OBGYN - Gyn Cancers

From Iusmicm

(Difference between revisions)
(Created page with '=Gyn Cancers= ==Cancers== *Ovarina / fallopian tube **Primary peritoneal cancer, looks the same, treated the same *cervical *Endometria *rare: **vulva **vagina **trophoblastic …')
(→Cancers)
 
(7 intermediate revisions not shown)
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**vagina
**vagina
**trophoblastic
**trophoblastic
 +
 +
 +
{|border=1
 +
!Cancer
 +
!Incidence
 +
!Kills (Rank)
 +
!Lifetime Risk
 +
!Risk Factors
 +
|-
 +
!Cervical
 +
|12.2k / year (#3)
 +
|'''#3 (#1 worldwide'''; 4.2k / year)
 +
|1/135
 +
|High Grade Dysplasia, smoking, a lifestyle cancer (early parity, early coitus, multiple partners)
 +
|-
 +
!Endometrial (Uterine)
 +
|'''41k / year (#1)'''
 +
|#2 (7.1k / year)
 +
|'''1/38'''
 +
|Obesity, HTN, Diabetes, Atypical Hyperplasia
 +
|-
 +
!Ovarian
 +
|23k / year (#2 at 23% of gyn ca)
 +
|'''#1''' (47% of gyn ca)
 +
|~1/70
 +
|BRCA1, BRCA2, HNPCC, (not smoking)
 +
|}
==Epidemiology==
==Epidemiology==
 +
*Who gets it and how many?
 +
 +
==Presentation - Differential Dx==
 +
*Common presentations of gyn cancers include:
 +
**Adnexal Mass
 +
**Abnormal Pap
 +
**Post Menopausal Bleeding
 +
 +
==Prevention==
 +
*Prevention
 +
**Screening: BRCA
 +
**Vaccines
 +
**Role of HRT
 +
 +
==Detection / Diagnosis==
 +
*Pathology
 +
*Staging
 +
*(Treatment)
==Adnexal mass and ovarian cancer==
==Adnexal mass and ovarian cancer==
Line 20: Line 65:
*23% of gyn cancers are ovarian.
*23% of gyn cancers are ovarian.
*47% of deaths are caused by ovarian
*47% of deaths are caused by ovarian
 +
*1 / 70 lifetime risk in US
===Embryology / Oncology===
===Embryology / Oncology===
-
*Gi-> ovary is a krukenburg
+
*Epithelial adenocarcinoma:
 +
**originate from the peritoneal mesothelium
 +
**make up 65% of Ovarian cancers
 +
*Germ Cell:
 +
**originiate from the yolk sac (dysgerminoma, teratoma)
 +
**make up 25% of ovarian cancers
 +
*Stromal:
 +
**Originate from the gonadal ridge –mesenchyme near protonephros (granulosa and theca cells)
 +
**Make up 8% of ovarian cancers
 +
*Metastatic:
 +
**Make up only 2% of ovarian cancers
 +
**Called Krukenburg tumors
 +
 
 +
===Epithelial Ovarian Cancer: Histologic Types===
 +
*Histology (and the structure it recapitulates)
 +
**Serous (Tube)
 +
**Endometrioid (Endometrium)
 +
**Mucinous (Cervix)
 +
**Clear cell (Kidney)
 +
**'''Brenner (Transitional)'''
 +
 
 +
===Ovarian Cancer: Pt History===
 +
*Epidemiology - Clinical
 +
*'''History: there is NO classic profile''':
 +
**Age / Parity
 +
**Menstrual history
 +
**Surgical Hx: hysterectomy or BTL
 +
**BCP / hormonal therapy history
 +
**Personal and family cancer history
 +
**Ethnicity
 +
 
 +
===Ovarian Cancer: Risk Factors===
 +
 
 +
====Factors that Decrease Risk====
 +
*Factor: Relative Risk
 +
*Nulliparous: 1.0
 +
*1 Full term pregnancy: 0.6
 +
*> 5 Full term pregnancies: 0.29
 +
*Use of Oral Contraceptions:
 +
**Never: 1.0
 +
**Ever 0.75
 +
**3 mo - 4 yrs: 0.6-0.7
 +
**> 10 years: 0.2
 +
*Bilateral Tubal Ligation: 0.5
 +
*Hysterectomy: 0.5
 +
*Breast feeding (linear with duration): 0.7
-
===EOC===
 
-
*Brenner is transitional
 
-
===Decreased Risk===
 
*Tying the tubes decreases one's risk, probably because there is decreased environmental exposure.
*Tying the tubes decreases one's risk, probably because there is decreased environmental exposure.
*Anything that makes the ovary quiescent will decrease the risk of ovarian cancer.
*Anything that makes the ovary quiescent will decrease the risk of ovarian cancer.
-
===Increased Risk===
+
====Factors that Increase Risk====
 +
*Factor: Relative Risk
 +
*Hx of Breast Cancer:
 +
**None: 1.0
 +
**1st Degree Relative: 2.1
 +
**Personal History: 10
 +
*Hx of Ovarian Cancer:
 +
**None: 1.0
 +
**One 1st Degree Relative: 3.1
 +
**>2 1st Degree Relatives: 4-15
 +
**Hereditary Cancer Syndrome: 12-30
 +
*Saturated Fat Diet: ?
 +
 
