GYN CA

Question 1

vulvar intraepithelial neoplasm

Answer 1

VIN- cellular atypia contained w/in the epithelium. characterized by loss of epithelial cell maturation, cellular crowding, nuclear hyperchromatosis an abnormal mitosis

VIN I (mild), VIN II moderate, VIN III, severe depends on depth

20% have coexistent invasive CA penetrating basement membrane.

correlated w/ HPV infection- other risks: cigarette and immune compromised

2 forms: young-> aggressive multifocal assoc HPV; older focal, slow to invade NOT HPV

Question 2

VIN affects

Dx?

Answer 2

premenopausal women 75% w/ HPV, median age 40; risk HPV 16 and 18, cigarettes, immunodeficiency

Dx: asymptomatic so need thorough inspection for masses, ulcers, color changes; pruritus/irritation, palpable abnormality, perineal burning, dysuria (not responsive to antifungel)

biopsy lisions that appear flat/raised, red/white

Question 3

Tx of VIN

Answer 3

depends of degree of disease

spontantous regression

Question 4

Pagets disease of the vagina- extramammary pages dieases

Dx?

Answer 4

uncommon apocrine gland neoplasia affecting the anogenital areas of women and men

Ages 50-80 in caucasion

recurs locally w/ minimal invasion , 20% coexistent adenocarciona(mets common then)

Dx: chronic inflam changes: hyperemic, sharp demarcations, thickened, puritic, velvety red lesions-> eczematous and scar to white plaques

most common in Pts > 60y but symptoms of vulvar pruritus and vulvodynia precede by years - Biopsy

Question 5

Tx of Pagets disease of the vulva

Answer 5

wide local excision in absence of invasion; fatal if spreads to the nodes
r/o adenocarciona
high recurrence rate may require maple local lesions

Question 6

Cancers of vulva

Answer 6

arise from skin, glandular tissue subq, mucosa

Most common- squamous cell (87%); malignant melanoma (6%), bartholins adenocarcinoma (4%), basal (

Question 7

Dx and staging of vulvar CA

Answer 7

annula exam finds vulvual parities, pain and bleeding, vulvar mass(fleshy, nodular, warty)
-> unifocal lesion 90% on labia majora; Dx w/ biopsy; 20% have secondary neoplasia (cervical)

surgically staged based on size, invasion, nodal and mets; radical local excision w/ inguinal-femoral lymph node dissection; 25% no palpable nodes and can use sentinel node biopsy

Question 8

Tx of vulvar CA

Answer 8

complete pelvic exam prior, wide local excision w/ inguinal lymph node dissection is Tx of choice.

Stage 1 disease - ipsilateral lymphadenectomy sufficient. II- modified radical vulvectomy; II and IV - radical vulvectomy, bilateral inguino-femoral lymph node dissection and pelvic execration

PreOP radiation and chemo
5yr survival = 75%
Melanoma- Lymphadenectomy rarely preformed- depth is key, METS = 100% mortality
Squamous - + inguinal lymph node = prognosis, >3 bad

Question 9

preinvasive disease of vagina - vaginal intraepithelial neoplasm (VAIN)

Answer 9

premalignant lesion but much less common than VIN or CIN

VAIN 1- limited to epithelium, II -thicker, III- involves> 2/3 epithelium and full thickness abnormalities (carcinoma in situ)

most common as multiracial lesion in vaginal apex associated w/ CIN, cervical CA, condyloma and Hx of HPV
Peak incidence mid-late 40s w/ 50-90% coexistent or prior neoplasia

Question 10

Dx of VAIN and Tx

Answer 10

almost always symptomatic
maybe d/c or poistcoital spotting. Dx due to Pap smear- persistently abnormal paps but no cervical neoplasia

annual pap smears if high grade CIN and hysterectomy to look for VAIN
colposcopy and biopsy

Tx: local excision or laser (r/o invasive), Intravaginal 5 FU is helpful w/ multifocal lesions and immunosuppression

Question 11

CA of the vagina

Answer 11

rare - only 1-2% of malignanies of gyn, secondary more common than primary
squamous most common, adenocarciona, sarcomas and melanomas

clear cell adenocarcinoma in 1970s w/ DES

squamous - ulcerated, nodular, posterior wall and upper 1/3 of vagina; spread lymphatic to inguinal nodes and deep pelvic or direct extension; hematogenous spread potential

