Neoplasms Flashcards
Cervical Intraepithelial Neoplasia (CIN)
The abnormal growth of potentially precancerous cells in the cervix. Most cases remain stable or are eliminated by the host’s immune system without intervention
Atypical squamous cells
Nuclear atypia is present but is not sufficient to warrant the dx of squamous intraepithelial lesion
ASC-US
Atypical squamous cells of undetermined significance
ASC-H
Cytologic changes suggestive of HSIL, but lacking definitive interpretation
Has a significantly higher predictive value for diagnosing CIN2 or CIN2 than ASC-US Paps
Management of ASC-US Paps
Repeat Pap smear until there are 2 consecutive normal Paps
OR
Immediate colposcopy
OR
DNA testing for high-risk types of HPV
Those women with ASC-US Pap smears who test positive for high-risk HPV should undergo colposcopy
Those who test negative should have a Pap in 1 yr
A woman with ASC-US and positive HPV results has the same risk for high-grade dysplasia as if she had an LSIL Pap smear and thus requires colposcopic eval
A woman with ASC-US and negative HPV can be reassured, treated as if she had a nl Pap smear, and followed with a Pap in 1 yr
Atypical glandular cells
Atypia that is of glandular rather than squamous origin
More likely to be serious with glandular abnormalities than an ASC-US Pap, so the work up is more aggressive than with an ASC-US Pap
If ID-ed, it will also report endocervical adenocarcinoma and adenocarcinoma in situ
Subdivisions of atypical glandular cells
Atypical endocervical
Atypical endometrial
Atypical glandular cells not otherwise specified
It may also say “favors neoplasia”
Atypical glandular cell management
All pts with AGC Pap smears should have colposcopy with endocervical sampling with the exception of pts with atypical endometrial cells
In those pts who have an AGC Pap smear with an abnormal bleeding hx, or who are >35 yrs, an endometrial bx should be added to the initial colposcopy and endocervical sampling
Atypical glandular cells, not otherwise specified management
If the initial work-up is negative, repeating Paps at 4 to 6-month intervals is indicated until there are 4 consecutive, negative Pap smears
Atypical glandular cells, favors neoplasia management
If the initial work up is negative these pts are treated in the same manner as those with adenocarcinoma in situ Pap smears and require a diagnostic excisional procedure
Low-grade Sqamous Intraepithelial Lesions
Includes findings of CIN1 (mild dysplasia) and findings consistent with HPV infection
High-grade Squamous Intraepithelial Lesions
CIN2 and CIN3 lesions (moderate dysplasia, severe dysplasia, and carcinoma in situ)
LSIL management
Referral for colposcopy May do "watchful waiting" if under 25 yoa Endocervical sampling (along with biopsies of any lesions visualized on colposcopy)is considered preferred in pts with unsatisfactory colposcopy or in those with satisfactory colposcopy and no lesion identified.
Where are abnormal biopsy samples from LSIL colposcopy sent?
Pathologist determines if there is any evidence of precancerous changes, called cervical intraepithelial neoplasia
These changes are categorized as being mild (CIN1) or moderate to severe (CIN 2 or 3)
Management of LSIL biopsy that confirms CIN1
If the lesion does not extend into the endocervical canal, pts can be followed with serial Pap smears with or without colposcopy for up to 24 mos before tx is necessary
What if LSIL bx confirms CIN1 and the lesion extends into the cavity?
An excisional procedure is recommended
HSIL management
All women should receive colposcopy with bx of any abnl areas along with endocervical sampling
Excisional procedures are recommended if the entire cervix is not able to be visualized during the colposcopy if over 24 yoa
When should excisional procedures be performed with HSIL?
If the cervix, during colposcopy, appears clearly abnormal, with follow up done based on pathology report
Types of cervical CA
Squamous cell carcinoma -About 80-85% Adenocarcinoma Adenosquamous carcinoma Neuroendocrine carcinoma
RFs for cervical CA
HPV infection
Smoking
HIV infection
Chlamydia infection
Dietary factors (diets low in fruits and veggies)
Hormonal contraception
Multiple pregnancies
Age less than 17 with first full-term pregnancy
Exposure to the drug diethylstilbestrol (DES)
FHx of cervical CA
Stage 0 cervical CA
Full thickness involvement of the epithelium without invasion into the stroma (carcinoma in situ)
Stage IA cervical CA
Dx-ed only by microscopy, no visible lesions
IA1- stromal invasion <3 mm in depth and 7 mm or less in horizontal spread
IA2- stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or less
Stage IB cervical CA
Visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of more than 7 mm, no spread to nodes or other organisms
IB1- visible lesion less than 4 cm greatest dimension
IB2- visible lesion more than 4 cm
Stage IIA cervical CA
Without parametrial invasion, but may involve upper 2/3 of vagina
IIA1- visible and less than 4 cm, no node involvement, no distant sites
IIA2- visible and greater than 4 cm, no node involvement, no distant sites
Stage IIB cervical CA
With parametrial invasion, no node involvement
Stage I cervical CA
Limited to the cervix, no spread to nodes
Stage II cervical CA
Invades beyond cervix
Stage III cervical CA
The CA has spread to the lower part of the vagina or the walls of the pelvis. The CA may be blocking the ureters. It has not spread to nearby LNs or distant sites
Stage IIIA cervical CA
The CA has spread to the lower third of the vagina but not to the walls of the pelvis. It has not spread to nearby LNs or distant sites
Stage IIIB cervical CA
Either:
The CA has grown into the walls of the pelvis and/or has blocked one or both ureters, but has not spread to LNs or distant sites
OR
The CA has spread to LNs in the pelvis but not to distant sites. The tumor can be any size and may have spread to the lower part of the vagina or walls of the pelvis
Stage IVA cervical CA
Invades mucosa of bladder or rectum and/or extends beyond true pelvis, no nearby nodes are involved, no distant organs or involved
Stage IVB cervical CA
Distant metastasis, such as lung or liver
Tx of stage IA cervical CA
Usually treated by hysterectomy, or if she desires to maintain fertility, by cone bx, providing margins are clear
Tx of stage IA2 cervical CA
Same as stage IA, but LNs are removed as well
What may also be performed on women with early cervical CAs (smaller than 2 cm) who desire to preserve their fertility?
