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Repro Exam I > TIeman DSA Clinical Aspects of Ovaries > Flashcards

TIeman DSA Clinical Aspects of Ovaries Flashcards

1
Q

women and cancer

A

leading cause of death is heart disease

leading cancer dxes:

  1. breast
  2. lung
  3. colon and rectal
  4. uterine
  5. ovary
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2
Q

Genetic Screening

A 
Popular expectations are high
Could be prohibitively costly-
          - money
          - distress
          - social order
 Might we all one day be ‘assessed’ for genetic propensity to a battery of diseases?
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3
Q

Family History

A

The mainstay of front-line genetic screening
Three generation pedigree is ideal
Must review maternal and paternal lines
Genetic counselors are an excellent resource

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4
Q

Breast-ovarian cancer syndrome

A

Only approx. 10% of breast and ovarian cancers are hereditary.
BRCA 1- chromosome 17
BRCA 2- chromosome 13

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5
Q

Lynch II syndrome (HNPCC)

A

Nonpolyposis colorectal cancer syndrome
Mutations in the mismatch repair genes
Adenocarcinomas of colon, endometrium, breast, ovary, pancreas

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6
Q

Numbers of gynecologic cancer new cases per year—

A

Uterine corpus- 44,000

Ovarian- 22,000

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7
Q

Number of gyn cancer deaths per year—

A

Ovary- 13,900

Uterine – 7,900

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8
Q

CARCINOMA OF THE UTERUS

A

Most common female genital tract malignancy in the US
Most common clinical presentation is abnormal vaginal bleeding in perimenopausal or postmenopausal woman

Risk factors:
Obesity
Unopposed estrogen stimulation (esp. postmenopausal)
Tamoxifen 
Nulliparity
Diabetes 
Smoking
Late menopause
Polycystic ovary syndrome
Lynch syndrome
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9
Q

CARCINOMA OF THE UTERUS Risk is decreased by:

A 
Ovulation
Progestin therapy
Combination BCP’s
Early menopause
Multiparity
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10
Q

EVALUATION OF ABNORMAL VAGINAL BLEEDING

A

Pelvic exam/pap smear
- May find obviously benign reason for bleeding

Endometrial sampling
- Can be done in office

Transvaginal ultrasound
- Rarely pathologic if endometrial stripe <5mm

Fractional D&C
- With hysteroscopy, if available

Be sure to understand what a “fractional” D&C is

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11
Q

ENDOMETRIAL CARCINOMA tumor staging

A

Tumor staged surgically (FIGO)
* Requires fractional D&C

Stage 1—confined to uterine corpus
1a—confined to endometrium or < 50% myometrial invasion.
1b—invasion to > ½ of myometrium
Stage 2—invades cervix stroma. (Note that endocervix gland involvement still stage 1)
Stage 3—tumor invades serosa or adnexa, vagina, or lymph nodes
Stage 4— peritoneum, distant metastases, invasion of bladder or bowel mucosa, or inguinal lymph node involvement

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12
Q

ENDOMETRIAL CARCINOMA prognosis

A

affected by grade and histology of tumor
Grades 1,2 and 3 (95%, 85%, and 70% 5-year survival)

80% are favorable histology (Endometroid)
20% are unfavorable
Papillary serous carcinoma
Clear-cell carcinoma
Squamous cell carcinoma
Poorly differentiated carcinoma
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13
Q

ENDOMETRIAL CANCER TREATMENT

A

Depends on stage, histology and grade of tumor
Stage 1a and 1b,Grades I and II, favorable histology can be treated with TAH-BSO, peritoneal washings and removal of any enlarged lymph nodes
Grade 3 or unfavorable histology, or stage 2 tumors require TAH-BSO, cytology, and iliac/para-aortic node dissection +/- radiation
Stages 3 & 4 require surgical debulking + radiation + chemotherapy

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14
Q

SURVIVAL RATES- endometrial cancer

A

Stages 1a and 1b—90% 5-year survival rate
Stage 2—70-80% 5-year survival
Stage 3—30-60% 5-year survival
Stage 4—15% 5 year survival