Question 12

Dx and Tx of vaginal CA

Answer 12

10% asymptomatic - pruritis, post meno bleeding, positcoital spoting, watter/blodd d/c; can have urinary and GI symptoms
May be diagosed w/ persistent paps abnormal

Squam complicated w/ involved local structures - need pre-op imaging, cystoscope, proctosigmoidoscopy, IVP to assess spread

2cm or lower 2/3rds vagina get external nd internal radiation alone

Question 13

Dx and Tx of vaginal CA

Answer 13

10% asymptomatic - pruritis, post meno bleeding, positcoital spoting, watter/blodd d/c; can have urinary and GI symptoms
May be diagosed w/ persistent paps abnormal

Squam complicated w/ involved local structures - need pre-op imaging, cystoscope, proctosigmoidoscopy, IVP to assess spread

2cm or lower 2/3rds vagina get external and internal radiation alone

Question 14

Dx and Tx of vaginal CA

Answer 14

10% asymptomatic - pruritis, post meno bleeding, positcoital spoting, watter/blodd d/c; can have urinary and GI symptoms
May be diagosed w/ persistent paps abnormal

Squam complicated w/ involved local structures - need pre-op imaging, cystoscope, proctosigmoidoscopy, IVP to assess spread

2cm or lower 2/3rds vagina get external and internal radiation alone

Question 15

number one killer gyn cancer world wide

Answer 15

cervical CA in the developing world

endometrial in the US

Question 16

CIN - cervical intraepithelia neoplasia

Answer 16

premalignant changes in the cervical epithelium that can progress to cervical CA
severity depends on portion of epithelium showing disordered growth and development
-> changes start at basal layer and can expand

CIN 1- lower 1/3; II = lower 2/3rds; III = >2/3 and can expand full thickness of epithelium (Carcinoma in situ)

CIN most commonly occurs during menarche and after pregnancy w/ estrogen simulation of transformation zone

HPV primary cause = 6 and 11 lowest on but 90% condylomas; 16, 18, 31 and 45 high risk onc

Question 17

Epidem of CIN

Answer 17

most commonly diagnosed in 20s (25-35); mtpl and early exposure to HPV, early childbearing, low SES

Question 18

Dx and screenof CIN

Answer 18

asymptomatic, use Pap to sample transformatin zone (squamous-> columnar). Sample the endocervical and ectocervical cells of external os and also endocervical canal w/ city brush

all women >21 start screen at 21, test q3y; >30 can expand to 5 yr w/ HOV co-test; stop age 65-70y if 3 or > normal paps and no CIN 2-3 in past 20y

total hysterectomy can stop unless not CIN2-3, normal 3x can also stop

Question 19

Abnormal pap smears classes -6

Answer 19

HPV cell changes -> nuclear enlargement, multi nucleation, hyperchromasia, pweinuclear cytoplasmic clearing

ASC-US: Atypical squamous cells if undetermined significance
ASC-H: Atypical squad cells - cannot exclude high grade
LSIL: low grade squamous intraepithelial lesion
HSIL: sigh grade squamous intraepithelial lwsion
SCC: squamous cell carcinoma
AGC: Atypical glandular cells

Question 20

Atypical squamous cells in CIN

Answer 20

benign inflame response to infection/trauma -> preinvasive (10-15%);
ASC- H should have colposcopy;
ASC:US should have HPV testing(reflex) -> colposcopy

Question 21

who gets colposcopy

an additional endometrial biopsy?

Answer 21

ASC-H, LSIL, HSIL, AGC

Atypical glandular cells also get endometrial biopsy if >35 of

Question 22

Screen of 30y/o for HPV and pap w/ only + HPV how does screening change

Answer 22

repeat both HPV and pap n 1 yr; depending on result get colposcopy, sputtered and HPV 16 or 18 is positive get a colposcopy

Question 23

HPV test for high risk lesions (ASC-H, LSIL, HSIL)

Answer 23

not done for always high risk HPV types

Question 24

time course of + paps

Answer 24

epithelial abnormalities will regress over 6m-2y, some abnormalities persist at current level, others progress to more serious lesions

ASC and LSIL represent transient infection, HSIL more likely to persost

Question 25

colposcopy may visulaizw

Answer 25

acetowhite epithelium, mosaicism, punctiations, atypical vessels where they should be biopsy CIN ->1, 2, or3

