Women's Health EOR: Neoplasms (Smarty PANCE)

What is the most common type of breast cancer?

Invasive ductal carcinoma (IDC) - 70-80% of all breast cancers; invasive lobular carcinoma is second at 10-15%

What are the major risk factors for breast cancer? Use mnemonic BRCA-FH

BRCA mutations, Race (Caucasian), Childbearing (nulliparity/late first pregnancy >30), Age (>50), Family history (first-degree relative), Hormones (prolonged estrogen exposure - early menarche, late menopause, HRT)

What is the most common presenting sign of breast cancer?

Painless breast mass or lump (80-90% of cases) - any new dominant mass requires evaluation

What are the hormone receptors tested and their treatment implications?

ER/PR (treated with hormone therapy: tamoxifen or aromatase inhibitors), HER2 (treated with trastuzumab/Herceptin); triple-negative (ER-, PR-, HER2-) has limited targeted therapy and worse prognosis

What is the most important prognostic factor in breast cancer?

Lymph node status - number of positive axillary lymph nodes is strongest predictor of survival

What are the screening recommendations for average-risk women?

Age 50-74: mammography every 2 years (USPSTF); Age 40-49: individualized decision; Age 45+: annual (ACS); clinical breast exam every 1-3 years

What is the triple assessment for breast evaluation?

Clinical examination + Imaging (mammography/ultrasound) + Tissue sampling (core needle biopsy preferred over FNA)

What defines inflammatory breast cancer and its prognosis?

Rapidly progressive with erythema, warmth, peau d’orange involving ≥1/3 of breast, often without discrete mass; poor prognosis, requires neoadjuvant chemotherapy

CERVICAL CARCINOMAWhat is the most common cause of cervical cancer?

HPV infection (types 16 and 18 cause 70% of cervical cancers) - found in >99% of cervical cancer cases

What is the most common histologic type of cervical cancer?

Squamous cell carcinoma (80-85%); adenocarcinoma is second (10-15%, arising from endocervical glands)

What are the major risk factors for cervical cancer? Use mnemonic CHAMPS

Cigarette smoking, HPV infection (16/18), Age of first intercourse (early <18), Multiple sexual partners, Parity (high), STDs/HIV/immunosuppression

What are the early symptoms of invasive cervical cancer?

Often asymptomatic early; later presents with abnormal vaginal bleeding (postcoital, intermenstrual, postmenopausal), vaginal discharge, pelvic pain

What is the transformation zone and why is it important?

Junction between squamous epithelium (ectocervix) and columnar epithelium (endocervix) - most common site for dysplasia and cancer development

How is cervical cancer staged and what system is used?

FIGO staging: Stage I (confined to cervix), Stage II (beyond cervix but not to pelvic wall), Stage III (extends to pelvic wall/lower 1/3 vagina), Stage IV (bladder/rectum/distant metastases)

What is the treatment for early-stage cervical cancer (IA-IIA)?

Stage IA1: simple hysterectomy or conization; Stage IA2-IIA: radical hysterectomy with pelvic lymphadenectomy OR concurrent chemoradiation

CERVICAL DYSPLASIAWhat does ASC-US mean and what is the next step?

Atypical Squamous Cells of Undetermined Significance - next step is HPV testing (reflex HPV testing preferred) or repeat cytology in 12 months

What does LSIL mean and how is it managed?

Low-grade Squamous Intraepithelial Lesion (CIN 1) - age 21-24: repeat cytology in 12 months; age ≥25: HPV co-testing at 12 months OR immediate colposcopy

What does HSIL mean and what is the management?

High-grade Squamous Intraepithelial Lesion (CIN 2/3) - requires immediate colposcopy with endocervical assessment and biopsy; treat with excisional or ablative procedures

What is CIN and how is it graded?

Cervical Intraepithelial Neoplasia: CIN 1 (mild dysplasia/LSIL), CIN 2 (moderate dysplasia), CIN 3 (severe dysplasia/carcinoma in situ) - CIN 2/3 considered HSIL

What are the treatment options for CIN 2/3 (HSIL)?

LEEP (Loop Electrosurgical Excision Procedure) - most common; cold knife conization; cryotherapy; laser ablation - excisional methods preferred for diagnosis and treatment

What are the current cervical cancer screening guidelines?

Age 21-29: cytology every 3 years; Age 30-65: co-testing (cytology + HPV) every 5 years OR cytology alone every 3 years; Discontinue at age 65 with adequate prior screening

When can cervical cancer screening be discontinued?

Age ≥65 with adequate prior negative screening (3 consecutive negative cytology OR 2 consecutive negative co-tests within 10 years, most recent within 5 years) and no history of CIN 2+ in past 25 years

ENDOMETRIAL CANCERWhat is the most common gynecologic malignancy in the US?

Endometrial cancer - most common in developed countries (cervical cancer most common worldwide)

What is the most common histologic type of endometrial cancer?

