Neoplasia Flashcards
Risk factors for endometrial cancer
Nulliparity, obesity (10 fold increase if > 50lbs overweight), late menopause, hypertension and exposure to unopposed estrogens
% of women with complex atypical endometrial hyperplasia that will have endometrial cancer on biopsy
~30%
% of women diagnosed with endometrial cancer that are asymptomatic
Less than 5%
Hereditary uterine cancer syndromes
HNPCC (Lynch II due to DNA mismatch repair) and LiFraumeni syndrome (p53 mutation)
Top 5 cancers detected in women
Breast 28%, Lung 14%, Colon 10%, Uterine 6%, Ovary 3%
Top 5 GYN cancers diagnosed in women
Uterine 52%, Ovary 26%, Cervix 14%, Vulva 5%, Vagina 3%
Incidence of endometrial cancer in postmenopausal women with abnormal uterine bleeding
4-25%
Next step in a post-menopausal woman with vaginal bleeding and suspicious endometrial sampling of atypical cells.
Endometrial sampling has a 99% detection rate in postmenopausal women and D&C should follow for further investigation.
A patient presents with stage I endometrial adenocarcinoma. What additional test should you do to ensure no distant metastasis?
CXR. The lungs are the most common site of spread of endometrial cancer. MRI, CT, PET and CA-125 are not indicated for non-invasive endometrial cancer.
When do you see theca-lutein cysts
Pregnancy, typically bilaterally
A perimenopausal woman presents with an adenxal mass and new vaginal bleeding. What is the most likely ovarian neoplasm?
Granulosa cell tumor, due to increased production of estrogen and endometrial hyperplasia
Most common causes of postmenopausal vaginal bleeding
Atrophy of the endometrium (60-80%), hormone replacement therapy (15-25%), endometrial cancer (10-15%), polyps (2-12%), and hyperplasia (5-10%).
u/s findings that make endometrial cancer less likely
Endometrial lining
When might you consider doing a TVH +/-BSO in a woman with endometrial cancer over a TAHBSO?
If she has well-differentiated endometrial adenocarcinoma
Recommendation for endometrial cancer screening in a 68 year old woman on Tamoxifen for breast cancer
Annual exams
Risk factors for ovarian cancer
Nulliparity, family history, early menarche and late menopause, white race, increasing age and residence in North America and Northern Europe
What can decrease the risk of ovarian cancer in a woman by half?
OCPs. The risk of ovarian cancer in the general population is 1%, these can cut it down to 0.5%.
What percentage of breast and ovarian cancers in the US are attributable to BRCA 1 and 2 mutations?
5-10% of breast cancers and 10-15% of ovarian cancers
How can you differentiate a serous cystadenoma, mucinous cystadenoma and a functional ovarian cyst on ultrasound?
A functional cyst will be unilocular without evidence of blood, soft tissue or excrescences. Serous cystadenomas are typically larger than functional cysts and patients present with increasing abdominal girth. Mucinous cystadenomas tend to be large and multilocular.
What is involved in the staging process of ovarian neoplasms?
Vertical skin incision, ascites cytology, inspection of peritoneal cavity, TAHBSO, omentectomy and pelvic/para-aortic lymph node dissection.
What determines the prognosis of a patient with ovarian cancer?
Stage and maximum debulking of tumor to
What is the standard of care for women with advanced (stages III and IV) ovarian cancer in the US?
Surgical debulking followed by 4-6 rounds of chemotherapy with platinum agent + taxane agent. The overall response rate for this regimen is 60-80% and the 5-year survival for advanced cancer is 30%.
Most common ovarian tumor found in women
Dermoid. 80% occur during child-bearing years with a median age of 30.
Groups at higher risk for molar pregnancies
Asian women in the U.S., age 40, beta-carotene/folic acid deficient, and having 2 or more miscarriages.
Risk of recurrence for 1 molar pregnancy? 2?
1 = 1-2%. 2 = 10%.
What is responsible for the “snowstorm appearance” of this uterus on u/s?
