Gyn: gyn neoplasms
Terms
undefined, object
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- #1 gyn malig
- endometrial ca
- endometrial ca is strongly assoc w/ what?
-
high levels of unopposed estrogen
(HRT, tamoxifen, obesity, chr anov, early menarche/late menopause, ov granulosa cell tumor)
other factors: dm, nulliparity, htn, +FHx - peak age of endo ca
- 50-70
- most tumors are what type of cells
- adenocarcinomas
- how do mets occur?
-
direct extension (cervix)
intraperitoneal seeding
lymphatic (aortic, pelvic nodes)
hematogenous (lungs, vagina) - most common sx of endometrial ca
-
POSTMENOPAUSE BL
MENORRHAGIA
METRORRHAGIA
lower abd pain
cramp - signs of mets
-
uterus fixed, if spread to adnexa, peritoneum
HSM
general LAD
abd masses -
T or F
Pap smear may detect asx dz, and is very sensitive -
F
may detect asx dz
BUT IS NOT VERY SENSITIVE** - *use u/s to R/O...
-
fibroids,
polyps,
endometrial hyperplasia - What does ECC and EMB show**
- glandular cell hyperplasia/anaplasia w/ invasion into stroma/myometrium/bl vessels
- if ecc, emb sample is inadequate, what alternative can be used to obtain better sample
- d/c
- Surgical staging is based on what procedures to determine extent of spread
-
abd exploration
peritoneal washing
tah-bso
selective pelvic-periaortic node sampling - Stage or Grade is key prognostic factor for endo ca
- GRADE GRADE GRADE for endo ca*
- what need to do as tx plan for cervical, extrauterine spread
- adjuvant radiation
- how tx stage 1*
- hormone therapy (high dose progestins)
- how tx advanced and recurrent dz?
- chemo (doxorubicin, cisplatin)
- what used to dx endo ca
- ecc, emb
- what is key prog factor for endo ca
- grade
- postmenopausal woman shows up with bleeding, should you assume it is atrophic vaginitis?
- NO! SAMPLE it! to r/o ca
- #1cz of gyn ca deaths*
- ovarian ca
-
ovarian ca:
most common in what groups of females -
post-menopausal
pre-pubescent - RF of ovarian ca
-
*FHx of br or ov ca
*chr uninterrupted ovulation (nulliparity, infertility, delayed childbear, late menopause) - rf involve constant breakage and repair of ovaries, so what would supress ovulation to have protective effect?
- OCPs have protective effect on ovarian ca by suppress ovulation
- primary ovarian tumors are categorized by site of origin, are made up by what type of cells
-
epithelial (outside) (serous cystadenocarcinoma)
germ (dysgerminoma)
sex cord-stromal (func) - most common cell type of ovarian tumors, most common age group for that cell type
-
epithelial
>20yo -
sx course of ovarian tumor
(gi, gu, systemic) -
asx until late in dz
sx: abd pain, bloat, early satiety, constip, ur freq, pelvic press, vag bl, systemic sx (malaise, tired, wgt loss) - PE 3 findings* of ov tumor
-
1. solid, fixed, nodular pelvic mass
2. ascites
3. pleural effusion - DDx of ov tumor
-
fibroids (should not enlarge after menopause)
ectopic (fertile)
pelvic kidney (young)
Ca: krukenberg, retroperitoneal, colorectal
PID, ovarian cyst, endometriosis - Best way to eval adnexal mass
-
pelvic u/s*
(pos ct or mri) - 4 serum tumor markers for ovarian tumor
-
CA-125*
a-fetoprotein
LDH
hCG -
T or F
serum tumor markers are used to detect and to monitor -
F
low specificity=no good for screen - Surgical staging, as w/ endo ca, involves 3 procedures
-
1. TAH-BSO
2. omentectomy
3. tumor debulk - what tx is effective for dysgerminomas
- radiation
- what tx is good for epithelial cell tumors
- post-surg CHEMO (carboplatin, paclitaxel)
-
epithelial cell tumors are
a. low recur, good prog
b. hi recur, poor prog - hi recur, poor prog*
- women w/ strong FHx should have annual screen w/ what 2 tools
-
1. CA-125*
2. transvaginal u/s (adnexal mass) - pt w/ hx ovarian ca, after childbirth, what prophylactic procedure recommend?
- prophylactic oophorectomy
- what tx/med would help with prevention, dec risk of ovarian tumor?
- OCP
- pap smear has dec the incid and mortality of this gyn ca
- cervical ca
-
1. most common gyn malig
2. 2nd most common
3. 3rd most common
4. 4th most common -
1. endometrial ca
2. ovarian ca (lead death since asx til late)
3. cervical ca
4. vulvar ca - RF for cervical ca
-
smoking*
STD*
HPV* (16,18,31)
early onset sex
mult sex partners
imcpd state (hiv) - how are asx pts dx w/ cervical ca?
