Lower Genital Tract Malignancies

Question 1

Lifetime risk for HPV in sexually active men and women is at least ___%.

By 50 years of age, at least __% of women will have acquired genital HPV infection.

Answer 1

50%

80%

Question 2

An estimated 74% of new HPV infections occur in sexually active individuals ____-____ y/o

In studies of women ____ y/o, prevalence rates ranged from 28-46%

Answer 2

15–24

<25 y/o

Question 3

__ is a non-enveloped double-stranded DNA virus

Answer 3

HPV

Question 4

Over __ HPV types have been Identified.

Of these, ___-___ are anogenital types and ____-____ are oncogenic types

Answer 4

> 100
30-40
15-20 (16, 18, 31, 33, 35, 39, 45, 51, 52, 58)

Question 5

HPV __ and __ are most often associated with external genital warts.

Answer 5

6
11

these cause 90% of genital warts

Question 6

At what age are women at highest risk for HPV? Men?

Answer 6

W = 20-24 y/o
M = 25-29 y/o

Question 7

What are RF for HPV?

Answer 7

Early age of first coitus
Numerous sexual partners
Uncircumcised
Smoking

Question 8

___% of HPV is a transient infection

Median time to clearance = ___ months

Answer 8

80%

8 months

Question 9

What types of CA is most common with HPV?

Answer 9

Cervical: >95% (70% caused by 16 and 18)
Cutaneous squamous cell: 90%
Anal: >70%
Vaginal/Vulvar/Penile: >50%

Question 10

The HPV vaccine is approved for ages __-___ y/o

Answer 10

9-26 y/o

Question 11

Cervarix: effective against __ and __HPV types

Gardasil: effective against HPV types __, __, ___, ___

9-valent vaccine?

Answer 11

16 and 18

6, 11, 16, 18

6, 11, 16, 18, 31, 33, 45, 52, 53

Question 12

What are the 3 precursor HPV lesions?

Answer 12

Vulvar intraepithelial Neoplasia (40-50 y/o)
Vaginal intraepithelial Neoplasia
Cervical Intraepithelial Neoplasia (30-40 y/o)

Question 13

With Vulvar Intraepithelial Neoplasia
__% are asymptomatic

Sx include: ___, ___

What does the lesion look like?

Answer 13

50% asymptomatic

Pruritis, chronic irritation

Lesion: whitish, thickened, rough, 10-15%, hyperpigmented (watch for ulceration)

Question 14

How do you dx Vulvar Intraepithelial Neoplasia?

Answer 14

High suspicion in pts with abnormal pap, cervical dysplasia

Acetic acid stain
Colposcopy
Bx

Question 15

What is the tx for Vulvar Intraepithelial Neoplasia?

Answer 15

Laser vaporization
Excision
Imiquimod

Question 16

What is the recurrence rate for Vulvar Intraepithelial Neoplasia after tx?

What can be used to reduce recurrence rate?

Answer 16

25-50%

5-Fluoro-Uracil cream

Question 17

Vulvar CAs make up __-___% of gyn malignancies

Answer 17

4-5%

Question 18

Median age for vulvar CA is __ y/o

Answer 18

68 y/o

56% >65, 10% <45

Question 19

What puts a pt at higher risk for developing vulvar CA? (x4)

Answer 19

Poor SES
HVP infxn in younger pts
Smoking
H/O granulomatous venereal infection

Question 20

What are sx of vulvar CA? (x6)

Answer 20

Pruritus
Mass
Ulceration
Bleeding
Discharge
Pain

Question 21

How do you dx vulvar CA?

Answer 21

Bx

Question 22

What are the 4 types of vulvar CA types, which are most common?

Answer 22

Squamous cell CA: 86%
Melanoma: 5%
Adenocarcinoma: 1%
Other: 8%

Question 23

How do you tx EARLY vulvar CA?

Answer 23

Radical wide local excision w/ 2 cm margin

Inguinal lymphadenectomy or sentinel node bx (unilateral if lesion is lateral)

***Radical complete vulvectomy rarely necessary

Question 24

How do you tx LATE vulvar CA?

