OB-GYN (Oncology) – Flashcards
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Why has the incidence of Cervical Cancer decreased 4 fold in 40 years?
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1) Pap Smear screening 2) HPV vaccine
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There are two main types of cervical cancer and BOTH are influenced by HPV. What are they?
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1) *Squamous Cell (80%) 2) Adenocarcinoma
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Which types of HPV are responsible for 70% of al cervicle cancer
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HPV 16, 18
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What does the progression of cervical cancer require?
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Persistent HPV infection for many years
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Next to breast cancer, cervical cancer is the second most common cancer in females worldwide. Is this the case in the U.S.?
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NO
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What are the risk factors for cervical cancer?
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**(somewhat similar to RF for persistent HPV infection) 1) STDs - HPV—types 16, 18 associated with highest risk - HIV 2) Low socioeconomic status 3) > 1 sexual partner 4) Immunosuppression 5) Tobacco 6) Hx of previous cervical disease 7) DES exposure
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What is the most common presenting symptom in cervical cancer?
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Post coital bleeding and AUB, including post menopausal
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What are late findings of cervical cancer?
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1) Persistent vaginal discharge 2) Pelvic pain/leg swelling 3) Urinary symptoms
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What should be done if a woman has visible lesions?
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Refer for colposcopy
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Can a rectal exam for staging local invasion of cervical cancer?
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Yes
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What should be done to stage local and distant disease?
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Imaging
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What is stage I cervical cancer?
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Stage I disease confined to cervix A—microscopic B—clinical disease
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What is the MOST common gynegological malignancy in the US?
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Endometrial cancer
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Are there amy useful screening tests for endometrial cancer?
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No
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***What do 90% of patients with endometrial cancer experience?
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Abnornormal uterine bleeding (evaluate all women >35 years old)
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What are the risk factors for endometrial cancer?
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1) ***Unopposed estrogen*** e.g. anovulatory cycles (compare with ovarian cancer) 2) Obesity (increased peripheral conversion of androgens) 3) Affluent (compare with cervical cancer) 4) White 5) Low parity 6) Post-menopausal (particularly if on estrogen replacement w/o progestin) 7) Type 2 DM 8) Women with Lynch syndrome (familial nonpolyposis colorectal cancer)
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Is the prognosis of cervical cancer good?
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Absolutely. 96% 5-yr survival rate if confined to uterus (68% of patients) Take out the uterus and you are good to go
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What is the work-up for endometrial cancer?
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1) Endometrial biopsy (EMB) - Positive for cancer - Negative (90% diagnostic accuracy) 2) Transvaginal Ultrasound
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Is transvaginal ultrasound sufficient in the evaluation of premenopausal women?
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NO. Because there is no standardization of acceptable stripe thickness. For premenopausal women we go straight to biopsy
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What is the initial diagnostic test in postmenopausal women?
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Transvaginal ultrasound 4 mm endometrial stripe requires endometrial biopsy +/- D&C
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Where is the endometrial stripe measured from?
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It is Measured from echogenic interface between the endometrium/myometrium both anterior and posterior
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Can I do an endometrial biopsy?
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Yes its pretty easy
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What are the 4 possible endometrial results?
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1) Benign, proliferative, secretory, atrophic 2) Hyperplasia without atypia - Progesterone treatment - Endometrial biopsy every 3-6 months 3) Hyperplasia with atypia - Hysterectomy - If refused, progesterone then every 3 month endometrial biopsy is recommended 4) Cancer Staging and treatment
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What is the 2nd most common gynecologic malignancy?
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Ovarian Cancer - Risk is 1 in 70 in a lifetime - Risk increases from age 40 to age 60 - Median age at dx is 61
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What is the most common cause of gynecological cancer deaths?
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Ovarian Cancer (5-yr survival ~40%)
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What are the risk factors for ovarian cancer?
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1) Low/no parity 2) Breast/colon cancer 3) Tobacco
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What things are protective for ovarian cancer?
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1) Multiparity 2) Oral contraceptive pill (OCP) use 3) History of breastfeeding So....Take birth control pills, stop and have a baby, breastfeed, go back on pills, have 3 more kids and breastfeed them all, get your tubes tied and don't smoke
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What is the screening test for breast cancer?
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There isnt one. A bimanual examination during the annual exam is the most appropriate examination for early detection of ovarian cancer.
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Is CA-125 a screening test for ovarain cancer?
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No. Except possibly in the familial syndromes (e.g. BRCA1 mutation on chromosome 17) exhibiting a genetic component consistent with the disease, but may be used for post-treatment surveillance of ovarian cancer.
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What must be done with a woman with Familial Ovarian Cancer Syndrome (BRCA-1, BRCA-2)?
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1) Frequent pelvic exams (Annual) 2) Annual Trans-vaginal ultrasound (TVUS) 3) Serum markers (CA-125) every 6-12 months **Begining at age 30-55
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What is the most common physical exam finding in ovarian cancer?
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Pelvic mass/ascites
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What are the late findings assoicated with ovarian cancer?
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1) Anorexia 2) Early satiety 3) Weight loss 4) Constipation 5) Frequent UTIs in menopausal patient
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What will a transvaginal ultrasound show in a patient with ovarian cancer?
