1
Q
What is gestational trophoblastic neoplasia?
A
a spectrum that includes all neoplasms derived from abnormal placental (trophoblastic) proliferation, most often a benign disease known as hydatidiform mole
2
Q
What are the key clinical features of gestational trophoblastic neoplasia?
A
- clinical presentation as pregnancy
- reliable means of diagnosis by pathognomonic US findings
- a specific tumor marker known as hCG
3
Q
What is the difference between gestational trophoblastic neoplasia and hydatidiform mole?
A
- GTN is a spectrum of neoplasms derived from abnormal placental proliferation which includes hydatidiform mole
- GTN can arise from pregnancy but most commonly follows a hydatidiform mole
4
Q
What is a hydatidiform mole?
A
an abnormal proliferation of the syncytiotrophoblast and replacement of normal placental trophoblastic tissue by hydronic placental villi
5
Q
Hydatidiform Mole
A
- an abnormal conception, which leads to abnormal proliferation of the syncytiotrophoblast and replacement of normal placental trophoblastic tissue by hydropic placental villi
- can be complete without identifiable embryonic structures, or partial with some identifiable embryonic tissue
- complete arise from fertilization of an empty ovum followed by reduplication of the haploid sperm; partial arise from fertilization of a normal ovum by two sperm
- presents as a pregnancy with a larger-than-expected uterus, exaggerated subjective symptoms of pregnancy, and painless second-trimester bleeding with passage of grape-like masses if not detected sooner
- fetal heart tones will be absent, US finds a characteristic “snow-storm” appearance without fetal parts, and B-hCG is excessively elevated
- elevated B-hCG may produce severe nausea and vomiting, hypertension, proteinuria, and clinical hyperthyroidism due to activation of TSH receptors
- treatment is suction curettage; give Rhgam at the time of uterine evacuation and begin contraception to prevent intercurrent pregnancy
- patients then require subsequent monitoring of B-hCG to ensure adequate removal, first at 48 hours, then every 1-2 weeks while elevated, and 1-2 months thereafter
- complete more than partial, poses a risk for choriocarcinoma
6
Q
What is the difference between a complete and partial hydatidiform mole? How do the two differ in their genesis and karyotype?
A
- partial are those with some identifiable embryonic structures while complete have none
- partial are triploid with one haploid set of maternal chromosomes and two haploid sets of paternal chromosomes due to dispermic fertilization of a normal ovum
- complete are diploid, typically 46,XX, and are entirely of paternal origin since they result from fertilization of a blighted ovum by a haploid sperm that replicates
7
Q
Compare and contrast complete and partial hydatidiform moles.
A
- complete have no embryonic tissue while partial have some identifiable embryonic structures
- complete are diploid due to fertilization of an empty ovum by a haploid sperm that reduplicates while partial are triploid due to dispermic fertilization of a normal ovum
- complete have diffuse and more severe trophoblastic proliferation and hydropic villi while proliferation is more focal and mild in partial
- complete are usually diagnosed as a molar gestation while partial are more likely to present as a missed aborption
- clinically, complete usually have a much larger uterus than expected, co-occur with theca-lutein cysts, and carry a greater risk of malignancy
8
Q
Pregnancy with severe hypertension prior to 20 weeks gestation is highly suggestive of what?
A
molar pregnancy since the elevated B-hCG is likely to activate TSH receptors and present clinically as hyperthroidism
9
Q
How are gestational trophoblastic neoplasias classified?
A
- there are benign forms with hydatidiform moles being the most common and being divided into partial and complete
- there are malignant forms, including persistent non-metastatic GTN and metastatic GTN
10
Q
What is persistent gestational trophoblastic neoplasia?
A
a malignant form of GTN which follows any sort of pregnancy and is diagnosed when B-hCG levels do not fall appropriately after these pregnancies
11
Q
What is an invasive mole?
