Exam pt 2 Flashcards
(151 cards)
1
Q
what is the 4th most common CA in women
A
uterine CA
2
Q
what is a hallmark of ovarian CA
A
intra-peritoneal spreads
3
Q
2nd most common gynecologic malignancy with the highest mortality
A
Ovarian CA
*incidence increases w/ age and risk of relapse of advanced stage is 70%
4
Q
pathogenesis hypotheses for ovarian CA
A
- repeated ovulation/ trauma/ repair to ovarian epithelium allow genetic mutations and neoplasia
- excess gonadtotropin secretion –> increased estrogen –> epithelial proliferation and potential for malignant transformation
- starts as carcinoma insitu in fallopian tubes –> breaks free and invades ovaries
5
Q
____% of primary ovarian tumors derive from epithelial cells
A
90% *mostly serous
3% germ cells and 7% sex cord-stroma
6
Q
___% diagnosed with stage III/IV ovarian CA
A
75%
7
Q
____% 5 year survival of advanced stage ovarian CA
A
20%
8
Q
risk factors for ovarian CA
A
- women w/ ovaries
- long ovulation hx
- unexplained infertility
- nuliparity
- fhx of breast or ovarian CA / BRCA**
- diet
- estrogen replacement
- hx of endometriosis
9
Q
factors that decrease your risk for ovarian CA
A
- increased parity*
- oral contraceptive use*
- tubal ligation
- hysterectomy
*decreased ovulation
10
Q
symptoms of ovarian CA
A
bloating, fatigue, increased abdominal size, urinary urgency, constipation
11
Q
how do u evaluate an adenxal mass?
A
- transvaginal sonography (TVS)
- if normal rescan in 1 yr
- if abnormal evaluate tumor morphology index score, CA-125 biomarker, and color doppler
12
Q
prevalence of adenxal mass
A
2-7%
*7.8% of premenopausal women had adenxal masses 2.5cm or larger on random u/s (ovarian cysts)
13
Q
factors to consider when evaluating adenxal masses by TVUS
A
tumor size
borders
density
*morphology index score above 5 is concerning
14
Q
what is an elevated CA-125 in a premenopausal woman and a postmenopausal woman
A
premenopausal >200
postmenopausal >35
*biomarker for ovarian CA but not specific!
15
Q
how to treat an ovarian cyst
A
laparoscopy
16
Q
tumor markers
A
HE4: ovarian CA
CA-125: ovarian and others
CEA: mostly GI tract
CA 19-9: mucinous tumors, pancreatic tumors
( if HE4 normal and CA125 elevated in premenopausal likely endometrosis)
17
Q
screening for ovarian CA
A
there is no screening tool!
*just educate on signs
Can measure 5 protein in blood: Transthyretin apolipoprotein A-1 B2 microglobulin Transferrin CA 125 II
18
Q
surgical staging for ovarian CA. What should be done?
A
- hysterectomy
- both tubes and ovaries (BSO)
- pelvic washings
- pelivic lymph nodes
- periaortic lymph nodes
- peritoneal biopsies
- diaphram scraping
- omentectomy/biopsy
19
Q
stages for ovarianCA
A
Stage 1- stays where it started
Stage 2- spread next to the origin
Stage 3-spread outside pelvis
Stage 4- distally spread
20
Q
treatment of ovarian CA
A
- chemotherapy (IV or intraperitoneal)
- platiunum and taxane (6 cycles of 21 days)
- clinical trials
- surgery
**Platinum drugs are the most effective (carboplatin or cisplatin)- but some are resistant to it
21
Q
surveillance of ovarian CA after no evidence of disease
A
- 5 yr prognosis
- visit every 3 months for 2 years, then may space out
- H and P
- CA125
- imaging?
22
Q
what percent of ovarian CAs are genetic?