Question 26

TX of CIN1

Answer 26

repeat cytology q6months for 1 yr, or high risk HPV in 1 yr | Persistent for 2y then offer LEEP

Question 27

TX of CIN2

Answer 27

LEEP procedure or repeat pap+ clop q6m for 2 yrs in young women

Question 28

Tx of CIN3

Answer 28

LEEP procedure or large loop excision of transformation zone; traditionally cold knife conization lesions w/ endocervic TX w/ CKC or 2 stage LEEP to allow more endocervix removed

Question 29

F/u of LEEP and conization

Answer 29

can have cervical stenosis, cervical insufficiency, infection or bleeding persistence rate of II or III is 4% w/ recurrence 10-15% f/u pap q6m w/ pap and repeat pap and colposcopy at 1 yr; normal can return to normal screening for 20yrs

Question 30

Cervical CA

Answer 30

squamous cell - 80% w/ mets by direct extension Adenocarcinoma 20% (clear cell one type) 11000 annually w/ Dx at 53 usually and High risk 16. 18, 31 and 45 cervical CA is AIDS defining

Question 31

clinical manifestations and diagnosis of cervical CA

Answer 31

Usually asymptomatic, most commonly postcoital bleeding if symptoms watery d/c, pelvic pain/pressure, rectal/urinary tract, friable/bleeding cervical lesion, bimanual mass Pap smears do NOT dx CA- need tissue biopsy, need a colposcopy and biopsy

Question 32

TX of CIN1

Answer 32

repeat cytology q 6months for 1 yr, or high risk HPV in 1 yr Persistent for 2y then offer LEEP

Question 33

clinical manifestations and diagnosis of cervical CA

Answer 33

Usually asymptomatic, most commonly postcoital bleeding if symptoms watery d/c, pelvic pain/pressure, rectal/urinary tract, friable/bleeding cervical lesion, bimanual mass Pap smears do NOT dx CA- need tissue biopsy, need a colposcopy and biopsy

Question 34

Cervical CA staging

Answer 34

clinically staged vs surgically staged. Evaluation of invasion into adjacent structures and med - ising exam under anesthesia, CXR, cystoscope, proctoscope, IVP, barium enema -> MRI/CT cannot be used to determine stage; Once a stage has been assigned it does not change based on intraoperative findings and progression 1- confined to cervix(90% survival; II not to pelvic side walls to lower 1/3 vagina(75%); III - walls and L vagina(45%); IV beyond the pelvis, local invasion and METS(20%)

Question 35

Tx of cevical CA

Answer 35

stage 0 and I - simple hysterectomy or cold knife cone; Early: Stage 1a-IIa needs radiation or radical hysterectomy(bilateral pelvic node), parametric, upper vaginal cuff, uterosacral/cardinal ligment local vasc Advance: IIb-IV - chemoradiation w/ both external beam and intracavitary w/ cisplatin based chemo Recurrent- surgery(pelvic exenteration: removal of all pelvic organs -50% survival), usually but also radiation,

Question 36

Endometrial CA - 2 types

Answer 36

4th most common CA, most common gyn CA but curative Tx available w/ early symptoms and accurate Dx modalities obesity, chronic anovulation, nulliparity, late meno, unopposed estrogen use, HTN, Dm all increased risk ``` 2 etiologies: Type 1(80%) Hx of chronic estrogen exposure unopposed progestin (estrogen dependent neoplasms) atypical hyperplasia-> carcinomas (well differentiated w/ low grade nuclei) more favorable ``` Type 2(20%) - estrogen INdependent- occur in w/in background of atrophic endometrium or polyps. High grade nuclear atypia w/ Serous or clear cell histology; p53 mutation

Question 37

Prognosis of endometrial CA

Answer 37

Depth of myometrial invasion key to staging and prognosis; worse w/ >1/2 thickness of myometrium Direct extension most common; lymphatic system w/ sig penetration; shed transtubally through the fallopian tube; hematogenous spread less frequent to liver/lungs/bone Histionlogic grade key(Grade 1- high dif

Question 38

most common endometrial Ca

Answer 38

endometriod adenocarcinoma (75-80%) - 2/2 proliferation of glandular cells also- mucinous, clear cell, papillary serous, squamous

