Firecracker - Oncology Gynaecology Flashcards

1
Q

What is endometrial cancer and what are its risk factors?

A

Endometrial cancer is an adenocarcinoma of uterine tissue that is commonly related to exposure to high levels of estrogen.

The progression to endometrial cancer is like an uncontrolled proliferative (follicular) phase of menstrual cycle. Normal endometrium progresses to simple hyperplasia then to complex hyperplasia then to atypical hyperplasia and finally frank adenocarcinoma.
Risk factors include:

  • Prolonged unopposed estrogen exposure
  • HNPCC (hereditary nonpolyposis colorectal cancer)
  • Diabetes and obesity
  • Hypertension
  • Polycystic ovarian syndrome and chronic anovulation
  • Nulliparity

The average age of diagnosis is 61, but the age range of 50-59 is the largest affected group.

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2
Q

What is CIN-1 and how is it treated?

A

Cervical intraepithelial neoplasia-1 (CIN-1) is considered low-grade dysplasia found after colposcopy and describes dysplasia within the lower third of the cervical epithelium (closest to the epithelial surface).

Treatment of CIN-1 involves repeat pap smear in 6 and 12 months, and repeat HPV testing in 12 months. Excision by loop electrocautery excision procedure (LEEP) or conization, or laser ablation may be performed.

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3
Q

What ultrasound findings are associated with malignant ovarian tumors?

A

Ultrasound can be used to detect malignant ovarian tumors. Findings associated with a malignant mass include:

Size > 8 cm
Solid, or cystic and solid consistency
Nodular or papillary solid components
Multilocular, thick (>2 mm) septations
Bilateral tumors
Associated features including ascites, peritoneal masses, lymphadenopathy

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4
Q

What are some complications associated with endometrial cancer?

A

Complications of endometrial cancer include:

Local extension to fallopian tubes, ovaries, and cervix

Metastases to the peritoneum, pelvic lymph nodes, aortic lymph nodes, lungs, and vagina
96% 5-year survival rate if local, but 25% 5-year survival rate if metastases are present

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5
Q

What complications are associated with ovarian cancer?

A

Complications associated with ovarian cancer typically include low 5-year survival rates because tumors are frequently in advanced stages when detected.

Pseudomyxoma peritonei is a complication of mucinous cystadenocarcinoma where a rupture of the tumor produces copious mucinous ascites and peritoneal mucinous tumors.

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6
Q

If the result of a pap smear performed on a 22 year old patient is ACUS, what is the next step in management?

A

Atypical squamous cells of undetermined significance (ASCUS) characterizes cellular abnormalities in the cervical epithelium that are not explained by reactive changes and are not diagnostic of intraepithelial lesions.

Treatment of ASCUS involves HPV screening, repeat pap smear in 6-12 months, and repeat HPV testing in 12 months.

Due to the transitory nature of low-grade cervical dysplasia and HPV infection in young women, treatment is slightly different for women age 21-24. Women age 21-24 with ASCUS or LSIL should undergo repeat pap in 1 year or reflex HPV testing.

Note: Women age <21 should not undergo pap smear regardless of whether they are sexually active, due to the increased prevalence of transitory, clinically insignificant cervical dysplasia in this population and the long-term harm caused by treatment of these clinically insignificant findings.

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7
Q

How is endometrial cancer treated, regardless of stage?

A

Regardless of stage, endometrial cancer can be treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO).

If fertility is desired and the endometrial cancer is limited only to the endometrial lining, treatment can consist of progestins to limit growth until a TAH-BSO is ultimately performed.

If a endometrial tumor cannot be completely resected, it should be surgically debulked.
If the endometrial cancer is high-grade or the tumor has invaded beyond the endometrial lining, adjuvant radiation therapy is indicated in addition to surgery.

Chemotherapy is indicated for use in any case where endometrial cancer has spread beyond the uterus.

Patients who cannot be cured by surgery and radiation may show benefit from the use of hormone therapy (progesterone, tamoxifen).

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8
Q

What are the symptoms of ovarian cancer?

A

Malignant ovarian tumors are usually asymptomatic, or have minimal symptoms until it is late in the course of the disease.

