gyn onc Flashcards
(14 cards)
endometrial cancer
-Unopposed estrogen
-Chronic anovulation- PCOS
-Selective estrogen receptor modulators (SERMs)- May increase or decrease risk
-> For ex. tamoxifen increases the risk of endometrial polyps and endometrial CA
-Obesity
-Family hx (Lynch syndrome, etc.) -> colorectal CA, endometrial CA and ovarian CA
-Increasing age
-MC > 50yo
-Low parity or nulliparity
-Early menarche
-Late menopause
-Smoking
-MC sx- post-menopausal bleeding
-MCC of post menopausal bleeding- endometrial atrophy
-Type 1- endometrioid adenocarcinoma- (75%)
-Type 2- clear cell and papillary serous tumors
-!!Normal: ≤4 mm in pts with hx of postmenopausal bleeding
-postmenopausal bleeding + ≤4 mm -> NO endometrial bx
-postmenopausal bleeding + endometrial stripe >4 mm -> endometrial bx or dilation and curettage
-NO postmenopausal bleeding + endometrial echo of ≥11 mm -> endometrial sampling (risk of malignancy increases significantly)
endometrial ca tx
-Surgery with or by a gynecologic oncologist
-Exam under anesthesia
-Peritoneal fluid for cytology
-Total hysterectomy, B/L salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy
-open, laparoscopy, or robotic-assisted laparoscopy
-Ovarian preservation is possible -> but individualized
-Adjuvant radiation- may reduce risk of recurrence and improves survival in pts with Stage 1-2 ds with certain RF
-Adjuvant chemo:
-Paclitaxel
-Doxorubicin
-Cisplatin or carboplatin
-Hormone therapy:
-Medroxyprogesterone acetate or megestrol acetate for women who wish to preserve therapy OR who are poor surgical candidates
ovarian carcinoma
-LETHAL
-Major etiologies:
-Uninterrupted ovulation
-Inflammation
-Tubal CA-> metastasis to ovarian epithelium
-low parity
->50yo, MC- 70s
-BRCA 1 or 2
-24% have an inherited mutation
-Salpingo-oophorectomy -> reduce risk 95%
->70% have stage 3 at dx
-very high index of suspicion for vague abdominal complaints
-Hormonal contraception reduces risk by 40-50%
-BL tubal ligation, salpingectomy -> reduce
-Epithelial ovarian carcinoma - MC
-Germ cell tumors - MC in young
-Sex cord stromal tumors
-Metastatic tumors- krukenburg tumors (GI tract)
-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 workup and tx
-If a pelvic mass is palpated:
-US of pelvis
-Eval for complex adnexal masses
-If US suspicious for an ovarian malignancy:
-CT of abdomen and pelvis, or possible MRI
-CEA, CA-125, AFP
-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
-NO ROLE for radiation
-chemo: paclitaxel (taxane) and carboplatin for initial chemo
-May be given intraperitoneally or via IV
cervical carcioma
-2nd MC cancer
-RF:
-hx of untreated high grade CIN
-No screening for cervical neoplasia in >8 years
-High risk HPV infection
-Smokers
-1st intercourse at an early age
-Multiple sexual partners
-Hx of STIs
-Immunosuppression
-Histology MC:
-Squamous cell carcinoma (80%)
-Adenocarcinoma (15%)
-Postcoital bleeding
-Serosanguinous vaginal bleeding
-Metrorrhagia
-Dx:
-Colposcopy
-ECC, and punch bx of cervix
-To determine extent of tumor growth:
-US
-CT
-MRI
-PET scan
-Nuclear bone scan- pelvic, femur, spine
-Laparoscopy
-surgical staging: Exam under anesthesia, Cystoscopy, Sigmoidoscopy
cervical CA test
-never need to take out the ovaries for this!
-Microinvasive carcinoma: simple hysterectomy w/o node dissection -> do it vaginally!
-Early-stage (stage I-II):
-Radical hysterectomy (includes removal of parametria) and lymphadenectomy OR
-Primary radiation therapy
-Survival rates are similar regardless of method of tx
-Late stage (Stage IIb-Stage IV):
-Radiation AND chemo
-Cisplatin-based chemo
-Common sites of metastasis:
-Bone
-Kidneys, ureters, bladder
-Sigmoid and rectum
vulvar carcinoma
-MC >60 yo
-MC in pts with HPV
-MC types:
-Squamous cell carcinoma (90%)
-Melanoma
-Adenocarcinoma
-Verrucous carcinoma
-Bartholin’s gland carcinoma
-Basal cell carcinoma
-Paget’s disease of the vulva (PIC)
-MC sx -> unilateral lesion with thickened vulvar skin
-increased risk of colon, breast, and other malignancies
-Persistent vulvar pruritus, especially postmenopausal
-Nonhealing vulvar ulcer
-Most wait 6mo to seek tx
-higher risk in pts with:
-Lichen sclerosus
-Lichen planus
-suspicious of red, white or black lesions
-Nonhealing lesions
-Use colposcope to better inspect lesions
-Bx liberally!