 +
 
*Family history of breast cancer increases the risk for ovarian cancer by 2 fold.
*Family history of breast cancer increases the risk for ovarian cancer by 2 fold.
**A personal history makes the risk 10 fold higher!
**A personal history makes the risk 10 fold higher!
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===Adnexal Mass Ddx===
===Adnexal Mass Ddx===
-
*PID can form a pretty big, complex mass on the ovary with fallopian tube involvement.
+
*The differential diagnosis for an adnexal mass should include all of the following:
-
*How do we tell between good and bad?
+
**Physiologic
 +
**Gestational
 +
**Inflammatory
 +
***PID can form a pretty big, complex mass on the ovary with fallopian tube involvement.
 +
**Congenital
 +
**Traumatic
 +
**Neoplastic
-
*Good:
+
*How do we tell between good and bad?
-
**fluid filled (not solid)
+
*Good indicators:
-
**usually younger
+
**Asymptomatic
-
**asymptomatic
+
**Cystic
 +
***fluid filled (not solid)
 +
**Age between 15 and 45
 +
**Resolves
 +
*Bad indicators:
 +
**Pain or other vague symptoms
 +
**Symptomatic: Ascites
 +
**Complex, Solid: Omental cake
 +
**Persists: Adenopathy
 +
===Detective work: Diagnosis===
 +
*ROS:
 +
**'''65% of ovarian cancer patients DO have sypmtoms; often vague and non-gynecologic'''
 +
***Not really the ''"silent killer"''
 +
**Pain, GI symptoms, Fatigue, Weight change
-
*Bad:
 
-
**pain or other vague symptoms
 
-
**ascites
 
-
**complex, solid
 
-
**omental cake
 
-
**adenopathy.
 
-
===Evaluate the pt===
+
*Physical Exam:
-
*ROS:
+
**Lungs: dullness (Pleural effusion), ronchi, or wheezes?
-
**65% of ovarian pts do have sympstoms but often vague
+
**Abdomen-mass or fluid wave?
-
**Pin, GI symptoms, fatigue, weight change
+
-
*PE:
+
-
**Pleural effusion is frequent, ronchi, wheezes
+
-
**abdominal mass or fluid wave
+
**Rectovaginal exam; mass, nodularity
**Rectovaginal exam; mass, nodularity
 +
**General appearance
-
===Adnexal mass ddx===
 
-
*Pelvic exam
 
-
*US > CT
 
-
===FIGO Staging===
+
*Pelvic Exam
-
*Ovarian often goes to the lung.
+
*Labs
-
*Surface of the liver is stage 3 but parenchymal liver mets is stage 4.
+
*Imaging
 +
**Ultrasound
 +
**CT Scan
 +
**U/S > CT
-
===Survival===
+
 
-
*down
+
*Operation
 +
 
 +
===Surgical: FIGO Staging===
 +
*I = Limited to ovary (ies)
 +
*II = Extension to uterus, tubes, other pelvic tissues
 +
*III = Peritoneal surface implants, nodes
 +
**Surface of the liver is stage 3 but parenchymal liver mets is stage 4.
 +
*IV = Distant metastasis
 +
**Ovarian often goes to the lung.
 +
 
 +
===Ovarian Cancer: Outcomes===
 +
*5 year survival:
 +
**Stage I: 75%
 +
**Stage II: 60%
 +
**Stage III: 30%
 +
**Stage IV: 15%
===Ovarianc cancer===
===Ovarianc cancer===
*usually requires histology to know it is cancer.
*usually requires histology to know it is cancer.
-
===Ovarian cancer treatment===
+
===Ovarian Cancer: Treatment===
 +
*Goals of Operation:
 +
**Is this cancer?
 +
**Is this ovarian cancer?
 +
**What stage?
 +
*If apparently confined to ovary, do a “staging” operation.
 +
*If bulky disease, do a “debulking” operation
 +
 
 +
 
 +
*Operation
 +
**USO / BSO
 +
**Omentectomy
 +
**Lymphadenectomy
 +
**Peritoneal biopsies
 +
**Hysterectomy
 +
 
 +
 
 +
*Young patients, early stage: possibility of fertility-sparing surgery
 +
 
 +
====Epithelial Cancers: Treatment====
 +
*Recall that epithelial is one origin of ovarian cancer.
 +
*Epitheilal ovarian cancer treatment is specifically treated with chemotherapy.
 +
*Platinum and taxane-based combination chemotherapy
 +
**Platinum: Cisplatin, carboplatin
 +
**Taxane: Paclitaxel, docetaxel
 +
 
 +
===Ovarian Cancer: Familial Inheritance===
 +
*Ovarian Cancer Inheritance risks:
 +
**Lifetime risk in U.S.: 1.4%
 +
**One 1st-degree relative: 5%
 +
**> two 1st-degree relatives: 7%
 +
**HBOC: 6-50%
 +
*'''OF THESE, 3% WILL HAVE A HEREDITARY CANCER SYNDROME'''
 +
 
 +
 
 +
*Hereditary cancer syndromes are characterized by:
 +
**1/800 US BRCA and 1/600 HNPCC
 +
**Autosomal dominant inheritance
 +
**Early age of onset
 +
**Younger affected members in subsequent generations
 +
**Multiple cancers in individuals
 +
**Bilaterality of certain cancers
 +
**Male breast cancer (BRCA 2)
 +
===Cancer: Family History===
 +
*Obtaining a Family History of Cancer
 +
*3 + generation family history.
 +
*Update regularly
 +
*Maternal and paternal data
 +
*Race, ethnic background, all cancers, current age, age at diagnosis, age at death
 +
*Medical records review
 +
*Genetic counseling BEFORE TESTING!
===Familial Ovarian cancer===
===Familial Ovarian cancer===
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*Male breast cancer is so rare that if seen, suspect brca(2) mutation.
*Male breast cancer is so rare that if seen, suspect brca(2) mutation.
-
===CA125 Serum Testing===
+
===Clinical Use of Serum CA 125===
-
*CA 125 does not detect ovarian cancer at an earlier stage.
+
*CA 125 can be used to '''following response to chemotherapy'''
 +
*CA 125 can be used for '''surveillance for patients with known genetic mutation or strong family history''' indicative of a hereditary inheritance pattern
 +
**+ rectovaginal exam, +/- transvaginal pelvic ultrasound
-
===Triage===
+
 
