Gynecological oncology Flashcards

Question

What is the most common ovarian germ cel tumor? What is it composed of?

Answer 1

Teratoma: develops from totipotent germ cells (primary oocyte) of ovary and therefore can give rise to all kinds of cells and tissues Ectoderm = skin/sebaceous gland/hair follicles Mesoderm = muscle/urinary Endoderm = lung/ GI

Answer 2

Majority of teratoma are cystic and composed of mature well differentiated elements which are better known as dermoid cysts Complications * Torsion of the dermoid cyst * Rupture of the dermoid cyst * Malignant transformation into SCC USG appearance: heterogenous echogenic. Presence of hyperechoic nodule within the mass with distal acoustic shadowing: strong indicator of teratoma, signifies the presence of bone or tooth

Answer 3

Cystectomy is preferred via laparoscopy or laparotomy: make a definitive dx, preserve ovarian tissues. Avoid complications such as torsion, rupture and malignant transformation

Answer 4

Immature teratoma are solid and composed of immature undifferentiated elements Histologically graded from grade 1 (well differentiated) to grade 3 (poorly differentiated) based upon proportion of tissue containing immature neural elements. Mx * Usually surgery followed by chemo * Unilaterael oophorectomy is adequate provided the other ovary is not affected * TAHBSO is suggested if patient has completed family

Answer 5

Female version of male seminoma --> comprised of immature germ cells. Most common malignant germ cell tumor of the ovary. Clinical manifestation: torsion due to presence of a long ovarian pedicle. Rupture with haemoperitoneum Dx: contains syncytiotrophoblastic giant cells that produce placental ALP and LDH Mx: surgery followed by chemo Unilateral salpoingooophorectomy (USO) is usually curative an the contralateral ovary and uterus can be preserved for fertiity.

Answer 6

High risk HPV: 16, 18 Low risk HPV (non oncogenic --> LSIL/anogenital warts): 6, 11

Answer 7

Squamocolumnar junction (SCJ): ectocervix is the surface of the cervix that protrudes into the vagina and is covered with stratified squamous epithelium. Endocervix is the cervical canal which is lined with columnar epithelium. Transformation zone: during reproductive age the cervix is under the influence of estrogen, it tends to evert leading to exposure of columnar epithelium on ectocervix. * After exposure to estrogen, the glycogen from exfoliated vaginal cells is converted into lactic acid * Acidity stimulates the columnar epithelium to be replaced by squamous epithelium (metaplasia) Transformation zone contains embyronic cells that may be especially vulnerable to infection with HPV and to oncogenic transformation

Answer 8

Expression of HPV oncogene E6 and E7 are commonly detected in cervical cancer

Answer 9

* Women who never had sex before * Hysterectomy with removal of cervix * Pregnancy to avoid inducing bleeding and anxiety

Answer 10

* 1st pap smear screening starting at age 25 (1,1,3 yearly cycle). * 2nd pap smear 12 months later if result is normal * Repeat smear at least every 3 years if result is normal Rationale behind 1,1,3 yearly cycle: abnormal cervical cells usually take around 5-10 years to develop into cancer. Screening at 3 year interval is frequent enough to pick up changes

Answer 11

* Cervix cannot be seen * Blood in vagina or cervix during menstruation * Obvious or gross growth on cervix

Answer 12

* Scanty cells * Marked inflammation (increased PMNs) * Heavily blood stained (increased clotted blood) * Artefacts (air dried or too thick)

Answer 13

o Repeat smear every 6 months o Return to normal screening if normal x2 o Refer colposcopy again if ASCUS/ LSIL x2 or more severe abnormalities

Answer 14

o Repeat smear every 6 months o Return to normal screening if normal x3 o Continue screening for at least 3 times even if women reaches age of 65 o Refer colposcopy again at 24 months if ASCUS/ LSIL persists o Alternatively: FU at 12 months with smear and HPV testing: If both negative, then repeat at 24 months before return to routine screening; If either one positive during the 24-month period, refer to colposcopy

Answer 15

o Repeat smear x3 every 6 months, then o Repeat smear every 1 year for 10 years, then o Return to normal 3-yearly screening o If ASCUS/ LSIL within 12 months, then follow up with smear o If low-grade smear persists > 1 year then refer colposcopy

