Exam pt 2 Flashcards
what is the 4th most common CA in women
uterine CA
what is a hallmark of ovarian CA
intra-peritoneal spreads
2nd most common gynecologic malignancy with the highest mortality
Ovarian CA
*incidence increases w/ age and risk of relapse of advanced stage is 70%
pathogenesis hypotheses for ovarian CA
- repeated ovulation/ trauma/ repair to ovarian epithelium allow genetic mutations and neoplasia
- excess gonadtotropin secretion –> increased estrogen –> epithelial proliferation and potential for malignant transformation
- starts as carcinoma insitu in fallopian tubes –> breaks free and invades ovaries
____% of primary ovarian tumors derive from epithelial cells
90% *mostly serous
3% germ cells and 7% sex cord-stroma
___% diagnosed with stage III/IV ovarian CA
75%
____% 5 year survival of advanced stage ovarian CA
20%
risk factors for ovarian CA
- women w/ ovaries
- long ovulation hx
- unexplained infertility
- nuliparity
- fhx of breast or ovarian CA / BRCA**
- diet
- estrogen replacement
- hx of endometriosis
factors that decrease your risk for ovarian CA
- increased parity*
- oral contraceptive use*
- tubal ligation
- hysterectomy
*decreased ovulation
symptoms of ovarian CA
bloating, fatigue, increased abdominal size, urinary urgency, constipation
how do u evaluate an adenxal mass?
- transvaginal sonography (TVS)
- if normal rescan in 1 yr
- if abnormal evaluate tumor morphology index score, CA-125 biomarker, and color doppler
prevalence of adenxal mass
2-7%
*7.8% of premenopausal women had adenxal masses 2.5cm or larger on random u/s (ovarian cysts)
factors to consider when evaluating adenxal masses by TVUS
tumor size
borders
density
*morphology index score above 5 is concerning
what is an elevated CA-125 in a premenopausal woman and a postmenopausal woman
premenopausal >200
postmenopausal >35
*biomarker for ovarian CA but not specific!
how to treat an ovarian cyst
laparoscopy
tumor markers
HE4: ovarian CA
CA-125: ovarian and others
CEA: mostly GI tract
CA 19-9: mucinous tumors, pancreatic tumors
( if HE4 normal and CA125 elevated in premenopausal likely endometrosis)
screening for ovarian CA
there is no screening tool!
*just educate on signs
Can measure 5 protein in blood: Transthyretin apolipoprotein A-1 B2 microglobulin Transferrin CA 125 II
surgical staging for ovarian CA. What should be done?
- hysterectomy
- both tubes and ovaries (BSO)
- pelvic washings
- pelivic lymph nodes
- periaortic lymph nodes
- peritoneal biopsies
- diaphram scraping
- omentectomy/biopsy
stages for ovarianCA
Stage 1- stays where it started
Stage 2- spread next to the origin
Stage 3-spread outside pelvis
Stage 4- distally spread
treatment of ovarian CA
- chemotherapy (IV or intraperitoneal)
- platiunum and taxane (6 cycles of 21 days)
- clinical trials
- surgery
**Platinum drugs are the most effective (carboplatin or cisplatin)- but some are resistant to it
surveillance of ovarian CA after no evidence of disease
- 5 yr prognosis
- visit every 3 months for 2 years, then may space out
- H and P
- CA125
- imaging?
what percent of ovarian CAs are genetic?
