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Christopher R. Graber, MDSalina Women’s Clinic
08 March 2011
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OverviewEndometrial (Uterine) CancerVulvar CancerOvarian Cancer
Typical Presentation and DifferentialRisk Factors Different Types and StagingScreeningTreatment
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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
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Differential - Endometrial CancerPerimenopauseUterine fibroidsAdenomyosisUterine or cervical polypPostmenopausal endometrial atrophyEndometrial hyperplasia
Simple and complexWith and without atypia
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Endometrial CA risk factorsIncreased risk
Unopposed estrogenMenopause >52yoObesity (3x<50, 10x>50)NulliparityDMPCOS
Decreased risk
OvulationProgestin therapyOCPsMenopause <49yoNormal weightNulliparity
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Uterine CA – TypesEndometrioid adenocarcinomaClear cell carcinomaPapillary serous carcinomaSecretory carcinomaMucinous carcinomaSquamous carcinoma
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Uterine CA – Staging (surgical)IA – confined, < ½ myometrial invasionIB – confined, > ½ 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
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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
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Uterine CA -- ScreeningIf postmenopausal and EMB shows atrophy
Consider sono – endometrial stripe that measures less than or equal to 4mm is reassuring
Chances of CA if EMB showsSimple hyperplasia 1%Complex hyperplasia 5%Simple with atypia 10%Complex with atypia 25%
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Uterine CA – Treatment Treatment for CA is surgery
Hysterectomy plus staging procedureBy Gyn Oncology
Hysterectomy alone often done ifGrade I or IINo evidence of spreadType other than clear cell or papillary serous
Consider progestin therapy for hyperplasia
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pics
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OverviewEndometrial (Uterine) CancerVulvar CancerOvarian Cancer
Typical Presentation and DifferentialRisk Factors Different Types and StagingScreeningTreatment
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Vulvar CAA 63yo woman with daily itching and occasional bleeding
“down there”Duration: several years
A 45yo woman with history of lichen sclerosus reports she has a sore that won’t heal10y history of LS, usually well controlled
4% of cancer in genital tractCommon age 60-79yo; 15% under 40
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Vulvar CA – DifferentialHypertrophic vulvar dystrophyLichen sclerosusBenign skin lesions: mole, wart, freckleTraumaSTI – HSV, syphilis, chancroidHidradenitis suppurativa
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Vulvar CA – Risk FactorsHPVVulvar dystrophy
Lichen sclerosus – lifetime risk 3-5%Cervical or vaginal CA
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Vulvar CA – Types Squamous cell carcinoma (90%)MelanomaBartholin’s glandBasal cell carcinomaMetastatic
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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
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Vulvar CA – ScreeningAlways have a high index of suspicionBiopsy any suspicious lesionClose follow-up for lichen sclerosus
Q 3-6 months Keyes punch biopsy
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Vulvar CA – Treatment Surgical removal
Wide local excision (IA)HemivulvectomyRadical vulvectomy with bilateral inguinal –femoral node
dissection
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pics
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To be continued…
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OverviewEndometrial (Uterine) CancerVulvar CancerOvarian Cancer
Typical Presentation and DifferentialRisk Factors Different Types and StagingScreeningTreatmentBRCA overview
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Ovarian Cancer58 yo female complains of abdominal pain for several
months; has not seen a doctor for several yearsModerate nausea, weight loss
18 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
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Ovarian CA – Differential Anything that causes…
BloatingPelvic or abdominal painBack/leg painDiarrhea, gas, nausea,
constipation, indigestion
Difficulty eating or feeling full quickly
Pain during sexAbnormal vaginal bleedingTrouble breathing
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Ovarian CA – Risk FactorsIncreased risk ProtectiveAgeInfertilityEndometriosisNulliparityGenetics
BRCA, HNPCCEarly menarche/late menopause?Milk consumption?Vitamin D deficiency
Combined OCPs10y 60% reduction
Tubal ligationMultiparityYoung pregnancy, <25yo
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Ovarian CA – Types Epithelial
SerousMucinousEndometrioidClear cellBrennerUndifferentiated
Germ cellDysgerminomaYolk sac tumorTeratoma
Mature and immatureSex cord-stromal
Granulosa cellThecoma/FibromaSertoli-Leydig
Metatstatic
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Ovarian CA – Staging Stage I –limited to ovaries
IA – one ovary, confined IB – both ovaries, confined
IC – IA or IB, not confinedStage II – pelvic extension
IIA – uterus and/or tubes IIB – other pelvic tissuesIIC – IIA or IIB, not confined
Stage III – peritoneal involvementIIIA – microscopic IIIB – macroscopic, <2cmIIIC – macroscopic >2cm, positive lymph nodes
Stage IV – distant mets including liver parenchma
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Ovarian CA – Screening Routine screening is not recommended
No trial has shown improved M/M with screening
Annual examPelvic ultrasoundCA-125 Other tumor markers
LDH, AFP, hCG, Estradiol, Testosterone, Alk Phos
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Ovarian CA – Treatment Surgery
Removal of affected ovary(s)Staging procedure: free fluid or washings, peritoneal
biopsies, pap smear of diaphragm, infracolic omentectomy, retroperitoneal and paraaortic lymph nodes
Typically also uterus and cervix, overall debulkingChemotherapy and/or radiation
Paclitaxel, cisplatin, carboplatinExceptions: young patient, germ cell tumor, confined to 1
ovary
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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 damaged
“two-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)
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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
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BRCA – Who to Test
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BRCA + – For Ovary Consider ovarian cancer screening at age 30-35
Transvaginal 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 premenopausal
Better results for BRCA2 +
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BRCA + – For BreastConsider annual mammo and breast MRI at age 25For BRCA 2 – consider tamoxifen
Reduces breast cancer risk by 60%Consider prohylacitc bilateral mastectomy
Reduces breast cancer risk by 90-95%
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Breast CA sugery1800’s
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Points to RememberYou won’t find it if you don’t look for it
Postmenopausal bleeding is cancer until proven otherwiseIf you’re not sure what it is, biopsy itAsk about family history of breast/ovarian cancer
No screening for uterine CAAnnual exams are screening for vulvar CA
Always look, at least briefly, before a speculum examNo screening for ovarian CA
I don’t care what popular magazines say … No, I won’t order a CA-125 just because you want me to.