Answer 16

o Repeat vaginal cytology at 6 and 18 months o If both normal, no further cytology needed

Answer 17

o Repeat vaginal cytology at 6 and 12 months, then o Repeat vaginal cytology every 1 year for 10 years, then o Life-long vaginal cytology every 3 years

Answer 18

Majority is SCC. Less is adenocarcinoma, sarcoma, primary malignant melanoma Primary vaginal cancer is rare whereas metastastic disease to vagina or local extension from adjacent gynecological structures are more common

Answer 19

Posterior wall of the upper 1/3 of vagina is the most common site of primary CA Distribution of primary cancer: upper 1/3 =50%, middle 1/3 =20%, lower 1/3 =30% which has a much poorer prognosis partly because lymphatic spread to inguinal LNs is quicker and chance of bladder involvement

Answer 20

* Direct extension to pelvic soft tissue structure: parametrium, bladder, urethra, rectum, bony pelvis * Lymphatic spread: upper 2/3 drains into pelvic LNs and into paraaortic LNs. Lower 1/3 = drains into inguinal and femoral LNs and into pelvic LNs * Haematogenous spread: lungs, liver, bone

Answer 21

Mole/molar pregnancy (growth of growing tissues) Originates in the placenta and has the potential to locally invade uterus and metastasize. Considered benign but premalignant since it can develop into gestational trophoblastic neoplasia

Answer 22

Lesions characterized by abnormal proliferation of trophoblast of the placenta Comprises of benign non neoplastic lesions including hydatidiform mole, placental site nodule or exaggerated placental site

Answer 23

* Group of malignant neoplasms that consist of abnormal proliferation of trophoblastic tissues which arises from molar pregnancy (hydatidiform mole) or a non molar pregnancy * Molar pregnancy =50%: GTN that develops from molar pregnancy is usually invasive mole or choriocarcinoma, or rarely PSTT or ETT * Non molar pregnancy: miscarriage/tubal pregnancy = 25%, term or preterm pregnancy =25%. In the absence of tissue for definitive histopathologic dx, disease is diagnosed as a result of persistent elevation of hCG after evacuation of a molar pregnancy * Invasive mole * Choriocaricnoma * Placental site trophoblastic tumor (PSTT) * Epitheloid trophoblastic tumor (ETT)

Answer 24

Hydatidiform mole occurs after aberrant fertilization but not after non molar pregnancy: non molar pregnancy includes preterm or term delivery, spontaneous or induced abortion and ectopic pregnancy. Originates in villous trophoblast and characterized by abnormal chorionic villi with trophoblast hyperplasia as a consequence of overexpression of paternal genes.

Answer 25

* Typically presents to clinics with missed menstrual periods, positive pregnancy test and signs and symptoms consistent with early pregnancy complications * Usually presents between 8-24 weeks of gestation with peak at 14 weeks

Answer 26

* Molar pregnancy is suspected based upon unusualy high hCG levels or only after pathology evaluation of a failed pregnancy * Clinical presentation in early stages are early pregnancy complications and therefore clinicians will suspect more common pregnancy complications or an abnormal non molar pregnancy rather than molar pregnancy * Partial mole is often misdiagnosed as incomplete or silent miscarriage and correct dx is made only after pathology review

Answer 27

* Transvaginal USG pelvis * If the initial hCG level is high <100,000 mIU/mL, transvaginal ultrasound should be done * If USG shows normal singleton gestation, hCG and USG should be repeated in 1 week to exclude possibility of twin conception with normal fetus and co-existent molar pregnancy

Answer 28

Use of uterotonics (misoprostol, mifepristone, oxytocin) to induce uterine contractions is contraindicated since it will increase the risk of trophoblastic embolization to the lungs Obtaining a complete specimen for histological dx of hydatidiform mole is also more difficult with medication only evacuation

Answer 29

Must be advise to use reliable contraception during the entire interval of hCG monitoring New pregnancy during this period will make it difficult or impossible to interpret hCG results and would complicate management Contraception should be practised for at least 1 year after hCG has returned to normal before trying to get pregnancy again. Patients usually enjoy normal reproductive function after treatment