A
a complete mole that invades the myometrium without any intervening endometrial stroma as seen on a histologic sample
12
Q
Choriocarcinoma
A
- a malignant germ cell tumor composed of cyto- and syncytiotrophoblasts
- mimics placental tissue but villi are absent
- it spreads via the hematogenous route early (makes sense because the usual function of trophoblasts is to establish fetal blood flow) and goes to the lungs
- high B-hCG is characteristic and may lead to theca lutein cysts in the ovary or hyperthyroidism (since the a subunit of B-hCG resembles that of FSH, LH, and TSH)
- it arises as a complication of gestation (following hydatidiform mole, normal pregnancy, ectopic pregnancy spontaneous abortion, etc.) or as a spontaneous germ cell tumor
- when it arises from the gestational pathway it tends to respond well to chemotherapy; but those that arise spontaneously do not
13
Q
What should be done if abnormal bleeding continues for more than 6 weeks after pregnancy?
A
patient should be evaluated with hCG levels to exclude a new pregnancy or gestational trophoblastic neoplasia
14
Q
What is nonmetastatic persistent GTN and how is it treated?
A
- it is a persistence of GTN following any sort of pregnancy, which is malignant but not yet metastatic
- treated with single-agent chemotherapy such as MTX or actinomycin D
15
Q
How is metastatic GTN classified?
A
- it is divided into good- and poor-prognosis disease
- a short interval from the antecedent pregnancy (less than 4 months), pretherapy hCG levels less than 40,000, no brain or liver metastases, no antecedent term pregnancy, and no prior chemotherapy are all indicative of good prognosis
16
Q
Which HPV types are low-risk and which are high-risk?
A
- low-risk are 6 and 11
- high-risk are 16, 18, 31, and 33
17
Q
Low-risk HPV is associated with what diseases?
A
condylomata acuminata, aka genital warts, and with low-grade squamous intraepithelial lesions (LSILs)
18
Q
What are the internal and external cervical os?
A
- the internal os is the upper part of the cervix that opens into the endometrial cavity
- the external os is the lower part that opens into the vagina
19
Q
What is the ectocervix and what is the endocervix?
A
- the ectocervix is the exterior portion of the cervical canal
- the endocervix is the interior cervical canal
20
Q
Describe the cervical epithelium.
A
- the ectocervix is lined by stratified, non-keratinizing squamous epithelium
- the endocervix is lined by a columnar epithelium
- the squamocolumnar junction is where the two different epithelia meet
21
Q
What is the clinical significance of the squamocolumnar junction?
A
it is where the epithelium of the ectocervix and endocervix meet and is clinically important because it is where almost all cervical neoplasias arise
22
Q
Where is the squamocolumnar junction of the cervix located?
A
- during childhood, the SCJ is located just inside the external os
- during puberty, hormones and acidification cause a metaplasia that causes the SCJ to evert to a position on the enlarged cervical surface
- this metaplasia is known as transformation zone and the area between the original SCJ and new SCJ is known as the transformation zone
- during perimenopause, the new SCJ recedes upward into the endocervical canal, out of direct visual contact
23
Q
What is the transformation zone of the cervix?
A
it is the area between the original squamocolumnar junction just inside the external os and the active squamoucolumnar junction which changes throughout reproductive life
24
Q
What is a nabothian cyst?
A
- a benign cyst that arises from the normal metaplasia within the transformation zone of the cervix
- during this metaplasia, glands within the columnar epithelium may become trapped by squamous epithelium, forming the cyst
25
What are koilocytes?
cervical epithelial cells with shrunken, withered, raisin-like nuclei, indicative of cells infected by HPV without integration of the viral DNA into the host genome
26
What are the risk factors for cervical neoplasia?
- more than one sexual partner, past STD, or early first intercourse
- male partner who has had a partner with cervical cancer
- smoking
- HIV, organ transplant, immunosuppression
- diethylstilbestrol exposure
- infrequent or absent cervical cytology screening tests
27
How are epithelial cervical neoplasias classified?
- can be atypical squamous cells, either of undetermined significance or without ability to exclude HSIL
- LSIL, which encompasses HPV infection, mild dysplasia, or CIN I
- HSIL, which encompasses CIN 2 and CIN 3, carcinoma in situ, and moderate or severe dysplasia but is still a precursor lesion
- invasive squamous carcinoma
28
Describe colposcopy with directed biopsy.