Radical trachelectomy
The cervix, 2 cm of the upper vagina, and the pelvic nodes are removed with a cerclage placed in the lower uterine segment
Tx of stages IB1 and IIA of cervical CA
Radical hysterectomy with removal of the LNs or external beam radiotherapy
to the pelvis and brachytherapy (internal radiation)
May be given with or without chemo in order to reduce the risk of relapse
Tx of stages IB2 and IIA of cervical CA
Radiation therapy and cisplatin-based chemo, hysterectomy (which then usually requires adjuvant radiation therapy) or cisplatin chemo followed by hysterectomy
Tx of IIB-IVA cervical CA
Radiation and cisplatin-based chemo
Cervical CA follow-up
Includes detailed H&P, particularly abdominal complaints and LN assessment
Cervical CA can recur in 15-61% of cases in the first 2 yrs
Complaints worrisome for the recurrence of cervical CA
Vaginal bleed or d/c Bleeding after intercourse Abdominal or pelvic pain Urinary sx Change in bowel habits
Worrisome PE findings for the recurrence of cervical CA
Enlarged LNs (in particular groin or supraclavicular)
Vaginal lesions that are friable, raised or nodular
Nodularity in the rectovaginal septum
Palpable mass at any location, particularly the pelvis
Locations of vulvar CA
Most often affects labia, but may start on the clitoris or in glands on the sides of the vaginal opening
Type of vulvar CA
Majority of vulvar CAs are of squamous origin Other possibilities: Melanoma Adenocarcinoma Sarcoma Basal cell carcinoma
When in life does vulvar CA usually occur?
After menopause, in women age 50 or older
However, numbers in younger women are climbing
RFs of vulvar CA
Previous HPV infection
Previous cervical or vaginal CA, or syphilis infection
Who has a greater risk of developing vulvar CA that metastasizes?
Women with a condition called vulvar intraepithelial neoplasia
Vulvar CA sx
Ulcer, thickening, or lump -Usually on the labia majora -May be anywhere on the vulva Local itching, pain, burning, bleeding Pain with urination Pain with intercourse Unusual odor Nearly 20% with vulvar CA have no sx
Dx of vulvar CA
Pelvic exam to look for any skin changes
Excision and bx of the lesion to make an accurate dx
80% cure rate
Appearance of squamous vulvar carcinoma and adenocarcinoma
Usually appear as a growth on the surface of the vagina
Squamous carcinoma may present as an open sore (ulcer)
Adenocarcinoma may lie deeper so that it is not visible and detected only by palpation
Appearance of vaginal melanoma
Brown or black skin tag (polypoid), growth attached to the vaginal wall by a stem (pedunculated), nipple-like growth (papillary), or fungus like growth (fungating)
Appearance of sarcoma- vulvar CA
Grape-like mass
Tx of vulvar CA
Surgery to remove the CA cells. If the tumor is large (>2 cm) or has grown deeply into the underlying skin, the LNs in the groin area may also be removed
Radiation, with or without chemo, may be used to treat advanced tumors or vulvar CA that comes back
Stage 0 vulvar CA
Carcinoma in situ
Intraepithelial neoplasia grade III
Stage I vulvar CA
Lesion <2 cm
Confined to the vulva or perineum
No nodal metastasis
Stage Ia vulvar CA
Lesion <2 cm
Confined to the vulva or perineum and with stroma invasion 1 mm; no nodal metastasis
Stage Ib vulvar CA
Lesion <2 cm
Confined to the vulva or perineum and with stromal invasion >1 mm
No nodal metastasis
Stage II vulvar CA
> 2 cm in greatest dimension
Confined to the vulva and/or perineum
No nodal metastasis
Stage III vulvar CA
Tumor of any size with adjacent spread to the lower urethra and/or vagina or anus and/or unilateral regional LN metastasis
Stage IVa vulvar CA
Tumor invasion of any of the following: Upper urethra Bladder mucosa Rectal mucosa and/or pelvic bone and/or bilateral regional node metastases
Stage IVb vulvar CA
Any distant metastasis, including pelvic LNs