Question 39

Epidemiology and Risk of endometrial CA

Answer 39

premenopausal - 25%, postmenopausal 75%; Avg age is 61 Unopposed estrogen obesity, nulliparity, late meno, chronic anovulation(PCOS), tamoxifen(SERM- partial agonist/weak estrogen in endometrium), also: DM, HTN, CA of breas(unknown BRCA)t/ovary/colon(Lynch II) and FHx endometrial hyperplasia - risk of transformation depends on type Protective: combo OCPs, progestin contraceptives, high parity, pregnancy, physical activity, smoking

Question 40

Hx and PE of endometrial CA

Answer 40

postmeno bleeding or abnormal vaginal bleeding (menorrhagia, postcoital spots, intermenstrual bleeds); 10% nonbloody d/c; pelvic pain, pelvic mass and weight loss Obesity, acanthosis nigricans, HTN, typically NORMAL pelvic exam , advaced-

Question 41

DDx for endometrial CA

Answer 41

abnormal uterine bleeding-> uterine fibroids, endometrial polyps, adenomyoisis, endometrial hyperplasia, ovarian cysts, thyroid dysfunction post menopause- atrophy, exogenous estrogens, in addition; CA responsible for 20% of postmenopausal bleeding amount of blood does not equal risk of malignancy

Question 42

Dx of endometrial CA

Answer 42

endometrial biopsy (90-98%) sensitive; postmeno a transvaginal US can help - thickness 45 and those at risk regardless of age D and C +/- hysteroscope if EMB can't be done TSH, prolactin level and possibly FSH and estradiol; CBC r/o anemia preop. CA125 often pre op and followed; Pap smear- (endometrial cells in 40+ y/o an EMB should be done); pelvic US

Question 43

Tx for endometrial CA

Answer 43

Need surgical staging w/ path confirmation Stage I and II - total abdominal hysterectomy and bilateral salpingo-oohorectomy, pelvic washings, pelvic and para-aortic lymph node resection and complete resection of visible tumor Stage III and IV - malignancy to or beyond the uterine serosa, need pelvic radiation chemo or high dose progestin for recurrent disease F/u- PE q3m for 3y

Question 44

High risk features for endometrial CA Suggests?

Answer 44

radiation even if low stage I and II >50% myometrial invasion, papillary or clear cell tumors, grade 3 tumors, large tumor >2cm, spread beyond uterine fundus, lymphovascular involvement

Question 45

Ovarian CA - 3 types

Answer 45

5y survival 25-45%; 2nd most common gyn CA, lack of screening; 1/70 women avg age 61 Surface epithelium -90%; germ cells; ovarian stroma - Spread by: direct exfoliation (peritoneal-> carcinomatous ileum in the bowels), lymphatic, hematogenous (rare) 5-10% mets from primary - kruckenberg tumor

Question 46

kruckenberg tumor

Answer 46

mets to ovarvian CA from GI, breast or endometrium

Question 47

Pathogenesis of ovarian CA

Answer 47

unclear cause, malignant transformation of ovarian tussle after prolonged chronic uninterrupted ovulation(ovulation ruptures epithelium -> repair mech and can lead to somatic gene deletions and mutations) 10-15% familial CA, mutations in BRCA I mainly w/ small proportion of Pts w/ BRCA2; Lynch II syndrome -> breast, ovarian, colon, endometrial

Question 48

Risk factors for ovarian CA

Answer 48

familial ovarian CA syndome, family Hx, personal Hx of breast CA, uninterrupted ovulation (early menarche infertility, nulliparitym delayed childbearing, late onset menopause). Increasing age Protective:OCPs >5y, breastfeeding, multiparty, chronic anovulation, tubal ligation and hysterectomy (less blood flow)

Question 49

PE and Hx of ovarian CA

Answer 49

asymptomaic, vague, nospeccific complaints-> vague lower abdominal pain, abdominal dissension, bloating, early satiety, GI, urinary frequency, pelvic pressure, ascities-> SOB PE: solid fixed irregular pelvic massm ascitis, Ovarian CA METS= mary joseph nodule (umbilicus)