Initial symptoms of ovarian cancer include:

Bloating
Early satiety
Dyspepsia
Abdominal pain
Pelvic pain

Late symptoms of ovarian cancer include:

Back pain
Urinary frequency/urgency
Constipation
Fatigue
Dyspareunia
Menstrual changes

Physical exam findings of malignant tumors include fixed, solid, irregular, and bilateral adnexal masses.

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9
Q

What does ASC-H mean?

A

Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H) characterizes cellular abnormalities in the cervical epithelium that likely consist of a mixture of true high-grade squamous intraepithelial lesion and other findings that mimic such lesions.

Treatment of ASC-H involves HPV screening, endocervical biopsy, repeat pap smear in 6-12 months, and repeat HPV testing in 12 months.

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10
Q

What is the role of x-ray, CT and ultrasound in the diagnosis of endometrial cancer?

A

Endometrial biopsy is the gold standard for diagnosis of endometrial cancer. Findings associated with endometrial cancer include hyperplastic, abnormal glands with vascular invasion.

Serum studies may show an elevation of the CA-125 tumor marker. Remember that tumor markers are not diagnostic, but are useful for monitoring response to therapy.
In a patient where the suspicion for endometrial cancer is very high but the endometrial biopsy is normal, hysteroscopy with biopsy should be performed to visualize the uterine cavity and take additional samples.

A chest X-ray and CT can be used to detect the presence of metastases and ultrasound can be used to detect cervical masses and measure endometrial wall thickness.

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11
Q

What are follicular cysts and how are they treated?

A
  • Follicular cysts arise from ovarian follices in which fluid accumulates in a Graafian (mature) or previously ruptured follicle.
  • They are composed of granulosa cells, are cystic (roughly 3 cm in diameter), occur in the first 2 weeks of the menstrual cycle and may regress over the menstrual period.
  • This is the most common ovarian mass in a reproductive-age woman.
  • The clinical presentation of follicular cysts includes:
    • Abdominal pain and fullness
    • Palpable tender mass on bimanual exam
    • Peritoneal signs if torsion or rupture occur, which can cause sterile peritonitis
  • Patients typically require no treatment besides a follow up ultrasound to ensure cyst resolution.
    • If the mass does not regress, or if there is a high suspicion of cancer, an ovarian cystectomy can be peformed.
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12
Q

What are the different ways in which a cervical carcinoma lesion can be treated dependent on stage and type?

A

Surgery is the first-line treatment for invasive cervical carcinoma, with chemotherapy and radiation required in certain cases. Chemotherapy is used to prevent distant recurrence, while radiation reduces local recurrence.

For small invasive lesions with close surgical margins, chemotherapy should be used postoperatively to prevent distant recurrence from micrometastasis not detected at the time of surgery.

Patients with local disease (stage 1), where the lesion is visibly invasive or if it involves the uterus, but does not extend to the pelvic wall or lower third of the vagina, should be treated with radical hysterectomy with lymphadenectomy or with radiation therapy (to prevent local recurrence) and cisplatin-based chemotherapy.

Patients with advanced disease (stage 2-4) have lesions that extend into the parametrial tissue, pelvic wall, lower third of the vagina, adjacent organs, or any lesions that have metastases should be treated with radiation therapy and chemotherapy.

Recurrent cancer is treated with pelvic exenteration, which is a surgical procedure that removes all pelvic organs (uterus, tubes, ovaries, bladder, distal ureters, rectum, sigmoid colon, pelvic floor muscles, ligaments).

The Gardasil vaccine (tetravalent against HPV types 6, 11, 16, 18) is now FDA approved for both males and females. Note: women who have received the Gardasil vaccine still need regular pap smears!

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13
Q

What surgical procedure is indicated for malignant ovarian epithelial tumors?

A

Treatment for malignant epithelial ovarian cancer is based on surgery plus chemotherapy and radiation as needed.

Surgical removal is a Total abdominal hysterectomy plus bilateral salpingo-oophrectomy (TAH/BSO).

Multiagent chemotherapy is typically used for malignant ovarian germ cell tumors.
Another treatment for malignant ovarian germ cell tumors is a unilateral salpingo-oophrectomy (because they are rarely bilateral) if fertility is desired and TAHBSO is refused.

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14
Q

How are benign cystic teratomas treated?

A

Benign cystic teratomas (i.e. dermoid cyst) originate from germ cells and are composed ofmultiple dermal tissue layers (such as hair, teeth, and sebaceous gland).

