is peak incidence of cervical cancers?
Peak incidence is 45 years
List the locations of metastasis of cervical cancer
-direct extension
- Parametria/Broad Ligament
- Bladder
- Rectum
- Vagina
List the locations of metastasis of cervical cancer
-lymphatics
- Pelvic
- Para-aortic
- Supraclavicular
What is determined via clinical staging?
- prognosis
- treatment planning
Staging of cervical cancer
-urinary tract
- Cystoscopy
- Renal ultrasound
- Intravenous pyelogram
Staging of cervical cancer
-rectum
- Proctoscopy
- Gastrograffin enema
- Flexible sigmoidoscopy
What is the other modality for staging of cervical cancer?
Chest xray (looking for metastasis)
Treatment of Early Stage Cervical Cancer
- Radical hysterectomy
- Pelvic and para-aortic lymphadenectomy
- Stage IA2-IB2
+/- adjuvant radiation based on risk factors
Treatment of Advanced Stage Cervical Cancer
- Combination of external and internal radiation
- Whole pelvic radiation with brachytherapy
- Cisplatin given at a low dose as radiation sensitizing agent
What is the Benign Neoplasm of Uterine Cervix?
Endocervical Polyps
Etiology of endocervical polyps
- Common, 2-5% all women
- Benign, exophytic neoplasms
- Arise in endocervical canal
- Irregular bleeding
- Tx: excision in outpatient setting
Define endometriosis
- presence of extrauterine endometrial glands AND stroma
- a benign pathology of the uterine corpus
Etiology of endometriosis
- Common
- Implants are hormonally responsive meaning growth and maintenance of implants dependent upon estrogen – so unusual to see in post-menopausal women
- Sx: dysmenorrhea, pelvic pain, and infertility OR pts asymptomatic
List the Clinical Features of Endometriosis
- Dysmenorrhea
- Dyspareunia
- Infertility
- Bowel/bladder symptoms
Endometriosis on exam + diagnosis
- Tenderness
- Nodules
- Fixed uterus/adnexae
- Dx - biopsy
Tx of endometriosis
Empiric trial:
- NSAIDS
- Oral contraceptives
- GnRH agonist
Surgical management based on patient goals:
- Infertility
- Pain
Define adenomyosis
Endometrial glands and stroma are present within the myometrium (the muscular structure of the uterus)
Adenomyosis etiology
- Globular enlargement
- Can present with dysmenorrhea and menorrhagia
- Endometrial biopsy - normal
- Pt often asymptomatic
Diagnosis & Treatment of Adenomyosis
Diagnosis:
- Histology
- MRI
Treatment:
+/- hormonal manipulation
-Hysterectomy
Define endometrial polyps
Hyperplastic overgrowth of endometrial glands and stroma
Etiology of endometrial polyps
- Occurs in reproductive age women
- Pt presents with abnormal bleeding
- *Generally benign
- Can be caused by Tamoxifen
- Tx is polypectomy
Define leiomyomas
Benign smooth muscle neoplasm
**very common
Etiology of leiomyomas
- Occurs in reproductive age women
- Pt presents with abnormal uterine bleeding, pressure, pain, infertility
- Can result in large, irregularly shaped uterus
Leiomyomas are described according to…
- location*
- Intramural
- Submucosal
- Subserosal
- Intracavitary
- Pedunculated (these can torse and cause high amount of pain)
What should you consider when thinking of tx for leiomyomas?
- Severity of symptoms?
- Size of neoplasm?
- Location of neoplasm?
- Patient age?
- Reproductive plans?
Treatment of leiomyomas
- Expectant management
- Medical management
- -Hormonal therapy
- -NSAIDs
- Uterine artery embolization
- Surgical
- -Hysterectomy
- -Myomectomy
Define myomectomy
Surgical procedure to remove myomas or fibroids (aka leiomyomas)
Define endometrial hyperplasia
Increased proliferation of endometrial glands
Etiology of endometrial hyperplasia
- Precursor to carcinoma
- Seen in pre and postmenopausal women***
Clinical presentation of endometrial hyperplasia
- Postmenopausal bleeding
- Anovulatory premenopausal women
- Abnormal uterine bleeding
What are the risk factors for endometrial hyperplasia or cancer?