Question 50

Dx eval of ovarian CA tumor markers

Answer 50

Pelvic US - dx of adnexal mass, CT and MRI of pelvis/abdomen can assist (DON"T percents or cyst aspire) METS disease looked for - barium enema and IV pyelography; Serum tumor markers: CA125, AFP, lactate dehydrogenase (LDH), hCG

Question 51

Staging of ovarian CA

Answer 51

surgically staged -TAHBSO (toal abdom hys, bilat salpingo-oophorctomy), Omenectomy, peritoneal washing, pap smear of diaphragm, sampling of pelvic and para aortic lymph nodes

Question 52

Epithelial cell types- ovarian CA

Answer 52

65-70%; age 20+ serous, mucinous, endometroid, clear cell, brenner, undifferentiated

Question 53

Germ Cell types - ovarian CA

Answer 53

15-20%, 0-25+y teratoma, dysgerminoma, endodermal sinus tumor, choriocarcinoma, embryonal carcinoma

Question 54

Sex cord-stromal types - ovarian Ca

Answer 54

5-10%, all ages granulose-theca cell tumor, stroll-leydig cell tumor, fibroma

Question 55

US of Benign vs malignant of malignant mass

Answer 55

Benign: 8cm, solid or cystic, nodular/papillary components, Multilocular thick septations, doppler flow, bilateral, ascities, peritoneal mass, LAD

Question 56

Epithelial tumors epidemiology

Answer 56

low malignant potential -> serous cystadenocarcinoma (bad) seen in 50s accounting for 6%% of all all ovarian tumors and 90% of ovarian CA Serous most common- CA125 elvaated 80% and used to track Tx and recurrence

Question 57

Staging of Ovarian CA

Answer 57

1- limited to ovaries 2- extention to the pelvis 3 - extension to the abdominal cavity 4- distant METS

Question 58

Tx of epithelial tumors

Answer 58

Surgery mainstay -> TAHBSO w/ omentectomy, cytoreduction/debulking Tx after w/ chemo: carboplatin and paclitaxel; optimal debulking-> cisplatin and paclitaxel chemo 5 yr surrvival rate is 20% overall

Question 59

CA 125 elevated in

Answer 59

gyn CA(epithelia, fallopian, endometrial, endocervical), Non gyn CA: pancreatic, lung, brest, colon Benign gyn: ectopic, endometriosis, fibroids, PID Benign Non-gyn: pancreatitis, cirrhosis, peritonitis, recent laparotomy

Question 60

Germ cell pathogenesis and tumor markers

Answer 60

arise from primordial gem and 95% benign. undifferentiated, totipoten cells -> yolk sac, placenta, fetus benign- cystic mature teratoma(dermoid cyst) - mature tissue w/ skin, hair, teeth w/ sebacious materua dysgerminomas(no differentiation, malig)(50%) -LDH - more common in girls (asian/african) immature teratoma (20%) - N/A endodermal sinus (yolk sac) (20%) -AFP and hCG choriocarcinoma(trophoblast) - hCG *grow rapid and limited to 1 ovary and stage 1 @ diagnosis- curable

Question 61

Epidem and Manifestations of Germ cell tumors

Answer 61

20-25% of all ovarian tumors, acute pelvic pain, pressure symptoms of bladder/rectum or pain from torsion/rupture

Question 62

Tx of germ cell tumors

Answer 62

All curable surgery if benign dermoid cysts w/ ovarian cystectomy or oophprectomy - > usually unilateral Childbearing complete -> TAH/BSO all require multiagent chemo after unless dysgerminomas and immature teratomas Radiation post op - dysgerminomas

Question 63

Sex cord stromal tumors pathogenesis

Answer 63

originate the cells surrounding the oocyte(before differentiation into m/f) or from the ovarian stroma low grade malignancies which can occur at any age; Usually unilateral and rarely recur Granulosa theca - low grade malignancies and most common(70%)~ fetal ovaries, coffee-bean nuclei Cell-enaer bodies-> estrogen Sertoli-leydig - rare ~ testes -> testosterone Ovarian fibroma- mature fIbroblasts -> ascities

Question 64

Call-Exner bodies

Answer 64

granulosa cells w/ grooved "coffee bean" nuclei and cells arranges in small clusters around a central cavity

