Neoplasms - Breast and Reproductive Tract (CMPP)

Most Common Age for Vaginal cancer

age of 60-65

Most Common Type for Vaginal cancer

squamous cell carcinoma

Risk Factors for Vaginal cancer

HPV (16 and 18)

Presentation for Vaginal cancer

AUB (esp. post-coital)

Watery discharge

Dyspareunia

mass or ulcer of upper 1/3rd of the vagina

dx Method for Vaginal cancer

Colposcopy and biopsy

Tx for Vaginal cancer

Stage 1 → Exision ± XRT

Stage 2 to 4 → Chemoradition

When is XRT used for Stage 1 vaginal cancers

Tumor > 2 cm

Diethylstilbesterol (DES)

Nonsteroidal estrogen that had been discontinued in the US for being a carcinogen

What is the only carcinogen that is transplacental

DES

Daugthers of mothers who took DES are higher risk for

Cervical cancer (CINs)

Vaginal cancer

Congenital Anomly

Cervicovaginal clear cell carcinoma

A special type of malignancy of the cervix and vagina seen in daugthers of mothers who took DES

All DES daughters should recieve what screening

Yearly pelvic exams regardless of ag

Presentation of Cervicovaginal clear cell carcinoma

Polypoid mass, raised, hard, fleshy appearing lesion

Most commonly anterior wall of vagina

Management for Cervicovaginal clear cell carcinoma

Biopsy all lesions

Who most commonly gets Vulvar Cancer

Average age is 68

Caucasians

How does race effect vulvar cancer

White is more likely to get vulvar cancer

Black is more likey to present eariler and have higher spread

Most Common Types for Vulvar Cancer

1st - Squamous cell carcinoma

2nd - Melanoma

Risk Factors for Vulvar Cancer

HPV 16, 18

Chronic inflammatory condition (vulvar dystrophy)

Smoking

Obesity

Immunosuppression

Vulvar Intraepithelial Neoplasia (VIN)

precursor disease to vulvar cancer

Presentation of Vulvar Cancer

Fleshy, nodular, red, or warty vulvar lesion

Typically isolated

Vulvar pruritis

Vulvar bleeding or pain

Dysuria

dx for Vulvar Caner

Biopsy

Treatment for Vuvlar Cancer

Surgical removal/tumor debulking

Chemoradiation if needed or chemo alone

Most Common Site for Vuvlar Cancer

Labia Majora - 1st

Labia Minora - 2nd

Clitoris - Rare

Patients with vulvar cancer are also at risk for having

Synchronous second cancer due to HPV (cervical)

Most Common Cause of Death from Genital Tracet Cancer

Ovarian Cancer

When are most ovarian cancer dx

Stage 3 or 4

Most common ovarian caner

Epithelial tumors

Types of Ovarian Cancer

Epithelial

Germ cell

Sex-cord-stromal

Characterisitcs of Epithelial Ovarian Cancer

occur on the surface of the ovarian epithelium and mesothelium

Typically form > 55 y/i

Risk Factors for Ovarian Cancer

White Race

Late Age of Menopause

FHx of ovarian or endometrial cancers

Hx of Cancer

Prolonged interval of ovulation uninterrupted by pregnancy

Nullipartiy

Ovulation induction drugs

BRCA1/BRAC2 mutation

BRCA1/2 increases lifetime risk of

Ovarain Cancer

Breast Cancer

Lynch syndrome

non-polyposis colorectal cancer associated with adenocarcinomas of other sites, including the ovary

What genetic conditions cause ovarian cacner

BRCA

Lynch Syndrome

Peutz-Jehger’s

Turner’s

Methods of Reducing Ovarian Cancer

OCPs (Decreases ovulatory cycle)