Multiple hydropic villi in a complete molar pregnancy
Classic presentation of a complete molar pregnancy
Vaginal bleeding, uterus measuring greater than dates, no fetal parts (partial parts in partial moles), beta-hCG elevated (> 1,000,000 can be diagnostic), tachycardia and hypertension.
What beta-hCG level tells you that you should definitely find a pregnancy on TVUS, and if not, you should at least find a molar pregnancy or ectopic pregnancy?
> 1,500
Standard management for molar pregnancies
Suction and curettage. MTX of she develops gestational trophoblastic disease after suction and curettage.
What type of molar pregnancy has a higher risk for development of post-molar gestational trophoblastic disease (GTD)?
Complete (46XX, XY or YY). Partial (69XXY) moles have no risk for choriocarcinoma.
What are the differences between complete and partial molar pregnancies?
Partial moles may contain fetus/fetal parts, placenta/cord; complete moles do not. Partial moles are triploid karyotype (usually 69XXY, 69XXX, or 69XYY) resulting from fertilization of egg by dispermy; complete moles are diploid resulting from fertilization of “empty egg” by single sperm (46XX, 90%) or by two sperm (X & Y = 46XY 6-10%). Partial moles show marked villi swelling; complete moles show trophoblastic proliferation with hydropic degeneration. Clinically, partial moles present with lower Beta-hCG levels, affect older patients, have longer gestations, and are often diagnosed as missed or incomplete abortions. Complete moles usually present with larger uteri, preeclampsia and higher likelihood of developing into post-molar GTD.
How long should women wait after a molar pregnancy before trying to get pregnant again?
6 months. Resolution of the molar pregnancy and development of post-molar GTD is measured by beta-hCG levels (biopsy of choriocarcinoma is contraindicated because lesions are so vascular). If the patient gets pregnant then surveillance will be incomplete.
When do you bring chemotherapy on board when molar pregnancy is involved?
After resolution of the mole and presentation of choriocarcinoma, invasive moles or post-molar GTD.
Risk factors for persistence of molar pregnancy after evacuation
Large uterus, theca lutein cysts, high Beta-hCG
What must you do before treating a woman with topical steroids for lichen sclerosus?
Biopsy to r/o SCC
When do you recommend radical vulvectomy with groin lymph node dissection in a patient with hx of lichen sclerosis?
Findings of obvious, moderately differentiated carcinoma on punch biopsy.
When do you recommend wide local excision in a patient with hx of lichen sclerosis?
Microinvasive SCC
Most common vulvar cancers
SCC accounts for 90% of them
Risk factors for SCC of the vulva
Age > 65, smoking, hx of HPV and the chronic itch scratch cycle associated with lichen sclerosis
How does Paget’s disease of the vulva present?
This is in situ carcinoma of the vulva with weak association with breast cancer. Lacy white plaque-like hyperkeratotic lesions and poorly demarcated erythema on the vulva, no masses. Does not respond to topical steroids.
What cancer do you need to r/o if a patient presents with a pigmented vulvar lesion?
Melanoma, it represents ~5% of vulvar cancers despite minimal sun exposure.
Presentation of molluscum contagiosum on vulvar exam
Multiple shiny non-pigmented papules with a central umbilication
Presentation of vulvar intraepithelial neoplasia
Genital warts -> multicentric brown-pigmented papules
Next step once you find a mass in Bartholin’s gland
Excision/biopsy, especially in a post-menopausal women who rarely have new Bartholin cysts. This should make you highly suspicious of adenocarcinoma.
TX for VIN III
Local superficial excision and close supervision because these tend to have a high rate of recurrence
Medical treatments for condyloma acuminata
Trichloroacetic acid and/or imiquimod. Note that imiquimod has also been shown to be effective in low grade VIN.
