GYN malignancy Flashcards
what is endo CA
most common
- epithelial tumor
2 types of edno CA
type 1 - E dependent
type 2 E indep
risk factors for E dep
- obesty
- chronic anov (PCOS)
- unopposed E use
- tmoxifen
- early menarche/late meno
- Fam hx
prevention
avopid risk factors
screening for endo**
none
3 warning signs for endo
- post-meno bleeds
- irreg vag. bleeds
- abdo bloating, pain, bowel sx
diagnostic test for endo ca
- endo biopsy with pipelle instrument
- US is not appropriate replacement
morphology of type 1
- resembles normal endo
- increased gland to stroma
- cribiform architecture
- nuclear atypia
what is grading in endo
amount of solid area
- more solid area is worse
what can be seen in E dependent before
precursor lesions
4 types of lesions
simple vs. complex
with or without atypia
complex with atypia has 50% risk
2 types of type 2
serous (papillary)
clear cell
- both are high grade
morpho of serous
- papillary archi
- high grade nuclear
- macro nuleai
morpho of clear cell
- clear cytoplasm
- high nuclear grade
- various architecture
precursors for serous and clear cell
serous - endometrial intraepitheliam carcinoma
clear cell - none
4 prognostic factors
- myoinvasion
- lymphovascular invasion
- cervical invasion
- mets
mgmt of edno CA
surgical
outcomes for 2 types
type 1 - usually found early and cured
type 2 - usually found late and poor
etiology of cerv. CA
HPV- most only dev. sublincal infection
3 cofactors
- smoking
- immunocompromise
- OCP
2 types of cerv. prevention
1ry - avoid HPV and cofactors
2ry - paps
2 types of 2ry prevention
- traditional - pap smear
- liquid based cytology medium
- less false neg
- increase sens
tips for collection
- before bimanual
- don’t contam. with lube
- collect before STD swabs
- ensure visualization
what are challenges in cerv. screening
- high false neg
- less reduction in adenocarcinoma
- is opportunitic - relies on pt and halthcare provider
when to start screen
21 - long time to dev SIL and LSIL is transient
how often
annual is standard practice, but if have negs, can do every 2-3 years because of sig. lead time
when to stop
consider stopping at 65-70 or hysterectomy with normal pap Hx
- continue if at risk
- continure in hyterectomy if HSIL in past
what to do with abnormal result
colposcopic eval
*** bethesda classification
satisfactory vs. unsat
neg vs. epithelial cell abnormal
2 types of abnormal
- squamous
- ASC (us or H)
- LSIL
- HSIL
- carcinoma - glandular
- AGC atypical glandular cells
- AGC favour neoplasia
- adenocarcinoma
what is only one that doesn’t need colposcopy
ASC-US
- up to 5%
option for ASC-US
- immed. colposcopy
- repeat smears q6mox3
- HPV DNA test
5 alternative causes for abnormal smears
- atrophic changes
- inflamm/infection
- regen after injury
- CA of other source
- previous radiation
what is pap test NOT
screening test, not a diagnostic test
4 types of squamous lesions
normal squam cell
LSIL
HSIL
SCC
** what is cytopathology
koilocyte - HPV infected cell
- enlarged nuc
- irreg nuc
- hyperchromasia
- binucleation
- cytopasmic halo
3 types of glandular leasion
normal endo glands
adenocarcinoma in situ
adenocarcinoma
what is done in colposcopy
look inside and biopsy if abnormal
2 options for lesions
- exision
- cone biopsy - general
- LEEP - in office - ablation - no patho
- laser
- cautery
- cryotherapy
5 warning signs of cerv CA
- abnormal pap
- abnormal bleeds - ESP post coital
- pelvic pain/discharge
- bowel or bladder
- flank pain/sciatica/lower limb edema (terrible triad)
** prototypical case
42 yo female
heathy smoker
no pap for a few years
new onset coital bleeds
what is role for imaging
none- do a physcial
clinical mgmt plan
- refer to gyn onc
- determine stage
- determine optimal ther
** what is special about staging of cervical
only one done clincally - with hands
what is mgmt
tailored to pt
- advanced - chemorad
- early - surg or chemo rad
2 most common histo types
SCC
endocervical adenocarcinoma
morpho of SCC
sheets of malignant cells
- sometimes keratinzation
morpo of adenocarcinoma
presence of atypical glands growing in disorganized fashion and invading cervial stroma
outcomes