Answer 24

Radiation therapy
Chemotherapy
Radical excision, possible skin flap
**Exenteration rarely necessary (remove bladder, vagina, rectum)

Question 25

What is the survival rate from squamous vulva carcinoma for the following stages: Localized ___% _____ 5 yr survival Regional ____% ____ 5 yr survival Distant ___% _____ 5 yr survival

Answer 25

Localized: 60%, 87% Regional: 31%, 54% Distant: 5%; 14%

Question 26

The approach to dx and tx of vaginal CA is similar to the tx of ____ CA Tx includes?

Answer 26

Cervical Surgery External and intracavitary radiation

Question 27

What is the sensitivity and specificity for the pap smear screen for cervical CA?

Answer 27

Sensitivity: 26-92% (high for CA, low for dysplasia) Specificity: 90-97%

Question 28

How much does a pap smear usually cost and does it actually reduce mortality?

Answer 28

$70 | It does reduce mortality

Question 29

20%+ false negative results are due to ____ or ____

Answer 29

misinterpretation | inadequate sample

Question 30

The pap smear uses the _____ to evaluate the results

Answer 30

Bethesda System

Question 31

T/F: Cervical Intraepithelial Neoplasia are asymptomatic

Answer 31

T

Question 32

How do you dx a Cervical Intraepithelial Neoplasia?

Answer 32

Abnormal Pap smear - Colposcopy - Directed bx - Endocervical curettage - Test for high risk HPV types 16, 18

Question 33

What is the tx for the following? HPV infxn, CIN I : ______ CIN II in young pts : ______ CIN II, III, CIS : _____

Answer 33

HPV infection, CIN I : Observation CIN II in young pts : - Close observation if f/u reliable - Tx if poor follow-up or persistence CIN II, III, CIS : Immediate tx

Question 34

What is the tx for Cervical Intraepithelial Neoplasia?

Answer 34

Destructive therapy - Cryotherapy - Laser vaporization Excisional therapy - Loop Electrical Excision Procedure (LEEP) - Cold Knife Conization (CKC)

Question 35

What is the median age for cervical CA? What % of pts are <45 y/o

Answer 35

48 yrs 40%

Question 36

What are the RF for cervical CA?

Answer 36

``` HPV infxn Young age at first coitus Multiple partners Smoking Low SES Metropolitan areas Underdeveloped countries ```

Question 37

What are the signs of cervical CA?

Answer 37

Postcoital spotting (most common) Vaginal discharge/bleeding Pelvic pain radiating to the leg Dysuria / hematuria / rectal bleeding

Question 38

What are signs of cervical CA on the cervix during PE?

Answer 38

Friable, exophytic mass Necrotic ulceration Barrel shaped cervix

Question 39

What are signs of cervical CA in the PE is you are looking at the pelvis ?

Answer 39

Firm mass in the parametrium | Induration of the upper vagina

Question 40

Where may you find lymphadenopathy if a pt has cervical CA?

Answer 40

Inguinal | Supraclavicular

Question 41

What are the indications for bx of the cervix?

Answer 41

Abnormal findings on exam Mass or ulceration seen Abnormal Pap smear

Question 42

What is the most common cervical CA cell type?

Answer 42

``` Squamous CA (80-90%) Adenocarcinoma (5-15%) ```

Question 43

What is the tx for EARLY Cervical CA lesions?

Answer 43

Conization Simple hysterectomy Radical hysterectomy - radical trachelectomy (small lesions) - pelvic lymphadenectomy External and intracavitary radiation

Question 44

What is the tx for LATE Cervical CA lesions?

Answer 44

External radiation therapy Intracavitary radiation therapy Interstitial radiation therapy Sensitizing chemotherapy (Cisplatin, 5-Fu, gemcitabine)

Question 45

What is the cervical CA survival for the following stages: Localized ___% _____ 5 yr survival Regional ____% ____ 5 yr survival distant ___% _____ 5 yr survival

Answer 45

Localized: 47%; 91% Regional: 36%; 57% Distant: 12%; 16%

Question 46

How can you prevent lower genital tract malignancies?

Answer 46

``` HPV vaccination Reduce risk of sexually transmitted infxns Do not have sex early Do not smoke Get regular screening exams ```