10%
of that:
BRCA1 ~70-75%
BRCA2~ 20%
what is a significant family hx of ovarian CA
-2 first degree relatives (Breast or ovarian CA OR 1
screening for ovarian CA if BRCA +
- monthly BSE starting at 18
- annual mammograms at 25
- annual breast MRI
- 2x yearly ovarin screening w/ us and CA125 at 35
how can u reduce ones risk of ovarian CA if they are BRCA +
- screening
- surgery
- chemoprevention
*BSO reduces ~95%
Mastectomy ~40-50%
most common gyn malignancy in developed countries
endometrial CA
95% of uterine CA are endometrial, 5% are sarcomas
median age of endometrial CA
61
major risk factor for type I and type II endometrial CA
type I- unopposed estrogne
type II- age
80% of endometrial CA race: caucasian > black differentiation: well differentiated histology: grade 1 or 2, endometrioid Prognosis: favorable
type 1 endometrial CA
10-20% of endometrial CA race: caucasian = black differentiation: poorly differentiated histology: grade 3, serous, clear cell, mucinous, etc. Prognosis: poor
type 2 endometrial CA
risk factors of endometrial CA
- unopposed estrogen (type 1 only)
- obestity
- late menopause
- nulliparity
- diabetes
- hypertension
- tamoxifen
- endometrial hyperplasia
% risk of
simple endometrial hyperplasia w/o atypia
complex endometrial hyperplasia w/o atypia
simple endometrial hyperplasia with atypia
complex endometrial hyperplasia with atypia
1%
5%
10%
25%
*think coin size
factors that decrease risk of endometrial CA
- decrease estrogen or increased progesterone
- oral contraceptives
- pregnancy
- smoking
signs and symptoms of endometrial CA
abnormal bleeding
what do u do if someone presents w/ abnormal bleeding?
aka how do u dx endometrial CA
Biopsy!!!- endocervix and endometrium
-US:
___% of endometrioid ovarian CA have a synchronous endometrial CA
20%
what other CA has a 40-60% lifetime risk of endometrial CA
hereditary non-polyposis colorectal CA syndrome (Lynch syndrome)
**recommend prophylactic hysterectomy
spread patterns of endometrial CA
- direct extension- most common
- transtubal
- lymphatic
- hematogenous- mostly lungs
treatment of endometrial CA
- surgical staging
- postop radiation or chemo
- medical managment (progesterone, anti-estrogen?)** used as palliative care
prognostic variables of endometrial CA
young worse than old
2cm
hormone receptor status: + better than neg.
prognosis for stage IA endometrial CA
prognosis for stage IVB endometrial CA
88%
15%
most common gynocologic CA worldwide but not in US because of screening prevention
cervical CA
risk factors of cervical CA
HPV infection smoking multiple partners multiparity HIV STDs OCP use low socioeconomis status poor diet (Vit. deficiency) alcoholism
screening for cervical CA
PAP
*76% reduction in incidnece of invasive cervical CA
what HPV strains cause the most cervical CA
HPV 16 and 18 cause >70%
HPV 16 alone causes about 50%
symptoms of cervical CA
frequently asymptomatic
- abnormal vaginal bleeding
- postcoital bleeding
- vaginal discharge: watery, mucoid, purulent, and/or malodorous
- do not confuse with cervicitis
- pelvic or lower back pain
- bowel or urinary symptoms
treatments of cervical CA
- radical hysterectomy
- radiation
- chemoradiation
lower urinary tract dysfunction ranges from ___-___% following radical hysterectomy
20-80%
*most common types of dysfunction:
voiding, storage, recurrent UTI, UI
signs and symptoms of vulvar CA
pruritus (severe itching)
burning
nonspecific irritation
appreciation of a mass
how do you dx vulvar CA
biopsy everything
most common vulvar CA subtypes
squamous 90%
melanoma 5%
Basal 2%
Staging of vulvar CA is based on what
midline lesion?
