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Christopher R. Graber, MD Salina Women’s Clinic 08 March 2011

Gynecologic Cancer: Uterine, Vulvar , and Ovarian

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Gynecologic Cancer: Uterine, Vulvar , and Ovarian. Christopher R. Graber, MD Salina Women’s Clinic 08 March 2011. Overview. Endometrial (Uterine) Cancer Vulvar Cancer Ovarian Cancer Typical Presentation and Differential Risk Factors Different Types and Staging Screening Treatment. - PowerPoint PPT Presentation

Text of Gynecologic Cancer: Uterine, Vulvar , and Ovarian

  • Christopher R. Graber, MDSalina Womens Clinic08 March 2011

  • OverviewEndometrial (Uterine) CancerVulvar CancerOvarian Cancer

    Typical Presentation and DifferentialRisk Factors Different Types and StagingScreeningTreatment

  • Endometrial (Uterine) CancerA 58 yo obese woman presents with postmenopausal bleeding10 years without menses, now has had 4 months with irregular periods. No cramping.A 47 yo long-distance runner presents with heavier menses x 1yTypical menses: 3-5d, min flow. Now: 5-7d, heavy.2.6% of US women, 0.5% lifetime mortalityTypical: 50-65yo; 5% younger than 40

  • Differential - Endometrial CancerPerimenopauseUterine fibroidsAdenomyosisUterine or cervical polypPostmenopausal endometrial atrophyEndometrial hyperplasiaSimple and complexWith and without atypia

  • Endometrial CA risk factorsIncreased risk

    Unopposed estrogenMenopause >52yoObesity (3x50)NulliparityDMPCOSDecreased risk

    OvulationProgestin therapyOCPsMenopause

  • Uterine CA TypesEndometrioid adenocarcinomaClear cell carcinomaPapillary serous carcinomaSecretory carcinomaMucinous carcinomaSquamous carcinoma

  • Uterine CA Staging (surgical)IA confined, < myometrial invasionIB confined, > myometrial invasionII cervical stromal invasionIIIA invasion of serosa or adnexaIIIB vaginal or parametrial involvementIIIC 1&2 positive lymph nodesIVA invasion of bladder or bowelIVB distant metastases

  • Uterine CA ScreeningAlways have a high index of suspicionEMB for any woman >35yo with suspected anovulatory bleedingEMB for any other woman with long(er) history of anovulatory bleeding and other risk factorsConsider D&C if not able to obtain EMB

  • Uterine CA -- ScreeningIf postmenopausal and EMB shows atrophyConsider sono endometrial stripe that measures less than or equal to 4mm is reassuringChances of CA if EMB showsSimple hyperplasia1%Complex hyperplasia5%Simple with atypia10%Complex with atypia25%

  • Uterine CA Treatment Treatment for CA is surgeryHysterectomy plus staging procedureBy Gyn OncologyHysterectomy alone often done ifGrade I or IINo evidence of spreadType other than clear cell or papillary serousConsider progestin therapy for hyperplasia

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  • OverviewEndometrial (Uterine) CancerVulvar CancerOvarian Cancer

    Typical Presentation and DifferentialRisk Factors Different Types and StagingScreeningTreatment

  • Vulvar CAA 63yo woman with daily itching and occasional bleeding down thereDuration: several yearsA 45yo woman with history of lichen sclerosus reports she has a sore that wont heal10y history of LS, usually well controlled4% of cancer in genital tractCommon age 60-79yo; 15% under 40

  • Vulvar CA DifferentialHypertrophic vulvar dystrophyLichen sclerosusBenign skin lesions: mole, wart, freckleTraumaSTI HSV, syphilis, chancroidHidradenitis suppurativa

  • Vulvar CA Risk FactorsHPVVulvar dystrophyLichen sclerosus lifetime risk 3-5%Cervical or vaginal CA

  • Vulvar CA Types Squamous cell carcinoma (90%)MelanomaBartholins glandBasal cell carcinomaMetastatic

  • Vulvar CA Staging (surgical)IA confined to vulva, 2cm, 1mm invasionIB same as IA but >1mm invasionII confined to vulva, > 2cmIII adjacent spread to lower urethra, vagina, anus, and/or unilateral lymph nodes (regional)IVA invasion of upper urethra, bladder/rectal mucosa, pelvic bone and/or bilateral LNIVB distant metastases including pelvic LN

  • Vulvar CA ScreeningAlways have a high index of suspicionBiopsy any suspicious lesionClose follow-up for lichen sclerosusQ 3-6 months Keyes punch biopsy