Endometrioid adenocarcinoma (Type I) - 80-85% of cases, estrogen-dependent, better prognosis

What are the major risk factors for Type I endometrial cancer? Use mnemonic HOME

Hyperplasia (endometrial), Obesity (BMI >30), Menopause (late >55), Estrogen exposure (unopposed - PCOS, tamoxifen, nulliparity, early menarche)

What is the most common presenting symptom of endometrial cancer?

Postmenopausal bleeding (90% of cases) - any bleeding after menopause is abnormal and requires evaluation

What is the first-line diagnostic test for suspected endometrial cancer?

Endometrial biopsy (office-based) - high sensitivity (>90%) for detecting cancer in postmenopausal women

What endometrial thickness on transvaginal ultrasound warrants biopsy?

>4mm in postmenopausal women not on HRT is abnormal and requires endometrial sampling

What defines complex atypical hyperplasia and its cancer risk?

Precancerous endometrial condition with crowded glands and cytologic atypia - 25-30% risk of concurrent or progression to endometrial cancer

What is the standard treatment for endometrial cancer?

Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO); staging requires surgical exploration; lymphadenectomy for high-risk features

What are poor prognostic factors in endometrial cancer? Use mnemonic DAMN

Deep myometrial invasion (>50%), Advanced age (>60), Metastases/high grade, Non-endometrioid histology (Type II: serous, clear cell)

OVARIAN NEOPLASMSWhat is the deadliest gynecologic malignancy?

Ovarian cancer - highest mortality rate due to late-stage diagnosis (most diagnosed at Stage III/IV)

What are the three main categories of ovarian tumors?

Epithelial tumors (90% of malignant, serous most common), Germ cell tumors (teratomas, dysgerminomas), Sex cord-stromal tumors (granulosa, Sertoli-Leydig)

What is the most common type of malignant ovarian tumor?

Serous cystadenocarcinoma - epithelial tumor, often bilateral, associated with BRCA mutations

What are the major risk factors for ovarian cancer?

BRCA1/2 mutations (40-50% lifetime risk), family history, nulliparity, age >50, endometriosis, Lynch syndrome

What factors are protective against ovarian cancer?

Multiparity, breastfeeding, oral contraceptive use (5+ years reduces risk 50%), tubal ligation, hysterectomy

What is the classic presentation of ovarian cancer?

Insidious onset with vague abdominal symptoms - bloating, early satiety, pelvic/abdominal pain, urinary symptoms, weight loss; often advanced at diagnosis

What is the initial imaging for suspected ovarian mass?

Transvaginal ultrasound - evaluate size, complexity, solid components, septations, vascularity; CT/MRI for preoperative staging

What tumor marker is elevated in epithelial ovarian cancer?

CA-125 (>35 U/mL) - elevated in 80% of epithelial ovarian cancers but non-specific (also elevated in endometriosis, fibroids, pregnancy, PID)

What is the treatment for ovarian cancer?

Surgical staging with total hysterectomy, BSO, omentectomy, lymphadenectomy, peritoneal biopsies PLUS platinum-based chemotherapy (carboplatin/paclitaxel)

What ovarian tumor is most common in young women and contains hair/teeth?

Mature cystic teratoma (dermoid cyst) - benign germ cell tumor, most common ovarian tumor in women <30; treatment is cystectomy

VAGINAL/VULVAR NEOPLASMSWhat is the most common type of vulvar cancer?

Squamous cell carcinoma (90-95% of vulvar cancers) - two pathways: HPV-related (younger) and HPV-independent (older)

What are the two pathways for vulvar cancer development?

HPV-related pathway (types 16/18, younger women 40s-50s, warty/basaloid) and HPV-independent pathway (older women 60s-70s, keratinizing, associated with lichen sclerosus)

What is lichen sclerosus and its malignancy risk?

Chronic inflammatory condition causing white, atrophic vulvar skin with intense pruritus - 4-6% risk of malignant transformation to vulvar cancer

What is the most common presenting symptom of vulvar cancer?

Vulvar pruritus (most common), followed by vulvar mass/lump, ulcer, pain, or bleeding

What is VIN and how is it classified?

Vulvar Intraepithelial Neoplasia - precursor to invasive cancer; classified as usual type VIN (HPV-related) or differentiated VIN (HPV-independent, higher malignant potential)

What is the most important prognostic factor in vulvar cancer?

Inguinal/femoral lymph node status - lymph node involvement is strongest predictor of survival

What is the most common type of vaginal cancer?

Squamous cell carcinoma (80-90% of primary vaginal cancers) - note that most vaginal tumors are metastatic from other sites

What is clear cell adenocarcinoma of the vagina associated with?

Diethylstilbestrol (DES) exposure in utero - occurs in daughters of women who took DES during pregnancy (1940s-1970s)

What is VAIN and how is it managed?

Vaginal Intraepithelial Neoplasia (precursor to invasive cancer) - VAIN 1: observation; VAIN 2/3: laser ablation, topical 5-FU, or surgical excision

Why is primary vaginal cancer considered rare?

Only 1-2% of gynecologic malignancies - most vaginal tumors are metastatic (from cervix, endometrium, vulva, or other sites); diagnosis requires no cervical or vulvar involvement