- prolonged estrogen seen in these conditions:
- PCOS
- Obesity
- Exogenous (ERT or Tamoxifen)
- Granulosa cell tumor of ovary
- Over 40 with abnormal uterine bleeding
- Under 40 with abnormal uterine bleeding and risk factors
- AGUS on cytology
- Hereditary nonpolyposis CRC
Evaluation of endometrial hyperplasia
-normal vs. abnormal
Normal
-Secretory or proliferative endometrium
Abnormal
- Simple hyperplasia (with or without atypia)
- Complex hyperplasia (with or without atypia)
- Malignancy
Classification of endometrial hyperplasia
-simple hyperplasia
Histology
-Mild increase in gland to stroma ratio
Progression to cancer
-1%
Classification of endometrial hyperplasia
-complex hyperplasia
Histology
-Increased number and size of endometrial glands, marked gland crowding, and branching of glands
Progression to cancer
-3%
Classification of endometrial hyperplasia
-simple hyperplasia with atypia
Histology
-Glands have appearance of simple hyperplasia with cytologic atypia; uncommon
Progression to cancer
-8%
Classification of endometrial hyperplasia
-complex hyperplasia with atypia
Histology
-Considerable overlap with grade 1 adenocarcinoma
Progression to cancer
-29%
Prevention of endometrial hyperplasia
- OCPs
- Levonorgestrel IUD (5 years)
- Intermittent progestins (10 days/month)
- Depot medroxyprogesterone acetate (150 mg IM) Q 3 months
Treatment of endometrial hyperplasia
- Progestins
- Megestrol acetate 80-160 mg -PO BID
- Re-biopsy
*Surgery
What is the MC gyn cancer?
Endometrial carcinoma
Clinical presentation of endometrial carcinoma
- Postmenopausal bleeding
- AGUS on Pap cytology
- Size of uterus usually not altered
When is endometrial carcinoma generally diagnosed?
at early stage with endometrial biopsy
How can you distinguish endometrial carcinoma from leiomyoma?
Endometrial carcinomas are not usually markedly enlarged tumors whereas leiomyomas are big!
Type I Endometrial Cancer
- *estrogen dependent
- precursor: endometrial hyperplasia
- % cases = 90%
- biologic behavior: indolent, spread via lymphatics
- histology: endometrioid, well differentiated
- age: 55-65
- clinical setting: unopposed estrogen, obesity, HTN, diabetes
Type II Endometrial Cancer
- *estrogen independent
- precursor: endometrial intraepithelial carcinoma
- % cases: 10%
- biologic behavior: aggressive; intraperitoneal and lymphatic spread
- histology: serous, clear cell; poorly differentiated
- age: 65-75
- clinical setting: thin, atrophic endometrium
Tx of endometrial cancer
-surgically staged
- Hysterectomy
- Bilateral salpingoophorectomy
- Pelvic and para-aortic lymphadenectomy
- Pelvic cytology
Tx of endometrial cancer
-other options
- Surgery alone (early stage)
- Surgery + adjuvant radiation and/or chemotherapy (locally advanced)
Poor operative candidates for tx of endometrial cancer include…
Those who have undergone:
- Hormonal therapy
- Radiation
- Chemotherapy
Etiology of leiomyosarcomas
- Rare
- Peak incidence (40-60 years)
- Generally identified post-hysterectomy
- Surgically staged
- Adjuvant chemotherapy
- Gemcitabine
- Docetaxel
- Hematogenous metastasis
- -Chest, brain
- 5 year survival 30-40%
How are leiomyosarcomas distinguished from leiomyomas?
- Nuclear atypia
- Mitotic index (10 or more mitoses per hpf)
- Zonal necrosis
- spindle cell neoplasm