  • Vulvar CA Treatment Surgical removalWide local excision (IA)HemivulvectomyRadical vulvectomy with bilateral inguinal femoral node dissection

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  • To be continued

  • OverviewEndometrial (Uterine) CancerVulvar CancerOvarian Cancer

    Typical Presentation and DifferentialRisk Factors Different Types and StagingScreeningTreatmentBRCA overview

  • Ovarian Cancer58 yo female complains of abdominal pain for several months; has not seen a doctor for several yearsModerate nausea, weight loss18 yo female complains of subacute abdominal pain and urinary frequency; pelvic mass felt on examSono shows 9cm solid and cystic adnexal mass

    5th most common cancer in women in USHighest fatality-to-case ratio of all GYN CA

  • Ovarian CA Differential Anything that causes

    BloatingPelvic or abdominal painBack/leg painDiarrhea, gas, nausea, constipation, indigestion

    Difficulty eating or feeling full quicklyPain during sexAbnormal vaginal bleedingTrouble breathing

  • Ovarian CA Risk FactorsIncreased riskProtectiveAgeInfertilityEndometriosisNulliparityGeneticsBRCA, HNPCCEarly menarche/late menopause?Milk consumption?Vitamin D deficiencyCombined OCPs10y 60% reductionTubal ligationMultiparityYoung pregnancy,
  • Ovarian CA Types EpithelialSerousMucinousEndometrioidClear cellBrennerUndifferentiatedGerm cellDysgerminomaYolk sac tumorTeratomaMature and immatureSex cord-stromalGranulosa cellThecoma/FibromaSertoli-LeydigMetatstatic

  • Ovarian CA Staging Stage I limited to ovariesIA one ovary, confinedIB both ovaries, confinedIC IA or IB, not confinedStage II pelvic extensionIIA uterus and/or tubesIIB other pelvic tissuesIIC IIA or IIB, not confinedStage III peritoneal involvementIIIA microscopicIIIB macroscopic, 2cm, positive lymph nodesStage IV distant mets including liver parenchma

  • Ovarian CA Screening Routine screening is not recommendedNo trial has shown improved M/M with screening

    Annual examPelvic ultrasoundCA-125 Other tumor markersLDH, AFP, hCG, Estradiol, Testosterone, Alk Phos

  • Ovarian CA Treatment SurgeryRemoval of affected ovary(s)Staging procedure: free fluid or washings, peritoneal biopsies, pap smear of diaphragm, infracolic omentectomy, retroperitoneal and paraaortic lymph nodesTypically also uterus and cervix, overall debulkingChemotherapy and/or radiationPaclitaxel, cisplatin, carboplatinExceptions: young patient, germ cell tumor, confined to 1 ovary

  • BRCA OverviewBRCA is responsible for approx. 10% of ovarian cancer and 3-5% of breast cancer casesTumor suppressor genes that help repair DNADefective allele inherited, second copy becomes damagedtwo-hit hypothesis

    BRCA1 on chromosome 17, 1,200 different mutationsBRCA2 on chromosome 13, 1,300 different mutationsIncidence: 1 in 300 to 1 in 800 (1 in 40 Ashkenazi Jews)

  • BRCA OverviewBRCA1 risk of ovarian cancer is 39-46%BRCA 2 risk of ovarian cancer is 12-20%Baseline risk 1.5%

    BRCA1&2 risk of breast cancer is 65-74%Baseline risk 12.5% (1 in 8)

    Consider referral to a Genetic Counselor

  • BRCA Who to Test

  • BRCA + For Ovary Consider ovarian cancer screening at age 30-35Transvaginal sono and CA-125Consider prophylacitc bilateral salpingo-oophorectomy at age 40 or after childbearing is doneReduces ovarian cancer risk by 85-90%Reduces breast cancer risk by 40-70% if premenopausalBetter results for BRCA2 +

  • BRCA + For BreastConsider annual mammo and breast MRI at age 25For BRCA 2 consider tamoxifenReduces breast cancer risk by 60%Consider prohylacitc bilateral mastectomyReduces breast cancer risk by 90-95%

  • Breast CA sugery1800s

  • Points to RememberYou wont find it if you dont look for itPostmenopausal bleeding is cancer until proven otherwiseIf youre not sure what it is, biopsy itAsk about family history of breast/ovarian cancerNo screening for uterine CAAnnual exams are screening for vulvar CAAlways look, at least briefly, before a speculum examNo screening for ovarian CAI dont care what popular magazines say No, I wont order a CA-125 just because you want me to.