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15
Q

OVARIAN CANCER

A

Second most common, but #1 most lethal cancer of the female genital tract
- Accounts for most deaths of any gyn malignancy

Lethality due to late stage of disease at diagnosis and method of spread

Presenting symptoms are usually vague
- Increasing girth, pelvic/abdominal fullness, vague pelvic discomfort

Most patients are diagnosed in stages 3 or 4 in age group 50-70

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16
Q

OVARIAN CANCER RISK FACTORS

A 
Increased risk—regular ovulation:
White race/USA
Nulliparity/infertility
Late childbearing
Late menopause
Family history
BRCA genetic mutation
Decreased risk—ovulation interrupted:
Oral contraceptives
Multiparity
Breast feeding
Tubal ligation
hysterectomy
17
Q

OVARIAN CANCER SCREENING

A

Requirements for effective screening technique
- High positive and negative predictive value
- High sensitivity and specificity
- Cost effective
- Acceptable and widely available to population
Physical exam, sonography and biomarkers have all been studied, but none have been proven to be effective screening techniques

18
Q

Ovarian cancer PATIENT PRESENTATION

A 
History
Vague, non-specific symptoms
Abdominal discomfort, swelling, bloating
Dysuria, dyspareunia, constipation
Rarely, acute pain from torsion, rupture or hemorrhage

Physical Exam
Pelvic mass
Ascites
Abdominal mass

19
Q

OVARIAN CANCER HISTOLOGY

A 
80% Epithelial tumors  (all ages)
Serous (55%)
Mucinous (20%)
Endometroid (15%)
Clear cell (5%)
Benign tumors and tumors of low malignant potential may occur for each of the above type
Carcinosarcoma

10-15% germ cell (usually under age 30)
Dysgerminomas ,teratomas, embryonal cell carcinoma

5% gonadal-stromal tumors (usually over age 50)
Granulosa cell-theca cell tumors (secrete estrogen/progesterone)
Sertoli-Leydig cell tumors (secrete androgens)

1% others (soft tissue, metastatic, etc.)
fibroma
sarcoma
Krukenberg tumors

20
Q

OVARIAN CANCER–STAGING

A

Staged surgically

Stage 1—tumor confined to ovaries (1c=+cytology)
Stage 2—tumor spread confined to pelvis
Stage 3—tumor spread to abdominal peritoneal surfaces including omentum, surface liver/spleen. Mets to retroperitoneal lymph nodes
Stage 4—distant metastases. IVA: pleural effusion with (+) cytology. IVB: hepatic/splenic parenchymal mets, extra-abd lymph nodes.

21
Q

OVARIAN CANCER TREATMENTSURGERY

A

Surgical cytoreduction and sampling of high-risk areas

TAH-BSO
Peritoneal and pelvic washings for cytology
Omentectomy
Diaphragmatic scrapings
Sampling of multiple areas of peritoneum in the pelvis and abdominal cavity
Iliac/para-aortic node sampling

*** Excision of any visible tumor
Most important aspect for long term prognosis

22
Q

OVARIAN CANCER TREATMENT - POST-OPERATIVE

A

Platinum-based chemotherapy dependent upon stage, histology and grade of tumor

Epithelial Tumors

  • Stage 1-low grade—no further treatment
  • Stage 1-high grade and beyond—platinum-based chemotherapy. Carboplatin plus paclitaxel
  • Strongly consider intrap-peritoneal chemotherapy

Germ cell tumors
Platinum-based chemotherapy, bleomycin, etoposide

Gonadal-stromal tumors
Relatively chemoresistant

23
Q

ovarian cancer prognosis

A

Epithelial cell tumors
Stage 1—75-95% 5-year survival
Stage 2—65%
Stages 3 and 4—20%

Germ cell tumors
Stage 1—95%
Stage 2—80%
Stage 3—60-70%

Gonadal-stromal tumors
Stage 1—90%

Repro Exam I (12 decks)

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