Womens- oncology Flashcards
Endometrial Cancer- pathophysiology
Most common gynecologic malignancy
- 75%
Adenocarcinoma
Spread
- direct extension
- lymphatic mets
- peritoneal implants
- hematogenous spread
Endometrial Cancer- cause
Protective - OCPs, prego, breast feeding
Endometrial Cancer- epidemiology
Risk - 3%
Advanced age >45 7th decade Lynch syndrome Unopposed estrogen Tamoxifen White females DM Nullparity/infertility
Endometrial Cancer- S/S & PE
Abnormal uterine bleeding - 70-90% - how present - 6-19% - postmenopausal w/ bleeding -> all need to be worked up Abnormal vaginal discharge - clotting Intermittent spotting Lower abdom cramps/pain
PE - Nl - can’t usually palpate anything
Endometrial Cancer- labs & imaging
Hgn/Hct - anemia?
Hcg - make sure not pregnancy
Tumor marker - CA125
Pap - incidentally endometrial cells
Pelvic US - transvaginal
- most sensitive
- endometrial thickening or stripe >4mm -> get biopsy
Endometrial biopsy - gold
- office vs hysteroscopy vs D&C
Endometrial Cancer- treatment
Refer to gyn!
Hysterectomy w/ salpingo-oophrectomy
Radiation
Chemo
Screening Routine of asymptomatic - not advised - no good sensitive/specific test - most present w/ symptoms and good prog Lynch syndrome - 12-54% of getting in life - Hysterectomy - preventative
Endometrial Cancer- prognosis
Overall good
- stage 3 + - not good
Cervical Cancer- pathophysiology
3rd most common gynecologic malignancy
- 2nd most common female maglignancy
Squamous cell
- HPV 16 - 59%
- HPV 18 - 13%
- HPV 58, 33, 45 - 4-5%
Adenocarcinoma
- HPV 16 - 36%
- HPV 18 - 37%
- HPV 45, 31, 33 - 2-5%
Cervical Cancer- cause
HPV - 99.7%
- HPV 16&18
- vaccines have dec this by 75%
- can also cause vulvar, vaginal, penile, anal cancers, anogenital warts
HPV persists -> progresses to cancer
- initial infection -> high grade cervical intraepithelial neoplasia -> invasive cancer
- takes around 15yrs
HSV2 - coinfection
Cervical Cancer- epidemiology
Early onset sexual activity Multiple sex partners High risk sexual partner Hx of STD hx of vulvar/vaginal squamous intraepithelial neoplasia or cancer Immunosuppression Smoking DES exposure Long term OCP
Cervical Cancer- S/S & PE
Asymptomatic
Most common
- irregular/heavy vaginal bleeding
- postcoital bleeding
- vaginal discharge
Advanced
- pelvic/lower back pain
- bowel or urinary symptom
PE - pelvic exam
- cervix - nl or lesion -> raised or friable = biopsy
Cervical Cancer- diagnosis
Bethesda System Atypical Squamous Cells - ASC - differ from nl cells - not premalignant - ASC-US -> unknown significance - ASC-H -> HSIL cannot be excluded Cytologic findings - squamous intraepithelial neoplasia (SIL) - premalignant - LSIL - low grade - HSIL - high grade
Glandular cell
- Atypcial Glandular cell (AG)
- Adenocarcinoma in situ (AIS)
- Adenocarcinoma
Histologic findings
- Cervical intraepithelial neoplasia (CIN) - premalignant
Cervical Cancer- labs & imaging
Cervical Cytology
- pap smear - not diagnostic
- sample cervical cells from transformation zone
Cervical biopsy
- from area that looks most suspicious - avoid necrotic
- unusually firm/expanded
- hemostatic agents
Colposcopy
- can’t visualize lesion - but hgh suspicion
- visualize SCJ and transformation zone
- application of acetic acid to aid visualization
- w/ biopsy - most appropriate histologic tech
CT - ONLY if worried about mets
Cervical Cancer- treatment
LEEP - loop electrosurgical excision procedure
- frequently used to treat CIN II or III
- small fine, wire loop attached to electrosurgical generator or excise tissue of interest
- output
Core Biopsy
- conization - excision of cone shaped part of cervix -> more likely to lead to incompetent cervix
Therapy - must address primary tumor and adjacent tissue/lymph nodes
- depends on age, stage, pt/phys preference
Radical hysterectomy + pelvic lymphadenectomy, radion w/ concomitant chemo - combo?