radical vulvectomy
inguinal lymphnodes (>1mm invasion)
Stages of vulvar CA
Stage 1: confined to vulva
Stage 2: extension to adjacent structures
Stage 3: positive inguinal femoral lymph nodes
Stage 4: upper 2/3 of urethra, upper vagina, distant
treatment of paget disease of the vulva
-wide local excision or vulvectomy 2cm margins is preferred
-radical vulvectomy
+/- lymph node dissection
+/- chemo/radiation
*60% experience local recurrence and may require 5cm margins
vulva is diffusely involved, with very thin, whitish epithelial areas, termed “onion skin” epithelium or “cigarette paper”
lichen sclerosus
an itch that rashes
itching contributes to epidermal thickening or hyperplasia and inflammatory cell infiltrate, which in turn leads to heightened sensitivity that triggers more mechanical irritation
Lichen Simplex Chronicus
rare inflammatory skin condition that can be generalized or isolated to the vulva and vagina
Sx:
whitish, lacy bands of keratosis near the reddish ulcerated-like lesions
chronic vulvar burning
pruritus
insertional dyspareunia
profuse vagina discharge
Lichen Planus
lesion: atrophic, thin, whitish epithelium w/ frequent perianal halo or keyhole distrubution
lichen sclerosis
lesion: pale red to yellowish pink plaques, often oily appearing, scaly crust
seborrheic
lesion: eczematous lesions w/ underlying erythema
dermatitis (allergic, irritant, or atopic)
lesion: annular pink plaques with silvery scalre that bleed if removed (auspitz sign)
psoriasis
lesion: lichenified, hyperplastic plaques of red to reddish brown
lichen simplex chronicus
lesion: white lacy network (wickham striae) w/ flat-topped lilac papules and plaques
lichen planus
hallmark: other hair-bearing areas often affected-scalp and chest, also back and face
seborrheic
hallmark: symmetric w/ extension into areas of irritant or allergen contact
dermatitis (allergic, irritant, or atopic)
hallmark: elbows, knees, scalp also affected
psoriasis
hallmark: erosive vaginitis w/ demarcated edges
lichen planus
hallmark: symmetric w/ variable pigmentation
lichen simplex chronicus
hallmark: cigarette paper, parchment-like skin, halo or loss of elasticity
lichen sclerosis
fiery, red background mottled w/ whitish hyperkeratotic areas
pagets disease
** high risk of underlying internal carcinoma, particularly of the colon and breast
most common presenting complaint of vulvar CA
pruritus
*may notice a red or white ulcerative or exophytic lesion arising most commonly on the posterior 2/3s of either labum majus
what is the most common non-SCC of the vulva
melanoma
another word for uterine leiomyomata
fibroids and myomas
represent localized prliferation of smooth muscle cells surrounded by a pseudocapsule of compressed muscle fibers
uterine leiomyomata
_____ are the most common indications for hysterectomy, accouting for approximately 30% of this operation
leiomyomata
leiomyomata centered in the muscular wall of the uterus
intramural leiomyomata
leiomyomata just beneath the uterine serosa
subserosal leiomyomata
leiomyomata just beneath the endometrium
submucosal leiomyomata
leiomyomata that remains connected to the uterus by a stalk
pedunculated leiomyoma
*subtype of subserosal
uterine malignancy is imore typical in postmenopausal patients who present with
rapidly enlarging uterine massess, postmenopausal bleeding, unusual vaginal discharge, and pelvic pressure
menstrual blood loss of >80 mL
menorrhagia
on abdominopelvic examination, uterien leiomyomata usually present as a __
a large, midline, irregular-contoured mobile pelvic mass w/ a characteristic “hard feel” or solid quality
-the degree of enlargement is usually state in terms “weeks size” that are used to estimate equivalent gestational size
treatment for uterine myomas
most do not require (surgical or medical) treatment
___ is commonly sused before a planned hysterectomy to reduce blood loss as well as the difficulty of the procedure. It can also be used as a temporizing medical therapy until natrual menopause occurs
gonadoropin-releasing hormone agonist (GnRH analogs)
a surgical treatment is warranted in patients who desire to retain childbearing potential or whose fertility is compromised by the myomas, creating significant intracavitary distortion
myomectomy