 +
*'''CA 125 does not detect ovarian cancer at an earlier stage.'''
 +
 
 +
 
 +
*When NOT to Obtain a Serum CA 125 Level:
 +
**When a low-risk patient asks you for it!
 +
***Requires extensive counseling
 +
***Poor sensitivity and specificity
 +
*When operation is already indicated
 +
 
 +
 
 +
*Non-malignant conditions that may elevate the CA 125:
 +
**PID
 +
**Adenomyosis
 +
**Benign neoplasm
 +
**Endometriosis
 +
**Functional cyst
 +
**Menstruation
 +
**Infertility
 +
**Leiomyomata
 +
**Hepatitis
 +
**Pancreatitis
 +
**Cirrhosis
 +
**Colitis
 +
**CHF
 +
**Diverticulitis
 +
**Postoperative period
 +
**Renal disease
 +
**SLE
 +
**Pneumonia
 +
**Diabetes
 +
 
 +
===Chemoprevention with Oral Contraceptives===
 +
*OC use for > 5 years reduces risk of ovarian cancer by 60% in the general population
 +
*Protective effect increases with increasing duration of use
 +
*Protection continues for 10 years following discontinuation
===Prophylactic Surgery===
===Prophylactic Surgery===
-
*These prophylactic surgeries (breast and ovary) are not completely protective because we just can't find every cell.
+
*Oophorectomy:
-
*After prophy, a 5% risk over 20 years for developing cancer (as a brca pt).
+
**Reduced ovarian cancer risk by 95-100%
 +
**Reduced breast cancer risk by 53-68%
 +
**Reduced risk of fallopian tube cancer and primary peritoneal cancer
 +
**Evidence suggests that many BRCA-related ovarian cancers are actually fallopian tube primaries
 +
 
 +
 
 +
*Bilateral Mastectomy:
 +
**BRCA patients ~ 85-100% reduction in risk for breast cancer
 +
 
 +
 
 +
*'''These prophylactic surgeries (breast and ovary) are not completely protective because we just can't find every cell.'''
 +
*'''After prophy, a 5% risk over 20 years for developing cancer (as a brca pt).'''
**But that's much better.
**But that's much better.
==Abnormal Pap Smear and Cervical Cancer==
==Abnormal Pap Smear and Cervical Cancer==
-
*
 
-
===Cervical Cancer screening===
+
===Cervical Cancer Epidemiology===
-
*Moved up to 21 b/c we were over treating.
+
*12,200 new cases in the US per year
-
*Coposcopy is magnifying the cervix to identify early microscopic changes.
+
*4,210 deaths in the US per year
 +
*180 new cases in Indiana
 +
*< 100 deaths in Indiana
 +
*Life time risk 1 / 135
 +
*2nd to breast cancer for cancer death in women ages 20-39
 +
*500,000 women die each year world wide
 +
*'''Number one cancer killer of women worldwide'''
 +
 
 +
 
 +
*In the US 60% are Stage I at diagnosis
 +
*More common in minorities, disadvantaged
 +
*Early coitus, early parity, multiple partners
 +
*Associated with / caused by HPV 16,18,31,33
 +
*Not all infected patients develop cancer
 +
*Smoking increases risk
 +
 
 +
===Cervical Cancer: Prevention===
 +
*Randomized Double-Blind Clinical Trial:
 +
**2392 Young women vaccinated with 3 doses of placebo or HPV-16 virus-like particle vaccine
 +
**At a median of 17.4 months, 3.8 / 100 women of the placebo women and 0 / 100 of the treated women had persistent HPV infection
 +
*Nine CIN events were all the placebo group
 +
 
 +
===Cervical Cancer: Screening===
 +
*Begin screening at age 21 regardless of age of onset of sexual intercourse
 +
**'''Moved up to 21 b/c we were over treating.'''
 +
*Repeat every 2 years if normal and lowrisk from age 21-29
 +
*After age 30, and 3 consecutive negatives, and low-risk, screen every 3 years
 +
*May stop after age 70
 +
*No need for Pap after total hysterectomy
 +
 
 +
 
 +
*Low risk: No history of high grade dysplasia, HIV, or other immunosuppression
 +
*Remember the pap is a screening test
 +
**If abnormal, or if the cervix appears or feels abnormal, proceed with diagnostic test
 +
*Colposcopy
 +
*Directed Biopsy
 +
 
 +
 
*ASCUS = atypica squamous cells of undetermined significance
*ASCUS = atypica squamous cells of undetermined significance
-
*AGUS = atypical ?
 
-
===Colposcopy===
+
====Interpreting Results====
-
*Use acetic acid to highlight abnormal spots; biopsy them.
+
*The Bethesda system:
-
*Must do a cone biopsy if you have an inadequate simple (cervical) biopsy.
+
**LGSIL
 +
**HGSIL
 +
**AGUS/ASCUS
-
===Pyramid===
 
-
*Treat red and yellow, wait on blue and green.
 