- a method for further evaluation of an abnormal cervical cytology test
- the cervix is washed with a 3-4% acetic acid solution, which dehydrates cells, causing those with large nuclei (dysplasia or HPV-infected) to appear white
- this is visualized with a binocular stereomicroscope with a green filter that helps also identify abnormal vasculature
- directed biopsy is performed on areas with white epithelium, abnormal vascular patterns, or punctate lesions, which are most commonly seen around the squamocolumnar junction
29
What is required for a colposcopy to be considered satisfactory?
the entire squamocolumnar junction and the entire margins of abnormal areas must be visualized
30
What is an endocervical curettage?
- a method for evaluating an abnormal cervical cytology test when colposcopy is not able to visualize all the necessary components
- involves using a small curette to collect cells from the endocervical canal and then using an endocervical brush to retrieve additional cells dislodged in the curette specimen
31
How are women with atypical squamous cells of undetermined significance (ASC-US) on cytology managed?
the preferred next step is HPV testing
- if HPV testing is negative, repeat co-testing in 3 years
- if testing is positive, colposcopy is indicated
another acceptable approach is to repeat cytology 1 year later
- if it is negative, no further management is required and routine screening is sufficient
- if positive and shows ASC or a more severe lesion, then colposcopy is indicated
32
How do recommendations for management of ASC-US differ in women age 21-24?
- perform reflex HPV testing: if negative, continue routine screening; if positive, repeat cytology in 12 months
- if repeat cytology is negative, finds ASC-US, or finds LSIL, repeat cytology again in 12 months; routine to normal screening if this three total tests show this
- if follow-up cytology shows progression to ASC-H, AGC, or HSIL, perform colposcopy
33
How are women with low-grade squamous intraepithelial lesions (LSILs) on cytology managed?
- if HPV testing is negative, monitor the patient closely with repeat cotesting in 12 months; if repeat testing shows ASC or more or HPV testing is positive, perform colposcopy
- if HPV testing isn't performed, is positive, or the patient has a past history of ASC-US with positive HPV testing, perform colposcopy
34
Why do women age 21-24 have different options for management of abnormal cytology findings?
- because ASC and LSIL are more common in younger women and the likelihood of spontaneous regression in this population is higher
- furthermore, HPV DNA testing is more likely to be positive, so using it as a triage method is less useful
35
Describe cervical cancer screening recommendations.
- perform cytology every three years beginning at age 21
- add reflex HPV testing at 30 and perform cytology every five years as long as results are normal
- discontinue cytology at 65 years of age if the patient has no history of CIN 2 or higher
36
How should a cytology finding of HSIL be managed?
because CIN 2 or 3 is likely with HSIL cytology findings, immediate treatment with LEEP is the preferred management
37
How is ASC-H found on cytology further evaluated?
with colposcope
38
What is the recommendation for managing the following cervical cytology findings?
- ASC-US
- ASC-H
- AGC
- LSIL
- HSIL
- ASC-US: perform HPV testing or repeat cytology in one year, and if positive, perform colposcopy
- ASC-H: perform colposcopy
- AGC: perform colposcopy, HPV testing, and ECC; add endometrial sampling if the women is over 25 or has risk for endometrial neoplasia
- LSIL: perform HPV testing or repeat cytology in one year, and if positive, perform colposcopy
- HSIL: treat with LEEP
39
What are the two types of cervical atypic?
atypical squamous cells and atypical glandular cells
40
What is the recommendation for AGC findings on cervical cytology?
perform colposcopy, HPV testing, and ECC; add endometrial sampling if the women is over 25 or has heightened risk for endometrial neoplasia
41
What methods are available for ablation of cervical dysplasia?
cryotherapy, laser ablation, electrofulguration, or cold coagulation
42
What is LEEP?
an excisional method for treating cervical neoplasia that relies on electrosurgical energy
43
What parts of the cervix are excised when treating cervical neoplasia with excision rather than ablation?
a cone-shaped specimen is removed from the cervix, including the SCJ, all identified lesions on the ectocervix, and a portion of the endocervical canal
44
When is excisional therapy preferred over ablative therapy for cervical intraepithelial neoplasia?
excisional is preferred...