These masses are often asymptomatic, but if they rupture the oily contents that are released can cause peritonitis.

Treatment of dermoid cysts involves cystectomy with attempted preservation of the ovary if benign.

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15
Q

What is the most common histological type of cervical dysplasia?

A

Cervical cancer is typically squamous cell carcinoma (80% of cases), but can be adenocarcinoma (15% of cases) or a mixed adenosquamous (5% of cases).

Risk factors for cervical cancer include:

Early sexual intercourse
HPV 16, 18, 31, 33
Multiple partners
Smoking
Immunodeficiency
History of STDs

Invasive Cervical Carcinoma is now the least common gynecological cancer in the USA due to the success of the Pap smear at detecting precancerous lesions.

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16
Q

What is colposcopy?

A

Colposcopy is a diagnostic procedure where a dissecting microscope (colposcope) is used to obtain an illuminated and magnified view of the cervix for biopsy.

Acetic acid is used to improve visualization of abnormal areas as the solution causes metaplastic cells to reflect light and appear white, referred to as “acetowhite” changes.

In order to best detect cervical intraepithelial neoplasia, multiple biopsies are taken.

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17
Q

What is the clinical presentation of corpus luteum cysts?

A

Corpus luteum cysts occur when fluid accumulates in corpus luteum during pregnancy. They are composed of theca cells, are cystic or hemorrhagic, usually larger and firmer than follicular cysts, and a more common in later weeks of the cycle.

The clinical presentation of corpus luteum cysts includes:

Abdominal pain
Palpable tender mass on bimanual exam
Greater risk of torsion or rupture than follicular cysts

Like with follicular cysts, patients typically do not require treatment. If the mass does not regress, or if there is a high suspicion of cancer, an ovarian cystectomy can be performed. A rupture with significant hemorrhage requires surgical hemostasis with cystectomy.

18
Q

What histological cervical changes are characterized by high-grade squamous intraepithelial lesion (HSIL)?

A

High-grade squamous intraepithelial lesion (HSIL) characterizes moderate or severe cellular dysplasia in the cervical epithelium, including carcinoma in situ. Remember: as carcinoma in situ has not penetrated the basement membrane it is considered precancerous.

HSIL should be followed-up with colposcopy to determine whether cervical intraepithelial neoplasia is present.

19
Q

What is the clinical presentation of endometriomas?

A
  • Endometrioma is a mass consisting of endometrial tissue, typically the spread of endometriosis to the ovary and has similar behaviour to other sites of endometriosis
  • These masses are frequently asymptomatic, but when symptomatic may present as a tender palpable mass and have similar symptoms to endometriosis including:
    • Abdominal pain
    • Dyspareunia
    • Potential infertility

Because of high recurrence rates, cystectomy or oophorectomy is often required. Pharmacologic agents that can be used to lessen symptoms include:

  • Oral contraceptives and progestins
  • GnRH agonists
  • Danazol
20
Q

If limited to endometrial lining, how can endometrial cancer be managed so that fertility is preserved?

A

Regardless of stage, endometrial cancer can be treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO).

If fertility is desired and the endometrial cancer is limited only to the endometrial lining, treatment can consist of progestins to limit growth until a TAH-BSO is ultimately performed.

If a endometrial tumor cannot be completely resected, it should be surgically debulked.
If the endometrial cancer is high-grade or the tumor has invaded beyond the endometrial lining, adjuvant radiation therapy is indicated in addition to surgery.

Chemotherapy is indicated for use in any case where endometrial cancer has spread beyond the uterus.

Patients who cannot be cured by surgery and radiation may show benefit from the use of hormone therapy (progesterone, tamoxifen).

21
Q

How is cervical atypical squamous cells of undetermined significance treated?

A

Atypical squamous cells of undetermined significance (ASCUS) characterizes cellular abnormalities in the cervical epithelium that are not explained by reactive changes and are not diagnostic of intraepithelial lesions.

Treatment of ASCUS involves HPV screening, repeat pap smear in 6-12 months, and repeat HPV testing in 12 months.

Due to the transitory nature of low-grade cervical dysplasia and HPV infection in young women, treatment is slightly different for women age 21-24. Women age 21-24 with ASCUS or LSIL should undergo repeat pap in 1 year or reflex HPV testing.

