Malignant Diseases

Human Chorionic Gonadotropin (hCG)

• Hormone secreted by the placental trophoblastic cells

• Found in urine and blood of pregnant women

• Elevated levels are found with GTN

Peutz-Jeghers syndrome

• Inherited disorder characterized by the presence of polyps of the small intestine and melanin pigmentation of the lips, mucosa, fingers and toes

• Anemia from the intestinal polyps is common

Polypoid

Containing more than two normal sets of chromosomes

Teratogenic

Causing congenital anomalies or birth defects

What is the most common site of pelvic malignancy in developed countries?

Endometrium

3 main Uterine cancers:

• Endometrial Carcinoma

• Leiomyosarcoma

• Carcinoma of the cervix

Endometrial Cancer

• 2x as common as cervical cancer

• Ultrasound is very effective in staging endometrial and cervical cancer (when advanced) (TV)

• CT and MRI are good at evaluating lymphatic spread for staging

Endometrial Carcinoma

• Most commonly encountered malignancy of the female genital tract

• Usually found in post-menopausal women

  • Over age 50

• Increased risk with high estrogen levels

  • Estrogen has a proliferative effect on the endometrium

• Thickened endometrium spreads to adjacent areas and into the myometrium

• Earliest change in endometrial cancer is thickened endometrium

Endometrial Carcinoma is associated with:

• Ackerman’s Triad

  • Obesity, diabetes, and HTN

• Nulliparity

• PCOS

• Dysfunction Uterine Bleeding (DUB)

• Endometrial Hyperplasia

• Granulosa-theca cell tumor

• late menopause (after 52 y/o)

• adenomatous polyps

• women on HRT

• African Americans

Tamoxifen

• Treatment for breast cancer

• Can increase chance of endometrial cancer, especially in post-menopausal women

• Can change the appearance of the endometrium

Endometrial Carcinoma symptoms:

• * Usually asymptomatic

• Abnormal vaginal bleeding or discharge after menopause

• Bleeding within the endometrial cavity may cause uterine pelvic pain

What provides endometrial carcinoma diagnosis?

D&C (Dilation and Curettage) with endometrial biopsy

ENdometrial Carcinoma Staging:

• Stage 1 - Limited to the endometrium

• Stage 2 - Spreads to Cervix

• Stage 3 - Spreads to adnexa, vagina, pelvic, and periaortic lymph nodes

• Stage IV - Bladder and bowel mets as well as distant mets

Endometrial Carcinoma Treatment:

• Total Abdominal Hysterectomy

• Bilateral Salpingo-Oophrectomy

• Radiation Therapy

• Stage IV may include chemotherapy or hormone therapy

Endometrial Hyperplasia

• Endometrial thickening not specific to endometrial cancer

• May be a precursor to endometrial cancer

  • 25% of pt’s with atypical endometrial hyperplasia progress to endometrial cancer

  • In post-menopausal female, must be considered cancer until proven otherwise

• May be due to prolonged estrogen stimulation

• Abnormal bleeding

• Associated w/ Tamoxifen

Endometrial Hyperplasia U/S appearance:

• Thickened endometrium

• >14 mm suggests hyperplasia

• In post-menopausal female, 8mm is upper limits of normal

Leiomyosarcoma

• RARE, fast growing malignancy of fibroids

• Aggressive growth

• Rarely diagnosed prior to surgery

• Localized re-growth and metastasis are common

• Associated w/ perimenopausal or postmenopausal growth of fibroid

• Requires serial ultrasounds to check growth

Common leiomyosarcoma metastasis sites:

• Lung is common sites

• Others include:

  • Bone

  • Brain

  • Abdomen

Leiomyosarcoma risk factors:

• nulliparity

• increasing age

  • perimenopausal

  • postmenopausal

  • in the 5th decade of life

• obesity

• history of pelvic radiation

• exposure to tamoxifen

Leiomyosarcoma symptoms (in women over 40):

• Abnormal vaginal bleeding (56%)

• Palpable pelvic mass (54%)

• Pelvic or abdominal pain (22%)

Leiomyosarcoma prognosis:

• B/c uterine LMSs are extremely aggressive, prognosis depends on tumor stage and grade