- if endocervical curettage is positive
- if the colposcopy is unsatisfactory
- if there is a substantial discrepancy between the screening cervical cytology and the histologic data from biopsy and ECC
45
Cervical Cancer
- most cases are squamous cell while adenocarcinoma makes up only a small percentage of cases
- the average age of diagnosis is about 50 years old and CIN precedes invasive carcinoma by about 10 years
- the key risk factor is high-risk HPV infection; secondary risk factors include smoking and immunodeficiency
- symptoms most often include watery vaginal discharge, intermittent spotting, and postcoital bleeding
- may invade through the anterior uterine wall into the bladder, blocking the ureters and causing hydronephrosis with post renal failure; a common cause of death in these patients
- staging is based on histologic assessment and on physical and laboratory examination; surgical findings guide treatment but do not affect staging
- treatment options include surgery (conization, hysterectomy, and/or lymph node dissection) radiation therapy, and chemotherapy (usually cisplatin)
- after treatment, patients should have follow-up every four months for two years, and then every six months until 5 years post-treatment
- recommend cervical cytology annually for the patient's lifetime and CXRs annually for the first 5 years
46
What are the guidelines for administration of the HPV vaccine?
- recommended for boys and girls age 11-12 but as early as 9 years old
- if the first dose is given before age 15, then a second is needed 6 to 12 months later
- if the first dose is given after age 15, a second is needed 1-2 months later and a third 6 months after the first
47
Uterine Leiomyoma
- a hormonally responsive (to estrogen) benign tumor derived from the smooth muscle of the myometrium
- most are intramural but can be subserosal or submucosal
- presents with abnormal uterine bleeding, namely progressively heavier and longer menstrual flow, a progressive increase in pelvic pressure, and secondary dysmenorrhea
- if they grow significantly they may even apply pressure to the ureters as they cross the pelvic brim, leading to hydroureter and hydronephrosis
- patients may experience a dull, intermittent, low midline cramping pain if a submucosal leiomyoma becomes pedunculate and prolapses through the internal os
- diagnosed based on physical exam and imaging studies; usually felt as a large, midline, irregular-contoured mobile pelvic mass with a solid quality
- hysteroscopy, hysterosalpingography, saline infusion US, and exploratory surgery may also be necessary
- treatment is usually conservative and directed toward the symptoms; progestin supplementation and prostaglandin synthetase inhibitors control dysmenorrhea and menstrual flow while estrogen antagonists can reduce fibroid size
- surgical treatment may include a myomectomy or hysterectomy
- uterine artery embolization is a newer treatment
48
What differentiates a subserosal, submucosal, and intramural leiomyoma?
- subserosal are just below the uterine serosa
- submucosal are just below the endometrium
- intramural are in the muscular wall
49
Leiomyosarcoma
- a uterine malignancy
- most often seen in postmenopausal patients presenting with a rapidly enlarging uterine mass, postmenopausal bleeding, unusual vaginal discharge, and pelvic pain
50
What surgical options are available for the treatment of uterine leiomyomas?
- myomectomy can be used if the patient has a rapidly enlarging asymptomatic mass, symptoms are not well controlled medically, or the mass is causing hydronephrosis and the patient wishes to remain fertile
- hysterectomy is the definitive treatment but should only be used in symptomatic women who have completed childbearing
51
Describe uterine artery embolization?
- a method for selectively embolizing the uterine artery with polyvinyl alcohol particles to cause an acute infarction of a targeted leiomyoma
- may cause acute post-embolization pain and fever, delayed infection, or delayed passage of necrotic fibroid tissue
- not considered a viable option in patients who desire future childbearing
52
What is MRI-guided focused ultrasound surgery?
a treatment option for leiomyosarcoma which delivers concentrated ultrasound energy to raise the temperature and cause coagulative necrosis
53
What is the most common gynecologic cancer?
endometrial carcinoma
54
What are the kinds of endometrial hyperplasia?
