Gynecologic neoplasms Flashcards
What are uterine leiomyomas (fibroids)
Most common BENIGN neoplasm with discrete, round, firm, multiple tumors made of smooth muscle and connective tissue
What are some characteristics of leiomyomas (fibroids)
- ) They are estrogen and progesterone sensitive, increasing in size during pregnancy
- ) 25% caucasians have it, 50% black women have it
The majority of leiomyomas are asymptomatic. What are the symptoms if they are present
- ) Bleeding - longer heavier periods
- ) Pressure
- ) Pain - dysmenorrhea
- ) Pelvic symptoms - irregularly enlarged uterus felt on physical examination
What labs are important to order for uterine leiomyoma
Ultrasound to look for uterine myomas or masses
Uterine leiomyoma has both a pharmacologic and surgical treatment. What are the pharmacologic treatments
NSAIDs + OCP’s + medroxyprogesterone acetate
GnRH analogs to reduce size and used prior to surgery
What are the complications of leiomyoma
Infertility due to myoma
There are two types of endometrial cancer. What are they, and their pearls
Type 1: Endometriod - derived from atypical endometrial hyperplasia, are 75% of cancers, caused by unopposed estrogen stimulation, and happens at younger age
Type 2: Serous - 25% of cancers, from serous cells and unrelated to estrogen but related to p53, more aggressive
What are the symptoms of endometrial cancer
Early finding: Bleeding
Late finding: Pain
How does one diagnose endometrial cancer
Endometrial/endocervical biopsy
Ultrasound shows thickened endometrium
Treatment of endometrial cancer dependds on whether woman is of childbearing age or postmenopausal. What are they
- ) Childbearing: High dose progestins
2. ) Postmenopausal: TAH/BSO with radiation, but if worse then give chemotherapy
Something can protect against endometrial cancer. What is it?
Hormonal contraceptives
How does cervical cancer happen
Upper third is made of columnar cells that is exposed to acidic vaginal pH resulting in metaplasia to squamous cells, eventually leading to cervical intraepithelial neoplasia (CIN)
What is both squamous cell and adenocarcinoma of CIN result in
- ) HPV 16 - squamous cell carcinoma
- ) HPV 18 - adenocarcinoma
Also associated are immunosuppression, HIV, STD,s tobacco, and OCPs (this protected against endometrial cancer)
What are some common symptoms of cervical cancer
Metrorhagia, postcoital spotting, cervical ulcerations
What is the screening recommendations for cervical cancer
- ) Pap smear every two years from age 21
- ) If woman > 30yo with 3 consecutive normal tests, can be tested every 3 years and screened with HPV DNA
- ) Screening d/c after 70yo if 3 or more normal smears
Pearls
4.) If immunosuppression or DES exposure, screen indefinitely
What is the algorithm for ASC-US for cervical cancer
If ASC-US, proceed to HPV DNA testing, if negative repeat pap smear at 12 months if less than age 24 and 3 years if greater than age 25, if positive then do colposcopy
Or you can skip to colposcopy
What do you do if someone has ASC-H (atypical squamous cells - cannot exclude HSIL)
Colposcopy
How do you manage LSIL (Low grade intraepithelial lesion)
If no visible lesion, do endocervical sampling
If CIN 2, 3 - ablation or excision
If no CIN 2,3 - repeat pap smear at 6 and 12 months
How do you manage AGC (Atypical glandular cells of undetermined significance)
Colposcopy with endocervical sampling, but if bleeding ttoo then do endometrial sapling as well
How do you manage HSIL (High grade squamous intraepithelial lesion
Same as LSIL
If CIN 2, 3 - ablation or excision
If no CIN 2,3 - repeat pap smear at 6 and 12 months or you can do excision in this case anyways (unlike LSIL)
What is the treatment for CIN 1, and persistent CIN 1
Close observation by pap smear at 6 and 12 months or HPV DNA testing at 12 months, and after two negative pap smears or negative DNA test, then proceed to normal rates
However, iif persistent, do ablation or excision
What is the treatment for CIN 2 and 3
Ablation, excision, or hysterectomy
What is the treatment for invasive disease
Microinvasive carcinoma: Cone biopsy or simple hysterectomy
Stage 1A2, up to 2A - radical hysterectomy with radiation and chemotherapy
Stage 1B2 and above - radiation and chemotherapy only
Picture of stages on page 340
What is the most common cause of death if cervical cancer goes untreated
Uremia when ureteral obstruction is bilateral
What are the risk factors for vulvar cancer
HPV again, but this time lichen sclerosus, diabetes, HTN, CV disease, immunosuppression
What is in the history of vulvar carcinoma
Lesions that eventually become like cauliflower and ulcerated
How do you diagnose vulvar carcer
Vulvar punch biopsy with vulvar pruritis, especially if postmenopausal
The treatment for vulvar cancer differs whether it is high grade VIN or totally invasive. What is the treatment
VIN: Topical chemotherapy, laser ablation
Invasive: Radical vulvectomy and lymphadenectomy
Vaginal cancer has different subtyptes depending on age. What are they
Postmenopause: Squamous cell
Younger women: Adenocarcinoma, clear cell adenocarcinoma from DES
What are the risk factors and symptoms for vaginal cancer
Risk factors: Immunosuppresion, low socioeconomic status, chronic irritation from pessary or prolapse, radiation for cervical cancer, smoking
Symptoms: Abnormal vaginal bleeding or postcoital bleeding, most likely found in upper vagina
What are the risk factors for ovarian cancer
- Age, low parity, decreased fertility, delayed childbearing
- Positive family history
Risk decreased by OCP use, increased by BRCA mutation
What is a good tumor marker for ovarian cancer and when is it most effective
CA-125: Marker for progression and recurrence
- ) Preenopause: Could be endometriosis
- ) Postmenopause: Raised Ca-125 more suspicious of a malignant ovarian tumor
What is the first step in diagnosis if a symptomatic patient presents and you are concerned for ovarian cancer
Transvaginal ultrasound - if > 8cm, solid, multilocular, bilateral, and see ascites, think of cancer
The treatment of ovarian masses depends on whether they are premenopausal or postmenopausal. What is it
Premenopausal: Close observation if all signs of benign tumor, but if malignant suspicion then surgically evaluate
Postmenopausal: Follow closely with ultrasound
What is the treatment of ovarian cancer
Surgery - TAH and BSO
Postoperative chemotherapy
Only do radiation therapy if dysgerminomas
Remember that OCP use decreases the risk of this and endometrial cancer
