gynecologic oncology Flashcards
A 67 year old G0, LMP 12 years ago presents with postmenopausal bleeding x 2 weeks. She is using 2 pads/day and denies: heavy vaginal bleeding, pain, dizziness, headache or syncope.
Past medical history is significant for HTN, DM.
On pelvic exam, you note no abnormal findings except for about 5-10 cc of blood in the vaginal vault.
-triage- us
-Your patient cannot tolerate the endometrial biopsy in the office. With your supervising MD, you elect to perform dilation and curettage with hysteroscopy in the OR.
-Your patient undergoes a total hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy. Pathology reveals stage 1A well-differentiated endometrioid type endometrial carcinoma. No adjuvant therapy is indicated.
epidemiology
-About 66,000 cases/year in U.S.
-It is the 8th leading cause of cancer deaths in U.S. cisgender women
-RF:
-Unopposed estrogen
-Chronic anovulation- PCOS
-Exogenous estrogen use
-Selective estrogen receptor modulators (SERMs)- May increase or decrease risk of endometrial CA, depending on SERM
-> For ex. tamoxifen increases the risk of endometrial polyps and endometrial CA
-Obesity
-Family hx (Lynch syndrome, etc.)
-Increasing age
-MC > 50yo
-Low parity or nulliparity
-Early menarche
-Late menopause
-Smoking
-Hx of Lynch syndrome - Increased risk of colorectal CA, endometrial CA and ovarian CA
signs and symptoms
-MC sx: postmenopausal bleeding
-90% of pts with endometrial CA
-BUT only 15-25% of pts with postmenopausal bleeding will have endometrial CA
-MCC of postmenopausal bleeding: endometrial atrophy
-Other symptoms:
-Pelvic pain
-Pelvic mass
-Wt loss
types of endometrial CA
-Type 1: Endometrioid adenocarcinoma: 75% of all endometrial CA
-Usually low grade
-Usually limited to uterus at time of dx
-Type 2: Clear cell and papillary serous tumors
-More aggressive tumors
-NEVER NEED TO KNOW STAGING
natural hx of endometrioid type endometrial carcinoma
-simple hyperplasia
-complex hyperplasia
-complex hyperplasia with atypia
-carcinoma
endometrial CA triage
-Pelvic US with attention to endometrial stripe (AKA endometrial echo)
-!!Normal: ≤4 mm in pts with hx of postmenopausal bleeding
-Pts with postmenopausal bleeding and this finding on US do NOT need an endometrial bx
-Pts with hx of postmenopausal bleeding and who have an endometrial stripe >4 mm require endometrial sampling (endometrial biopsy or dilation and curettage)
-In pts w/o postmenopausal bleeding, the risk of malignancy increases significantly with an endometrial echo of ≥11 mm -> endometrial sampling
normal
Pelvic ultrasound : EM stripe =1.48 cm
Hysteroscopy: normal findings in postmenopausal patient. Note R tubal ostium labeled below
hysteroscopy in a patient with endometrial CA
surgical staging
-Surgery should be performed with or by a gynecologic oncologist
-Exam under anesthesia
-Peritoneal fluid for cytology
-Total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy
-May be performed by open procedure, laparoscopy or robotic-assisted laparoscopy
-Ovarian preservation is possible in some premenopausal patients, but the decision must be individualized
-pic-dont need to know
adjuvant therapy
-Adjuvant radiation therapy may reduce risk of recurrence and improves survival in pts with Stage 1-2 ds with certain RF
-Adjuvant chemotherapy:
-Paclitaxel
-Doxorubicin
-Cisplatin or carboplatin
-Hormone therapy:
-Medroxyprogesterone acetate or megestrol acetate for women who wish to preserve therapy OR who are poor surgical candidates
A 67 year old para 0, LMP 10 years ago, has noted increased abdominal girth and indigestion for the past four months
Two months ago, her PMD suggested she was “just getting older” after performing an exam and finding her in good health
On exam, you note a fluid wave and bilateral adnexal masses
Your patient undergoes total hysterectomy, bilateral salpingo-oophorectomy, lymphadenectomy, appendectomy and omentectomy along with peritoneal fluid washings and subdiaphragmatic scraping. Pathology reveals stage 3A epithelial ovarian carcinoma. She begins adjuvant chemotherapy with paclitaxel and carboplatin.
ovarian carcinoma
-most LETHAL gynecologic malignancy
-Major etiologies:
-Uninterrupted ovulation
-Inflammation
-Tubal CA with early metastasis to ovarian epithelium
-About 19,000 cases/year in U.S.
