Endometrial Cancer/ Cervical cancer.

Question 1

risk factors for endometrial carcinoma

Answer 1

• increasing age
• estrogen (estrogen therapy, nulliparity, late menopause)
• obesity
• polycystic ovary syndrome
• diabetes
• HNPCC
• tamoxifen therapy.!!

Question 2

types of endometrial cancer

Answer 2

Type 1 = Endometrioid -estrogen dependent

• most common
• favorable prognosis

Type 2 - non-estrogen dependent - 4 types

• worse prognosis
• p53 mutations common.
• papillary serous
• clear cell
• adenosquamous
• undifferentiated

Question 3

symptoms of endometrial carcinoma

Answer 3

1 most common presenting symptom = post-menopausal bleeding!!!

also. ..
- postmenopausal endometrial cells on cervical cytology
- abnormal uterine bleeding - irregular/heavy menses
- abnormal uterine bleeding with history of anovulation

Question 4

T/F Endometrial cancer is staged surgically

Answer 4

True!

Endometrial and ovarian cancer is staged surgically - while cervical cancer is staged clinically.

Question 5

how is endometrial cancer usually spread?

Answer 5

Through direct extension
ALSO
transtubal (goes to fallopian tubes)
-lymphatic - pelvic, then para-aortic nodes
-blood - rare.

Question 6

Most common gynecologic cancer

Answer 6

endometrial cancer

Question 7

When does endometrial cancer happen, typically?

Answer 7

-60-70 years old.

Question 8

what is the precursor to type 1 endometrial cancer?

Answer 8

-atypical endometrial hyperplasia

Question 9

what is the precursor to type 2 endometrial cancer?

Answer 9

there isn’t one.

Question 10

What is the #1 cause of post menopausal bleed?? Hint - not endometrial cancer

Answer 10

atrophic endometritis/ vaginitis from low estrogen state.

Question 11

What is the difference between Simple and Complex Endometrial hyperplasia?

Answer 11

Simple or complex refers to architecture.

LESS important than if atypia is present (atypia is much more related to progression to cancer)
-only the “atypic” varieties of both of these confer significantly increased risk of cancer progression.

Question 12

Workup for a pt suspected to have endometrial cancer

Answer 12

Endometrial biopsy!!

-can do a transvaginal ultrasound along with it or not. BUT always do the biopsy. it is 90% sensitive.

Question 13

If an endometrial biopsy comes back positive, what is the next step?

Answer 13

-evaluate for surgery.(labs, CT scan to detect advanced disease, CXR, EKG)

Question 14

how do positive lymph nodes affect staging in endometrial cancer?

Answer 14

-positive nodes change it from stage 2 to stage 3

Question 15

T/F - most endometrial cancer is detected at stage 2 or later.

Answer 15

FALSE.

72% of endometrial cancer is detected at stage 1

Question 16

What is the most important predictor of survival in endometrial cancer?

Answer 16

stage/histologic type

Question 17

What is the most important predictor of recurrence rate in early endometrial cancer?

Answer 17

lymph node metastasis

Question 18

Treatment for endometrial cancer

Answer 18

-primary treatment is surgery.
remove uterus (hysterectomy) + remove ovaries (high risk of metastasis) = BSO - bilateral salpingo oophorectomy
-lymph node dissection may also be done
-radiation for those who can’t tolerate surgery
-adjuvant treatment depends on pathologic risk factors.

Question 19

Post-op follow up for endometrial cancer

Answer 19

similar to cervical cancer. Everyone can recur, and it usually happens in the first 2 years.

-clinical exam every 3-4 months for 2 years, every 6mo for 3 years, then yearly after 5 yrs.

Question 20

T/F - recurrence is quite fatal in endometrial cancer.

Answer 20

False. It is quite fatal in cervical cancer. But 80% of recurrences are cured in endometrial cancer

Question 21

T/F - biopsy/endometrial sampling is needed for diagnosis of endometrial cancer.

Answer 21

true.

Question 22

T/F - Pap smears can reduce incidence of cervical cancer by 70%

Answer 22

true

Question 23

T/F: 75% of cervical cancer occurs in developing countries.

Answer 23

true

Question 24

T/F: infection with HPV 16 almost invariably leads to cancer.

Answer 24

False. High risk HPV infection is necessary but insufficient for cervical cancer.

Question 25

these strains of HPV cause warts

Answer 25

6 and 11

Question 26

risk factors for cervical cancer (besides HPV)

Answer 26

- immunocompromised - smoking - multiple partners - low Socioeconomics

Question 27

This type of cancer makes up 80% of cervical cancers.

Answer 27

Squamous cell carcinoma | adenocarcinoma 2nd most common

Question 28

Recommendations for Pap smear screening

Answer 28

- start at age 21. - every three years from 21-65 years old. exceptions: HIV, immunocompromised, or previously had cervical cancer

Question 29

pathogenesis of cervical neoplasia

Answer 29

almost exclusively due to HPV.

Question 30

how is cervical cancer staged?

Answer 30

clinically (physical exam/rectovaginal exam/chest Xray, etc)

Question 31

What is the usual pattern of spread for cervical cancer? How does this affect treatment options

Answer 31

Most often, it spreads/ invades locally. It can also spread via lymphatics -hematogenous/intraperitoneal spread is rare.

Question 32

Pros and cons of surgery vs. radiation for early stage cervical cancer.

Answer 32

``` Surgery -preserves ovarian fxn -you get histology information But.. -surgery has risks/morbidity -may also need radiation after surgery anyway. ``` Radiation: -no surgery, done as an outpatient treatment But... -permanent ovarian failure (radiation kills em) -permanent bowel issues. -risk of bowel and bladder fistulae, strictures

Question 33

what does CIN stand for?

Answer 33

Cervical intraepithelial neoplasia. It is a precursor to cervical cancer (30% probability of becoming cancer if untreated)

Question 34

T/F The HPV vaccine has been readily accepted in the US, vaccination rates for girls 13-17 are >90% now.

Answer 34

False. Only 33% of girls get the full series. | Even lower for boys.

Question 35

symptoms of cervical cancer

Answer 35

(usually not present until late) - abnormal bleeding (between periods, with intercourse, after menopause) - vaginal discharge - leg pain/ pelvic pain with advanced disease

Question 36

T/F: biopsy is needed for disagnosis of cervical cancer.

Answer 36

true

Question 37

Treatment for the different stages of cervical cancer.

Answer 37

Stage determines treatment! Early (1-1B1 - very small tumor) = radical hysterectomy with lymph node dissection, OR chemoradiation Locally advanced = primary chemoradiation Metastatic disease = systemic chemotherapy

Question 38

Is it possible to get pregnant again after treatment for cervical cancer?

Answer 38

Yes - they can do a "radical trachelectomy" - removing cervix, reattaching uterus to the vagina! 70% can get pregnant after this.

Question 39

Describe Post-surgery surveillance for cervical cancer

Answer 39

appointments / physical exam (ROS, lymph nodes, pelvic exam) - every 3 mo for 2 years - every 6 mo for 3 years. - annually after 5 years. - From the beginning, pap smear and chest x ray yearly.

Question 40

describe recurrence rates for cervical cancer

Answer 40

80% of recurrences occur in 2 years. - overally poor prognosis for these patients. - The higher the stage, the higher the recurrence and the higher mortality.