-
===Cervical Cancer Staging===
+
*Histologic diagnoses:
 +
**CIN 1
 +
**CIN 2
 +
**CIN 3/CIS
 +
**Invasive cancer
 +
 
 +
====Classification Terminology for Cervical Cytology====
 +
*The 2001 Bethesda System
 +
 
 +
 
 +
*Two types of atypical squamous cells (ASC)
 +
**'''Atypical squamous cells of undetermined significance (ASCUS)'''
 +
**'''Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions (ASC-H)'''
 +
 
 +
 
 +
*Squamous intraepithelial lesions (SIL)
 +
**'''Low-grade SIL (LSIL)''': Mild dysplasia, cervical intraepithelial neoplasia 1 (CIN 1)
 +
**'''High-grade SIL (HSIL)''': Moderate and severe dysplasia, CIN 2/3, carcinoma in situ (CIS)
 +
 
 +
 
 +
*Cervical intraepithelial neoplasia (CIN)
 +
**'''CIN 1''': Mild dysplasia; includes condyloma (anogenital warts)
 +
**CIN 2: Moderate dysplasia
 +
**CIN 3: Severe dysplasia; includes CIS
 +
*'''CIN caused by HPV can clear without treatment.'''
 +
 
 +
===Cervical Cancer: Diagnosis===
 +
*Inadequate Colposcopy:
 +
**T-Zone not fully visualized
 +
**Can’t see the entire lesion
 +
**Lesion extends into canal
 +
**Discordance
 +
**Positive endocervical curettage (ECC)
 +
**Suspect invasion
 +
 
 +
====What is a colposcopy?====
 +
*Use of a magnifying instrument
 +
*Application of a vinegar-like solution onto the cervix
 +
**Use acetic acid to highlight abnormal spots; biopsy them.
 +
*See abnormalities that can’t be seen with the naked eye
 +
*Feels like getting a Pap test, but lasts longer
 +
*'''Must do a cone biopsy if you have an inadequate simple (cervical) biopsy.'''
 +
 
 +
====Cervical Biopsy====
 +
*Removal of a small piece of tissue from the cervix
 +
*Endocervical curettage is often performed to evaluate lesions within the cervical canal
 +
 
 +
====Biopsy Results and Management====
 +
*CIN I
 +
**Observation
 +
*CIN II and III
 +
**Laser
 +
**Cryotherapy
 +
**Cone Biopsy: LEEP, laser cone, or cold-knife cone
 +
**Hysterectomy may be recommended
 +
 
 +
 
 +
*Cancer: Gynecologic Oncology Consultation
 +
 
 +
 
 +
*If the colposcopy is inadequate, or invasion is suspected, proceed with definitive diagnostic test:
 +
**LEEP Excision
 +
**Cold Knife Cone
 +
 
 +
 
 +
*If lesion is visible, biopsy can be diagnostic without cone
 +
 
 +
====What is a cervical conization?====
 +
*Removes a coneshaped piece of tissue
 +
*Often allows for diagnosis and treatment
 +
*Performed with local anesthesia in the office or under general anesthesia in the operating room
 +
 
 +
===Abnormal Pap: Epidemiology===
 +
*12,210 cancers
 +
**Treat
 +
*300,000 HSIL
 +
**Treat
 +
*1.25 million LSIL
 +
**Wait and see
 +
*2-3 million ASC
 +
**Wait and see
 +
*50-60 million women screened
 +
 
 +
===Clinical Staging of Cervical Cancer===
 +
*Stage I: Disease confined to the cervix
 +
*Stage II: Vagina or parametrial extension
 +
*Stage III: Distal vagina, lateral pelvic wall, or hydronephrosis
 +
*Stage IV: Mucosa of bowel / bladder, or distant disease
 +
 
 +
 
 +
*Estimates of 5 year survival:
 +
**Stage I: 82-85%
 +
**Stage II: 61-66%
 +
**Stage III: 37-39%
 +
**Stage IV: 11-12%
 +
 