Note: Women age <21 should not undergo pap smear regardless of whether they are sexually active, due to the increased prevalence of transitory, clinically insignificant cervical dysplasia in this population and the long-term harm caused by treatment of these clinically insignificant findings.

22
Q

What are mucinous and serous cystadenomas and how are they treated?

A

Mucinous or serous cystadenomas are the most common ovarian tumors. Originating in epithelial tissue, they may resemble endometrial or tubal histology, contain cystic or mucinous contents, and may form calcifications (psammoma bodies), which may become extremely large.

These tumors are frequently asymptomatic until they become significantly large, at which point they will present as a palpable mass on bimanual exam.

Treatment of mucinous of serous cystadenomas includes unilateral salpingo-oophorectomy or total abdominal hysterectomy-bilateral salpingo-oophorectomy if postmenopausal.

23
Q

What is cervical dysplasia?

A

Cervical dysplasia is a pre-cancerous squamous cell lesion of the cervix that may progress to invasive cervical cancer in up to 22% of cases, depending on the grade.

It is usually detected by pap smear that will show koilocytes, which are cells with clear halo surrounding hyperchromatic, atypical nuclei that begin at the basal layer and extend outward.

Dysplasia may progress to carcinoma in situ and invasive carcinoma, or it may regress spontaneously.

24
Q

What histological cervical changes are characterized by low-grade squamous intraepithelial lesion (LSIL)?

A

Low-grade squamous intraepithelial lesion (LSIL) characterizes mild cellular dysplasia in the cervical epithelium.

LSIL should be followed-up with colposcopy to determine whether cervical intraepithelial neoplasia is present.

25
Q

What is pseudomyxoma peritonei?

A

Pseudomyxoma peritonei is a complication of mucinous cystadenocarcinoma where a rupture of the tumor produces copious mucinous ascites and peritoneal mucinous tumors.

26
Q

What is a benign cystic teratoma?

A

Benign cystic teratomas (i.e. dermoid cyst) originate from germ cells and are composed ofmultiple dermal tissue layers (such as hair, teeth, and sebaceous gland).

These masses are often asymptomatic, but if they rupture the oily contents that are released can cause peritonitis.

Treatment of dermoid cysts involves cystectomy with attempted preservation of the ovary if benign.

27
Q

What tumor markers are associated with malignant ovarian tumors?

A

While there are tumor markers associated with ovarian cancer, they are not diagnostic and should be used only to monitor the efficacy of cancer treatment. Tumor markers associated with ovarian cancer include elevated:

CA-125 in up to 80% of epithelial cell tumors
LDH in dysgerminomas
AFP in endodermal sinus (yolk sac) tumors

28
Q

What risk factors are associated with developing cervical cancer?

A

Risk factors for cervical cancer include:

Early sexual intercourse
HPV 16, 18, 31, 33
Multiple partners
Smoking
Immunodeficiency
History of STDs

29
Q

What symptoms are associated with cervical cancer?

A

Although typically asymptomatic in early stages, cervical cancer can present with the following symptoms:

Vaginal bleeding (postcoital or spontaneous)
Pelvic pain
Cervical discharge
A palpable cervical mass

30
Q

What complications can be associated with benign ovarian tumors?

A

Complications associated with benign ovarian tumors include tumor torsion, and tumor rupture with hemorrhage.

31
Q

How are malignant ovarian epithelial tumors treated?

A

Surgical removal is a Total abdominal hysterectomy plus bilateral salpingo-oophrectomy (TAH/BSO).

Multiagent chemotherapy is typically used for malignant ovarian germ cell tumors.

Another treatment for malignant ovarian germ cell tumors is a unilateral salpingo-oophrectomy (because they are rarely bilateral) if fertility is desired and TAHBSO is refused.

32
Q

From what cells do stromal cell tumors originate?

A

Stromal cell tumors originate from granulosa theca (estrogens), or Sertoli-Leydig cells (testosterone and other androgens) and secrete hormones based on the cells of origin. They have malignant potential.

Clinical findings associated with stromal cell tumors include:

Precocious puberty with granulosa theca cell tumors
Virilization with Sertoli-Leydig cell tumors

Treatment of stromal cell tumors is similar to mucinous or serous cystadenomas and consists of unilateral salpingo-oophorectomy for premenopausal women, or total abdominal hysterectomy-bilateral salpingo-oophorectomy if postmenopausal.

33
Q

What are some risk factors associated with endometrial cancer?