early - cured with surg or chemorad
late- maybe cured with chemorad
SE of therapy
- loss of fert
- meno
- sexual dys
- bowel bladder tox
3 parts of ovary and their potential neoplasms
- primordial germ cells - germ cell tumors
- sex cords - stromal tumors
- epitheliom - carcinoma
epi of of germ cell tumors
the good
- 10-15%
- young females
- typically curable even with mets
types of germ cell tumors and their effect
1. mature teratoma (95%) - benign all the rest are malig 2. immature teratoima 3. dysgerminoma 4. yolk sac carc 5. embryonal carc. 6. choriocarc 7. gonadoblastoma
histo of teratoma
derivatives of any cell layer
- made up of mature adult type tissue
epi of stromal tumors
the bad (3-5%)
- women of all ages
- usually early stage and cured
epi of epithelial tumors
the ugly (80-85%)
- 5 subtypes
- each has it’s own chars
5 subtypes
- serous - most common
- endometriod
- mucinous
- clear cell
- transitionnal
histo of serous
often bilateral ovaries
- solid and cyctic mass with papillary projections
histopath of serous
- pap archi
- high nuclear grade
- macronuleaoli
- abundant mitosis
- psammoma bodies
histopath of mucious
- mucin producing
- large, unilateral
- atypia varies
- pools of mucin
endometrioid histopath
unilat
- often hemmoragic
- morpho ident to endo CA
histpath of clear cell
unilat
- solid and cystic mass
- may be hemorragic
2 risk factors for epithelial ovarian Ca
- incessant oviualtion
- nulliparity
- early menarche/ late meno
- not on OCP - genetics
3 related familial sysndromes
- site specific familial ovarian cancer syndrome
- BRCA
- lynch
10% have gentic link
prevention/screening
- avoidance of risk factors - OCP, childbearing
- prophylactic surg in high risk women
- no good screening - US is NOT good
screening for women at high risk (BRCA)
- transvag US q6 months
- mammography
- colonoscoly
- prophylactic surg
warning signs
often asymptomatic
- abdo bloating
- abdo pelvic pain
- bowel/bladder
- vag bleeds
prototypical case
60yo female - meno 8 years - 6 month sx On exam - fluid wave - omental cake - fixed irreg mass - cul-de-sac nodularity
4 diagnositc tests
- pelvic transvag US
- tumor markers
- CT
- CXR, barium enema
what is only type with no tumor markers
immature teratoma
tumor marker for epi, germ cell, stroma
epi - CA-125
germ - LDH, AFP, B-hCG
stromal - inhibin
limitations of CA-125
premeno - low spec., affected by benigh conditions
post-meno
- very hiogh PPV
- non-mucinous
*** what is involved in calculating risk of malig. index for adnexal masses
RMI = UxMxCA125
what is U
U = 1 (U/S 0 or 1)
U = 4 (U/S 2-5)
1 point for presence of: multilocarity, bilateral, solid, ascites, mets
what is M
M = 4 for postmeno M = 1 for premeno
CA-125
absolute value
where is cutoff
RMI>200 - refer
main treatment
surg - unless too unwell
4 roles for surg
- diagnosis
- staging
- debulking
- adjuvant facilitation
what is role of debulking
relat. between amount of disease left and length of survival
3 prognostic factors
- stage
- optimal debulking
- tumor biol
what is vulvar CA
skin CA of the vulva
epi of vulvar
- uncommon
- 90% SCC
- can often be a second primary malig (cervix/anus)
2 types of vulvar
- type 1 - HPV related
2. type 2 - non HPV
risks for type 1 (3)
HPV
smoking
immune suppress
risk for type 2
chronic vulvar disease
- lichen sclerosis
prevention/screening
- avoid risk factors
- no good screen
- treat preinvasive lesions
- surveillance colposcopy
warning sx
- vulvar itch
- burning
- irreg. bleeding
- vulvar lesion
- groin pain swelling
- bowel/bladder pain in advanced
diagnostic tests
- physical exam
- colposcopy if nothing visible on physical
- skin biopsy
keys to surgical mgmt
- wide local margin
- assess sentinal nodes
- neoadjuvant chemorad for locally advanced disease
histopath
- most are SCC
- look at depth, tumor width, lymph invasion, status of margins
reasons behind sentinal LN
- mets to groin nodes
- risk increases exponentially when depth >1mm
- node dissection is morbin
- do sentinal node instead and if clear leave the rest
what does sentinal LN allow
ultrastaging of this node and detection of small mets
outcomes for vulvar
depends on the stage