 +
===Cervix Cancer: Treatment===
*Goal is to get a negative margin.
*Goal is to get a negative margin.
*Will irradiate the entire tumor.
*Will irradiate the entire tumor.
Line 118: Line 473:
*Even radical hysterectomy leaves the ovaries.
*Even radical hysterectomy leaves the ovaries.
**Cervical cancer very rarely involves the ovaries.
**Cervical cancer very rarely involves the ovaries.
 +
 +
====Chemotherapy====
 +
*Stage IA1 (microinvasive): Cone vs. Simple Hysterectomy
 +
*Stage IA2-IB1: Radical Hysterectomy vs. Radiation
 +
*>Stage IB2: Concurrent platinum-based chemotherapy and radiation
 +
 +
====Surgical Treatment====
 +
*'''Only indicated if “negative margin” can be achieved'''
 +
*Advantages:
 +
**Permits More Accurate Assessment
 +
**Preserves Ovarian Function
 +
**Preserves Vaginal Function
 +
**Less Long-Term Morbidity
 +
 +
====Radiation Therapy====
 +
*'''Appropriate for all stages and patients with high surgical risk'''
 +
*Indicated when negative surgical margin cannot be achieved
 +
**Advanced disease >IB2
 +
**Obesity (BMI>30)
==Post-Menopausal Bleeding and Endometrial Carcinoma==
==Post-Menopausal Bleeding and Endometrial Carcinoma==
 +
*Incidence in US women:
 +
**41,000 cases / year
 +
*'''Most common gynecologic cancer'''
 +
*1 / 38 lifetime risk
 +
*7,100 deaths / year
 +
*'''2nd most common cause of death due to gynecologic cancer'''
 +
 +
===Endometrial Pt Profile===
 +
*Age: 75% post-menopausal
 +
*Etiology: Prolonged unopposed estrogen stimulation
 +
*Clinical Presentation:
 +
**Abnormal bleeding, post-menopausal
 +
**Associated factors: obesity, hypertension, diabetes
 +
*HNPCC (Lynch)
 +
 +
===Endometrial Cancer: Risk Factors===
 +
 +
===Endometrial Cancer: Two Types===
 +
*Type I
 +
**Estrogen Related
 +
**'''Younger and heavier patients'''
 +
**Low grade
 +
**Perimenopausal
 +
**Exogenous estrogen
 +
**Insulin resistance
 +
 +
*Type II
 +
**Aggressive
 +
**Unrelated to estrogen stimulation
 +
**'''Occurs in older & thinner women'''
 +
**'''Potential genetic basis'''
 +
***Lynch syndrome
 +
***Familial trend
 +
 +
 +
===Endometrial Carcinoma===
 +
*Pathology
 +
**> '''70% adenocarcinomas'''
 +
**Histologic ''grade important''
 +
**Poor prognosis cell types: papillary serous and clear cell carcinomas, mixed tumors
 +
 +
 +
*FIGO Stage - Surgical Findings:
 +
**Stage 1: Confined to uterus
 +
**Stage 2: Extension to cervix
 +
**Stage 3: Regional spread (serosa, adnexa, vagina, parametria, pelvic / aortic nodes)
 +
**Stage 4: Metastases (Bladder / rectum, inguinal nodes, distant metastases)
 +
 +
 +
*Stage: Frequency; Survival
 +
**Stage 1: 75%; 90%
 +
**Stage 2: 13%; 60%
 +
**Stage 3: 9%; 40%
 +
**Stage 4: 3%; <10%
 +
 +
===Endometrial (uterine) Cancer: Diagnosis===
 +
*Pts with uterine cancer often present with AUB / PMB:
 +
**Abnormal Uterine Bleeding
 +
**Postmenopausal bleeding
 +
 +
 +
*Office biopsy (Pipelle)
 +
*Dilation and curettage (D&C)
 +
*Hysteroscopy
 +
 +
===Endometrial (uterine) Cancer: Treatment===
 +
*Mainstay is surgical
 +
**Total hysterectomy
 +
**BSO
 +
**Pelvic & PA Nodes
 +
 +
===Endometrial (uterine) Cancer: Surgical Staging===
 +
*Conceptual rationale:
 +
**Defines extent of disease
 +
**Minimizes over / under treatment
 +
**Minimally increases perioperative morbidity / mortality
 +
**Decreases overall Rx risks and costs
 +
**Allows comparison of therapeutic results
 +
 +
===Endometrial (uterine) Cancer: Adjuvant Therapy===
 +
*Options:
 +
**Brachytherapy
 +
**External beam radiotherapy
 +
**Hormonal therapy
 +
**Cytotoxic chemotherapy
 +
**Combination therapy
 +
-
Did not cover all topics.
+
*Determining Factors:
 +
**Stage
 +
**Histologic subtype
 +
**Staging completeness
 +
**Tumor biology
 +
**Medical conditions

Current revision as of 13:27, 16 December 2011

Contents

[edit] Gyn Cancers

[edit] Cancers

  • Ovarina / fallopian tube
    • Primary peritoneal cancer, looks the same, treated the same
  • cervical
  • Endometria
  • rare:
    • vulva
    • vagina
    • trophoblastic


Cancer Incidence Kills (Rank) Lifetime Risk Risk Factors
Cervical 12.2k / year (#3) #3 (#1 worldwide; 4.2k / year) 1/135 High Grade Dysplasia, smoking, a lifestyle cancer (early parity, early coitus, multiple partners)
Endometrial (Uterine) 41k / year (#1) #2 (7.1k / year) 1/38 Obesity, HTN, Diabetes, Atypical Hyperplasia
Ovarian 23k / year (#2 at 23% of gyn ca) #1 (47% of gyn ca) ~1/70 BRCA1, BRCA2, HNPCC, (not smoking)

[edit] Epidemiology

  • Who gets it and how many?

[edit] Presentation - Differential Dx

  • Common presentations of gyn cancers include:
    • Adnexal Mass
    • Abnormal Pap
    • Post Menopausal Bleeding

[edit] Prevention

  • Prevention
    • Screening: BRCA
    • Vaccines
    • Role of HRT

[edit] Detection / Diagnosis

  • Pathology
  • Staging
  • (Treatment)

[edit] Adnexal mass and ovarian cancer

  • 23k new cases / year
    • breast cancer is 200k
    • teal is the color of ribbon for ovarian
  • 16k deaths / year
  • 23% of gyn cancers are ovarian.
  • 47% of deaths are caused by ovarian
  • 1 / 70 lifetime risk in US

[edit] Embryology / Oncology

  • Epithelial adenocarcinoma:
    • originate from the peritoneal mesothelium
    • make up 65% of Ovarian cancers
  • Germ Cell:
    • originiate from the yolk sac (dysgerminoma, teratoma)
    • make up 25% of ovarian cancers
  • Stromal:
    • Originate from the gonadal ridge –mesenchyme near protonephros (granulosa and theca cells)
    • Make up 8% of ovarian cancers
  • Metastatic:
    • Make up only 2% of ovarian cancers
    • Called Krukenburg tumors

[edit] Epithelial Ovarian Cancer: Histologic Types

  • Histology (and the structure it recapitulates)
    • Serous (Tube)
    • Endometrioid (Endometrium)
    • Mucinous (Cervix)
    • Clear cell (Kidney)
    • Brenner (Transitional)

