Week 4- Gynecologic Malignancies

Question 1

What are the two types of endometrial cancer?

Answer 1

Type 1:

• lower risk, more common
• lower age
• estrogen related (obesity, PCOS, T2DM…)

Type 2:

• higher risk, less common
• higher age
• not estrogen related

Question 2

Staging of Endometrial Cancer

Answer 2

I: confined to uterus

II: cervix

III: adenexae, uterine serosa, vaginal lymph nodes

IV: bowel, bladder, distant

Question 3

When can you use hormone therapy in the treatment of endometrial cancer?

Answer 3

In well differentiated cases..progestin works

Question 4

What is the risk of other cancers to women who have been diagnosed with endometrial cancer?

Answer 4

2x risk of breast and 3-7 x risk of colorectal

Question 5

What factors DECREASE your risk of endometrial cancer? What factors INCREASE your risk?

Answer 5

Decrease

• multiparity >3, OCP, exercise, SMOKING, coffee

Increase

• HNPCC (suggest prophylactic hysterectomy and oophorectomy ~ 40 y.o)
• Obesity (3-10x)
• DM (2-3X)
• Anovulatory cycles (e.g. PCOS)
• Tamoxifen (but still a low absolute risk 1/1000–> 2/1000)

Question 6

What is tamoxifen?

Answer 6

A selective estrogen modulator - it is an antagonist in the breast and an agonist in the uterus

Question 7

What are the acute and chronic effects of radiation therapy

Answer 7

Acute:

• entertitis
• cystitis
• dermatitis
• bone marrow suppression
• fatigue

Chronic

• ovarian ablation
• fibrosis, atrophy
• bleeding
• stricture/fistulae

Question 8

False positive rate for pap?

Answer 8

< 1%

Question 9

RIsk factors for cervical cancer

Answer 9

Risk factors for cervical cancer include: young age at first coitus, multiples sexual partners, young age at marriage, young age at first pregnancy, high parity (vs. low parity for endometrial cancer), divorce, lower socioeconomic status, smoking, sexual partner with multiple sexual partners. A woman who has been sexually active in her lifetime is always at risk of cervical cancer - even if she is not currently sexually active or has not been for a long time.

Question 10

Is the pap more or less likely to miss an invasive cancer or a precursor lesion

Answer 10

Sooooo counterintuitive

Neoplastic cells are frequently obscured by inflammatory changes when invasive carcinoma is present. Therefore, nearly 50% of women with invasive cancer have false-negative smears. The error rate (false negative rate) of the Pap test to detect dysplasia is ranges from 15 - 30%.

Question 11

Severe squamous dyskaryosis would show….

Answer 11

loss of cellular maturation on the surface

Question 12

This question highlights the natural history of dysplasia if left untreated. Dysplastic lesions of the cervix will either regress, persist, progress to carcinoma in situ or progress to invasive disease. High-grade cervical dysplasia should be treated as this is a pre-malignant lesion. Most low grade lesions/CIN I will regress after 18 months. Persistent low-grade lesions should however by treated. High-grade lesions have a risk of progressing to invasive disease. The risk of CIN 2 progressing to invasion is around 5% and CIN 3 progressing is >12%.

Question 14

LSIL vs. HSIL and CIN1 vs CIN2/3

Answer 14

LSIL and HSIL are based on cytology (= Bethesda system)

• LSIL= mild dyskaryosis, CIN1
• HSIL= severe dyskaryosis, CIN 3

The CIN grading is based on biopsy

• CIN1 is <1/3 of thickness (from basal up)
• CIN 2/3 is >2/3 of thickness (from basal up)=

Question 15

What is gestational trophoblastic disease?

Answer 15

GTD: proliferative disorder of trophoblasts

• Hyatidiform mole
  
  • complete= empty ovum + 2 sperm (*completely *sperm), no fetal tissue but *completely *covers uterus (snowstorm) and completely invades (…15-20%…)
  • partial= normal ovum + 2 sperm, fetal tissue present
• Gestational trophoblastic neoplasia (can occur after ANY pregnancy, but more likely to occur after a molar pregnancy
  
  • Invasive mole
  • Choriocarcinoma (from villous trophoblasts)
  • Placental site trophoblastic tumors

Question 16

Why women have to use contraception for a year following a molar pregnancy?

