Tieman Carcinoma CIS

Question 1

A 57 y/o female presents with post-menopausal vaginal bleeding of 3 weeks duration.
Patient is G0P0Ab0. She has type II diabetes treated with diet and exercise. She takes oral premarin. She does not smoke.

risk factors? dx?

Answer 1

G0
taking estrogen without progesterone
obesity increases estrogen

dx is post-menopausal vaginal bleeding, etiology uncertain

diff’l: uterine cancer, endometrial hyperplasia, etc.

Question 2

post-menopausal woman

Pelvic exam reveals brown blood at cervical os, but no lesions. Fundus of the uterus can be felt about midway between pubis and umbilicus, firm and irregular contour.

what does this tell you?

Answer 2

shouldn’t be able to feel the uterus in a post-menopausal woman. It is enlarged.

Question 3

how thick should endometrial stripe be?

Answer 3

under 5 mm

Question 4

Path report reveals endometrial hyperplasia with multiple areas of atypia.
Pelvic ultrasound reveals a slightly enlarged uterus with multiple 3-4 cm fibroids and endometrial stripe of 12 mm. Ovaries are normal and no other abnormalities seen.

What’s next?

Answer 4

do a fractional D and C

separately curette the endocervical canal and then also the uterine cavity

most efficiently with historoscopy

this helps differentiate between Stage I and Stage II

Question 5

Hysteroscopy with fractional D&C is performed. Hysteroscopy reveals multiple areas of thickened endometrium with some polypoid formation.
Ecc performed and endometrial curettage done.
Path reveals a well-differentiated (Grade 1) endometroid adenocarcinoma of the endometrium with no involvement of the endocervical tissue.

stage? next step?

Answer 5

stage I , which we can only determine fully via surgery (unlike in carcinoma of the cervix)

oophorectomy (TAHBSO)

and lymph node dissection

Question 6

how does uterine cancer spread?

Answer 6

lymphatic: along the internal iliacs into the peri-aortics

and locally in the pelvis through the uterine wall into adjacent structures

Question 7

after TAH-BSO, can a pt resume oral estrogen

Answer 7

sure. the end organ is gone now, no increased risk.

Question 8

uninterrupted ovulation increases the risk of what?

Answer 8

ovarian cancer

Question 9

most common type of uterine cancer?

Answer 9

epithelial

Question 10

how do you differentiate between granulosa cell and sertoli leydig tumors?

Answer 10

granulosa– tend to be estrogens

sertolil leydig– tend to have testosterone

Question 11

you’ve got a pt in whom you suspect ovarian cancer. What testing do we do?

Answer 11

CBC, LFT’s, Lytes, BUN/Creatinine all normal
CA 125 and CA 19-9 slightly elevated
AFP, BHCG, LDH, estradiol, and testosterone levels normal
Inhibin-B normal.

no single marker or test as shown to be sensitive or specific enough for screening purposes, but these are useful to help us once we have a differential

Question 12

CA 125 and CA 19-9

Answer 12

tend to be elevated in epithelial cancers

Question 13

Alpha Feto Protein is usually high in what?

Answer 13

germ cell tumors

Question 14

BHCG elevated in what?

Answer 14

germ cell tumors

sometimes granulosa

Question 15

LDH elevated in what tumors?

Answer 15

germ cell tumors

Question 16

estradiol and testosterone levels are useful for what kinds of tumors?

Answer 16

granulosa

Question 17

Inhibin-B level - what does it do?

Answer 17

inhibits pituitary from secreting FSH (B is later in the cycle)

associated with granulosa tumors

young patients would have higher normal inhibin levels than older ones

Question 18

A 24 y/o female presents with the sudden onset of right-sided pelvic pain. She denies any GI symptoms, dysuria, or menstrual irregularities. She is G0P0Ab0 and her LMP was 10 days ago and regular in flow and timing.
PE reveals normal VS and a woman in obvious distress from pain. Exam was normal except for mild RLQ tenderness to deep palpation w/o rebound. Pelvic/Rectal revealed a tender right adnexal mass of about 12 cm in size.

differential?

Answer 18

ovarian torsion
ovarian cyst
ectopic pregnancy

benign stuff, likely

Question 19

older lady with post-menopausal bleeding. large ovary. inhibin 3x normal, estradiol elevated

Answer 19

this ended up being a granulosa tumor. Don’t discount the possibility in older, post-menopausal women!