exam 3 - Gyn Oncology Flashcards
(52 cards)
A 67 year old G0, LMP 12 years ago presents with postmenopausal bleeding x 2 weeks. She is using 2 pads/day and denies: heavy vaginal bleeding, pain, dizziness, headache or syncope. Past medical history is significant for HTN, DM. On pelvic exam, you note no abnormal findings except for about 5-10 cc of blood in the vaginal vault. -triage- us
Your patient cannot tolerate the endometrial biopsy in the office.
With your supervising MD, you elect to perform dilation and curettage with hysteroscopy in the OR.
Your patient undergoes a total hysterectomy, bilateral salpingo
-oophorectomy and lymphadenectomy.
Pathology reveals stage 1A well
-differentiated endometrioid type endometrial carcinoma.
No adjuvant therapy is indicated.
epidemiology of endometrial cancer and risk factors
-About 66,000 cases/year in U.S.
-It is the 8th leading cause of cancer deaths in U.S. cisgender women
-RF:
-Unopposed estrogen
-Chronic anovulation- PCOS
-Exogenous estrogen use
-Selective estrogen receptor modulators (SERMs)- May increase or decrease risk of endometrial CA, depending on SERM
-> For ex. tamoxifen increases the risk of endometrial polyps and endometrial CA
-Obesity
-Family hx (Lynch syndrome, etc.)
-Increasing age
-MC > 50yo
-Low parity or nulliparity
-Early menarche
-Late menopause
-Smoking
-Hx of Lynch syndrome - Increased risk of colorectal CA, endometrial CA and ovarian CA
signs and symptoms - endometrial cnacer
MC sx: postmenopausal bleeding (90% of endometrial CA pts).
But only 15-25% of pts with postmenopausal bleeding have CA.
MCC of postmenopausal bleeding: endometrial atrophy.
Other symptoms: pelvic pain, pelvic mass, weight loss.
types of endometrial CA
Type 1: Endometrioid adenocarcinoma (75%), usually low grade and limited to uterus at dx.
Type 2: Clear cell and papillary serous tumors, more aggressive.
NEVER NEED TO KNOW STAGING.
natural hx of endometrioid type endometrial carcinoma
Progression: simple hyperplasia
-> complex hyperplasia
-> complex hyperplasia with atypia
-> carcinoma
endometrial CA triage
Pelvic US with attention to endometrial stripe.
Normal ≤4 mm in postmenopausal bleeding → no bx needed.
>4 mm → endometrial sampling.
No PMB but ≥11 mm → sampling.
-Pelvic US with attention to endometrial stripe (AKA endometrial echo)
-!!Normal: ≤4 mm in pts with hx of postmenopausal bleeding
-Pts with postmenopausal bleeding and this finding on US do NOT need an endometrial bx
-Pts with hx of postmenopausal bleeding and who have an endometrial stripe >4 mm require endometrial sampling (endometrial biopsy or dilation and curettage)
-In pts w/o postmenopausal bleeding, the risk of malignancy increases significantly with an endometrial echo of ≥11 mm -> endometrial sampling
normal
Pelvic ultrasound : EM stripe = 1.
48 cm
Hysteroscopy: normal findings in postmenopausal patient. Note R tubal ostium labeled below
hysteroscopy in a patient with endometrial CA
surgical managment endometrial cancer
-Surgery should be performed with or by a gynecologic oncologist
-Exam under anesthesia
-Peritoneal fluid for cytology
tx: surgical resection
-Total hysterectomy with bilateral salpingo - oophorectomy
- pelvic and para
-aortic lymphadenectomy (check for lymph node spread)
-May be performed by open procedure, laparoscopy or robotic
-assisted laparoscopy
-Ovarian preservation is possible in some premenopausal patients, but the decision must be individualized
-pic: dont need to know
endometrial - adjuvant therapy
Radiation reduces recurrence in Stage 1–2 with RF.
Chemo: paclitaxel, doxorubicin, cisplatin or carboplatin.
Hormone: medroxyprogesterone or megestrol acetate for fertility desire or poor surgical candidates.
A 67 year old para 0, LMP 10 years ago, has noted increased abdominal girth and indigestion for the past four months. Two months ago, her PMD suggested she was ‘just getting older’ after exam. On exam, you note a fluid wave and bilateral adnexal masses.
Your patient undergoes total hysterectomy, BSO, lymphadenectomy, appendectomy, and omentectomy with cytology and subdiaphragmatic scraping.
Stage 3A epithelial ovarian carcinoma.
Begins chemo with paclitaxel and carboplatin.
ovarian carcinoma
Most lethal GYN malignancy.
Etiologies: uninterrupted ovulation, inflammation, tubal CA with early metastasis.
19,000 cases/year.
Lifetime risk 1.2%.
24% have inherited mutation.
70% diagnosed at Stage III.
- 5-year survival 20–30%.
Vague sx.
ovarian CA RF
Low parity, age >50, uninterrupted ovulation, family hx, BRCA1/2 (15–45% risk), hx of other adenocarcinomas.
factors that decrease risk of ovarian CA
OCPs (risk ↓ by >40–50%), bilateral tubal ligation, bilateral salpingectomy (w/ hysterectomy), prophylactic BSO in high risk pts.
s&s of ovarian CA
-abd pain
-abd bloating
-early satiety
-urinary frequency
-increase abd girth
-indigestion
-fatigue
-back pain
-urinary incontinence
-constipation
-pelvic pain
-unexplained wt loss
ovarian CA: histology
-Epithelial ovarian carcinoma (70-75% of all ovarian neoplasms, and 90-95% of all ovarian CA)
-Germ cell tumors (15-20% of all neoplasms) -> MC in young pts
-Sex cord-stromal tumors (5-10% of all neoplasms)
-Metastatic tumors -Krukenburg tumors (GI tract)
septations ovarian ca
large pleural effusion in pt with metastatic ovarian carcinoma
ovarian CA: workup
Pelvic mass → pelvic US.
Complex adnexal mass on US→ CT or MRI, labs: CEA, CA-125, AFP.
ovarian CA: surgical staging/debulking procedure
-exam under anesthesia
-exploratory laparotomy, peritoneal fluid aspiration, subdiaphragmatic scrapings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymphadenectomy, appendectomy, omentectomy
-optimal debulking removes all but <1cm of visible ds, if possible
-if pt is desirous of fertility AND malignancy involves ONLY 1 ovary -> pt may be candidate for unilateral salpingo-ooporectomy w/o hysterectomy
Abridged FIGO staging (dont need to know)
Stage 1: ovaries; 2: pelvic extension; 3: peritoneal or lymph node mets; 4: distant mets
ovarian CA: adjuvant therapy
No radiation.
Standard chemo = taxane + carboplatin.
IV or intraperitoneal.
A 38 year old P1001, LNMP unknown, UCG negative, complains of a history of vaginal spotting for four months, notably immediately after intercourse.
Colposcopy, ECC, cervical bx → squamous cell carcinoma.
Stage IA.
Undergoes radical hysterectomy.
cervical carcinoma epidemiology
13,000 new cases/year; 4,000 deaths.
2nd MC cancer worldwide.
HPV is causative.
RF: CIN hx, no screening, high risk HPV, smokers, early sex, multiple partners, STIs, immunosuppression.
Histology: SCC (80%), adenocarcinoma (15%).
