ICL 9.4: Gynocologic Malignancy Cases

Question 1

Location: Primary Care Office

64 y/o postmenopausal patient presents with concerns for persistent itching of her left vulvar area.

what else would you like to know?

Answer 1

1. sexually active?
2. discharge?
3. past STD?
4. lesions?

Question 2

Location: Primary Care Office

64 y/o postmenopausal patient presents with concerns for persistent itching of her left vulvar area.

if it’s unilateral only and there is a lesion

PMH HTN, well controlled on Lisinopril, hypothyroidism, well controlled on levothyroxine, previous vulvar itching that was diffuse and improved with steroid ointment approximately 1 year ago

PSH: 2 prior cesareans, appendectomy

FH: thyroid disease

PE: largest lymph node 2 cm left groin (multiple bilateral 1 cm lymph nodes), 1.5 cm lesion on left vulva, vagina is pale and atrophic without lesions or discharge, cevix is pale but no mucus or draining

diagnosis?

Answer 2

do a biopsy

squamous cell carcinoma of vulva

Question 3

what does squamous cell carcinoma of the vulva look like histologically?

Answer 3

1. reduced stroma with lymphocytes
2. atypical tumor cells
3. atypical mitosis
4. keratinous pearl (looks like a pink onion)

Question 4

how do you treat squamous cell carcinoma?

Answer 4

evaluation for distant metastasis with PET/CT

1. if locally advanced disease that is resectable, plan for modified radical vulvectomy/left inguinofemoral lymph node dissection
2. if distant disease, plan for chemotherapy

lymph node involvement is the most important predictor of patient prognosis – patient’s presenting with lymph node involvement (Stage III) have an overall survival of 43% at 5 years – those with distant spread consistent with Stage IV disease have an overall survival of 13% at 5 years

Question 5

Location: Emergency department

56 y/o postmenopausal patient presents with concerns for abdominal pain/discomfort, nausea/early satiety

PMH: Hypertension, GERD

PSH: Appendectomy, cesarean section
OB/Gyn Hx: G2P2, LMP at 51 yo, no HRT use

FH: mother/grandmother with breast cancer, uncle with prostate cancer, brother with pancreatic cancer

abdomen mildly tender to palpation in the lower abdomen, palpable nodule at the umbilicus that is mildly tender to palpation and measuring 2 cm, dull to percussion with fluid wave

uterus is anteverted, small, NT, immobile with palpable nodularity on rectovaginal examination

adnexae: Left adnexal mass palpable and immobile on examination; unable to palpate right adnexa.

Answer 5

ovarian cancer, Meig’s syndrome, maybe ectopic pregnancy if it was a younger patient but this lady is 56

CT of abdomen and pelvis would help since she has multisystemic involvement

Question 6

what are the non-gynecologic and gynecology tumor markers?

Answer 6

non-gynecologic
CA 19-9, CEA

gynecologic:
CA125, CEA, AFP, B-hCG, LDH, inhibin A/B

Question 7

CA125 marker

Answer 7

epithelial ovarian cancer

Question 8

CEA marker

Answer 8

mutinous ovarian cancer

Question 9

HCG marker

Answer 9

embryonal carinoma

choriocarcinoma

Question 10

inhibin A/B marker

Answer 10

granuloma cell tumor

Question 11

lactate dehydrogenase marker

Answer 11

dysgerminoma

Question 12

alpha-fetoprotein marker

Answer 12

endodermal sinus tumor

embryonal carcinoma

Question 13

what is the most common malignant ovarian cancer?

Answer 13

epithelial ovarian cancer

average age of diagnosis is 63

can be serous, mucinous, endometriod, clear cell, transitional

Question 14

what are the 3 histologic types of varian cancer?

Answer 14

1. epithelial ovarian cancers

serous, mucinous, endometriod, clear cell, transitional

2. sex cord stromal cancers

granulosa cell, thecoma, fibroma, sertoli cell, sertoli-leydig, steroid

3. germ cell cancers (rare and usually benign)

dysgerminoma, yolk sac, embryonal carcinoma, choriocarcinoma, teratoma