Firecracker - Oncology Gynaecology Flashcards
What is endometrial cancer and what are its risk factors?
Endometrial cancer is an adenocarcinoma of uterine tissue that is commonly related to exposure to high levels of estrogen.
The progression to endometrial cancer is like an uncontrolled proliferative (follicular) phase of menstrual cycle. Normal endometrium progresses to simple hyperplasia then to complex hyperplasia then to atypical hyperplasia and finally frank adenocarcinoma.
Risk factors include:
- Prolonged unopposed estrogen exposure
- HNPCC (hereditary nonpolyposis colorectal cancer)
- Diabetes and obesity
- Hypertension
- Polycystic ovarian syndrome and chronic anovulation
- Nulliparity
The average age of diagnosis is 61, but the age range of 50-59 is the largest affected group.
What is CIN-1 and how is it treated?
Cervical intraepithelial neoplasia-1 (CIN-1) is considered low-grade dysplasia found after colposcopy and describes dysplasia within the lower third of the cervical epithelium (closest to the epithelial surface).
Treatment of CIN-1 involves repeat pap smear in 6 and 12 months, and repeat HPV testing in 12 months. Excision by loop electrocautery excision procedure (LEEP) or conization, or laser ablation may be performed.
What ultrasound findings are associated with malignant ovarian tumors?
Ultrasound can be used to detect malignant ovarian tumors. Findings associated with a malignant mass include:
Size > 8 cm
Solid, or cystic and solid consistency
Nodular or papillary solid components
Multilocular, thick (>2 mm) septations
Bilateral tumors
Associated features including ascites, peritoneal masses, lymphadenopathy
What are some complications associated with endometrial cancer?
Complications of endometrial cancer include:
Local extension to fallopian tubes, ovaries, and cervix
Metastases to the peritoneum, pelvic lymph nodes, aortic lymph nodes, lungs, and vagina
96% 5-year survival rate if local, but 25% 5-year survival rate if metastases are present
What complications are associated with ovarian cancer?
Complications associated with ovarian cancer typically include low 5-year survival rates because tumors are frequently in advanced stages when detected.
Pseudomyxoma peritonei is a complication of mucinous cystadenocarcinoma where a rupture of the tumor produces copious mucinous ascites and peritoneal mucinous tumors.
If the result of a pap smear performed on a 22 year old patient is ACUS, what is the next step in management?
Atypical squamous cells of undetermined significance (ASCUS) characterizes cellular abnormalities in the cervical epithelium that are not explained by reactive changes and are not diagnostic of intraepithelial lesions.
Treatment of ASCUS involves HPV screening, repeat pap smear in 6-12 months, and repeat HPV testing in 12 months.
Due to the transitory nature of low-grade cervical dysplasia and HPV infection in young women, treatment is slightly different for women age 21-24. Women age 21-24 with ASCUS or LSIL should undergo repeat pap in 1 year or reflex HPV testing.
Note: Women age <21 should not undergo pap smear regardless of whether they are sexually active, due to the increased prevalence of transitory, clinically insignificant cervical dysplasia in this population and the long-term harm caused by treatment of these clinically insignificant findings.
How is endometrial cancer treated, regardless of stage?
Regardless of stage, endometrial cancer can be treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO).
If fertility is desired and the endometrial cancer is limited only to the endometrial lining, treatment can consist of progestins to limit growth until a TAH-BSO is ultimately performed.
If a endometrial tumor cannot be completely resected, it should be surgically debulked.
If the endometrial cancer is high-grade or the tumor has invaded beyond the endometrial lining, adjuvant radiation therapy is indicated in addition to surgery.
Chemotherapy is indicated for use in any case where endometrial cancer has spread beyond the uterus.
Patients who cannot be cured by surgery and radiation may show benefit from the use of hormone therapy (progesterone, tamoxifen).
What are the symptoms of ovarian cancer?
Malignant ovarian tumors are usually asymptomatic, or have minimal symptoms until it is late in the course of the disease.
Initial symptoms of ovarian cancer include:
Bloating
Early satiety
Dyspepsia
Abdominal pain
Pelvic pain
Late symptoms of ovarian cancer include:
Back pain
Urinary frequency/urgency
Constipation
Fatigue
Dyspareunia
Menstrual changes
Physical exam findings of malignant tumors include fixed, solid, irregular, and bilateral adnexal masses.
What does ASC-H mean?
Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) characterizes cellular abnormalities in the cervical epithelium that likely consist of a mixture of true high-grade squamous intraepithelial lesion and other findings that mimic such lesions.
Treatment of ASC-H involves HPV screening, endocervical biopsy, repeat pap smear in 6-12 months, and repeat HPV testing in 12 months.