A
10%
of that:
BRCA1 ~70-75%
BRCA2~ 20%
23
Q
what is a significant family hx of ovarian CA
A
-2 first degree relatives (Breast or ovarian CA OR 1
24
Q
screening for ovarian CA if BRCA +
A
- monthly BSE starting at 18
- annual mammograms at 25
- annual breast MRI
- 2x yearly ovarin screening w/ us and CA125 at 35
25
how can u reduce ones risk of ovarian CA if they are BRCA +
1. screening
2. surgery
3. chemoprevention
*BSO reduces ~95%
Mastectomy ~40-50%
26
most common gyn malignancy in developed countries
endometrial CA
95% of uterine CA are endometrial, 5% are sarcomas
27
median age of endometrial CA
61
28
major risk factor for type I and type II endometrial CA
type I- unopposed estrogne
| type II- age
29
```
80% of endometrial CA
race: caucasian > black
differentiation: well differentiated
histology: grade 1 or 2, endometrioid
Prognosis: favorable
```
type 1 endometrial CA
30
```
10-20% of endometrial CA
race: caucasian = black
differentiation: poorly differentiated
histology: grade 3, serous, clear cell, mucinous, etc.
Prognosis: poor
```
type 2 endometrial CA
31
risk factors of endometrial CA
1. unopposed estrogen (type 1 only)
2. obestity
3. late menopause
4. nulliparity
5. diabetes
6. hypertension
7. tamoxifen
8. endometrial hyperplasia
32
% risk of
simple endometrial hyperplasia w/o atypia
complex endometrial hyperplasia w/o atypia
simple endometrial hyperplasia with atypia
complex endometrial hyperplasia with atypia
1%
5%
10%
25%
*think coin size
33
factors that decrease risk of endometrial CA
1. decrease estrogen or increased progesterone
2. oral contraceptives
3. pregnancy
4. smoking
34
signs and symptoms of endometrial CA
abnormal bleeding
35
what do u do if someone presents w/ abnormal bleeding?
aka how do u dx endometrial CA
Biopsy!!!- endocervix and endometrium
| -US:
36
___% of endometrioid ovarian CA have a synchronous endometrial CA
20%
37
what other CA has a 40-60% lifetime risk of endometrial CA
hereditary non-polyposis colorectal CA syndrome (Lynch syndrome)
**recommend prophylactic hysterectomy
38
spread patterns of endometrial CA
1. direct extension- most common
2. transtubal
3. lymphatic
4. hematogenous- mostly lungs
39
treatment of endometrial CA
1. surgical staging
2. postop radiation or chemo
3. medical managment (progesterone, anti-estrogen?)** used as palliative care
40
prognostic variables of endometrial CA
young worse than old
2cm
hormone receptor status: + better than neg.
41
prognosis for stage IA endometrial CA
prognosis for stage IVB endometrial CA
88%
15%
42
most common gynocologic CA worldwide but not in US because of screening prevention
cervical CA
43
risk factors of cervical CA
```
HPV infection
smoking
multiple partners
multiparity
HIV
STDs
OCP use
low socioeconomis status
poor diet (Vit. deficiency)
alcoholism
```
44
screening for cervical CA
PAP
| *76% reduction in incidnece of invasive cervical CA
45
what HPV strains cause the most cervical CA
HPV 16 and 18 cause >70%
HPV 16 alone causes about 50%
46
symptoms of cervical CA
frequently asymptomatic
- abnormal vaginal bleeding
- postcoital bleeding
- vaginal discharge: watery, mucoid, purulent, and/or malodorous
* do not confuse with cervicitis
- pelvic or lower back pain
- bowel or urinary symptoms
47
treatments of cervical CA
1. radical hysterectomy
2. + radiation
3. chemoradiation
48
lower urinary tract dysfunction ranges from ___-___% following radical hysterectomy
20-80%
*most common types of dysfunction:
voiding, storage, recurrent UTI, UI
49
signs and symptoms of vulvar CA
pruritus (severe itching)
burning
nonspecific irritation
appreciation of a mass
50
how do you dx vulvar CA
biopsy everything
51
most common vulvar CA subtypes
squamous 90%
melanoma 5%
Basal 2%
52
Staging of vulvar CA is based on what
midline lesion?