**otherwise a hysterectomy
indications for a m yomectomy include
a rapidly enlarging pelvic mass
symptoms unrelieved w/ medical management
enlargement of an asymptomatic myoma to the point of causing hydronephrosis
what is the def of infertility
1 yr attempting conception
% of male infertility
35%
% of tubal/pelvic infertility
35%
pretesticular reasons for infertility
- hypogonadotropic hypogonadism (Kallman’s, tumor, trauma, empty sella, iatrogenic)
- coital disorder (ED)_
- Ejaculatory failure (psychosexual, post-genitourinary surgery, neural, drug-related)
what hormone decreases fertility in males (decreases sperm count)
testosterone
*shuts down hormonal signally needed to make sperm
testicular reasons for infertility
- genetic (Klinefelters-XXY, Y chromosome deletions, immotile cilia,)
- Congenital (cryptorchidism, infective- orchitis)
- Antispermatogenic (heat, chemo, drugs, irradiation,)- vascular, torsion, immunologic, idiopathic
post-testicular reasons for infertility
- Epididymal (congenital, infective)
- Vasal (genetic: CF-abnormal development of vas deferens, acquired: vasectomy)
- Accessory gland infection
- immunologic
- idiopathic
red lesion indicates
newer lesion
a chocolate cyst
endometrioma
_____% of infertile women will have endometriosis
25-50%
best treatment for endometrioma
removal of cyst bc has less recurrence and side effects than drainage
screening test for endometriosis
no screening test
-surgery is diagnostic and treatment
treatment options for endometriosis
- conservative: remove the endometriosis
70-100% relief of pelvic pain
*generally recommend hormone suppression after to decrease recurrence risk - Radical: remove the uterus and fallopian tube
90% relief of pelvic pain
ovarian conservation if ovaries uninvolved
medical therapy of endometriosis
- NSAIDS
- Continuous OCs (pseudopregnancy)
- Progestogens (depo provera/norethindron, Mirena, implanon)
- Anti-progestins
- Aromatase inhibitors (off label)
- Danazol (androgen- suppresses FSH and LH)
- GnRH agonists
How do GnRH agonists help tx endometriosis
GnRH causes ovaries to shut down by removing pulsatile release of GnRH–> no FSH and LH release from pituitary–> no ovulation
**causes pt to go into medical menopause and may have associated symptoms (use add-back therapy to treat symptoms)
how should the flow of treatment go for endometriosis pain
try NSAIDs and birth control pill
- still pain, treat w/ GnRH
- still pain, treat w/ laparoscopy
*if you suspect someone has endometriosis and they are trying to get pregnant soon, do surgery sooner
% of ovulatory disorders
15%
2 causes of anovulation
- Estrogenized (PCOS)
2. Not estrogenized (hypothalamus or pituitary)
what is the most common endocrine defect that causes infertility
PCOS
5-10% reproductive age women
DDX of PCOS
CAH
hypercortisolism
PRL
thyroid
clinical features of PCOS used to diagnose
need at least 2 out of 3
- oligo- or anovulation
- chemical or clincal signs of hyperandrogenism (elevated serum androgen concentration, or hirsutism, male pattern hair loss, acne)
- Polycystic-appearing ovaries
*diagnose by exclusion
Pathophysiology: increased LH over FSH release from pituitary –> increased androgen production from theca cells in ovary
- insulin–> acts synergistically w/ LH to enhance ovarian androgen production
- insulin –> inhibits production of SBHG from liver (increased levels of free testosterone)
PCOS
how to evalute PCOS
- Gonadotropins (FSH, LH) and E2
- TSH
- Prolactin
- Pelvic US
- Testosterone, DHEAS
- 17OHP
- Glucose screening
- lipid panel
medical concerns related with PCOS
- prevention of endometrial hyperplasia
- prevention of DM2
- infertility
normal hgbA1c and for DM2
nl: 6.4%
* not as sensitive but easier to perform
treatment for DM2
metformin
statins
insulin sensitizer:
- disubstituted biguanide
- modest glucose disposal improvement
- primary: reduces hepatic glucose output
metformin
insulin sensitizer:
- thiazolidinedione
- improves sensitivity at liver, skeletal muscle, adipose
- modest: hepatic glucose output
- primary:glucose disposal improvement
Rosiglitazone
how to treat PCOS menstrual irregularity
- combined oral contraceptives (also helps manage testosterone levels)
- progestins
*estrogen causes endometrial lining to grow, which increases endometrial hyperplasia and increases risk of endometrial CA if not shedding