[edit] Ovarian Cancer: Pt History

  • Epidemiology - Clinical
  • History: there is NO classic profile:
    • Age / Parity
    • Menstrual history
    • Surgical Hx: hysterectomy or BTL
    • BCP / hormonal therapy history
    • Personal and family cancer history
    • Ethnicity

[edit] Ovarian Cancer: Risk Factors

[edit] Factors that Decrease Risk

  • Factor: Relative Risk
  • Nulliparous: 1.0
  • 1 Full term pregnancy: 0.6
  • > 5 Full term pregnancies: 0.29
  • Use of Oral Contraceptions:
    • Never: 1.0
    • Ever 0.75
    • 3 mo - 4 yrs: 0.6-0.7
    • > 10 years: 0.2
  • Bilateral Tubal Ligation: 0.5
  • Hysterectomy: 0.5
  • Breast feeding (linear with duration): 0.7


  • Tying the tubes decreases one's risk, probably because there is decreased environmental exposure.
  • Anything that makes the ovary quiescent will decrease the risk of ovarian cancer.

[edit] Factors that Increase Risk

  • Factor: Relative Risk
  • Hx of Breast Cancer:
    • None: 1.0
    • 1st Degree Relative: 2.1
    • Personal History: 10
  • Hx of Ovarian Cancer:
    • None: 1.0
    • One 1st Degree Relative: 3.1
    • >2 1st Degree Relatives: 4-15
    • Hereditary Cancer Syndrome: 12-30
  • Saturated Fat Diet: ?


  • Family history of breast cancer increases the risk for ovarian cancer by 2 fold.
    • A personal history makes the risk 10 fold higher!
  • Diet is questionable.

[edit] Adnexal Mass Ddx

  • The differential diagnosis for an adnexal mass should include all of the following:
    • Physiologic
    • Gestational
    • Inflammatory
      • PID can form a pretty big, complex mass on the ovary with fallopian tube involvement.
    • Congenital
    • Traumatic
    • Neoplastic


  • How do we tell between good and bad?
  • Good indicators:
    • Asymptomatic
    • Cystic
      • fluid filled (not solid)
    • Age between 15 and 45
    • Resolves
  • Bad indicators:
    • Pain or other vague symptoms
    • Symptomatic: Ascites
    • Complex, Solid: Omental cake
    • Persists: Adenopathy

[edit] Detective work: Diagnosis

  • ROS:
    • 65% of ovarian cancer patients DO have sypmtoms; often vague and non-gynecologic
      • Not really the "silent killer"
    • Pain, GI symptoms, Fatigue, Weight change


  • Physical Exam:
    • Lungs: dullness (Pleural effusion), ronchi, or wheezes?
    • Abdomen-mass or fluid wave?
    • Rectovaginal exam; mass, nodularity
    • General appearance


  • Pelvic Exam
  • Labs
  • Imaging
    • Ultrasound
    • CT Scan
    • U/S > CT


  • Operation

[edit] Surgical: FIGO Staging

  • I = Limited to ovary (ies)
  • II = Extension to uterus, tubes, other pelvic tissues
  • III = Peritoneal surface implants, nodes
    • Surface of the liver is stage 3 but parenchymal liver mets is stage 4.
  • IV = Distant metastasis
    • Ovarian often goes to the lung.

[edit] Ovarian Cancer: Outcomes

  • 5 year survival:
    • Stage I: 75%
    • Stage II: 60%
    • Stage III: 30%
    • Stage IV: 15%

[edit] Ovarianc cancer

  • usually requires histology to know it is cancer.

[edit] Ovarian Cancer: Treatment

  • Goals of Operation:
    • Is this cancer?
    • Is this ovarian cancer?
    • What stage?
  • If apparently confined to ovary, do a “staging” operation.
  • If bulky disease, do a “debulking” operation


  • Operation
    • USO / BSO
    • Omentectomy
    • Lymphadenectomy
    • Peritoneal biopsies
    • Hysterectomy


  • Young patients, early stage: possibility of fertility-sparing surgery

[edit] Epithelial Cancers: Treatment

  • Recall that epithelial is one origin of ovarian cancer.
  • Epitheilal ovarian cancer treatment is specifically treated with chemotherapy.
  • Platinum and taxane-based combination chemotherapy
    • Platinum: Cisplatin, carboplatin
    • Taxane: Paclitaxel, docetaxel

[edit] Ovarian Cancer: Familial Inheritance

  • Ovarian Cancer Inheritance risks:
    • Lifetime risk in U.S.: 1.4%
    • One 1st-degree relative: 5%
    • > two 1st-degree relatives: 7%
    • HBOC: 6-50%
  • OF THESE, 3% WILL HAVE A HEREDITARY CANCER SYNDROME


  • Hereditary cancer syndromes are characterized by:
    • 1/800 US BRCA and 1/600 HNPCC
    • Autosomal dominant inheritance
    • Early age of onset
    • Younger affected members in subsequent generations
    • Multiple cancers in individuals
    • Bilaterality of certain cancers
    • Male breast cancer (BRCA 2)

[edit] Cancer: Family History

  • Obtaining a Family History of Cancer
  • 3 + generation family history.
  • Update regularly
  • Maternal and paternal data
  • Race, ethnic background, all cancers, current age, age at diagnosis, age at death
  • Medical records review
  • Genetic counseling BEFORE TESTING!

[edit] Familial Ovarian cancer

  • HBOC = hereditary breast ovarian cancer syndrome.
    • BRCA is an example.
  • If one person has breast and ovarian cancer, there is s90% chance that they carry brca mutations.
  • Male breast cancer is so rare that if seen, suspect brca(2) mutation.

