Gyn Onc Sub I Flashcards
Lifetime risk of tumors of uterine corpus
1:37
Lifetime risk of tumor of ovary
1:75
Death percentage for uterine cancer
1/5
Death percentage for ovarian cancer
2/3
death percentage for cervical cancer
1/3
Death percentage for vulvar cancer
1/5
Pathogenesis of ovarian cancer
Repeated ovulation/trauma/repair of epithelium
excess gonadotropin secretion _. increased esrogen _.. epithelial proliferation
site of origin
fimbriae
Risk factors for Ovarian Cancer
Long ovulation history, nuliparity, family hx of cancer, estrogen replacement
Decreased risk of ovarian cancer
increased parity, OCP, TL, hysterectomy
symptoms of ovarian cancer
bloating, abdominal pain, urinary symptoms, constipation
prevalence of adnexal masses
2-8%
Prevalance of adnexal masses in premenopausal
7.8% (6.6% are simple cysts)
Prevalence of adnexal mass in post-meno
2.5%
cystic mass with normal CA-125
repeat US in 6 mo
what causes elevated CA-125 besides OC?
uterine ca, colon ca, breast ca, stomach ca, liver, ca, endometriosis, PID, liver, heart, kidney, failure, pregnancy
HE4
new ovarian cancer TM, if both elevated concerning
CEA
GI tract marker
CA19-9
mucinous or pancreatic tumor
Beta HCG
embryonal, choriocarcinoma
AFP
endodermal sinus, embroynal
LDH
dysgerminoma
Inhibin A and B
granulosa cell
when to refer for pelvic mass?
elevated CA125, ascites, nodular or fixed mass, evidnece of mets, family hx of 1+ 1st degree relatives
Ovarian Stage IA
Limited to ovary - intact capsule
Ovarian Stage IB
tumor both ovaries, but intact capsule
Ovarian IC
Tumor to one or both
1C1: surgial spill
1C2: capsule rupture prior to surgery
1C3: malignant cells in ascites
Ovarian stage I
confined to ovaries
Ovarian Stage II
Involves 1 or both ovaries w/ pelvic extension below pelvic brim or primary peritoneal
IIA ovarian cancer
extension to uterus or tubes
IIB ovarian cancer
other pevlic intraperitoneal tissues
Stage III ovarian cancer
spread to peritoneum outside pelvis or retroperitoneal lymph nodes
Stage IIIA Ovarian
positive RP LN
Stage IIIA2 Ovarian
microsopic extrapelvic + RP LN
Stage IIIB Ovarian
Macroscopic extrapelvic <2cm + LN (capsule of liver or spleen)
Stage IIIC Ovarian
Macroscopic extrapelvic >2cm + LN (capsule of liver or spleen)
Stage IV ovarian
distant mets
Stage IV A ovarian
pleural effusion
Stage IV B ovarian
hepatic or splenic parenchymal
Type I vs Type II Ovarian cancer
Type I: low grade, clear cell, mucinous, borderline (20-25%
slowly growing; primary site ovarian epithelium
Type II: high grade, p53 mutations, 75-80%, primary site FT
rapidly aggressive
Schiller Duval Bodies
Endodermal sinus tumor
Call exner bodie
Granulosa cell tumor
Why primary debulking
increased overall survival
improved GI function
less tumor - fewer cells to kill - less opportunity for resistance
increased # cells in active phase
Stroma tumor tx
surgery is primary tx –> BEP
Germ Cell tumor tx
conservative surgery -> BEP or BVP
Platinum refractory
progress on chemo
platinum resistant
recur <6 mo
how much of Ovarian tumors are genetic
10%
70-75% BRCA1
20% BRCA2
2% Lynch
Significant family hx for BRCA
2 first deg relative with breast or ovary cancer, one <50
One UL breast cancer <30
one bilatereal BC <40
one male BC
Lifetime risk of OC with BRCA1
39-66%
lifetime risk for BRCA2 OC
10-27%
Lifetime risk of OC w/ MMR
9-12%
Life time risk of endometiral cancer with MMR
20-60%
risk of OC at 40 with BRCA1/2
2-3%
risk of OC at 70 with BRCA 1/2
46% and 12%
what age start Mammograms and MRI for BRCA`
25
what age to start OC screening for BRCA
35
Risk reduing BSO
95% reduction
risk reducing mastectomy
40-50%
Risk factors for endometrial cancer
Unopposed Estrogen, obesity, late meno, nulliparity, DM, HTN, tamoxifen, endometrial hyperplasia
Risk of progression with Simple w/o atypia
1%
Risk of progression with Simple w atypia
8%
Risk of progression with complex w/o atypia
3%
Risk of progression with comple w/ atypia
29-50%
protective factors for endometrial cancer
OCPs, pregnancy, smoking
symptoms of uterine cancer
Abnormal bleeding
Spread of endometrial cancer
direct extension, transtubal, lymphatic, hematogenous
Stage I endometrial Cancer
confined to uterus
Stage IA Endo Ca
<50% myometrial
Stage IB endo Ca
> 50% myometrial
Stage II Endo Ca
invasion of cervical stroma, but not beyond uterus
Stage III endo Ca
Local or regional spread
Stage IIIA endo CA
Invades serosa of corpus and/or adenxa
Stage IIIB endo CA
vaginal or parametrial
Stage IIIC end CA
mets to pelvic or PA nodes
Stage IVA endo CA