- hyperplasia without atypia can be simple, in which case both glandular and stromal elements proliferate and there is very little association with endometrial carcinoma
- hyperplasia without atypia can be complex, in which there is a proliferation of primarily glandular elements only; glands appear back-to-back and it represents a true intraepithelial neoplastic process
- hyperplasia with atypia which is a precursor lesion to endometrial carcinoma
55
What ultrasound finding is consistent with endometrial hyperplasia or carcinoma?
an endometrial thickness over 4 mm in a postmenopausal patient
56
What are risk factors for endometrial hyperplasia and cancer?
- long-term use of estrogen replacement therapy
- tamoxifen use
- obesity
- nulliparity or history of infertility
- early menarche, late menopause
57
Endometrial Hyperplasia
- risk factors are related to exposure to estrogen
- the hallmark is abnormal uterine bleeding
- diagnosis is made by endometrial sampling and D&C is used to exclude the possibility of coexistent endometrial cancer afterwards
- classified as simple without atypia, complex without atypia, or with atypia
- simple without has very little association with cancer, complex without has a weak association as it is a true intraepithelial neoplastic process, and with atypia is a precursor lesion with a strong association to cancer
- medical therapy includes progestins and is first-line, but hysterectomy is definitive therapy and recommended after a patient has completed childbearing
58
How do progestins help treat endometrial hyperplasia?
- alter the enzymatic pathways which convert estradiol to weaker estrogens
- decrease the number of estrogen receptors on endometrial glandular cells
- thin the endometrium and induce stromal decidualization
59
Endometrial Polyps
- a hyperplastic protrusion of endometrium
- most commonly seen in perimenopausal or immediately postmenopausal women
- most often caused by tamoxifen, which has weak pro-estrogenic effects on the endometrium
- presents with abnormal uterine bleeding
- rarely demonstrate malignant change but polyps in postmenopausal women or those who are taking tamoxifen are more likely to be associated with endometrial carcinoma
60
Endometrial Cancer
- most cases are seen in postmenopausal women presenting with postmenopausal bleeding
- most are adenocarcinomas but there can be a squamous epithelium coexisting with the glandular components
- type I, endometrioid, are more common, caused by exposure to unopposed estrogen, tend to be low-grade, and have a favorable prognosis
- type II, non-endometrioid, are less common, said to be estrogen-independent and arise spontaneously, arise from an atrophic endometrium, and have a less favorable prognosis
- diagnosis is made based on endometrial sampling; preoperative CA-125 can be helpful in advanced disease
- the single most important prognostic factor is histologic grade while depth of myometrial invasion is second most
- hysterectomy is the primary treatment; surgical staging requires concurrent BSO, lymph node dissection, and peritoneal washing
61
Uterine Sarcoma
- arise from the myometrium or endometrial stroma
- progressive uterine enlargement in the postmenopausal period is often indicative; other symptoms include postmenopausal bleeding, pelvic pain, and vaginal discharge
- surgical removal is the most reliable method for diagnosis
- virulence is directly related to the number of mitotic figures and degree of cellular atypia found on histology
- staging is surgical and based on the same criteria as endometrial adenocarcinoma
OBGYN
flashcards
Decks in class (21)
# Cards
-
Gynecology55
-
Contraception52
-
STDs27
-
Sexuality and Sexual Assault22
-
Principles of Chemotherapy45
-
Gyn Onc61
-
Obstetric Physiology71
-
Labor & Delivery113
-
Postpartum Hemorrhage29
-
Third Trimester Bleeding16
-
PROM12
-
Ectopic Pregnancy0
-
Post-Term Pregnancy12
-
High Risk OB97
-
Primary Care Topics34
-
Pelvic Support, UTI, Incontinence21
-
Breast Disorders47
-
Gyn Procedures8
-
UWise138
-
Gyn UWise41
-
UWorld64