Answer 30

* Serial monitoring of serum B-hCG until undetectable level is reaeched and is maintained for several months * Regular monitoring to detect relapse which usually occurs within the 1st 12 months Surveillance protocol * Every month until non detectable for 3 weeks, then * Every month for 6 months for partial mole * Every month for 12 months for complete mole

Answer 31

No, surgery is 1st line Prophylactic chemotherapy indicated in high risk patients after suction evacuation to decrease the risk of subsequent progression and risk of GTN High risk features include * Pre evacuation uterine size larger than dates * hCG levels >100,000mIU/mL * Bilateral ovarian enlargement due to theca lutein cysts

Answer 32

Presence of edematous chorionic villi with trphoblastic proliferation invading the myometrium. Always preceded by hydatidiform mole (molar pregnancy) 15% remains localized to uterus, and 5% are metastasis (metastasis to lung and vagina common, but liver and CNS system can also happen) * Deep myometrial invasion can occur (less readily removed by suction evacuation). * Uncontrolled intraperitoneal hemorrhage and utereine perforation (rupture) can occur if deep myometrial invasion is left untreated Dx confirmed by histological exam of uterus after hysterectomy which is rarely performed unless there is uncontrolled bleeding or perforation Usually managed as residual trophoblastic disease with chemotherapy

Answer 33

Invasive, highly vascular and anaplastic trophoblastic tissue made up of cytotrophoblasts and syncytiotrophoblasts without villi Arises from products of gestation or ovaries (germ cell tumor) * Molar pregnancy: choriocarcinoma is more common after a complete mole rather than a partial mole * Non molar pregnancy: chorciocaricnoma is the most common type of GTN following non molar pregnancy * PSTT (placental site trophoblastic tumor) or epitheloid trophoblastic tumor (ETT) only makes up only 1-2% of GTN Most aggresssive histologic type of GTN and is highly malignant and characterized by vascular invasion and widespread metastasis. * Dx is often delayed following a non molar pregnancy and thus metastases are more common than after a molar pregnancy. * Highly malignant with invasion and necrosis of uterine wall * Most common sites of metastasis is lung

Answer 34

* Develop from extravillous, intermediate trophoblast * Arises most commonly after non molar pregnancy or miscarriage although it can also occur after a molear pregnancy * Secretes low levels of hCG (in comparison to invasive mole and choriocarcinoma) * Associated with less vascular invasion, necrosis and hemorrhage than choriocarcinoma * Tends to remain localized in uterus for long periods before metastasizing to regional LNs and other metastastic sites

Answer 35

* Develops from neoplastic transformation of chorionic type extravillous trophoblast * Dx is typically late due to slow growth, paucity of symptoms and low/absent hCG production * 50% patients present with metastatic disease

Answer 36

* Serial measurement of hCG is part of the post-treatment surveillance o Elevation, plateau or persistence (remains elevated) of hCG level that does not return to undetectable level suggests development of GTN

Answer 37

o Previous molar pregnancy o Previous non-molar pregnancy o Any women of reproductive age with metastatic symptoms without an obvious primary site of malignancy

Answer 38

o High levels = Invasive mole and choriocarcinoma o Low levels = PSTT and ETT

Answer 39

* Stage I = Disease confined to the uterus * Stage II = GTN extends outside of uterus to the adnexa or to the vagina but is limited to genital structures * Stage III = GTN extend to the lungs, with or without uterine, pelvic or vaginal involvement * Stage IV = Metastatic disease outside of the lungs, pelvis and vagina

Answer 40

3 LEEPs is max for HSIL (preferred over ablative therapy (as no histology obtained): includes electrocoagulative diathery, laser vaporization, cryosurgery (cold probe to freeze away abnormal cells) Any more than 3 --> suspect its carcinoma and opt for hysterectomy

Answer 41

At least 1b

Answer 42

* LEEP associated with lower incidence of cervical incontinence. An obstretics complication causing preterm, hence if there is fertility desire may do LEEP instead of CKC. * LEEP is also an office procedure (look and deal with) in comparison to CKC which requires RA/GA

Answer 43

* ASCUS x2 * ASCUS with high risk HPV * LSIL or above * AGC-NOS or above