GYN Malignancies

Question 1

Name the 3 most common gynecologic malignancies in the order of prevalence.

Answer 1

1. adenocarcinoma of the endometrium
2. epithelial ovarian cancer
3. squamous cell carcinoma of the cervix

Question 2

What are the risk factors of endometrial cancer?

Answer 2

atypical hyperplasia
unopposed estrogen
obesity

nulliparous
late menopause
diabetes
HTN

Question 3

Contrast type 1 and type 2 endometrial cancers

Answer 3

type 1 is estrogen related, type 2 is estrogen unrelated
type 1 occurs in younger patients, type 2 in older patients
type 1 are typically heavier, type 2 thinner
type 1 is usually low grade, type 2 high grade (aggressive)
type 1 more curable/ longer pre-cancer phase, type 2 potential basis (lynch)
type 1 often have PTEN and KRAS mutations, type 2 often have p53 mutations

type 1 has an endometriod histology and type 2 has serous histology

Question 4

What is the histologic appearance of type 1 cancers?

Answer 4

endometrial hyperplasia- increased glandular tissue and increasingly less regular architecture (cribriform- back to back)

nuclei become larger, rounder and nucleoli are more prominent

Question 5

What is the histologic appearance of endometrial carcinoma type 2?

Answer 5

instead glands there is papillary structure, malignant cells line the surface of glands with a high N/C ratio and more pleomorphism

Question 6

Who needs an endometrial biopsy to rule out endometrial cancer?

Answer 6

any one with post menopausal bleeding
perimenopausal inter menstrual bleeding
bleeding with history of involution

postmenopausal women with Pap test

thickened endometrial stripe via sonography

Question 7

What are different surgical techniques that are used to control endometrial cancer based on pathology present?

Answer 7

can include peritoneal cytology, TAH/BSO, pelvic and aortic lymph node dissection

purpose of procedure:
defines extent of disease
minimizes over/under treatment
min. increases perioperative morbidity/mortality
decreases over rx risk and cost
allows comparison of therapeutic results

Question 8

Wha is the usual treatment for endometrial cancer regarding adjuvant postoperative therapy?

Answer 8

whole pelvic radiation and vaginal cuff boost, mostly for stage II + and with nodal involvement

can reduce recurrence by up to 50% with 25-30d treatment

Question 9

What are risk factors for ovarian cancer?

Answer 9

increased age (post-menopausal)
family history
infertility/ low parity
uninterrupted ovulation
personal cancer history, esp. breast cancer

decreased risk: OCPs, pregnancy, tubal ligation, breast feeding

Question 10

Serious tumor is generated from which ovarian precursor?

Answer 10

surface epithelial cells (represents 65-70% of tumors)

*note many “ovarian” epithelial carcinomas are thought to arise form the fibrillated end of the uterine tube

Question 11

Contrast the mutations found in low and high grade epithelial ovarian cancer.

Answer 11

low grade: KRAS, BRAF, PTEN, B-catenin

high grade p53

Question 12

Is CA125 a reliable screen for ovarian cancer?

Answer 12

although CA125 is elevated in most advanced epithelial ovarian cancers it has poor sensitivity and poor specificity and is only used in screening high risk population (increase pre-test probability)

Question 13

What is the optimal therapy for ovarian cancer?

Answer 13

(aggressive surgery yields best survival results-optimal cytoreduction)

TAH and BSO +/- infra colic omentectomy, peritoneal samples from pelvis, gutters and diaphragm surfaces, pelvic and aortic lymph node dissection for staging

in younger women, reproductive conservation may be appropriate

Question 14

When is chemotherapy recommended for ovarian cancer?

Answer 14

all patients should receive a taxmen and a platinum, 73% will respond although many women with advanced disease will experience recurrence

Question 15

What are important points for follow up of ovarian cancer/

Answer 15

recto-vaginal pelvic exam and CA125/3-4mo for 2 years
discuss HRT, diet and exercise and continue general health maintenance (mammography, pap smear, bone density, CRC, cholesterol etc.)

Question 16

What are risk factors for cervical cancer?

Answer 16

early age of intercourse
number of sexual partners
smoking- ability to fight HPV infection
lower SES
high-risk male partner
other sexually transmitted diseases

Question 17

What percent of cervical cancers world wide contain HPV?

Answer 17

99.7% contain integrated HPV DNA; most likely to infect the squamocolumnar junction of the cervix

Question 18

How does HPV initiate oncogenesis?

Answer 18

HPV E6 and E7 interfere with the normal action of p53 and RB E2F; causes cell to NOT undergo apoptosis (p53) and skip growth arrest (RB)

Question 19

What are qualities of cervical cells that have become metaplastic?

Answer 19

low grade dysplastic cells: larger nucleus, more course chromatin, halo around the nucleus (contains HPV particles)

Question 20

What is the defining feature of cervical squamous cell CARCINOMA?

Answer 20

basal invasion through the epithelium

Question 21

Summarize key reasons why cervical cancer screening works.

Answer 21

sampling the cervix is relatively non-invasive
natural progression of cancer is slow
changes can be recognized microscopically
changes can be treated before invasion
Pap test is relatively inexpensive
HPV testing is integrated into screening in patients over 29yo

Question 22

What is the most classic sign of cervical cancer?

Answer 22

post-coital bleeding

also: foul vaginal discharge, abnormal bleeding, pelvic pain, unilateral leg swelling or pain, pelvic mass, gross cervical lesion

Question 23

What modalities are used in cervical cancer staging?

Answer 23

general physical exam
recto-vaginal pelvic exam
CXR
cystoscopy and proctoscopy
IVP- intravenous pyelogram or CT

Question 24

What is the mainstay of treating advanced cervical cancer?

Answer 24

chemoradiation: 4-5 weeks, 2 or more implants, especially concurrent with cisplatin based chemo (radio sensitizer)