Cervical Cancer- staging
Staging
CIN1 - mild dysplasia - disordered growth of lower third of epithelial lining
CIN2 - Moderate dysplasia - abnormal maturation of lower 2/3 of lining
CIN3 - Severe dysplasia - >2/3 of epithelial thickness
CIS - cervical cancer, carcinoma insitu
- full thickness
- 25-30
Cervical cancer
- >40
0 - Carcinoma in situ - some of cells of cervix have cancer
I - cervix carcinoma confined to uterus
II - carcinoma invades beyond uterus but not to pelvic wall or to lower third of vagina
III - tumor extends to pelvic wall and/or causes hydronephrosis or nonfunctioning kidney
IV - tumor extends beyond true pelvis or involves bladder or rectum
Cervical Cancer- screening
Screening Age <21 - no screening recommended Age 21-30 - pap every 3yr - consider reflex to HPV testing Age 30-65 - Pap and HPv every 5yrs OR - Pap every 3yrs Age >65 - disc if not abn cells - 3neg paps in a row or 2 neg w/in 10yrs and most recent was 5yrs ago Annual if - HIV, immunocompromised, exposure to DES, prev treated for cervical cancer Continue screening post hysterectomy - hx of CIN2, CIN3, cervix is still present
F/U
- every 3m for 5yr - high risk
- every 6m for 5yr - low risk
- Pap test yearly
- recurrence suspected? - CT/PET
Screening Adolescents Most LSIL/CIN1 - regress spontaneously - 61% in 1 yr - 91% in 3yr Treat lesions that would resolve w/out therapy treat for CIN - LEEP - inc risk of - preterm birth - low birth weight - preterm premature rupture of membranes
HPV Vaccine
Gardasil 9
- against HPV
- 9-26yo
Breast Cancer- pathophysiology
Screening
- 15% - not detected on mammogram
- 30% w/ mass in interval b/t mammograms
Breast Cancer- cause
“nfiltrating ductal carcinoma - most common of invasive
Infiltrating lobular carcinoma - 8% of invasive
Mixed ductal/lobular carcinoma - mixed invasive - 7%
Other - metaplastic, mucinous, tubular, medullary, papillary carcinomas - 5%
Ductal Carcinoma in situ (DCIS)
- heterogeneous group of precancerous lesions - confined to breast ducts/lobules - precurosr lesion to invasive
- size of lesion, nuclear grade, presence and extent of comedo necrosis, architectural pattern
Breast Cancer- S/S & PE
Hard, immobile single dominant mass
Local advanced dis
- axillary adenopathy
- erythema, thickening, dimplings of skin - peau d’orange -> inflammatory breast cancer
Met dis
- bone, liver lungs
Breast Cancer- diagnosis
Mammgogram findings
- soft tissue mass or density
- spiculated, high density mass
Breast U/S
- hypoechogenicity, internal calcifications, shadowing, spiculated/indistinct/angularg margins
Breast MRI
- irregular or spiculated mass margins, heterogeneous internal enhancement, enhancing internal septa
Breast Cancer- labs & imaging
Inc alk phos or bone pain -> bone scan
Inc liver enzymes -> CT abdomen/pelvis
Pulm symptoms -> CT chest
Stage III or higher -> whole boday PET/CT
Receptor testing
- ER pos/neg - estrogen
- PR pos/neg - progesterone
- HER-2 pos/neg - human pidermal growth factor 2
Triple neg breast cancer - poor prognosis
- 13%
Breast Cancer- treatment
Screening Age <40 - no recommended screening Age 40-75 - screening mammogram ev 2 yrs Age 75 - screening mammogram ev 2yrr if life expectance >10yr
High risk - MRI, U/S
Self-breast exam - monthly, controversial if effective