radical vulvectomy
inguinal lymphnodes (>1mm invasion)
53
Stages of vulvar CA
Stage 1: confined to vulva
Stage 2: extension to adjacent structures
Stage 3: positive inguinal femoral lymph nodes
Stage 4: upper 2/3 of urethra, upper vagina, distant
54
treatment of paget disease of the vulva
-wide local excision or vulvectomy 2cm margins is preferred
-radical vulvectomy
+/- lymph node dissection
+/- chemo/radiation
*60% experience local recurrence and may require 5cm margins
55
vulva is diffusely involved, with very thin, whitish epithelial areas, termed "onion skin" epithelium or "cigarette paper"
lichen sclerosus
56
an itch that rashes
itching contributes to epidermal thickening or hyperplasia and inflammatory cell infiltrate, which in turn leads to heightened sensitivity that triggers more mechanical irritation
Lichen Simplex Chronicus
57
rare inflammatory skin condition that can be generalized or isolated to the vulva and vagina
Sx:
whitish, lacy bands of keratosis near the reddish ulcerated-like lesions
chronic vulvar burning
pruritus
insertional dyspareunia
profuse vagina discharge
Lichen Planus
58
lesion: atrophic, thin, whitish epithelium w/ frequent perianal halo or keyhole distrubution
lichen sclerosis
59
lesion: pale red to yellowish pink plaques, often oily appearing, scaly crust
seborrheic
60
lesion: eczematous lesions w/ underlying erythema
dermatitis (allergic, irritant, or atopic)
61
lesion: annular pink plaques with silvery scalre that bleed if removed (auspitz sign)
psoriasis
62
lesion: lichenified, hyperplastic plaques of red to reddish brown
lichen simplex chronicus
63
lesion: white lacy network (wickham striae) w/ flat-topped lilac papules and plaques
lichen planus
64
hallmark: other hair-bearing areas often affected-scalp and chest, also back and face
seborrheic
65
hallmark: symmetric w/ extension into areas of irritant or allergen contact
dermatitis (allergic, irritant, or atopic)
66
hallmark: elbows, knees, scalp also affected
psoriasis
67
hallmark: erosive vaginitis w/ demarcated edges
lichen planus
68
hallmark: symmetric w/ variable pigmentation
lichen simplex chronicus
69
hallmark: cigarette paper, parchment-like skin, halo or loss of elasticity
lichen sclerosis
70
fiery, red background mottled w/ whitish hyperkeratotic areas
pagets disease
| ** high risk of underlying internal carcinoma, particularly of the colon and breast
71
most common presenting complaint of vulvar CA
pruritus
*may notice a red or white ulcerative or exophytic lesion arising most commonly on the posterior 2/3s of either labum majus
72
what is the most common non-SCC of the vulva
melanoma
73
another word for uterine leiomyomata
fibroids and myomas
74
represent localized prliferation of smooth muscle cells surrounded by a pseudocapsule of compressed muscle fibers
uterine leiomyomata
75
_____ are the most common indications for hysterectomy, accouting for approximately 30% of this operation
leiomyomata
76
leiomyomata centered in the muscular wall of the uterus
intramural leiomyomata
77
leiomyomata just beneath the uterine serosa
subserosal leiomyomata
78
leiomyomata just beneath the endometrium
submucosal leiomyomata
79
leiomyomata that remains connected to the uterus by a stalk
pedunculated leiomyoma
| *subtype of subserosal
80
uterine malignancy is imore typical in postmenopausal patients who present with
rapidly enlarging uterine massess, postmenopausal bleeding, unusual vaginal discharge, and pelvic pressure
81
menstrual blood loss of >80 mL
menorrhagia
82
on abdominopelvic examination, uterien leiomyomata usually present as a __
a large, midline, irregular-contoured mobile pelvic mass w/ a characteristic "hard feel" or solid quality
-the degree of enlargement is usually state in terms "weeks size" that are used to estimate equivalent gestational size
83
treatment for uterine myomas
most do not require (surgical or medical) treatment
84
___ is commonly sused before a planned hysterectomy to reduce blood loss as well as the difficulty of the procedure. It can also be used as a temporizing medical therapy until natrual menopause occurs
gonadoropin-releasing hormone agonist (GnRH analogs)
85
a surgical treatment is warranted in patients who desire to retain childbearing potential or whose fertility is compromised by the myomas, creating significant intracavitary distortion
myomectomy
| **otherwise a hysterectomy
86
indications for a m yomectomy include