-Lifetime risk: 1.2% (with no family hx)
-24% of pts with ovarian CA have an inherited mutation
-Salpingo-oophorectomy can reduce the risk of malignancy in these patients by up to 95%
->70% have stage III at diagnosis
-5 year survival of 20-30% when diagnosed at stage III
-Most patients have sx before dx, but sx are vague
-Have a very high index of suspicion for vague abdominal complaints
ovarian CA RF
-Low parity
-Increasing age (usually >50, most common in 70s)
-Uninterrupted ovulation - Lack of use of hormonal contraception
-Family hx of ovarian CA in first degree relative(s)
-BRCA 1 or 2 mutation
-15-45% risk of ovarian CA
-Family hx of other adenocarcinomas
factors that decrease risk of ovarian CA
-Hormonal contraception
-Use of oral contraceptives in reproductive life reduces risk in average risk people by >40-50%
-Reduces risk in hens by >90%
-Bilateral tubal ligation
-Bilateral salpingectomy
-Should be performed with all hysterectomies today
-Prophylactic bilateral salpingo-oophorectomy (in high risk patients)
s&s of ovarian CA
-abd pain
-abd bloating
-early satiety
-urinary frequency
-increase abd girth
-indigestion
-fatigue
-back pain
-urinary incontinence
-constipation
-pelvic pain
-unexplained wt loss
ovarian CA: histology
-Epithelial ovarian carcinoma (70-75% of all ovarian neoplasms, and 90-95% of all ovarian CA)
-Germ cell tumors (15-20% of all neoplasms) -> MC in young pts
-Sex cord-stromal tumors (5-10% of all neoplasms)
-Metastatic tumors -Krukenburg tumors (GI tract)
septations ovarian ca
large pleural effusion in pt with metastatic ovarian carcinoma
ovarian CA: workup
-If a pelvic mass is palpated:
-US of pelvis
-Evaluate for complex adnexal masses
-See lecture on adnexal masses
-If US reveals is suspicious for an ovarian malignancy:
-CT of abdomen and pelvis, or possible MRI
-CEA, CA-125, alpha-fetoprotein
ovarian CA: surgical staging/debulking procedure
-exam under anesthesia
-exploratory laparotomy, peritoneal fluid aspiration, subdiaphragmatic scrapings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymphadenectomy, appendectomy, omentectomy
-optimal debulking removes all but <1cm of visible ds, if possible
-if pt is desirous of fertility AND malignancy involves ONLY 1 ovary -> pt may be candidate for unilateral salpingo-ooporectomy w/o hysterectomy
Abridged FIGO staging (dont need to know)
Stage 1: Tumor limited to ovaries
Stage 2: Tumor involves one or both ovaries with pelvic extension
Stage 3: Tumor involves one or both ovaries with microscopically confirmed peritoneal metastasis outside the pelvis or regional lymph node metastasis
Stage 4: Distant metastasis (excludes peritoneal metastasis)
ovarian CA: adjuvant therapy
-No role for radiation therapy
-Standard chemotherapy: taxane and carboplatin for initial chemotherapy
-May be given intraperitoneally or via IV
A 38 year old para 1011, LNMP unknown, UCG negative, complains of a history of vaginal spotting for four months, notably immediately after intercourse.
Your patient undergoes colposcopy, endocervical curettage, and cervical biopsies that reveal a diagnosis of squamous cell carcinoma. Clinical staging reveals early stage (IA) disease, and she undergoes radical hysterectomy
cervical carcinoma epidemiology
-Approx 13,000 new cases per year, resulting in about 4,000 deaths per year
-2nd MC cancer among pts worldwide
-Causative organism: HPV
-RF:
-hx of untreated high grade CIN
-No screening for cervical neoplasia in >8 years
-High risk HPV infection
-Smokers
-1st intercourse at an early age
-Multiple sexual partners
-Hx of STIs
-Immunosuppression
-Histology MC:
-Squamous cell carcinoma (80%)
-Adenocarcinoma (15%)
-Other rare types