how to treat PCOS infertility
- lifestype modification (5% decrease in fat can help)
- injectable gonadroptropins
- ovarian drilling
- aromatase inhibitors (ex. letrozole)
best treatment of PCOS and infertility
best to use both or clomiphene alone
*Metformin does not help fertility but does help with endocrine issues
how does aromatase inhibitor, Letrozole work
causes low estrogen level to increase FSH level which causes ovulation
*better live birth rate (better rate of ovulation)
Causes of central anovulation
- defects within HP unit
(hypothalamic lesions, GnRH deficiency, prolactin excess, pituitary defects-adenoma, empty sella, tumors) - CNS-Hypothalamus
(nutrition, exercise, anorexia nervosa, stress, female athlete triad
how to evaluate and treat central anovulation
evaluate w/ MRI
Tx w/
lifestyle modification
gonadotropins
pulsatile GnRH
*clomide and letrozole won’t help because hypothalamus is the problem not the pituitary
% of unexplained (+ age-related) infertility
10%
how do you measure ovarian reserve
-Day 3 FSH/Estradiol. Anti-mullerian hormone
unexplained inferility definition
failure to conceive after 12 months in the setting of:
regular menses
at least 1 patent fallopian tube (HSG)
normal sperm count
treatment for unexplained infertility
superovulation/IUI
IVF
Cost-effectiveness 2010 study showed what
FSH/IUI added no additional value
studies show women with infertility have similar stress levels to those with:
CA
HIV
going through a divorce
which of the follwing is an epithelial cell tumor? dermoid cyst sertoli-leydig cell lymphoma muscinous cystadenoma
muscinous cystadenoma
which of hte followin gis a germ cell tumor brenner cell lymphoma endometrioid teratoma
teratoma
which of the follwing is an ex of a stromal cell neoplasm serous cystadenoma dysgerminoma endometrioid sertoli-leydig cell
sertoli-leydig cell
what tumor of the ovary should always be treated with hysterectomy, bilateral salpinogo-oophorectomy, and staging theca lutein cyst dysgerminoma cystadenocarcinoma brenner cell tumor
cystadenocarcinoma
a pt not using OCP, with regular periods, presents w/ acute pain late in luteal phase. this is most c/w dermoid cyst mucinous cystadenoma serous cystadenoma hemorrhagic corpus luteum
hemorrhagic corpus luteum
coelomic epithelium gives rise to what ovarian neoplasm
serous cystadenoma
gonadal stroma gives rise to what ovarian tumor
granulosa theca
germ cells result in what ovarian neoplasm
teratoma
what percent of serous cystadenomas are benign
70%
most common type of benign epithelial cell neoplasm
serous
when a child or adolescent presents w. an ovarian neoplasm, the most common type is
benign cystic teratoma
Brenner cell tumors may be associated with
mucinous tumors
which of the following neoplasms can contribute to precocious puberty in a female child
granulosa theca cell tumor
in the reproductive age group, about what percent of nonfunctional ovarian neoplasms are benign
70%
which ovarian tumor has the highest malignant potential dermoid serous cystadenoma mucinous cystadenoma brenner tumore
serous cystadenoma
malignant ovarian epithelial cell tumors spread primarily by
direct extension w/in peritoneal cavity
women with BRCA1 gene have a cumulative lifetime risk of ___ for developing breast CA and ___ for developing ovarian CA
50-80%
15-45%
what is the primary surgical approach involved in the treatment of ovarian carcinoma
cytoreductive surgery or “tumor debulking”
which of the follwiong is a tumor that is metastatic to the ovary from other sites fibrosarcoma krukenberg tumor immature teratome malignant mesodermal sarcoma
krukenberg tumor
what is a pathognomic sign of tubal carcinoma
profuse serosanguineous vaginal discharge
which of the following is the most common virilizing ovarian tumor gynandroblastoma arrhenoblastoma adrenal rest tumor leydig cell tumor
arrhenoblastoma
the presence of signet-ring cell type in ovarian tumors ism ost characteristic of
krukenberg tumors
breast CA metastatic to the ovary is found in what proportion of cases
25%
what percent of epithelial ovarian carcinomas occur in familial or hereditary patterns
5%
meigs syndrome couples ascites and right pleural effusion with ___
ovarian fibroma
