Malignancy of genital tract

Question 1

What is the most common cause of death in cervical cancer?

Answer 1

renal failure

Question 2

What are the signs and symptoms of cervical cancer?

Answer 2

1. Asymptomatic in the early stages (hence the need for screening)
2. Vaginal bleeding - most common clinical finding. Can be intermenstrual or postcoital
3. Foul smelling (blood-tinged) vaginal discharge
4. Dyspareunia
5. Pelvic pain
   note: dyspareunia + pelvic pain can be a sign of advanced cervical CA

Question 3

What are the risk factors of cervical cancer? (10)

Answer 3

1. immunocompromised state (infection -> cancer)
2. Genetics
3. Iatrogenic
4. Early coitarche
5. Multiple partners (more than 6)
6. HPV infection
7. History of STI
8. OCP use
9. History of vulvar/vaginal dysplasia
   10/ Smoking - squamous cell carcinoma

Question 4

How is cervical cancer screened and diagnosed?

Give five characteristics of ATYPIA

Give other findings of abnormal cells

Answer 4

1. Screening is pap smear at 21 years old or 3 years after the beginning sexual activity not less than 21 years old.
2. this is via conventional cytology or liquid-based cytology
3. Visual inspection with acetic acid (abnormal tissue becomes white)
4. Visual inspection with Lugol’s iodine - there are scattered non-iodine uptake areas if neoplasia
5. Co-testing (same time HPV DNA test with cytology) and Reflex testing (Cytology then DNA)
6. Definitive diagnosis is COLPOSCOPY GUIDED BIOPSY
7. increased N:C ratio
8. hyperchromasia
9. perinuclear halo
10. nuclear irregularity
11. chromatin clumping
12. Koilocytosis - perinuclear cavitation, from HPV infected keratinocytes

Question 5

What are the prognostic factors in cervical cancer?

Answer 5

1. Tumor size
2. FIGO stage (most important determinant)
3. Nodal involvement
4. Lymph vascular space involvement
5. Histologic type (adenocarcinoma has poorer prognosis)

Question 6

What is the treatment for cervical cancer?

When is follow up?

What are the 3 types of cervical cancer? what are some traits?

Answer 6

1. Concurrent chemoradiation is the mainstay treatment with CISPLATIN as the agent (nephrotoxic, make sure renal function is there)
2. Surgery, cone biopsy or radical trachelectomy (removal of cervix, upper vagina, and parametrium)
3. If patient cannot receive chemo, radiation alone may be given: external beam radiotherapy (teletherapy)
   - Internal beam radiotherapy: brachytherapy
4. weekly during therapy
5. 2 weeks after completion
6. then 3 months for the first 2 years, every 6 months for the second 3-5 years, annually thereafter.
7. Squamous cell carcinoma - most common type
8. Adenocarcinoma - more recurrent, poorer prognosis, but same pattern and spread
9. Mixed, adenosquamous

Question 7

Which HPV types cause cervical cancer and which cause condyloma acuminata?

Answer 7

High risk = 16 and 18 (cervical cancer)

Low risk = 6 and 11 (condyloma acuminata)

Question 8

What is the normal thickness of the endometrium at the proliferative phase and secretory phase?

Answer 8

1. proliferative phase = 1-2mm

2. secretory phase = 8-14mm

Question 9

What are the four types of endometrial hyperplasia?

How do you diagnose endometrial hyperplasia?

Symptoms?

Treatment?

Answer 9

1. Simple hyperplasia without atypia - increased dilated glands
2. Complex hyperplasia without atypia - glands are crowded with scant stroma between them
3. Simple hyperplasia with atypia
4. complex hyperplasia without atypia - glands are irregularly shaped and are crowded. Nucleus shows atypia (increased N:C, perinuclear halo, chromatin clumping)
5. Transvaginal ultrasound, for premenopausal women <15mm, for postmenopausal women <5mm.
6. Endometrial sampling and D&C
7. Intermenstrual or irregular bleeding for premenopausal women
8. any vaginal bleeding in post menopausal women
9. for simple and complex without atypia, MPA 10-20mg OD for 14 days, after 3 mos reasses then if endometrium is normal, MPA 5mg/10days/month for 12 months. IF PERSISTENT, 40mg OD for 3 months
10. EHBSO if no desire for uterine preservation

3.If simple or complex WITH atypia, MPA 10-20mg OD for 3 mos, if persistent 3 mos MPA 40mg, if still persistent EHBSO

Question 10

What is the most common malignancy in the genital tract?

Where is it more common in women of what menopausal status?

What are the two types?

Answer 10

Endometrial carcinoma

Perimenopausal and postmenopausal

1. Type I = Endometrial CA
2. Type II = serious papillary

Question 11

What are signs and symptoms of endometrial carcinoma?

Answer 11

1. AUB (most common symptom)
2. Enlarged uterus
3. Stigmata of chronic anovulation such as hirsutism, acanthosis and acne

Question 12

What are risk factors for endometrial carcinoma?

What is the route of spread?

What is the gold standard of diagnosis?

What is the degree of differentiation?

Management?

Answer 12

1. Unopposed estrogen stimulation, or exogenous estrogen without progesterone
2. Unopposed menopausal estrogen replacement therapy
3. Late menopause after 52 years
4. Early menarche
5. Obesity (x10 increased risk)
6. Diabetes
7. Nulliparity
8. PCOS or chronic anovulation
9. Tamoxifen (usually for breast cancer) because it is inhibitory to the breast but stimulatory to the endometrium
10. pelvic and paraaortic node drainage sites
11. Hysteroscopic guided biopsy
12. G1 = <6%, well differentiated
13. G2 6-50% moderately differentiated
14. G3 >50% of solid compartments = poorly differentiated
15. TAHBSO, node sampling, peritoneal washing
16. Adjuvant therapy can include radiation; hormone treatment
17. Advanced or Recurrent: Chemotherapy with high-dose progestin

Question 13

Just read Ovarian CA in the transes