What is the role of x-ray, CT and ultrasound in the diagnosis of endometrial cancer?
Endometrial biopsy is the gold standard for diagnosis of endometrial cancer. Findings associated with endometrial cancer include hyperplastic, abnormal glands with vascular invasion.
Serum studies may show an elevation of the CA-125 tumor marker. Remember that tumor markers are not diagnostic, but are useful for monitoring response to therapy.
In a patient where the suspicion for endometrial cancer is very high but the endometrial biopsy is normal, hysteroscopy with biopsy should be performed to visualize the uterine cavity and take additional samples.
A chest X-ray and CT can be used to detect the presence of metastases and ultrasound can be used to detect cervical masses and measure endometrial wall thickness.
What are follicular cysts and how are they treated?
- Follicular cysts arise from ovarian follices in which fluid accumulates in a Graafian (mature) or previously ruptured follicle.
- They are composed of granulosa cells, are cystic (roughly 3 cm in diameter), occur in the first 2 weeks of the menstrual cycle and may regress over the menstrual period.
- This is the most common ovarian mass in a reproductive-age woman.
- The clinical presentation of follicular cysts includes:
- Abdominal pain and fullness
- Palpable tender mass on bimanual exam
- Peritoneal signs if torsion or rupture occur, which can cause sterile peritonitis
- Patients typically require no treatment besides a follow up ultrasound to ensure cyst resolution.
- If the mass does not regress, or if there is a high suspicion of cancer, an ovarian cystectomy can be peformed.
What are the different ways in which a cervical carcinoma lesion can be treated dependent on stage and type?
Surgery is the first-line treatment for invasive cervical carcinoma, with chemotherapy and radiation required in certain cases. Chemotherapy is used to prevent distant recurrence, while radiation reduces local recurrence.
For small invasive lesions with close surgical margins, chemotherapy should be used postoperatively to prevent distant recurrence from micrometastasis not detected at the time of surgery.
Patients with local disease (stage 1), where the lesion is visibly invasive or if it involves the uterus, but does not extend to the pelvic wall or lower third of the vagina, should be treated with radical hysterectomy with lymphadenectomy or with radiation therapy (to prevent local recurrence) and cisplatin-based chemotherapy.
Patients with advanced disease (stage 2-4) have lesions that extend into the parametrial tissue, pelvic wall, lower third of the vagina, adjacent organs, or any lesions that have metastases should be treated with radiation therapy and chemotherapy.
Recurrent cancer is treated with pelvic exenteration, which is a surgical procedure that removes all pelvic organs (uterus, tubes, ovaries, bladder, distal ureters, rectum, sigmoid colon, pelvic floor muscles, ligaments).
The Gardasil vaccine (tetravalent against HPV types 6, 11, 16, 18) is now FDA approved for both males and females. Note: women who have received the Gardasil vaccine still need regular pap smears!
What surgical procedure is indicated for malignant ovarian epithelial tumors?
Treatment for malignant epithelial ovarian cancer is based on surgery plus chemotherapy and radiation as needed.
Surgical removal is a Total abdominal hysterectomy plus bilateral salpingo-oophrectomy (TAH/BSO).
Multiagent chemotherapy is typically used for malignant ovarian germ cell tumors.
Another treatment for malignant ovarian germ cell tumors is a unilateral salpingo-oophrectomy (because they are rarely bilateral) if fertility is desired and TAHBSO is refused.
How are benign cystic teratomas treated?
Benign cystic teratomas (i.e. dermoid cyst) originate from germ cells and are composed ofmultiple dermal tissue layers (such as hair, teeth, and sebaceous gland).
These masses are often asymptomatic, but if they rupture the oily contents that are released can cause peritonitis.
Treatment of dermoid cysts involves cystectomy with attempted preservation of the ovary if benign.
What is the most common histological type of cervical dysplasia?
Cervical cancer is typically squamous cell carcinoma (80% of cases), but can be adenocarcinoma (15% of cases) or a mixed adenosquamous (5% of cases).
Risk factors for cervical cancer include:
Early sexual intercourse
HPV 16, 18, 31, 33
Multiple partners
Smoking
Immunodeficiency
History of STDs
Invasive Cervical Carcinoma is now the least common gynecological cancer in the USA due to the success of the Pap smear at detecting precancerous lesions.
What is colposcopy?
Colposcopy is a diagnostic procedure where a dissecting microscope (colposcope) is used to obtain an illuminated and magnified view of the cervix for biopsy.
Acetic acid is used to improve visualization of abnormal areas as the solution causes metaplastic cells to reflect light and appear white, referred to as “acetowhite” changes.
In order to best detect cervical intraepithelial neoplasia, multiple biopsies are taken.