[edit] Clinical Use of Serum CA 125

  • CA 125 can be used to following response to chemotherapy
  • CA 125 can be used for surveillance for patients with known genetic mutation or strong family history indicative of a hereditary inheritance pattern
    • + rectovaginal exam, +/- transvaginal pelvic ultrasound


  • CA 125 does not detect ovarian cancer at an earlier stage.


  • When NOT to Obtain a Serum CA 125 Level:
    • When a low-risk patient asks you for it!
      • Requires extensive counseling
      • Poor sensitivity and specificity
  • When operation is already indicated


  • Non-malignant conditions that may elevate the CA 125:
    • PID
    • Adenomyosis
    • Benign neoplasm
    • Endometriosis
    • Functional cyst
    • Menstruation
    • Infertility
    • Leiomyomata
    • Hepatitis
    • Pancreatitis
    • Cirrhosis
    • Colitis
    • CHF
    • Diverticulitis
    • Postoperative period
    • Renal disease
    • SLE
    • Pneumonia
    • Diabetes

[edit] Chemoprevention with Oral Contraceptives

  • OC use for > 5 years reduces risk of ovarian cancer by 60% in the general population
  • Protective effect increases with increasing duration of use
  • Protection continues for 10 years following discontinuation

[edit] Prophylactic Surgery

  • Oophorectomy:
    • Reduced ovarian cancer risk by 95-100%
    • Reduced breast cancer risk by 53-68%
    • Reduced risk of fallopian tube cancer and primary peritoneal cancer
    • Evidence suggests that many BRCA-related ovarian cancers are actually fallopian tube primaries


  • Bilateral Mastectomy:
    • BRCA patients ~ 85-100% reduction in risk for breast cancer


  • These prophylactic surgeries (breast and ovary) are not completely protective because we just can't find every cell.
  • After prophy, a 5% risk over 20 years for developing cancer (as a brca pt).
    • But that's much better.

[edit] Abnormal Pap Smear and Cervical Cancer

[edit] Cervical Cancer Epidemiology

  • 12,200 new cases in the US per year
  • 4,210 deaths in the US per year
  • 180 new cases in Indiana
  • < 100 deaths in Indiana
  • Life time risk 1 / 135
  • 2nd to breast cancer for cancer death in women ages 20-39
  • 500,000 women die each year world wide
  • Number one cancer killer of women worldwide


  • In the US 60% are Stage I at diagnosis
  • More common in minorities, disadvantaged
  • Early coitus, early parity, multiple partners
  • Associated with / caused by HPV 16,18,31,33
  • Not all infected patients develop cancer
  • Smoking increases risk

[edit] Cervical Cancer: Prevention

  • Randomized Double-Blind Clinical Trial:
    • 2392 Young women vaccinated with 3 doses of placebo or HPV-16 virus-like particle vaccine
    • At a median of 17.4 months, 3.8 / 100 women of the placebo women and 0 / 100 of the treated women had persistent HPV infection
  • Nine CIN events were all the placebo group

[edit] Cervical Cancer: Screening

  • Begin screening at age 21 regardless of age of onset of sexual intercourse
    • Moved up to 21 b/c we were over treating.
  • Repeat every 2 years if normal and lowrisk from age 21-29
  • After age 30, and 3 consecutive negatives, and low-risk, screen every 3 years
  • May stop after age 70
  • No need for Pap after total hysterectomy


  • Low risk: No history of high grade dysplasia, HIV, or other immunosuppression
  • Remember the pap is a screening test
    • If abnormal, or if the cervix appears or feels abnormal, proceed with diagnostic test
  • Colposcopy
  • Directed Biopsy


  • ASCUS = atypica squamous cells of undetermined significance

[edit] Interpreting Results

  • The Bethesda system: 
**LGSIL
**HGSIL
**AGUS/ASCUS


  • Histologic diagnoses:
    • CIN 1
    • CIN 2
    • CIN 3/CIS
    • Invasive cancer

[edit] Classification Terminology for Cervical Cytology

  • The 2001 Bethesda System


  • Two types of atypical squamous cells (ASC)
    • Atypical squamous cells of undetermined significance (ASCUS)
    • Atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesions (ASC-H)


  • Squamous intraepithelial lesions (SIL)
    • Low-grade SIL (LSIL): Mild dysplasia, cervical intraepithelial neoplasia 1 (CIN 1)
    • High-grade SIL (HSIL): Moderate and severe dysplasia, CIN 2/3, carcinoma in situ (CIS)


  • Cervical intraepithelial neoplasia (CIN)
    • CIN 1: Mild dysplasia; includes condyloma (anogenital warts)
    • CIN 2: Moderate dysplasia
    • CIN 3: Severe dysplasia; includes CIS
  • CIN caused by HPV can clear without treatment.

[edit] Cervical Cancer: Diagnosis

  • Inadequate Colposcopy:
    • T-Zone not fully visualized
    • Can’t see the entire lesion
    • Lesion extends into canal
    • Discordance
    • Positive endocervical curettage (ECC)
    • Suspect invasion

[edit] What is a colposcopy?

  • Use of a magnifying instrument
  • Application of a vinegar-like solution onto the cervix
    • Use acetic acid to highlight abnormal spots; biopsy them.
  • See abnormalities that can’t be seen with the naked eye
  • Feels like getting a Pap test, but lasts longer
  • Must do a cone biopsy if you have an inadequate simple (cervical) biopsy.