Ovarian Cancer- pathophysiology
2nd most common gynecologic malignancy
Most common cause of gynecologic cancer death
Avg age - 63
Epithelial Carcinoma - 95% 1. Serous - most common - from ovarian tissue - filled w/ watery or mucous material - grow large enough to fill abdominal cavity - usually smaller than mucinous 2. Mucinous - GI origin - appendix and met to ovary - filled w/ opaque, thick, mucoid material - largest tumor Germ cell/sex cord stromal tumors - 5%
Ovarian Cancer- cause
Protective
- multiparity
- breast feeding
- oral contraceptives
- salpingo-oophorectomy
- tubal ligation
- hysterectomy
Ovarian Cancer- epidemiology
Age BRCA mutation - 2-3% Hereditary cancer syndromes - lynch syndrome Infertility Nullparity Less risky risk factors - endometriosis, PCOS, postmenopausal hormone therapy, obesity, smoking, asbestos Smoking
Ovarian Cancer- S/S & PE
Acute
- usually already advanced
- pleural effusion
- bowel obstruction
- venous thromboembolism
Subacute
- Adenxal mass
- Pelvic/abdominal symptoms - bloating, urinary urgency/frequency, early satiety, pelvic/abdominal pain
Ovarian Cancer- diagnosis
Majority diagnosed at an advanced stage
- confined primary site - 15%
- spread to regional lymph nodes - 17%
- distant mets - 6%
- unstaged - 7%
Ovarian Cancer- labs & imaging
Full surgical removal PREFERED - don’t just get a biopsy
CT A/P or Pelvic U/S
CA -125
Ovarian Cancer- screening
Screening
No recommendations for screening
- high false pos
- low prevalence
Risk stratification - preventive measures
Ovarian Cancer- prognosis
5yr survival
- stage 1 - >90%
- regional dis - 75-80%
- distant met - <25%
Overall 5yr survival in women w/ ovarian cancer <45%
- due to spread at time of diagnosis
Ovarian Cancer- staging
Staging
1 - tumor limited to one or both ovaries
2 - tumor involves one or both ovaries w/ pelvic extension
3 - tumor involves one or both w/ confirmed peritoneal mets - outside pelvis and/or regional lymph node mets
4 - distant mets
Vulvar Cancer- pathophysiology
4th most common gynecologic malignancy
Squamous cell carcinoma - 75% Keratinizing, differentiated, simplex - older, not associated w/ HPV - associated w/ vulvar dystrophies Classic/warty/bowenoid - young - HPV 16, 18, 33
Verrocous - variant of squamous cell
Basal cell - non met
Melanoma - 2nd most common
Sarcoma - poor prognosis
Paget dis of vulva - intraepithelial carcinoma
Bartholin gland carcinoma - most often adeno or squamous cell
- can be transitional, adenosquamous, adenoid cystic
Vulvar Cancer- cause
HPV
- intraepithelial - 87%
- Invasive vulvar cancer - 29%
HPV 16 -23%
HPV 33 - 7%
HPV 18 - 5%”
Vulvar Cancer- epidemiology
VIN Piror hx of cervical cancer Cigarette smoking Vulvar lichen sclerosu Immunodeficiency syndromes Northern European ancestry HPV infect
Vulvar Cancer- S/S & PE
Abnormal findings on labia majora - most common
- Unifocal vulvar - plaqu, ulcer, mass
- Fleshy, nodular, warty
Vulvar pruritis
Vuvlar bleeding/pain
Dysuria, dyschezia, rectal bleeding, enlarged lymph node in groin, lower extremity edema
Vulvar Cancer- diagnosis
Biopsy
Vulvar Cancer- prognosis
Diagnosed at an early stage
Confined to primary site - 59%
Reginal dis - 30%
Distant met - 6%
5yr survival - 72%
Med age of death - 78yr
