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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.

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gynecologic cancer uterine vulvar and ovarian

Gynecologic Cancer:Uterine, Vulvar, and Ovarian

Christopher R. Graber, MD

Salina Women’s Clinic

08 March 2011

overview
Overview
  • Endometrial (Uterine) Cancer
  • Vulvar Cancer
  • Ovarian Cancer
  • Typical Presentation and Differential
  • Risk Factors
  • Different Types and Staging
  • Screening
  • Treatment
endometrial uterine cancer
Endometrial (Uterine) Cancer
  • A 58 yo obese woman presents with postmenopausal bleeding
    • 10 years without menses, now has had 4 months with “irregular periods.” No cramping.
  • A 47 yo long-distance runner presents with heavier menses x 1y
    • Typical menses: 3-5d, min flow. Now: 5-7d, heavy.
  • 2.6% of US women, 0.5% lifetime mortality
  • Typical: 50-65yo; 5% younger than 40
differential endometrial cancer
Differential - Endometrial Cancer
  • Perimenopause
  • Uterine fibroids
  • Adenomyosis
  • Uterine or cervical polyp
  • Postmenopausal endometrial atrophy
  • Endometrial hyperplasia
    • Simple and complex
    • With and without atypia
endometrial ca risk factors
Endometrial CA risk factors
  • Increased risk
  • Unopposed estrogen
  • Menopause >52yo
  • Obesity (3x<50, 10x>50)
  • Nulliparity
  • DM
  • PCOS
  • Decreased risk
  • Ovulation
  • Progestin therapy
  • OCPs
  • Menopause <49yo
  • Normal weight
  • Nulliparity
uterine ca types
Uterine CA – Types
  • Endometrioid adenocarcinoma
  • Clear cell carcinoma
  • Papillary serous carcinoma
  • Secretory carcinoma
  • Mucinous carcinoma
  • Squamous carcinoma
uterine ca staging surgical
Uterine CA – Staging (surgical)
  • IA – confined, < ½ myometrial invasion
  • IB – confined, > ½ myometrial invasion
  • II – cervical stromal invasion
  • IIIA – invasion of serosa or adnexa
  • IIIB – vaginal or parametrial involvement
  • IIIC 1&2 – positive lymph nodes
  • IVA – invasion of bladder or bowel
  • IVB – distant metastases
uterine ca screening
Uterine CA – Screening
  • Always have a high index of suspicion
  • EMB for any woman >35yo with suspected anovulatory bleeding
  • EMB for any other woman with long(er) history of anovulatory bleeding and other risk factors
  • Consider D&C if not able to obtain EMB
uterine ca screening1
Uterine CA -- Screening
  • If postmenopausal and EMB shows atrophy
    • Consider sono – endometrial stripe that measures less than or equal to 4mm is reassuring
  • Chances of CA if EMB shows
    • Simple hyperplasia 1%
    • Complex hyperplasia 5%
    • Simple with atypia 10%
    • Complex with atypia 25%
uterine ca treatment
Uterine CA – Treatment
  • Treatment for CA is surgery
    • Hysterectomy plus staging procedure
    • By Gyn Oncology
  • Hysterectomy alone often done if
    • Grade I or II
    • No evidence of spread
    • Type other than clear cell or papillary serous
  • Consider progestin therapy for hyperplasia
overview1
Overview
  • Endometrial (Uterine) Cancer
  • Vulvar Cancer
  • Ovarian Cancer
  • Typical Presentation and Differential
  • Risk Factors
  • Different Types and Staging
  • Screening
  • Treatment
vulvar ca
Vulvar CA
  • A 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 heal
    • 10y history of LS, usually well controlled
  • 4% of cancer in genital tract
  • Common age 60-79yo; 15% under 40
vulvar ca differential
Vulvar CA – Differential
  • Hypertrophic vulvar dystrophy
  • Lichen sclerosus
  • Benign skin lesions: mole, wart, freckle
  • Trauma
  • STI – HSV, syphilis, chancroid
  • Hidradenitis suppurativa
vulvar ca risk factors
Vulvar CA – Risk Factors
  • HPV
  • Vulvar dystrophy
    • Lichen sclerosus – lifetime risk 3-5%
  • Cervical or vaginal CA
vulvar ca types
Vulvar CA – Types
  • Squamous cell carcinoma (90%)
  • Melanoma
  • Bartholin’s gland
  • Basal cell carcinoma
  • Metastatic
vulvar ca staging surgical
Vulvar CA – Staging (surgical)
  • IA – confined to vulva, ≤ 2cm, ≤1mm invasion
  • IB – same as IA but >1mm invasion
  • II – confined to vulva, > 2cm
  • III – 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 LN
  • IVB – distant metastases including pelvic LN
vulvar ca screening
Vulvar CA – Screening
  • Always have a high index of suspicion
  • Biopsy any suspicious lesion
  • Close follow-up for lichen sclerosus
    • Q 3-6 months
  • Keyes punch biopsy
vulvar ca treatment
Vulvar CA – Treatment
  • Surgical removal
    • Wide local excision (IA)
    • Hemivulvectomy
    • Radical vulvectomy with bilateral inguinal –femoral node dissection
overview2
Overview
  • Endometrial (Uterine) Cancer
  • Vulvar Cancer
  • Ovarian Cancer
  • Typical Presentation and Differential
  • Risk Factors
  • Different Types and Staging
  • Screening
  • Treatment
  • BRCA overview
ovarian cancer
Ovarian Cancer
  • 58 yo female complains of abdominal pain for several months; has not seen a doctor for several years
    • Moderate nausea, weight loss
  • 18 yo female complains of subacute abdominal pain and urinary frequency; pelvic mass felt on exam
    • Sono shows 9cm solid and cystic adnexal mass
  • 5th most common cancer in women in US
  • Highest fatality-to-case ratio of all GYN CA
ovarian ca differential
Ovarian CA – Differential

