Tieman Carcinoma CIS Flashcards
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?
G0
taking estrogen without progesterone
obesity increases estrogen
dx is post-menopausal vaginal bleeding, etiology uncertain
diff’l: uterine cancer, endometrial hyperplasia, etc.
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?
shouldn’t be able to feel the uterus in a post-menopausal woman. It is enlarged.
how thick should endometrial stripe be?
under 5 mm
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?
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
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?
stage I , which we can only determine fully via surgery (unlike in carcinoma of the cervix)
oophorectomy (TAHBSO)
and lymph node dissection
how does uterine cancer spread?
lymphatic: along the internal iliacs into the peri-aortics
and locally in the pelvis through the uterine wall into adjacent structures
after TAH-BSO, can a pt resume oral estrogen
sure. the end organ is gone now, no increased risk.
uninterrupted ovulation increases the risk of what?
ovarian cancer
most common type of uterine cancer?
epithelial
how do you differentiate between granulosa cell and sertoli leydig tumors?
granulosa– tend to be estrogens
sertolil leydig– tend to have testosterone
you’ve got a pt in whom you suspect ovarian cancer. What testing do we do?
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
CA 125 and CA 19-9
tend to be elevated in epithelial cancers
Alpha Feto Protein is usually high in what?
germ cell tumors
BHCG elevated in what?
germ cell tumors
sometimes granulosa
LDH elevated in what tumors?
germ cell tumors
estradiol and testosterone levels are useful for what kinds of tumors?
granulosa
Inhibin-B level - what does it do?
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
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?
ovarian torsion
ovarian cyst
ectopic pregnancy
benign stuff, likely
older lady with post-menopausal bleeding. large ovary. inhibin 3x normal, estradiol elevated
this ended up being a granulosa tumor. Don’t discount the possibility in older, post-menopausal women!