-Bx- punch bx
-colposcopy for further eval of lesion at time of bx
-Staging- Formerly was staged clinically, but now staged surgically
vulvar cancer tx
-Squamous cell CA in situ (VIN3):
-Local excision
-Extensive VIN3 lesions:
-Skinning vulvectomy- Vulvar skin is removed and a skin graft is used
-Invasive vulvar CA:
-Hemivulvectomy in some cases
-Radical vulvectomy with lymphadenectomy (inguinal nodes)
-Clitoris is spared if not involved in some cases
-50% risk of postop infection and/or wound breakdown
-Adjuvant therapy:
-Radiation
-Chemo:
-5-fluorouracil
-Mitomycin AND/OR cisplatin
-Sites of distant metastasis
-Lungs
-Liver
-Bone
vaginal carcinoma
-30% have hx of CIN 3 or invasive cervical carcinoma treated w/i past 5 years
-RF:
-!Increasing age (>55yo)
-Prior h/o cervical carcinoma in situ, cervical CA (as above)
-H/O diethylstilbestrol (DES) exposure in utero
-Abnormal vaginal bleeding
-Dysuria
-Urinary frequency
-Abnormal findings on PE:
-Masses
-Ulcerative lesions
-Exophytic lesions
-Careful and extensive colposcopy is useful
-DX:
-colposcopy and punch Bx of vaginal lesion
-Tx:
-Radiation- typically
-Initially, external beam RT
-Next, brachytherapy
-Surgical management may be indicated, depending on histologic type and location
-May include vaginectomy, partial vaginectomy, or total pelvic exenteration
molar pregnancy
-AKA hydatidiform mole or gestational trophoblastic disease
-1:1500 pregnancies
-age- extremes of reproductive life
-can become Choriocarcinoma (placenta CA) -> 20%
-1:20,000 pregnancies
-Almost 100% curable
-Placental site trophoblastic tumors are very rare but can arise after any kind of gestation
biparental complete moles vs partial moles
-biparental complete moles:
-Very rare
-maternal + paternal genes are present -> only paternal are expressed
-genetic, autosomal recessive trait
-basically just a placenta
-N/V (due to increased bHCG)
-Thyrotoxicosis
-Pre-eclampsia (< 20 wks!)
-Vaginal bleeding and passage of vesicular tissue
-Uterine size greater than dates
-Partial moles:
-69, XXX or 69, XXY
-Results from duplication of paternal chromosomes or from dispermy
molar pregnancy workup
-Serum quant HCG - tumor marker
-US
-Chest x-ray if pt will have surgery (MC mets is to lungs)
-CBC
-Type and screen; type and crossmatch
-Coagulation studies
-Pre-eclamptic labs if pre-eclampsia
-Dx:
-bHCG: elevated beyond normal range; may plateau
-US: vesicles seen on transvaginal US -> cluster of grapes, snowstorm, no HR
-Def dx: pathological analysis of tissue
mole pregnancy tx
-Suction curettage
-Complications:
-Significant blood loss
-If pre-eclampsia, may have pulmonary edema and hemoconcentration
-If not desirous of fertility -> hysterectomy
-Risk of persistent ds 3-5% regardless of tx
-Rh immune globulin if Rh-
-F/U pelvic exams for 6-12mo
-Eval for vaginal metastatic ds
-F/U bHCG
-q 2 days after surgery
-Then q 1-2wks while elevated
-Then q 1-2mo
-Pt must be counseled to use highly reliable BC x 1 year -> bc how will you know if its a separate pregnancy or a reoccurrance!!
nonmetastatic gestational trophoblastic ds vs choriocarcinoma
-nonmetastatic gestational trophoblastic ds -> bHCG remains elevated but no evidence of metastases
-choriocarcinoma- any metastatic ds from the molar preg (lung (MC), vagina, brain, kidney, liver)
-Choriocarcinoma tx:
-methotrexate
-actinomycin D
