OBGYN - Gyn Cancers
From Iusmicm
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(Created page with '=Gyn Cancers= ==Cancers== *Ovarina / fallopian tube **Primary peritoneal cancer, looks the same, treated the same *cervical *Endometria *rare: **vulva **vagina **trophoblastic …') |
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==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== | ||
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*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=== | ||
- | * | + | *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 | ||
- | |||
- | |||
- | |||
*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. | ||
- | === | + | ====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: |
- | * | + | **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: |
- | ** | + | **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 | ||
- | |||
- | |||
- | |||
- | |||
- | |||
- | |||
- | + | *Physical Exam: | |
- | * | + | **Lungs: dullness (Pleural effusion), ronchi, or wheezes? |
- | ** | + | **Abdomen-mass or fluid wave? |
- | + | ||
- | + | ||
- | + | ||
- | ** | + | |
**Rectovaginal exam; mass, nodularity | **Rectovaginal exam; mass, nodularity | ||
+ | **General appearance | ||
- | |||
- | |||
- | |||
- | + | *Pelvic Exam | |
- | * | + | *Labs |
- | * | + | *Imaging |
+ | **Ultrasound | ||
+ | **CT Scan | ||
+ | **U/S > CT | ||
- | === | + | |
- | * | + | *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. | ||
- | === | + | ===Clinical Use of Serum CA 125= |
- | *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 | ||
+ | |||
+ | ===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 | + | ===Cervical Cancer Epidemiology=== |
- | *Moved up to 21 b/c we were over treating. | + | *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 | ||
+ | |||
+ | ===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 | ||
- | |||
- | === | + | ====Interpreting Results==== |
- | * | + | *The Bethesda system: |
- | * | + | **LGSIL |
+ | **HGSIL | ||
+ | **AGUS/ASCUS | ||
- | |||
- | |||
- | ===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. | ||
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*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% | ||
+ | |||
+ | ==Uterine Cancer== | ||
+ | |||
+ | ===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 | ||
+ | |||
+ | ===Uterine Cancer: Treatment=== | ||
+ | *Mainstay is surgical | ||
+ | **Total hysterectomy | ||
+ | **BSO | ||
+ | **Pelvic & PA Nodes | ||
+ | |||
+ | ===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 | ||
+ | |||
+ | ===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 |
Revision as of 14:44, 15 December 2011
Gyn Cancers
Cancers
- Ovarina / fallopian tube
- Primary peritoneal cancer, looks the same, treated the same
- cervical
- Endometria
- rare:
- vulva
- vagina
- trophoblastic
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
- 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
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
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
- 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.
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.
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
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
- 65% of ovarian cancer patients DO have sypmtoms; often vague and non-gynecologic
- 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
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
- usually requires histology to know it is cancer.
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
- 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.
==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 a low-risk patient asks you for it!
- 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
- 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.
Abnormal Pap Smear and Cervical Cancer
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
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
Interpreting Results
- The Bethesda system:
**LGSIL **HGSIL **AGUS/ASCUS
- 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.
- 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.
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
- 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%
Uterine Cancer
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
Uterine Cancer: Treatment
- Mainstay is surgical
- Total hysterectomy
- BSO
- Pelvic & PA Nodes
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
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