Question 65

Meigs syndrome

Answer 65

triad of ovarian tumor (fibroma), ascities and R hydrothorax

Question 66

Epidemiology and Clinical manifestations of Sex cord- stromal cells

Answer 66

Ages 40 and 70 w/ avg age 50 Dx; Sertoli-leydig at 40y/o Granulosa cell tumors -> estrogen w/ endometrial hyperplasia and 5% have concurrent endometrial CA Granulosa-theca -> estradiol and inhibin A/B-> feminization, precocious puberty, menstrual irregularities, secondary amenorrhea, post meno bleeding; endometrial hyperplasia and need to sample Sertoli leydig -> androgens (testosterone, androstenedione) w/ virilizing effects w/ breast atrophy, hirsutism, deep voice, acne, clitoromegaly, receding hair

Question 67

Tx of sex cord-stromal tumors

Answer 67

low grade lesions, unilateral and do not recur -> unilateral salpingo-oophorectomy if childbearing complete get hysterectomy and bilateral NO chemo or radiation 5yr survival 70%-90%, slow growing and late recurrence at 15-20y for granulosa

Question 68

Fallopian tube cancer

Answer 68

RARE- progression of tumors similar to ovarian w/ periotoneal spread and ascites Usually adenocarcinoma arising from mucosa, often result of metastasis from primary tumors Caucasion w/ risks of BRCA1/2, nullparity and infertility See: asymptomatic;Latzkostriad-profuse watery d/c, pelvic pain, and pelvic mass Dx: CA125, US Staged surgercially w/ chemo (carboplatin and paclitaxel f/u)

Question 69

Gestational trophoblastic disease def and 4 types

Answer 69

abnormal proliferation of trophoblastic (placental) tissue); maternal tumor results from abnormal fetal tissue; make hCG; sensitive to CHEMO and still fertile molar-80%; persistent/invasive-10-15%; choriocarcinoma - 2-5%; placental site trophoblastic tumors (rare)

Question 70

Hydratidiform moles stats and risks

Answer 70

complete(90%) or partial(10%) - 80% of GTD complete- no fetus; partial - abnormal fetus 1/1000 oregnancies w/ global rates higher in asians Risk: extreme age and Hx of GTD; null parity; diets low in beta-carotene, folic acid and animal fat; smoking, infertility SAB, blood group A, OCP

Question 71

Complete molar pregnancy

Answer 71

90% vs incomplete; 2/2 fertilization of empty egg and 1 normal sperm that replicates; (paternal derived) -> chromosome pattern of 46, XX trophoblastic proliferation, diffuse swelling of chorionic villi and hydropc degeneration -? grape like vesicles filling uterus in absence of fetus villi syncytiotrophoblasts ->hCG >100,000 w/ large theca lutean cyst (~LH) and hyperthyroidism (~TSH); hyperemesis gravidarum and preeclampsia before 20 wks; higher malignent potential -15%

Question 72

Hx and PE of complete mole

Answer 72

irreugular or heavy bleeding **(2/2 tumor separation from decidua), High hCG-> nausea/vomitting, irritability, dizziness, photophobia, (preeclampsia), nervousness, anorexia, tremors (hyperthyroidism) HTN, tachycardia, tachypnea, absence of fetal heart sounds, uterine size > GA, grape like molar clusters in vagina or cervical os e/ blood, bilateral large theca lutein cysts)

Question 73

DDX and eval of complete mole

Answer 73

serum hCG >100,000, pelvic US w/ no fetus or amniotic fluid, "snowstorm" pattern due to chorionic villi, bilateral theca lutein cysts(15%) definitive is intrauterine tisse DDx: mtpl gestations, erythroblastosis fetalis, intrauterine infection, uterine fibroids, threatened abortion, ectopic, normal intrauterine pregnancy

Question 74

Tx and F/u for complete mole

Answer 74

immediate removal of uterine contents w/ D and C. IV oxytocin after, +/- RhoGAM. maybe hysterectomy get baseline CBC, coag, hCG, renal, thyroid and liver tests prior, RH status antihypertensives(beta blockers) symptomatically. serial hCG, 48 hrs post evac + weekly q3w, normal at 14w; subsequent pregnancy have early US and hCG levels

Question 75

PArtial molar pregnancy -

Answer 75

formed w. normal ovum and 2 sperm simultaneous -> tripled karyotype (69, XXY) focal hydropic villi and trophblastic hyperplasia w/ cytotrophoblast(not making hCG)-> normal/slight elv hCG levels presence of a fetus on histo w/ amniotic fluid and HR. mtpl anomalies, syndactyl and hydrocephalis and growth restricted, SAB late 1st/early 2nd tri; LOW malign potential