Anything that causes…

  • Bloating
  • Pelvic or abdominal pain
  • Back/leg pain
  • Diarrhea, gas, nausea, constipation, indigestion
  • Difficulty eating or feeling full quickly
  • Pain during sex
  • Abnormal vaginal bleeding
  • Trouble breathing
ovarian ca risk factors
Ovarian CA – Risk Factors

Increased risk

Protective

  • Age
  • Infertility
  • Endometriosis
  • Nulliparity
  • Genetics
    • BRCA, HNPCC
  • Early menarche/late menopause
  • ?Milk consumption
  • ?Vitamin D deficiency
  • Combined OCPs
    • 10y  60% reduction
  • Tubal ligation
  • Multiparity
  • Young pregnancy, <25yo
ovarian ca types
Ovarian CA – Types
  • Epithelial
    • Serous
    • Mucinous
    • Endometrioid
    • Clear cell
    • Brenner
    • Undifferentiated
  • Germ cell
    • Dysgerminoma
    • Yolk sac tumor
    • Teratoma
      • Mature and immature
  • Sex cord-stromal
    • Granulosa cell
    • Thecoma/Fibroma
    • Sertoli-Leydig
  • Metatstatic
ovarian ca staging
Ovarian CA – Staging
  • Stage I –limited to ovaries
    • IA – one ovary, confined IB – both ovaries, confined
    • IC – IA or IB, not confined
  • Stage II – pelvic extension
    • IIA – uterus and/or tubes IIB – other pelvic tissues
    • IIC – IIA or IIB, not confined
  • Stage III – peritoneal involvement
    • IIIA – microscopic IIIB – macroscopic, <2cm
    • IIIC – macroscopic >2cm, positive lymph nodes
  • Stage IV – distant mets including liver parenchma
ovarian ca screening
Ovarian CA – Screening
  • Routine screening is not recommended
    • No trial has shown improved M/M with screening
  • Annual exam
  • Pelvic ultrasound
  • CA-125
  • Other tumor markers
    • LDH, AFP, hCG, Estradiol, Testosterone, Alk Phos
ovarian ca treatment
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 debulking
  • Chemotherapy and/or radiation
    • Paclitaxel, cisplatin, carboplatin
  • Exceptions: young patient, germ cell tumor, confined to 1 ovary
brca overview
BRCA Overview
  • BRCA is responsible for approx. 10% of ovarian cancer and 3-5% of breast cancer cases
    • Tumor suppressor genes that help repair DNA
    • Defective allele inherited, second copy becomes damaged
      • “two-hit hypothesis”
  • BRCA1 on chromosome 17, 1,200 different mutations
  • BRCA2 on chromosome 13, 1,300 different mutations
  • Incidence: 1 in 300 to 1 in 800 (1 in 40 Ashkenazi Jews)
brca overview1
BRCA Overview
  • BRCA1 – 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 for ovary
BRCA + – For Ovary
  • Consider ovarian cancer screening at age 30-35
    • Transvaginal sono and CA-125
  • Consider prophylacitc bilateral salpingo-oophorectomy at age 40 or after childbearing is done
    • Reduces ovarian cancer risk by 85-90%
    • Reduces breast cancer risk by 40-70% if premenopausal
      • Better results for BRCA2 +
brca for breast
BRCA + – For Breast
  • Consider annual mammo and breast MRI at age 25
  • For BRCA 2 – consider tamoxifen
    • Reduces breast cancer risk by 60%
  • Consider prohylacitc bilateral mastectomy
    • Reduces breast cancer risk by 90-95%
points to remember
Points to Remember
  • You won’t find it if you don’t look for it
    • Postmenopausal bleeding is cancer until proven otherwise
    • If you’re not sure what it is, biopsy it
    • Ask about family history of breast/ovarian cancer
  • No screening for uterine CA
  • Annual exams are screening for vulvar CA
    • Always look, at least briefly, before a speculum exam
  • No 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.
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