Pregnancy

Tubal Ligation

Salpingetomy

Breast Feedings

Presentation of Ovarian Cancer

Bloating

Pelvic / Abd Pain

Difficulty eating or feeling full quickly

Urinary urgency or frequency

dx Method for Ovarain Cance

TVUS

What is the most important determinant to the prognosis of ovarain cancer

Staging

What is the common spreading of ovarian cancer

Transabdominal dissemination is most common

Lymphatic spread in advanced disease

common site for ovarian cancer spread is the omentum

What can elevate CA-125

Epithelial Ovarian Tumors

Endometriosis

PID

Pregnancy

Liver Disease

Renal Disease

When is CA-125 used for ovarian tumor

Montior diseas

Why don’t we screen ovarian cancer with CA125

Poor specificity in premenopausal population

Multiple non-cancerous diseases can elevate

Treatment Options for Ovarian Cancer

Tumor Debulking

Cytoreductive surgery

Chemotherapy

What procedures can go into debulking ovarian cancer

En bloc resection of uterus, tubes, ovaries, and pelvic tumors

Omenetectomy

Bowel Resection

Removal of diaphargmatic and peritoneal implants

± Appendectomy

When do we usually treat ovarian cancer with chemo?

Stage IC and higher

What is the usually regimn for ovarian cancer chem

Taxol + Plantinum Drugs

Most common gynecologic malignancy in US

Endometrial cancer

Risk Factors for Endometrial cancer

Obese

Nulliparity

Late Menopause

Diabetic

HTN

GB Disease

Breast, Colon, or Ovarian Cancer

Chronic Anovulation / PMOS

Severe liver disease

Tamoxifen Use

Unoppose estrogen use

Lynch Syndrome

What medication has a protective effect for endometrial cancer

OCPs

Who most commonly gets endometrial cancers

Average age 58

Most are postmenopausal (PMP Bleed)

White

Presentation of Endometrial Cancer

AUB (esp. in postmenopaual)

Normal Pap

dx method for Endometrial Cancer

(GOLD) Endometrial Biopsy

TVUS for endometrial thickness (> 4mm)

Prognositc Factors for Endometrial Cancer

Stage

Grade

Age

Myometrial Invasion

Peritonal Cytology

Most common type of endometrial cancer

Adenocarcinoma

How does endometrial cancer spread

Direct extension through myometrium into serosa, downward to cervix, exfoliated cells in fallopian tubes

Lymphatic spread to pelvic and para-aortic nodes

Treatment for Endometrial Cancer

Hysterectomy and bilateral salpingo-oophorectomy and staging

± XRT and Chemo

Indication for XRT for Endometrial Cancer

Extends beyond inner ½ of myometrium

Nodal involvment

Cervical extension

Indication for Chemo for Endometrial Cancer

Spread of cancer beyond uterus

Women with endometrial cancer are higher risk for

Breast Cancer

Colon Cancer

How do we test for the chemo effectiveness in endometrial cancer

Test for estrogen and progesterone

When is high dose progesterone used to treat endometrial cancer

ER / PR +

What is the cancer profile of Lynch II Syndrome

Colon

Breast

Ovarian

Endometrial

Presentation of Breast Cancer

Oftne asymptomatic if not large tumor

Breast mass

Thickening of breast

Redness of skin

Scaling of skin

Ulceration of Nipple

Retraction of Nipple

Spontaneous Nipple Discharge

Peau d’orange

Edema of the skin of the breast caused by edema or blockage of the lymphatics

Late finding of breast cancer

Paget’s Disease of Breast

A sharp demarcated scaling plaque that mimics ecezma

Sign of cancer

Typically, the presence of breast pain indicates that the condition

Benign expect of inflammatory breast cancer

Risk Factors of Breast Cancer

Increasing age

Female

White race

Obesity (BMI > 30)