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Complex cystic mass
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What is most useful in following ovarian cancer treatment?
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Serum marker CA-125
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What else may Serum marker CA-125 be useful in?
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Postmenopausal patients in combination with clinical evaluation/US
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What is a sustained elevation of Serum Marker CA-125 mean?
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1) 80% in non-mucinous epithelial ovarian tumors 3) Most beneficial in postmenopausal pelvic mass, >65u/ml is 75% predictive of malignancy
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What does variable elevation of Serum Marker CA-125 mean?
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1) Endometriosis, leiomyomata, PID 2) Hepatitis, cirrhosis 3) CHF 4) Other malignancies
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Vulvular cancer is usually caused by Squamous Cell Carcinoma. What are the two hypotheses?
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1) Young/HPV/vulvar intraepithelial neoplasia (VIN) 2) Older/chronic inflammation/lichen sclerosus *Caucasian women over 65
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What is the second most common type of vulvar cancer?
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Malignant Melanoma *Bottom line (Any suspicious lesion or pigmented lesion requires biopsy)
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What is Gestational Trophoblastic Disease (GTD) unique?
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Because maternal lesions arise from fetal tissue (trophoblastic epithelium of placenta)
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What are the 3 types of Gestational Trophoblastic Disease (GTD)?
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1) Benign hydatidiform mole (noninvasive) 2) Invasive mole (in the middle) 3) Choriocarcinoma---- frankly malignant * All of these are associated with functional trophoblastic material * All are associated with high levels of Beta HCG
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Is the majority of Gestational Trophoblastic Disease (GTD) bengign or malignant?
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Benign
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What are the ris factors for Gestational Trophoblastic Disease (GTD)?
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1) age > 35 2) age < 20 3) Hx of trophoblastic tissue
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What are the 2 varietes of Hydatidiform Moles (Mole means false conception in latin)
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1) Complete Hydatidiform mole 2) Partial Hydatidiform mole
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What is complete Hydatidiform mole?
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1) No identifiable fetal features 2) Generalized hydatidiform swelling of villi 3) Diffuse trophoblastic hyperplasia 4) Diploid paternal: 90% 46XX/10% 46XY 5) hCG typically >100K, (nl preg peaks at <100K) In the complete mole, it appears that the ovum is inactivated while the sperm (or two) duplicates.
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What is partial Hydatidiform mole?
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LESS SEVERE 1) Fetal features identifiable (triploidy stigmata) 2) Focal swelling chorionic villi 3) Focal trophoblastic hyperplasia 4) Triploid: 2/3 paternal 5) May detect Fetal heart tones In the event of a partial mole with a complete fetus, the fetus usually manifests stigmata of triploidy e.g. growth retardation and multiple congenital malformations
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What is the clinical presentation of Hydatidiform moles?
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1) Vaginal bleeding in this population portends anemia in 50% 2) Increase in uterine size disproportionate to gestational age is classic, despite 50% occurrence. . It is due to expanded chorionic tissue, retained blood, and exuberant trophoblast, and is thus closely associated with increased hCG levels, which in turn lead to hyperemesis and hyperthyroidism.
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How is a complete mole diagnosed?
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1) Ultrasound (US) "snowstorm" PATHOGNOMONIC (because all of the fluid filled grape like villi are bouning sound waves) 2) CBC to exclude anemia
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How is a partial mole diagnosed?
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1) Detected after tissue examination of a spontaneous abortion (SAB) 2) Ultrasound - Focal placental cysts/gestational sac +/- fetus
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***What is the clinical presentation of a complete mole?
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1) Vaginal Bleeding in the 1st Trimester 2) Hyperemsis Gravidara 3) Increased risk of pre-eclampsia 4) Expulsion of Grape like Vessicles 5) Uterus is larger than expected for dates 6) Hyperthyrodism
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***What is the clinical presentation of a partial mole?
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1) Same as complete mole but less severe 2) Uterus is smaller than expected for dates
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Describe an invasive mole
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1) Occurs in 5-10% of molar pregnancies 2) Complete mole extends into myometrium
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How is the diagnosis of an invasive mole made?
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Persistent HCG levels following evacuation of molar pregnancy
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Do invasive moles metastasize?
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No
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What is required to treat an invasive mole?
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Hysterectomy
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What population of patients are at a higher risk for Choriocarcinoma?
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1) 50% have a preceding molar pregnancy 2) 50% have preceding SAB, induced AB, ectopic or normal pregnancy *Persistent HCG levels after any of these is Choriocarcinoma until proven otherwise
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Describe Choriocarcinoma
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1) Highly anaplastic 2) No chorionic villi 3) Necrosis and hemorrhage 4) Rapidly invasive 5) Hematogenous metastasis - Common: Vagina and Lungs - Other: CNS, GI/liver, kidney
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What is the treatment for Choriocarcinoma?
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Chemotherapy
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How long should B-HCG levels be followed for any molar pregnancy (particularly Choriocarcinoma)?
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- Followed monthly for 1 year - Up to 5 years if metastases
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How long is contraception recommended after a molar pregnancy?
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6-12 months
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Is there an increased risk of a molar pregnancy if you had it once?
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Yes. - Increased risk of subsequent GTN, esp in women >40 - No increased risk of obstetric complications once pregnant