Answer 16

Because 15-20% of complete moles (empty egg, 2 sperm) invade (2-4% of partial).

After the D&C you have to monitor bHCG levels. They should normalize in 9-11 wks

Question 17

What is the typical prognosis for gestational trophoblastic neoplasia? What are high risk factors?

Answer 17

GTN survival >95% at 5 yrs

The Five F’s

antecedent Full term pregnancy (more likely to be choriocarcinoma)

Far away mets

bHCG > 4…(??)

Failed low risk chemo (methotrexate)

>4 months since pregnancy

Question 18

The most common route of spread of endometrial cancer is….

The most common route of spread of ovarian cancer is….

Answer 18

uterine= direct!

ovarian= exfoliation of ovarian cells into abdominal cavity

Question 19

What is an example of a germ cell tumour?

Answer 19

Germ cell origin (10-15% of all ovarian cancers) include: teratoma, dysgerminoma, endodermal sinus tumor, embryonal carcinoma, choriocarcinoma and gonadoblastoma.

Most ovarian cancers are epithelial

Question 20

What is the most predictive screening test for ovarian cancer?

Answer 20

Ca 125

but CEA may be elevated in metastatic bowel cancer

But it should be noted that NONE of the screening tests are very good.

Question 21

In the pre-menarchal age group it is uncommon to have a pelvic mass the most likely cause being a germ cell tumor. In the reproductive age group >90% of ovarian masses are benign and most likely represent functional and or benign cysts such as follicular cysts, corpus luteal cysts and or benign cystic teratomas. In the postmenopausal age group ovarian carcinomas should always be considered first such as serous cystadenocarcinoma the most common type of epithelial ovarian carcinoma. Epithelial ovarian cancers account for >80% of ovarian cancers.

PREMENARCHAL AND POSTMENOPAUSAL ADNEXAL MASSES ARE MORE LIKELY TO BE MALIGNANT

Question 22

What are the causative agent of LSILs and HSILs?

Answer 22

LSIL: low risk HPV serotypes

HSIL: HPV 16-18

Question 23

Is CT/MRI/PET included in the staging of cervical cancer?

Answer 23

No- but you might do them anyways.

You would do a physical, cystoscopy, sigmoidscopy, IVP (intravenous pyelogram), CXR

Question 24

What is the treatment for HSIL confirmed on biosy (CIN III)? What about invasive squamous cell carcinoma of the cervix?

Answer 24

LEEP!

Radical hysterectomy + lymph node dissection + chemoradiation….

Question 25

Most leiomyomas are benign…except:

Answer 25

leiomyosarcoma

Question 26

Hyperplasia of endometrium can be simple or complex (and each of these can be with or without atypia…). This the precursor lesion to endometrial adenocarcinoma. Endometrial adenocarcinoma is staged with FIGO staging.

A second type of endometrial cancer (?type 2) is papillary serous carcinoma

Question 27

What is the most common type of ovarian cancer?

Answer 27

• High grade serous carcinoma (thought to originate in the oviduct as Serous tubal intraepithelial cancer (STIC)) (70%)
• Clear cell carcinoma (10%)
• Endometrioid carcinoma (10%)
• low-grade serous carcinoma (<5%)
• mucinous carcinoma (<5%)

Question 28

What percentage of ovarian HGSC have BRCA mutations?

Answer 28

20%

Question 29

What kind of mass is a dermoid cyst?

Answer 29

a germ cell tumour- dermoid cysts are a type of teratoma

Question 30

krukenberg tumour…

Answer 30

metastatic tumour to ovary- signet ring cells

Question 31

What percent of cervical carcionoma are adenocarcinomas? Are they easier or harder to detect than squamous cell via pap?

Answer 31

15% are adenocarcinomas (HPV 18).

Harder to detect that SILs

Question 32

Which ones is multiparity a protective factor for:

• cervical cancer
• endometrial cancer
• ovarian cancer

Answer 32

Protective for: endometrial and ovarian, risk for cervical