a rapidly enlarging pelvic mass
symptoms unrelieved w/ medical management
enlargement of an asymptomatic myoma to the point of causing hydronephrosis
87
what is the def of infertility
1 yr attempting conception
88
% of male infertility
35%
89
% of tubal/pelvic infertility
35%
90
pretesticular reasons for infertility
1. hypogonadotropic hypogonadism (Kallman's, tumor, trauma, empty sella, iatrogenic)
2. coital disorder (ED)_
3. Ejaculatory failure (psychosexual, post-genitourinary surgery, neural, drug-related)
91
what hormone decreases fertility in males (decreases sperm count)
testosterone
| *shuts down hormonal signally needed to make sperm
92
testicular reasons for infertility
1. genetic (Klinefelters-XXY, Y chromosome deletions, immotile cilia,)
2. Congenital (cryptorchidism, infective- orchitis)
3. Antispermatogenic (heat, chemo, drugs, irradiation,)- vascular, torsion, immunologic, idiopathic
93
post-testicular reasons for infertility
1. Epididymal (congenital, infective)
2. Vasal (genetic: CF-abnormal development of vas deferens, acquired: vasectomy)
3. Accessory gland infection
4. immunologic
5. idiopathic
94
red lesion indicates
newer lesion
95
a chocolate cyst
endometrioma
96
_____% of infertile women will have endometriosis
25-50%
97
best treatment for endometrioma
removal of cyst bc has less recurrence and side effects than drainage
98
screening test for endometriosis
no screening test
| -surgery is diagnostic and treatment
99
treatment options for endometriosis
1. conservative: remove the endometriosis
70-100% relief of pelvic pain
*generally recommend hormone suppression after to decrease recurrence risk
2. Radical: remove the uterus and fallopian tube
90% relief of pelvic pain
ovarian conservation if ovaries uninvolved
100
medical therapy of endometriosis
1. NSAIDS
2. Continuous OCs (pseudopregnancy)
3. Progestogens (depo provera/norethindron, Mirena, implanon)
4. Anti-progestins
5. Aromatase inhibitors (off label)
6. Danazol (androgen- suppresses FSH and LH)
7. GnRH agonists
101
How do GnRH agonists help tx endometriosis
GnRH causes ovaries to shut down by removing pulsatile release of GnRH--> no FSH and LH release from pituitary--> no ovulation
**causes pt to go into medical menopause and may have associated symptoms (use add-back therapy to treat symptoms)
102
how should the flow of treatment go for endometriosis pain
try NSAIDs and birth control pill
- still pain, treat w/ GnRH
- still pain, treat w/ laparoscopy
*if you suspect someone has endometriosis and they are trying to get pregnant soon, do surgery sooner
103
% of ovulatory disorders
15%
104
2 causes of anovulation
1. Estrogenized (PCOS)
| 2. Not estrogenized (hypothalamus or pituitary)
105
what is the most common endocrine defect that causes infertility
PCOS
| 5-10% reproductive age women
106
DDX of PCOS
CAH
hypercortisolism
PRL
thyroid
107
clinical features of PCOS used to diagnose
need at least 2 out of 3
1. oligo- or anovulation
2. chemical or clincal signs of hyperandrogenism (elevated serum androgen concentration, or hirsutism, male pattern hair loss, acne)
3. Polycystic-appearing ovaries
*diagnose by exclusion
108
Pathophysiology: increased LH over FSH release from pituitary --> increased androgen production from theca cells in ovary
- insulin--> acts synergistically w/ LH to enhance ovarian androgen production
- insulin --> inhibits production of SBHG from liver (increased levels of free testosterone)
PCOS
109
how to evalute PCOS
1. Gonadotropins (FSH, LH) and E2
2. TSH
3. Prolactin
4. Pelvic US
5. Testosterone, DHEAS
6. 17OHP
7. Glucose screening
8. lipid panel
110
medical concerns related with PCOS
1. prevention of endometrial hyperplasia
2. prevention of DM2
3. infertility
111
normal hgbA1c and for DM2
nl: 6.4%
| * not as sensitive but easier to perform
112
treatment for DM2
metformin
| statins
113
insulin sensitizer:
- disubstituted biguanide
- modest glucose disposal improvement
- primary: reduces hepatic glucose output
metformin
114
insulin sensitizer:
- thiazolidinedione
- improves sensitivity at liver, skeletal muscle, adipose
- modest: hepatic glucose output
- primary:glucose disposal improvement
Rosiglitazone
115
how to treat PCOS menstrual irregularity
- combined oral contraceptives (also helps manage testosterone levels)
- progestins
*estrogen causes endometrial lining to grow, which increases endometrial hyperplasia and increases risk of endometrial CA if not shedding
