Neoplasms

Question 1

endometrial cancer general characteristics

Answer 1

• MC gyn cancer and 4th MC malig in women in US
• postmen make up 75% pts
• Adenocarcinomas make up 75% cancer cell types
• RF: obesity, nulliparity, infertility, late menopause, DM, unopposed E, HTN, gallbladder dz, chronic tamoxifen use, not related to sexual hx
• white women more likely to develop than black women
• OCPs have protective effect
• SMOKING IS CONSIDERED PROTECTIVE

Question 2

Clinical features, dx, and management of endometrial cancer

Answer 2

• features: cardinal sx = postmen bleeding (90% pts)
  
  • obesity, HTN, DM may be present
• Dx: US, pap, endometrial bx
  
  • endocervical curettage is definitive choice, endometrial bx has accuracy of 90-95%
• management: total hysterectomy with bilateral salpingo-oophorectomy
  
  • radiotx may be indicated, chemo at advanced stages
  • recurrence txd with high dose progestins or antiestrogens

Question 3

PCOS characteristics and clinical features

Answer 3

• MCC androgen excess and hirsutism
• bilaterally enlarged polycystic ovaries, amenorrhea or oligomenorrhea, and infertility
• normal puberty and adolescence followed by progressively longer eps of amenorrhea
• genetic predisposition is somewhat implicated
• increased risk for endometrial hyperplasia and carcinoma d/t unopposed E
• Features: 1/2 pts are hirsute, truncal obesity, acne, menstrual irreg, impaired glucose tolerance in 30% pts

Question 4

PCOS dx and tx

Answer 4

• dx: US - “string of pearls” within ovaries
  
  • lab test - elevated androgen, increased LH/FSH ratio, lipid abnormalities, insulin resistance
• tx: weight reduction improves hirsutism, lipid and glucose parameters, and fertility
  
  • androgen-lowering agents (including OCP)
  • infert treated with clomiphene citrate (clomid)
  • lipid abnlities and insulin resistance managed medically
    
    • metformin increases ovulation and pregnancy rates

Question 5

ovarian CA characteristics and clinical features

Answer 5

• high risk women = older (>/= 69), nulliparous, white, + fhx ovarian or endometrial CA
• long-term OCP may be protective - ovulation suppression
• 10% genetic predisposition, 90% sporadic
• 80% of ovarian CA is epithelial in origin
• Features: dx often delayed d/t no specific sxs
  
  • late dz presents w/ ascites, abdominal distention, early satiety, change in bowel habits, fixed mass
  • sister mary joseph nodule = met at the umbilicus

Question 6

ovarian CA dx, tx, and protective factors

Answer 6

• Dx: BRCA1 associated w/ 5% cases, CA-125 used to follow tx, especially in postmen women
  
  • inhibin A and B
  • transvag or abd US useful in distinguishing benign from malignant
  • histologic exam via bx = dx
• tx: surgery plus chemo and radiation
  
  • chemo = IV carboplatin and paclitaxel
• protective factors: OCP, tubal ligation, BSO (bilat salpingo-oophorectomy), breastfeeding, chronic anovulation, ANYTHING that reduces number of ovulations

Question 7

cervical carcinoma Etiology, RF, sxs, dx, tx

Answer 7

• bimodal distribution (35-39; 60-64)
• RF: HPV exposure, early coitarche, multiple sex partners, immunosuppression, SMOKING, low SE status, lack of reg pap smears
• sxs: postcoital bleeding, vaginal bleeding and d/c, dyspareunia
• dx: abnormal cytology, HPV (+), gross lesion
• tx:
  
  • stage 1: conservative, simple, or radical hysterectomy
  • stage 2 +: chemo +/- radiation

Question 8

cervical dysplasia

Answer 8

• MCC: HPV 16 and 18 (18 MC with adenocarcinoma)
• Most HPV infxns regress in 2 yrs
• HPV not enough to cause cancer itself - requires cofacts (smoking, hormones, OCP (>5y), dietary, immunosuppression (lupus), HIV)
• RF: old, AA, low ES, low edu, increased # sex partners, SMOKING, multiparous,, hx of STD
• Indications for conization (LEEP or cold knife):
  
