Neoplasms Flashcards
What is definitive treatment for moderately differentiate vulvar squamous cell carcinoma?
Radical vulvectomy and groin node dissection
Squamous cell carcinoma is most common vulvar malignancy and may arise in setting of chronic irritation from lichen sclerosus.
DDx for vulvar squamous cell carcinoma:
- Shiny red/purple polygonal papules and plaques
- Thin, inelastic, white, “crinkled tissue paper” appearance
- White plaque-like lesions and poorly demarcated erythema
- Cauliflower-like lesions
- Lichen planus
- Lichen sclerosus
- Paget’s disease of the vulva (in situ carcinoma of vulva)
- Verrucous carcinoma
Bartholin gland mass - making the differential
Abrupt onset, post-menopausal: Primary vulvar adenocarcinoma is most likely
Slower onset: Fibroma, lipoma; younger age - benign Gartner’s duct cyst
Indications for trichloroacetic acid or imiquimod
Condyloma
Indication for cryotherapy
Cervical dysplasia
Flat, subtle, white vulvar lesions
Suggestive of vulvar dysplasia from HPV
DDx: Condyloma would be less flat
Indications for laser treatment
Vulvar HSIL with multifocal lesions
What are the guidelines regarding cervical screening? What are the special rules for ages 21-24?
If cytology shows ASCUS, either test for HPV now (+ —> colposcopy, — —> resume 3 years) or test with cytology in 1 year (+ —> colposcopy, — —> resume 3 years)
If 21-24 yo, if HPV+, repeat cytology at 12 months rather than colposcopy
What are signs of cervical cancer, and which are most concerning?
Atypical vessels (hairpin shapes or larger vessels branching from smaller ones)
Punctation = new blood vessels on end
Mosaicism = new blood vessels on their sides
Ectropion = columnar epithelium not yet undergone squamous metaplasia - reddish ring of tissue surrounding external os
Acetowhite epithelium can represent dysplasia but is less concerning
When should cervical screening be stopped?
Age 65 if negative 3x in a row or co-test negative 2x in a row in past 10 years
Continue if history of moderate-severe dysplasia or cancer
Risk factors for ovarian cancer; what is protective?
Low parity; delayed childbearing
Long-term suppression of ovulation appears to be protective against ovarian cancer - use OCPs
Different types of ovarian cysts
Functional ovarian cyst - 3-5 cm, form at time of ovulation; no blood, soft tissue elements or excrescences
Endometrioma - isolated collection of endometriosis involving ovary
Serous cystadenoma - larger than functional cysts; increased abdominal girth
Mucinous cystadenoma - multilocular and large
Dermoid tumor - solid components, echogenic; teeth, cartilage, bone, fat, hair
What is a routine part of ovarian cancer staging?
Omentectomy - does not spread hematogenously, but rather transcoelomic (across peritoneal surfaces)
Pelvic lymphadenectomy (but not inguinal)
What are the ovarian tumor subtypes? What are their risks?
Epithelial (90%) - malignant usually 6th decade of life
Germ cell (5%) - 10-30 yo
Sex-cord stromal (1-2%): granulosa cell tumors secrete high levels of estrogen —> endometrial hyperplasia or cancer
What typically causes ovarian torsion (lower quadrant pain, abdominal tenderness, on exam adnexal fullness and moderate tenderness and some voluntary guarding)
Dermoid cyst/mature cystic teratoma - enlarges ovary and are oily, which means less dense than surrounding tissue, rising to more anterior position and creating instability of infundibulopelvic ligament
What should someone with BRCA1?
Bilateral salpingo-oophorectomy between 35-40 yo
BRCA2 can be postponed to after age 40
What are the germ cell tumor markers to order?
LDH: Dysgerminoma
hCG: Choriocarcinoma
AFP: Yolk sac or endodermal sinus tumors
Inhibin: granulosa cell tumor - would also have elevated estrogen
What are the risk factors for endometrial cancer?
Nulliparity; late menopause; unopposed estrogens; obesity; HTN; diabetes
Not typically genetically inherited except for Lynch II syndrome
Signs of endometrial cancer
Bleeding; vaginal discharge; abdominal pain
What should be done for postmenopausal woman with light spotting?
Pelvic transvaginal ultrasound or endometrial biopsy - to rule out cancer
Causes: atrophy of endometrium; menopause hormone therapy; endometrial cancer; polyps; endometrial hyperplasia
What should you do if a patient has a new palpable breast mass or lymph node?
Needle aspiration
How do OCPs affect various cancer risks?
Decreased risk of ovarian and endometrial (ever used)
Increased risk of cervical (current or recent use)
Call-Exner bodies
Granulosa cell tumor
LDH and rapidly enlarging, painful pelvic mass
Dysgerminoma
Elevated bhCG and AFP, and rapidly increasing pelvic pain
Embryonal carcinoma
What is struma ovarii?
Mature teratoma that produces thyroxine
How is choriocarcinoma staged?
Chest x-ray, not CT
Cuboidal, non-ciliated epithelium in ovarian mass is?
Cystadenoma (benign)
Dysgerminomas secrete…
LDH, bhCG
what is imiquimod used for?
Warts, VIN
Condyloma acuminata can be treated how?
Imiquimod (induces local cytokines)
Trichloroacetic acid
BRCA1 and BRCA2 should undergo what ovarian cancer screening?
Pelvic US and CA-125 q6months starting at 30 yo
How does atypical glandular cells on Pap test affect workup if <35 vs >=35?
> =35 or <35 with risk factors of endometrial cancer (abnormal uterine bleeding, anovulation, obesity) - add endometrial biopsy
All cases require colposcopy and endocervical curettage
Endometrial cells on Pap test are worked up how, based on age?
<45: benign
>=45, especially postmenopausal: endometrial biopsy
Does atypical squamous cells of undetermined significance suggest increased risk of cancer?
No, not without positive HPV status
Hydatidiform mole vs fibroids
Mole is soft, cystic villi, not irregular uterine enlargement or firm mass
What should be evaluated in new-onset constipation with early satiety and pain, unrelated to bowel movements in female >=50 yo?
Malignancy - ovarian cancer, colon cancer
Risk factors for hydatudiform mole
Infertility
Extremes of age (<=15 and >35)
Do women with postmenopausal bleeding require a Pap test?
Yes - cervical cancer peak is ~50 years old
Complete vs partial mole
Complete is one sperm, empty ovum; 46,XX, no fetal tissue
Partial is two sperms, normal ovum; 69,XXY, fetal tissue
Fat necrosis calcifications
Coarse (not micro)
Postmenopausal vaginal cancer tends to be what?
Squamous (as opposed to adenocarcinoma in younger)
Inhibin is marker for what ovarian cancer?
Granulosa
LDH marker and sheets of uniform “fried egg” cells
Dysgerminoma
Which ovarian cancer can secrete both AFP and bHCG?
Embryonal carcinoma