- pap, colposcopy, bx
- what sx do pts w/ cervical ca have?
-
post-coital bl*
meno/metrorrhagia (bl!)
pelvic pain
vaginal d/c* - PE of cervical ca shows?
-
cervical discharge/ulcer*
pelvic mass or fistula - DDx of vaginal bl, d/c
- cervicitis, vaginitis, std, actinomycosis
- how dx cervical ca
- bx lesions
- when should pt undergo endocervical curettage (ECC) and colposcopy
-
paps showing:
dysplasia
squamous intraepithelial NEOplasia
2 consec atypical sq cells of undermined signif (ASCUS) - 2 ways of categorizing cervical ca
-
1. cervical intraepithelial neoplasia (CIN)
2. invasive cervical carcinoma (dep >3mm, wid >7mm) - how are the two categories of cervical ca related
-
LSIL (low grade sq intraepi lesions) = CIN I (mild dysplasia)
HSIL= CIN II (mod), CIN III (sev) - is staging for cervical surgical or clinical?
- clinical
- procedures for staging (2)
-
1. pelvic exam under anesthesia--eval invasion into adjacent struc
2. CXR, IVP--eval mets -
T or F
CT/MRI can be used for staging - F!!* CT/MRI CANNOT BE USED FOR STAGING!
- Tx of CIN I
-
most regress spon
observe*: pap, colpo q3mo for 1yr - Tx of CIN II/III
-
cryosurgery*
LEEP* (loop electrocautery excision procedure)
laser -
T or F
Cold knife conization of the cervix has a lower rate of complic than LEEP or cryo -
F
cold knife conization has HIGHER rate of complic - when is cold knife conization used?
-
1. lesion not fully visualize
2. discrep b/w bx, hi-grade cytology
3. adenocarcinoma in situ
4. positive ECC
5. microinvasive SCC - tx of Invasive CA if early
- radical hysterectomy and lymph node dissection
- all stages of invasive ca can be tx w/...
-
radiation and chemo**
(or less radical surg) - what tx improves survival in bulky tumors or adv dz?
- radiation +/-chemo
- which gyn ca peaks after menopause? (60 yo)
- vulvar ca
- 90% of vulvar ca is which cell type
- squamous cell carcinoma SCC
- RF for vulvar ca
-
DM
obesity
HTN
vulvar dystrophies
HPV 16,18 -
Most common sx of vulvar ca
Usu sx of vulvar ca -
vulvar pruritus
usu asx in early stages - PE look for 2
-
1. erythema, ulcer vulvar lesion
2. palpable vulvar mass - how dx vulvar ca
- bx
- staging clinical or surgical
- surgical
-
what is staging based on?
TNM -
tumor size
invasiveness
nodal involve
distant mets - tx primary tumor (2)
-
wide local excision
regional lymph node dissection - how is radiation used in vulvar ca (2)
-
1. reduce tumor burden
2. mets or recur dz - most common BENIGN* gyn lesions
- fibroid/uterine leiomyoma (smooth muscle)
- which race and age group most common w/ fibroids
-
bl
>35 -
T or F
fibroids are responsive to hormones. grow in preg. regress in menopause. -
T
hormonally responsive* -
T or F
malignant transformation to leiomyosarcoma is very common -
F
very RARE* (.1-.5%) - usu sx of fibroids
- asx
- pt may complain of... if have fibroids
-
abn uterine bl**-->anemia
pelvic press
dysmenorrhea
ur freq
pain (vasc compromise)
infertility (uncommon) - PE of uterus reveals...
- lumpy-bumpy** uterus: firm, non-tender irreg enlarged uterus
-
DDx of fibroids
abn bl -
carcinoma (cervical, endo, ov)
preg
endometriosis
adenomyosis -
T or F
a mass that cont to grow during menopause is fibroid -
F
hormone responsive fibroid does not grow during hormone dec in menopause - what tool to confirm dx of fibroids
- u/s
- how tx asx fibroids
- expectantly w/ serial exams and u/s to monitor growth*
- Tx of fibroids w/ sev sx or exhibit post-menopausal growth
- hysterectomy or myomectomy* (to preserve fertility)
- which group of women should use medical therapies for fibroids
- peri-menopausal women about to have menopause
- what are some examples of medical therapies for fibroids
-
medroxyprogesterone
danazol
GnRH agonist - Common cz of bl nipple d/c
- intraductal papilloma
- Most common benign br disorder in premenopausal women**
- fibrocystic change*
- what causes fibrocystic change
- exag stromal resp to hormones and growth factors
- common sx of fibrocystic change
- cyclic, premenstrual b/l br pain/tender/swell
- PE of fibrocystic change reveals
- excessive tissue nodularity
- Dx fibrocystic change w/ what two tools
-
FNA
cytologic exam of dominant lesion - Tx involves
-
dec nicotine, caffine
vit E supp
hormonal tx (progestin, danazol, tamoxifen)
diuretics for premen mastalgia -
T or F
fibrocytic change has inc risk for br ca -
trick!