Question 76

Hx and PE of partial molar pregnancy

Answer 76

delayed menses and pregnancy diagnosis, NORMAL/slight elv hCG-> less severe symptoms 90% w. vaginal bleeding from miscarriage or ab bleeding 1st tri; diagnosed later Typically normal exam, may have coexistent fetus w/ HR. IUGR and size

Question 77

Diagnosis and Ddx of partial molar pregnancy

Answer 77

Heg will be normal/slight elv. pelvic US may show fetus w/ HR , congenital malformations and IUGR. Amniotic fluid is REDUCED. -- -intrauterine tissue may contain anechoic spaces juxtaposed against chorionic villi to look like swiss cheese; need path exam

Question 78

Tx and f/u of incomplete molar pregnancy

Answer 78

D and C.

Question 79

Malignant gestational trophoblastic disease

Answer 79

molar (complete and incomplete) typically benign but 20% transform potenital for local invasion (3 types) persistent invasive (75%); Choriocarcinoma (25%) and PSTT(rare) malignancy occurs months to years after mole (25% after normal pregnancy, 25% after miscarriage/ectopic). can be metastatic v nonmetastaic (1-uterus, 2 to pelvis vagina, 3 -lung, 4 distant), good or poor prognosis

Question 80

Tx of malignant gestational trophoblastic disease

Answer 80

chemo- NO surgery except is high risk of=r PSTT serum hCG monitotes

Question 81

persistent invasive moles

Answer 81

follow D and C of molar pregnancy. characterized by penetration of large, swollen (hydropic) villi and trophoblasts into the myometrium, sometime through -> rupture, hemoperitoneum and anemia. Rarely mets and can spontaneous regress 1 in 15000 pregnancies

Question 82

Hx and PE of persistent invasive mole

Answer 82

plateauing or rising hCG after treatment for molar pregnancy asymptomatic but can have abnormal uterine bleeding exam similar to molar pregnancy- high hCG, large uterine size and prominent theca lutein cyst

Question 83

Dx and Tx of persistent intrauterine mole

Answer 83

hCG levels and pelvic US key US-> 1+ intrauterine masses w. possible myometrium invasion; doppler shows high vascular flow Tx- single agent chemo: methotrexate or actinomycin D. If mets: low risk -> single agent, high risk -> multi agent F/u with hCG and reliable contraception

Question 84

Choriocarcinoma pathogen and epidemiology

Answer 84

malignant necrotizing tumor- arise wks to yrs after any pregnancy; pure epithelial tumor ->histo: sheets of anaplastic cytotrophoblasts and syncytiotrophoblasts in absence of chorionic villi Spreads hematogenously and often METs 1/20,000-40000, > Asian/african

Question 85

PE and Hx of choriocarcinoma

Answer 85

late post partum bleeding (after 6-8 wks) but also can have irregular uterine bleeding often present METS-> lungs (cough, dypsnea, resp distress), CNS (HA, dizzy, blackout,) hepatic, urologic, GU, Vaginal PE-? uterine enlargement and masses

Question 86

Dx and DDx fo choriocarcinoma

Answer 86

measure hCG and assess for METS w/ CBC, coag, renal and hepatic function tests pelvic US-> uterine masss w/ hemorrhave and nectosis. High vascular -> + doppler. CXR or CR of abdomen/chest or MRI (brain?) DDx: great imitator-> dx delayed due to context outside of pregnancy(wks to yrs)

Question 87

Tx and f/u of choriocarcinoma

Answer 87

Tx w/ single agent chemo, poor prognosis gets multi agent chema F/u w/ hCG and reliable contraception

Question 88

Placental site trophoblastic tumors

Answer 88

Rare and arise from placental implantation site. intermediate cytotrophoblasts from placental site infiltrate myometrium -> vessels Histo see absence of villi and prolif of intermediate trophoblasts and production of hPL (human placental lactogen) See irregular vag bleeding and maybe enlarged uterus LOW chronic hCG w/o syncutiotophoblast. highr hPL. pelvic US to see mass Tx: NOT as sensitve to chemo but rarely mets beyond uterus -> hystorectomy