116
how to treat PCOS infertility
- lifestype modification (5% decrease in fat can help)
- injectable gonadroptropins
- ovarian drilling
- aromatase inhibitors (ex. letrozole)
117
best treatment of PCOS and infertility
best to use both or clomiphene alone
| *Metformin does not help fertility but does help with endocrine issues
118
how does aromatase inhibitor, Letrozole work
causes low estrogen level to increase FSH level which causes ovulation
*better live birth rate (better rate of ovulation)
119
Causes of central anovulation
1. defects within HP unit
(hypothalamic lesions, GnRH deficiency, prolactin excess, pituitary defects-adenoma, empty sella, tumors)
2. CNS-Hypothalamus
(nutrition, exercise, anorexia nervosa, stress, female athlete triad
120
how to evaluate and treat central anovulation
evaluate w/ MRI
Tx w/
lifestyle modification
gonadotropins
pulsatile GnRH
*clomide and letrozole won't help because hypothalamus is the problem not the pituitary
121
% of unexplained (+ age-related) infertility
10%
122
how do you measure ovarian reserve
-Day 3 FSH/Estradiol. Anti-mullerian hormone
123
unexplained inferility definition
failure to conceive after 12 months in the setting of:
regular menses
at least 1 patent fallopian tube (HSG)
normal sperm count
124
treatment for unexplained infertility
superovulation/IUI
| IVF
125
Cost-effectiveness 2010 study showed what
FSH/IUI added no additional value
126
studies show women with infertility have similar stress levels to those with:
CA
HIV
going through a divorce
127
```
which of the follwing is an epithelial cell tumor?
dermoid cyst
sertoli-leydig cell
lymphoma
muscinous cystadenoma
```
muscinous cystadenoma
128
```
which of hte followin gis a germ cell tumor
brenner cell
lymphoma
endometrioid
teratoma
```
teratoma
129
```
which of the follwing is an ex of a stromal cell neoplasm
serous cystadenoma
dysgerminoma
endometrioid
sertoli-leydig cell
```
sertoli-leydig cell
130
```
what tumor of the ovary should always be treated with hysterectomy, bilateral salpinogo-oophorectomy, and staging
theca lutein cyst
dysgerminoma
cystadenocarcinoma
brenner cell tumor
```
cystadenocarcinoma
131
```
a pt not using OCP, with regular periods, presents w/ acute pain late in luteal phase. this is most c/w
dermoid cyst
mucinous cystadenoma
serous cystadenoma
hemorrhagic corpus luteum
```
hemorrhagic corpus luteum
132
coelomic epithelium gives rise to what ovarian neoplasm
serous cystadenoma
133
gonadal stroma gives rise to what ovarian tumor
granulosa theca
134
germ cells result in what ovarian neoplasm
teratoma
135
what percent of serous cystadenomas are benign
70%
136
most common type of benign epithelial cell neoplasm
serous
137
when a child or adolescent presents w. an ovarian neoplasm, the most common type is
benign cystic teratoma
138
Brenner cell tumors may be associated with
mucinous tumors
139
which of the following neoplasms can contribute to precocious puberty in a female child
granulosa theca cell tumor
140
in the reproductive age group, about what percent of nonfunctional ovarian neoplasms are benign
70%
141
```
which ovarian tumor has the highest malignant potential
dermoid
serous cystadenoma
mucinous cystadenoma
brenner tumore
```
serous cystadenoma
142
malignant ovarian epithelial cell tumors spread primarily by
direct extension w/in peritoneal cavity
143
women with BRCA1 gene have a cumulative lifetime risk of ___ for developing breast CA and ___ for developing ovarian CA
50-80%
15-45%
144
what is the primary surgical approach involved in the treatment of ovarian carcinoma
cytoreductive surgery or "tumor debulking"
145
```
which of the follwiong is a tumor that is metastatic to the ovary from other sites
fibrosarcoma
krukenberg tumor
immature teratome
malignant mesodermal sarcoma
```
krukenberg tumor
146
what is a pathognomic sign of tubal carcinoma
profuse serosanguineous vaginal discharge
147
```
which of the following is the most common virilizing ovarian tumor
gynandroblastoma
arrhenoblastoma
adrenal rest tumor
leydig cell tumor
```
arrhenoblastoma
148
the presence of signet-ring cell type in ovarian tumors ism ost characteristic of
krukenberg tumors
149
breast CA metastatic to the ovary is found in what proportion of cases
25%
150
what percent of epithelial ovarian carcinomas occur in familial or hereditary patterns
5%
151
meigs syndrome couples ascites and right pleural effusion with ___
ovarian fibroma