• Greater survival in:

  • premenopausal women

  • women with tumors <5cm

• Poor prognosis w/:

  • vascular infiltration

  • extrauterine spread

Cervical Carcinoma

• Second most common pelvic malignancy in US

• Decreased in the last few decades d/t PAP smears (early detection)

Cervical Carcinoma risk factors:

• Early sexual activity

• Multiple sex partners

• HPV

• Exposure to DES

  • DES-exposed daughters are 40x more likely to develop CCA (Clear cell adenocarcinoma) than women not exposed

    • But b/c this cancer is so rare, its only about 1/1000 of DES daughters that develop Cervical Cancer

    • DES also increased breast cancer risk

• Higher incidence in peri-menopausal women

Cervical lining two layers:

• Lower cervix is covered by squamous epithelium - 85-90% of cervical cancer lesions

• Cervical canal lines with columnar epithelium - 10-15% of cervical cancer lesions

• Junction between 2 cell types is where most cancers occur

Cervical Carcinoma clinical diagnosis:

• Occurs at a younger age than endometrial carcinoma

  • 25-40 y/o

  • Symptoms

  • None in early stages

• difficult to detect with US in stages 1-2

• Larger tumors and more advanced stages can be visualized

• Diagnosis made by cervical biopsy

Cervical Carcinoma symptoms:

• Abnormal bleeding

• pain

• bleeding after intercourse

• weight loss

• bladder irritability

• low bac pain

Pap Test

• Speculum is inserted and the cervix is swabbed to remove a small sample of cells

• Cells are evaluated for signs of changes in the cells that may lead to cancer

• If a PAP test is abnormal, a Colposcopy may be required

Colposcopy

• Abnormal PAP results

• Provides magnified view (2-60x) of he vagina and cervical tissue so that minor tissue changes can be identified

• Acetic Acid (vinegar solution) solution applied to area of interest

• Acetic acid reacts differently when it comes into contact with areas of abnormal tissue versus normal tissue

• Abnormal areas turn white

• Biopsy areas of suspicion

Cervical Carcinoma Treatment:

• Treatment determined by the stage of the disease

• Cryotherapy

• Cone biopsy of cervix

  • Technique for early stages when fertility preservation is desired

• Radiation therapy

• Total hysterectomy

Cone Biopsy AKA:

Cervical Conization

Cone Biopsy

• may remove cervical cancer or pre-cancerous tissue

• May be used to analyze cells of suspicious lesions

LEEP (Loop Electrosurgical Excision Procedure)

• uses a thin, low-voltage electrified wire loop to cut out abnormal tissue

• cut away abnormal cervical tissue that can be seen during colposcopy

• remove abnormal tissue high in the cervical canal that cannot be seen during colposcopy

Cervical Carcinoma U/S appearance:

• Not usually seen on US in stages 0-II

• May see enlarged cervix

• Scan kidneys to look for hydronephrosis

  • indicates stage III disease

• Scan for liver mets

Cervical Carcinoma differential diagnosis:

• cervical myoma

• prolapsed endometrial polyps

Fallopian Tube Carcinoma

• Rare → less than 1% of all GYN malignancies

• aggressive tumor most commonly in the 6th decade of life

• 8% are metastatic with primary sites being the ovary, uterus, or GI tract

• CA-125 may be suggestive of malignancy

Fallopian Tube Carcinoma risk factors:

• infertility

• nulliparity

• low parity

• pelvic inflammatory disease

• family hx of ovarian cancer

Fallopian Tube Carcinoma signs / symptoms:

• abdominal pain

• increased abdominal girth

• abnormal vaginal bleeding

• palpable pelvic mass

• small and hard to detect on pelvic exam

How is Fallopian Tube Carcinoma treated?

Radiation and chemotherapy

Asherman’s Syndrome AKA:

Fritsch Syndrome

Asherman’s Syndrome

• Normal endometrium replaced by fibrous adhesions

• Secondary to:

  • Previous D&C

  • Multiple Abortions

  • Infections

• Can cause absence of menstruation

Asherman’s Syndrome U/S appearance:

• Normal appearance

• Thickened endometrium