only if cellular atypia present - Name most common br lesion in women <30yo
- fibroadenoma
-
T or F
fibroadenoma is a benign, slow-grow tumor w/ epithelial and stromal components - T
-
PE shows fibroadenoma as...
discrete?
mobile?
tender?
solitary? - round, firm, discrete, mobile, nontender soiltary mass
- how dx fibroadenoma
- surgical excision--dx and tx
-
T or F
recurrence is uncommon in fibroadenoma - F
- what subtype of fibroadenoma is not slow-growing but fast growing and large? is it malig?
-
Phyllodes tumor* (fast, lg)
rarely malig (cystosarcoma phyllodes) - what is the most common ca?
- breast ca
- what is the most common of ca death in women? second most common cz of ca death?
-
lung ca
br ca - RF for br ca
-
F, old
prev hx br ca
br ca 1st degree relative
hx fibrocystic change w/ cellular atypia
(exposure to estrogen:)nulliparity, early menarche, late menopause
first full-term preg >35yo -
T or F
late menarche assoc w/ dec risk br ca - T
- what two mutations assoc w/ early-onset, familial br & ov ca
- BRCA-1,-2
- how does breast ca lesion feel on pe?
-
HARD, IMMOBILE, IRREG, PAINLESS MASS
pos nipple d/c
adv dz: skin change (dimple, red, ulcer, edema), axillary adenopathy -
T or F
some br ca may be asx and nonpalpable, thus only found on mammogram - TRUE!!**
- most common location of br ca
- upper outer quad
- common met sites of br ca
-
lymph nodes
brain
bone
lung
liver -
T or F
dx of br ca can be based on:
palpable mass
mammogram abn (microcalcif, hyperdense region)
u/s -
T
MAMMOGRAM ABN
U/S - if br w/ cystic lesion (fluid filled), what tool used to eval? when excise?
-
FNA
excise if not resolve, bl, or recurs - if br w/ solid lesion, what do to eval?
- bx
- what are 3 dif types of bx for br ca
-
1. stereotactic core bx (nonpalp lesion)
2. direct needle core bx (palp lesions)
3. open surg bx w/ needle localization (nonpalp) - What two prognostic factors can you test for?
-
estrogen/progesterone receptors (if +, GOOD!)
herzneu amplication -
Name special form of br ca.
highly aggressive, rapid grow ca, invade lymph, skin inflam. poor prog. - inflam br ca
- ductal carcinoma in situ of the nipple. burn, itch, nipple erosion (look like infection).
- paget's dz
- b/l br ca is more common in OLD or YOUNG women, w/ DCIS or LCIS.
-
b/l br ca more common in
young
lobular carcinoma - Stage or Grade is impt prognostic factor for br ca
- Stage
-
T or F
lobular carcinoma in situ inc risk of invasive carcinoma in both br - T
-
T or F
Carcinoma in situ (CIS) is classified as Lobular (LCIS) or Ductal (DCIS) - t
-
T or F
pts w/ LCIS d/t hi risk of invasive ca in both br, should have close f/u or b/l mastectomy (hi risk) - T
-
DCIS tx if sm tumor?
if lg tumor? -
sm: local excise, f/u
lg: wide excise+XRT or simple mastectomy (no node disect) - Invasive ca can be lobular or ductal. which one more common?
- ductal
-
staging is based on what three factors?
tnm -
tumor size
nodes
mets (bone scan, cbc, serum ca, cxr) - how tx localized invasive ca?
-
LUMPECTOMY + AXILLARY NODE DISSECTION + XRT
or
MODIFIED RADICAL MASTECTOMY (simple mast + ax node disect) -
T or F
all pre-menopausal women w/ pos nodes get chemo, regardless of estro-R status - T
-
T or F
post-menopausal women w/ +nodes get chemo only if neg estro-R status - T
-
T or F
if pt has mets, use chemo - T
-
T or F
if pt has recur dz, use chemo - T
-
T or F
if pt has +estro-R, tx pt w/ hormone therapy (tamoxifen) - T
- what med can pts w/ herzneu amplication and mets get?
- herceptin