Menopausal status

Estrogen exposure

Dense breast tissue

Early menarche and/or later menopause

Nulliparity

Delayed childbearing

Hx or FHx of Breast Cancer

Radiation

Genetics

ETOH Use

Benign Breast Disease

What has shown protective effect to breast cancer

Breastfeeding

Increased activity

What is the mainstay of breast cance screening

Mammography

Benefits to Screening Mammography

Can detect asymptomatic early disease

Decreased breast cancer mortality

What should be done if abnormal mammogram is taken

Additional views

± US

How does breast cancer appear on mammogram

Soft tissue mass

Clusterd microcalcifications

BI-RADs

A classification system for mammogram findings and recommendations

• Stage 0 (Incomplete) → Further eval

• Stage 1 (Normal) → Normal Follow-Up

• Stage 2 (Benign) → Normal Follow-up

• Stage 3 (Probably benign) → Shoter interval follow-up

• Stage 4 (Suscipoius) → Consider biopsy

• Stage 5 (Highly suggestive) → Biopsy or surgery

• Stage 6 (Biopsy proven) → Treat

When do we do breast US

evaluation of breast mass in a women under age 35

diagnostic follow-up of an abnormality seen on screening mammography

Benefits to Breast US

determine solid versus cystic mass

assessment of the axilla

guidance may be used for biopsy

Indication for MRI of the breast for screening

> 20-25% lifetime risk of breast cancer

BRCA 1 / 2 +

How does breast MRI compare to mammogram

Better sensitivity

Worse specificity

Downside to breast MRI

Needs IV contrast

Why did we stop recommending breast self examination

Not been shown to improve breast cancer diagnosis or breast cancer mortality

Increased risk for breast biopsy

What testing cannot be done on FNA sample of breast cancer

Receptor testing

What can be used to dx breast cancer

Fine Needle Aspirtion

Core Biopsy

Open Biopsy

Most accurate test for breast cancer

Open biopsy

What are the main pathologic types of breast cnacer

Invasive

NoninvasiveW

What types of breast cancer are invasive

Infiltrating ductal carcinoma (#1)

Lobular carcinoma

Most Common Type of Breast Cancer

Infiltrating ductal carcinoma

How does Infiltrating ductal carcinoma spread

Regional lymph (Usually axilla)

Bone

Liver

Lung

Brain

Charactertisitcs of Lobular Carcinoma

older women

common to have bilateral tumors

associated with multicentric or multifocal disease in the same breast

metastatic to meninges, serosal surfaces, lymph nodes in the mediastinum and retroperitoneum

What types of breast cancer are considered noninvasive

Ductal carcinoma in situ (DCIS)

Lobular carcinoma in situ (LCIS)

Paget disease of the nipple

Inflammatory carcinoma

What breast cancer is Most identified with an abnormal mammogram with microcalcifications

Ductal carcinoma in situ (DCIS)

Ductal carcinoma in situ (DCIS) is a precursor to

invasive breast cancer

What breast cancer is Most identified as an incidental finding on breast biopsies

Lobular carcinoma in situ (LCIS)

Presentation of Inflammatory Carcinoma of the Breast

does not present with a lump

swelling, erythema, and tenderness of the breast, as well as peau d’orange

What biomarkers do we test for breast cancer

Estrogen receptors

Progesterone receptors

human epidermal growth factor 2 (HER2)

Triple Negative Tumors

Breast tumors that present negative for ER, PgR, and HER2

Characteristics of Triple Negative Tumors

common in women under age 40

Worse prognosis, more aggressive, grow rapidly

common in Blacks

commonly are BRCA +

More common to be infiltrating ductal carcinoma

All women with Triple Negative Tumors should also test

BRCA germline testing

What is treatment for breast cancer based on

Staging

How is breast cancer categorized by stage

1. Noninvasvie carcinoma, DCIS, LCIS (Stage 0)

2. Early-stage (Operable) - Stage I, II, and some IIIA

3. Locally advanced / inoperable regional - Some IIIA, IIIB, IIIC

   1. Metastatic (Stage IV

Treatment for LCIS

Observation after biopsy

Bilateral prophylactic mastectomy

tamoxifen / raloxifene → reducing risk of invasive cancer

Treatment for DCIS

Local excision or mastectomy

Lumpectomy with radiation

Tamoxifen / raloxifene → reduce breast cancer risk

Treatment of Early Stage Breast Cancer

Lumpectomy and radiation

Mastectomy