Gyn: gyn neoplasms

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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

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