[edit] Cervical Biopsy

  • Removal of a small piece of tissue from the cervix
  • Endocervical curettage is often performed to evaluate lesions within the cervical canal

[edit] Biopsy Results and Management

  • CIN I
    • Observation
  • CIN II and III
    • Laser
    • Cryotherapy
    • Cone Biopsy: LEEP, laser cone, or cold-knife cone
    • Hysterectomy may be recommended


  • Cancer: Gynecologic Oncology Consultation


  • If the colposcopy is inadequate, or invasion is suspected, proceed with definitive diagnostic test:
    • LEEP Excision
    • Cold Knife Cone


  • If lesion is visible, biopsy can be diagnostic without cone

[edit] What is a cervical conization?

  • Removes a coneshaped piece of tissue
  • Often allows for diagnosis and treatment
  • Performed with local anesthesia in the office or under general anesthesia in the operating room

[edit] Abnormal Pap: Epidemiology

  • 12,210 cancers
    • Treat
  • 300,000 HSIL
    • Treat
  • 1.25 million LSIL
    • Wait and see
  • 2-3 million ASC
    • Wait and see
  • 50-60 million women screened

[edit] Clinical Staging of Cervical Cancer

  • Stage I: Disease confined to the cervix
  • Stage II: Vagina or parametrial extension
  • Stage III: Distal vagina, lateral pelvic wall, or hydronephrosis
  • Stage IV: Mucosa of bowel / bladder, or distant disease


  • Estimates of 5 year survival:
    • Stage I: 82-85%
    • Stage II: 61-66%
    • Stage III: 37-39%
    • Stage IV: 11-12%

[edit] Cervix Cancer: Treatment

  • Goal is to get a negative margin.
  • Will irradiate the entire tumor.
    • Try not to do sx if they will need radiation b/c radiation has more adverse effects if post-op.
  • Even radical hysterectomy leaves the ovaries.
    • Cervical cancer very rarely involves the ovaries.

[edit] Chemotherapy

  • Stage IA1 (microinvasive): Cone vs. Simple Hysterectomy
  • Stage IA2-IB1: Radical Hysterectomy vs. Radiation
  • >Stage IB2: Concurrent platinum-based chemotherapy and radiation

[edit] Surgical Treatment

  • Only indicated if “negative margin” can be achieved
  • Advantages:
    • Permits More Accurate Assessment
    • Preserves Ovarian Function
    • Preserves Vaginal Function
    • Less Long-Term Morbidity

[edit] Radiation Therapy

  • Appropriate for all stages and patients with high surgical risk
  • Indicated when negative surgical margin cannot be achieved
    • Advanced disease >IB2
    • Obesity (BMI>30)

[edit] Post-Menopausal Bleeding and Endometrial Carcinoma

  • Incidence in US women:
    • 41,000 cases / year
  • Most common gynecologic cancer
  • 1 / 38 lifetime risk
  • 7,100 deaths / year
  • 2nd most common cause of death due to gynecologic cancer

[edit] Endometrial Pt Profile

  • Age: 75% post-menopausal
  • Etiology: Prolonged unopposed estrogen stimulation
  • Clinical Presentation:
    • Abnormal bleeding, post-menopausal
    • Associated factors: obesity, hypertension, diabetes
  • HNPCC (Lynch)

[edit] Endometrial Cancer: Risk Factors

[edit] Endometrial Cancer: Two Types

  • Type I
    • Estrogen Related
    • Younger and heavier patients
    • Low grade
    • Perimenopausal
    • Exogenous estrogen
    • Insulin resistance
  • Type II
    • Aggressive
    • Unrelated to estrogen stimulation
    • Occurs in older & thinner women
    • Potential genetic basis
      • Lynch syndrome
      • Familial trend


[edit] Endometrial Carcinoma

  • Pathology
    • > 70% adenocarcinomas
    • Histologic grade important
    • Poor prognosis cell types: papillary serous and clear cell carcinomas, mixed tumors


  • FIGO Stage - Surgical Findings:
    • Stage 1: Confined to uterus
    • Stage 2: Extension to cervix
    • Stage 3: Regional spread (serosa, adnexa, vagina, parametria, pelvic / aortic nodes)
    • Stage 4: Metastases (Bladder / rectum, inguinal nodes, distant metastases)


  • Stage: Frequency; Survival
    • Stage 1: 75%; 90%
    • Stage 2: 13%; 60%
    • Stage 3: 9%; 40%
    • Stage 4: 3%; <10%

[edit] Endometrial (uterine) Cancer: Diagnosis

  • Pts with uterine cancer often present with AUB / PMB:
    • Abnormal Uterine Bleeding
    • Postmenopausal bleeding


  • Office biopsy (Pipelle)
  • Dilation and curettage (D&C)
  • Hysteroscopy

[edit] Endometrial (uterine) Cancer: Treatment

  • Mainstay is surgical
    • Total hysterectomy
    • BSO
    • Pelvic & PA Nodes

[edit] Endometrial (uterine) Cancer: Surgical Staging

  • Conceptual rationale:
    • Defines extent of disease
    • Minimizes over / under treatment
    • Minimally increases perioperative morbidity / mortality
    • Decreases overall Rx risks and costs
    • Allows comparison of therapeutic results

[edit] Endometrial (uterine) Cancer: Adjuvant Therapy

  • Options:
    • Brachytherapy
    • External beam radiotherapy
    • Hormonal therapy
    • Cytotoxic chemotherapy
    • Combination therapy


  • Determining Factors:
    • Stage
    • Histologic subtype
    • Staging completeness
    • Tumor biology
    • Medical conditions
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