  • unsatisfactory colpo
  • +endocerv curettage
  • Pap smear indicating adenocarcinoma in situ
  • bx that cannot rule out invasive CA
  • Discrepancy between pap smear and bx result

Question 9

cervical cytology results and recommended next steps

Answer 9

1. ASCUS (atypical squamous cells of undetermined significance)
   
   1. repeat cytology at 6-12 mo
      
      1. if both negative, return to routine screening
      2. if either +, colposcopy
2. AGC (atypical glandular cells of undetermined significance)
   
   1. colposcopy with bx of lesions
3. LSIL (low-grade intraepithelial lesions)
   
   1. colposcopy with bx of lesions
4. HSIL (high-grade intraepithelial lesions)
   
   1. colposcopy with bx of lesions

Question 10

vaginal neoplasia etiology, RF, and sxs

Answer 10

• etiology: 80-90% are mets from cervix, uterus, rectum, bladder
• MC: squamous cell carcinoma, upper 1/3 of vagina, posterior to cervix
• RF: same as cervical CA
• sxs: asymptomatic (found after hysterectomy)
  
  • vaginal bleeding (postcoital or postmenopausal)
  • watery, blood, malodorous discharge
  • vaginal mass
  • urinary sxs: urgency, frequency, dysuria, hematuria
  • GI sxs: constipation, melena

Question 11

vaginal neoplasia dx and tx

Answer 11

• dx: lugols soln (turn’s abnormal areas black)
  
  • punch bx: MC SCC
  • colposcopy
• tx: radiation and surgery
  
  • laser ablation
  • WLE

Question 12

vulvar neoplasia etiology, RF, sxs, dx, tx

Answer 12

• 4th MC, mean age = 65
• RF: age, HPV (16), hx of CIN or other genital malignancy, SMOKING, immunosuppression (HIV, SLE, chronic steroids), vulvar dystrophy (lichen sclerosis)
• sx: hx of lichen sclerosus (vulvar itching, visible vulvar lesions)
  
  • less common: bleeding, pain, ulceration, dysuria, enlarged groin nodes
• dx: Bx, vulvoscopy (acetowhite lesions)
• tx: radical vulvectomy and groin node dissection
  
  • if high risk - chemo

Question 13

Breast cancer RF

Answer 13

• age, sex, first degree relative, BRCA1 or 2
• associated factors: nulliparity, ealry menarche, late menopause, post men ERT or radiation exposure, advanced maternal age at first term birth
• ALL invasive lobular and 2/3 ductal carcinomas are HER2 pos (estrogen-receptor)

Question 14

Breast CA presentation

Answer 14

• single, nontender, firm, immobile mass
• 45% upper outer quadrant, 25% under nipple and areola
• signs: early, no palpable masses
  
  • rare: nipple d/c, retraction, dimpling, breast enlargement, shrinkage, skin thickening or peau d’orange, eczematous changes, breast pain, fixed mass, axillary node enlargement, ulcerations, arm edema, palpable supraclavicular nodes

Question 15

Breast CA dx

Answer 15

• any solid dominant breast mass on exam evaluated with FNA or excisional bx
• genetic testing for pts with strong family hx
• axillary lymph node staging with sentinel lymph node bx

Question 16

breast CA tx

Answer 16

• tamoxifen: for estrogen receptor pos dz and postmen women
• adjuvant chemo and hormonal manipulaiton
• lumpectomy with sentinel node bx preferred for early stage
• breast cancer associated with higher risk of endometrial cancer and vice-versa
• axillary lymph node status is the most important prognostic factor for invasive carcinoma in the absence of distant metastasis

Question 17

Paget dz of the breast

Answer 17

• uncommon, ductal carcinoma, presents as eczematous lesions of the nipple
• presentation: eczematoid eruption and ulceration of nipple and areola, pain, itching, burning
  
  • bloody d/c or nipple retraction
• signs: scale, crust, itching, palpable mass (50%)
• dx: full-thickness bx
• tx: local excision, breast conservation with whole breast radiation (if negative margins)
  
  • most are high grade and show HER2 overexpression