bladder or bowel
Stage IVB endo CA
distant mets
Adjuvent therapy for endometrial CA
radiation and ct
medical managmeent of endometrial cancer
progesterone or anti-estrogen
Stage IA tx of endo CA
Observation + VBT for high grade
Stage IB tx of endo CA
Observe + VBT or pelvic RT for high grade
Stage 3 and 4 tx of endo CA
surgical debulk –> CT and RT
how much decrease in cervical cancer after PAP
75%
LSIL
CIN1 mild dysplasia
HSIL
CIN2 - mod dys
CIN3 severe dys or CIS
HPV 16 accounts for how much cerivcal dyplasia
50%
average time of clerance of HPV
8-24 mo
9 valent vax for HPV
6, 11, 16, 18, 31, 33,45, 52, 58
Regression rates of CIN1 vs CIN 3
57% v 43%
Persistence rate of CIN1 vs CIN3
32% v 56%
Progression to cancer of CIN 1 v CIN3
1% v >12%
Symptoms of cervical cancer
post coital bleeding, abnomral bleeding, vaginal discharge, pelvic or back pain, bowel or urinary symptoms
Stage I Cervix
confined to cervix
Stage IA cervix
Microsopic only depth <5mm and <7mm wide
Stage IB cervix
1B1 <4cm
1B2 >4cm
Stage II Cervix
extends beyond cervix but not to pelvic wall, and upper 1/3 vagina
Stage IIA cervix
no parametrial, upper 2/3 vag
Stage IIB cervix
parametrial invovememnt
Stage III cevix
to pelvic sidewall and lower 1/3 vagina, hydronephrosis
Stage IIIA cervix
lower 1/3 vagina, but no side wall
Stage IIIB cervix
extension to pelvic sidewall or hydronephrosis
how is cervical cancer staged?
clinically
how are lower stages of cervical cancer treated?
radical hyst
middle stages of cervical cancer tx
rad hyst v radiation
advanced stages cervical cancer
chemo RT
above what stage gets Radiation and no rad hyst for cervical cancer
Stabe IB2
Complications of rad hyst
1% fistula
20-80% lower urinary tract dysfucntions - abnormal sstraining, storage dysfunction, recurrent UTI, incontience
intermediate risk factors for cervical cancer that require adjuvent RT
> 1/3 stromal invasion, LVSI, tumor diameter >4cm
High risk factors of cervical cancer that warrant adjuvent RT
positive nodes, positive margins, microsopic disease on parametrium
prognosis for stage I cervical ca
80-90%
prognosis stage II cerivcla cancer
60%
prognosis stage III cervcial cancer
30%
prognosis stage IV cervical cancer
<16%
VIN usual types
warty, basaloid, mixed
associated with HPV
differentiated VIN
associated with lichen sclerosis and p53
3-5% of LS
how much % of VIN pogress to vulvar cancer
10-16%
types of vulvar cancer
90% squamous
10% melanoma
2-3% basal cell
2% adenocarcinoma- intra-epithelial pagets
medical therapy for vulvar cancer
topical imiquimod 5% 3x week for 12-20 wks
Recurrence of VIN
30-50%
Stage I Vulvar
confined to vulva
1A <2cm
1B >2 cm
Stage II vulva
extension to adjacent – lower 1/3 urethra, 1/3 vagina, anus negatie node
Stage III vulva
lower 1/3 vagina or urethra, or anus + inguinal femoral LN
IIIA; 1 LN >5mm or 1-2 <5mm
IIIB: 2 LN > 5mm or 3+ <5mm
IIIC: + LN w/ extracapsular spread
Stage IV vulva
2/3 upper urethra, uper vagina, distant
5y survival of Stage I Vulvar
80%
5y survival of stage II Vuvlar
60%
nodeal invovlement in vulvar cancer
<2mm 0%
>2mm 20%
morbidity of vulvectomy
lymphedema 25-35%
infection 40-60%
wound breakdown 15-25%
tx stage I and II vulvar
WLE or hemivulvectomy
margin 2cm
when should vulvar tumors have BL LNE
2cm of midline
nodal sites of vulvar cancer
inguinal and femoral
Metastatic sites of vulvar cancer
pelvic nodes or extrapelvic mets
investigations for Vulvar lesion
1) cervical cytology
2) colposcopy
CT MRI of pelvis and goins
CXR
blood work
Stage IA Vulvar tx
WLE w/o LNE
when is radiation warrented in vulvar cancer
extracapsular LN spread
2+ groin nodes
complete mole histology
Diploid 46 XX - both Xs from paternal origin
florid cistern, trophoblastic prolif, absence of fetal parts
partial mole histology
Triploid w/ materal and paternal genetic origin
fetal parts
Choriocarcinoma
malignant tumors of absence of chrionic villi
abnormal syncytiotrophoblasts and cytotrophoblasts
distant spread to lungs
molar pregnancy presentation
abnormal bleeding in pregnancy
hyperemesis gravidarum
hyperhyroidism
snow storm apperance
Gestational trophoblastic neoplasia tx
low risk: methotrexate or actinomycin D
high risk: etoposide methotrexate and actinomycin, cyclophosphamide, vincrstine
prognostic factors in gestational trophoblaist disease
age <40 mole, abortion, term interval from pregnancy pretreatment bHCG largest tumor size site of mets number of mets previous failed chemo
surgery in GTN
hysterectomy for unctrolle dbleeding, but use embolization