Vulvar diseases you have to worry about when people are on immunosuppressive therapy
New condyloma/VIN from underlying HPV infection, yeast infections
TX for multifocal VIN lesions
CO2 laser ablation. Skinny vulvectomy is an option
Cervical cancer risk factors
Smoking and HPV exposure (early-onset sexual activity, multiple sexual partners, a sexual partner with multiple partners, history of HPV or other STDs, immunosuppression, smoking, low socioeconomic status and a lack of regular Pap smears)
Management options for a patient with ASCUS on pap smear
HPV DNA testing or repeat cytology at 12 months. If the HPV test is negative routine screening can be resumed at 3 years. If HPV is positive, or if repeat cytology at 12 months reveals ASCUS or higher, then colposcopy should be performed. Women ages 21 – 24: if HPV is positive, then repeat cytology at 12 months is recommended with colposcopy performed only if the repeat cytology reveals ASC-H (atypical squamous cell – cannot rule out high grade squamous intraepithelial lesion), AGC, or HSIL.
1st step in making the diagnosis of cervical cancer in a patient with a clinically apparent lesion
Cervical biopsy. Conization is not done because you can see the lesion, pap is not done because it is a screening test.
What should you do next if you see a small white cervical plaque on speculum exam?
Pap smear + cervical biopsy. Paps have a false negative rate of 20-30%. If pap is normal and biopsy shows no evidence of cervical dysplasia continue with routine screening.
What is an ectropion
An area of columnar epithelium that has not yet undergone squamous metaplasia. It appears as a reddish ring of tissue surrounding the external os.
Why are punctations and mosaicism concerning on colposcopy?
Punctations and mosaicism represent new blood vessels on end and on their sides, respectively. Atypical vessels usually represent a greater degree of angiogenesis.
What are indications for cervical conization (LEEP/cold knife)?
1) Unsatisfactory colposcopy (inability to visualize the entire transformation zone) 2) Positive endocervical curettage 3) Pap smear indicating adenocarcinoma in situ 4) Cervical biopsies that cannot rule out invasive cancer 5) Substantial discrepancy between Pap smear and biopsy results
Microinvasive cancer
Invades no further than 3mm beyond the basement membrane
When is hysterectomy indicated for cervical cancer?
When it becomes invasive
What are the guidelines for screening for cervical cancer?
21-29 yo: Start at age 21. Paps every 3 yrs. 30-65 yo: Pap + HPV test every 5 yrs or Pap every 3 yrs. 65+ yo: Stop screening if no hx of moderate to severe dysplasia, 3 negative Paps in a row, or 2 negative HPV co-test results in a row within the past 10 years, with the most recent test within the past 5 years. If vaccinated you still follow these guidelines. If history of cervical cancer, HIV, weakened immune system, or exposed to DES before birth do not follow these guidelines.
What is the most common presenting symptom in patients with fibroids?
Menorrhagia due to: 1) Increase in the uterine cavity size that leads to greater surface area for endometrial sloughing 2) Obstructive effect on uterine vasculature that leads to endometrial venule ectasia and proximal congestion in the myometrium/endometrium resulting in hypermenorrhea
Major complications are associated with fibroids during pregnancy
Red (carneous) degeneration due to rapidly expanding size and hemorrhage. Soft tissue dystocia.
Why are submucosal fibroids so strongly associated with infertility? When would you consider doing a myomectomy for non-submucosal fibroids to restore fertility?
Submucosal fibroids: 1) cause focal endometrial vascular disturbance 2) inflammation 3) secretion of vasoactive substances. Myomectomy is indicated when fibroids obstruct the fallopian tubes, cervical canal or endometrial cavity.
Medical tx for fibroids
Continuous GnRH agonists. This suppresses the HPO axis, reduces the amount of estrogen circulating and can shrink the fibroid by 40-60%. (Consequently mostly useful in perimenopausal women and helpful in reducing uterus size before hysterectomy)
Fibroid resection in a woman who wants to preserve fertility
Myomectomy
How long does it take for continuous GnRH therapy to have full effect?
3 months. Hot flashes typically resolve in 3-4 weeks. Once you stop hot flashes should not persist for more than 1-2 months, menses should return in 4-10 weeks, uterine size goes back to baseline by 3-4 months.