A

Risk factors include:

Prolonged unopposed estrogen exposure
HNPCC (hereditary nonpolyposis colorectal cancer)
Diabetes and obesity
Hypertension
Polycystic ovarian syndrome and chronic anovulation
Nulliparity

34
Q

What is the clinical presentation of follicular cysts?

A

The clinical presentation of follicular cysts includes:

Abdominal pain and fullness
Palpable tender mass on bimanual exam
Peritoneal signs if torsion or rupture occur, which can cause sterile peritonitis

35
Q

What is the most common type of ovarian cancer?

A

Ovarian cancer is typically originates from either epithelial cells (90% of cases) or germ cells. Serous cystadenocarcinoma is the most common malignant ovarian tumor. Ovarian masses are more likely to be malignant in postmenopausal women.

Risk factors for developing ovarian cancer include:

Genetic causes: Family history, BRCA-1 or BRCA-2, Lynch syndrome (HNPCC)
Increased total duration of ovulation: Infertility and nulliparity (due to prolonged unopposed estrogen production), early menarche, late menopause

Risk can be decreased by oral contraceptives or pregnancy, as this shortens the total time ovaries spend developing mature follicles.

36
Q

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

A

Cervical cancer spreads by local extension, and the 5-year survival rate based on extent of invasion is as follows:

Over 90% for microscopic lesions
65-85% for visible lesions with growth beyond the cervix but limited to the uterus
40% for those lesions that extend beyond the uterus
20% for metastatic lesions

Renal failure is the most common cause of death in patients with invasive cervical cancer.

Invasion of bladder and ureters causes ureteral obstruction which leads to hydronephrosis and postrenal failure.

37
Q

What are corpus luteum cysts?

A

Corpus luteum cysts occur when fluid accumulates in corpus luteum during pregnancy. They are composed of theca cells, are cystic or hemorrhagic, usually larger and firmer than follicular cysts, and a more common in later weeks of the cycle.

The clinical presentation of corpus luteum cysts includes:

Abdominal pain
Palpable tender mass on bimanual exam
Greater risk of torsion or rupture than follicular cysts

Like with follicular cysts, patients typically do not require treatment. If the mass does not regress, or if there is a high suspicion of cancer, an ovarian cystectomy can be performed. A rupture with significant hemorrhage requires surgical hemostasis with cystectomy.

38
Q

How should high-grade endometrial cancer, or cancer that has spread beyond the uterus be managed?

A

If the endometrial cancer is high-grade or the tumor has invaded beyond the endometrial lining, adjuvant radiation therapy is indicated in addition to surgery. Chemotherapy is indicated for use in any case where endometrial cancer has spread beyond the uterus.

39
Q

What is cervical intraepithelial neoplasia-2 and 3?

A

Cervical intraepithelial neoplasia-2 and 3 (CIN-2 and 3) is considered high-grade dysplasia found after colposcopy and describes dysplasia within the lower two-thirds of the cervical epithelium closest to the epithelial surface (CIN-2), up to full thickness atypia (CIN-3).

Treatment of CIN-2 or 3 involves excision by loop electrocautery excision procedure (LEEP) or conization or laser ablation, with repeat cervical cervical cytology every 6 months for 12 months. If negative for two visits, repeat one year later.

40
Q

In addition to postmenopausal vaginal bleeding, what are some additional symptoms associated with endometrial cancer?

A

Endometrial cancer manifests clinically with postmenopausal vaginal bleeding. Note that the most common cause of vaginal bleeding in postmenopausal women is atrophic vaginitis, but endometrial cancer must be ruled out.

In addition to postmenopausal vaginal bleeding, symptoms associated with endometrial cancer include:

Heavy menses
Mid-cycle bleeding
Abdominal pain
Fixed ovaries or uterus if tumor has extended locally

41
Q

How is cervical dysplasia graded?

A

Cellular grading of cervical dysplasia is done based on the histological pap smear findings, using the following grading system:

Atypical squamous cells of undetermined significance (ASCUS)
Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H)
Low-grade squamous intraepithelial lesion (LSIL)
High-grade squamous intraepithelial lesion (HSIL)
Cervical intraepithelial neoplasia-1 (CIN-1)
Cervical intraepithelial neoplasia-2 or 3 (CIN-2 or 3)
Squamous cell carcinoma

42
Q
A