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131 Cards in this Set
- Front
- Back
What is really the only benign tumor of the endometrium that you will see?
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Polyps
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What are endometrial polyps?
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OVERgrowths of endometrial stroma and glands that project into the endometrial cavity.
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At what age are benign endometrial polyps typically seen?
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Perimenopause
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How do small vs large polyps typically manifest?
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Small = Asymptomatic
Large = May ulcerate/bleed or protrude thru cervix |
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What do benign endometrial polyps consist of histologically?
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Polypoid endometrium with cystically dilated glands
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How often do benign endometrial polyps transform into malignancy?
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Very rarely!
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What is the most common invasive malignant carcinoma in the female genital tract?
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Carcinoma of the endometrium
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What can carcinoma of the endometrium develop from?
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Atypical endometrial hyperplasia
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What % of endometrial carcinoma is derived from
-Complex hyperplasia w/o atypia -Atypical endometrial hyperplasia |
Complex: <5%
Atypical: 23% |
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So what is atypical endometrial hyperplasia really considered to be?
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A premalignant disorder
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What 2 factors in atypical endometrial hyperplasia correlate with increased cancer risk?
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-PTEN gene loss
-Degree of atypia |
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How is atypical endometrial hyperplasia treated in young females that still want to have a family?
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-Remove the estrogen source and give high dose progestin
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How treatment is considered for atypical endometrial hyperplasia in older females?
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Hysterectomy
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And what is the malignancy that atypical EM hyperplasia has a 23% risk of transforming into?
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Carcinoma of the endometrium
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What USED to be the most common invasive carcinoma of the female genital tract? Why isn't it anymore?
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Invasive cervical carcinoma - its incidence has been greatly reduced by pap smears
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Every year, how many new cases develop of:
-Carcinoma of the endometrium -Invasive cervical carcinoma |
Carc of EM: 34,000
Cervical: 13,000 |
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Where does carcinoma of the endometrium rank among most common cancers in women?
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4th
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In what age groups is carcinoma of the endometrium
-Uncommon -Peak |
Uncommon <40
Peak in 55-65 yr olds |
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Will my mom get carcinoma of the EM?
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nope not possible
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What 4 factors can increase the risk of a woman to get carcinoma of the EM?
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-Obesity
-Diabetes -Hypertension -Infertility |
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What are 3 reasons a woman might be infertile?
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-Single
-Nulliparous -DUB/Anovulatory cycles |
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Why are patients with EM carcinoma more likely to have anovulatory cycles?
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Becuase of the repeated stimulation of estrogen and continuous high levels of it.
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So what is the predominant pathogenesis in development of endometrial carcinoma?
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Prolonged and excessive estrogen stimulation
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And what may precede endometrial carcinoma?
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Endometrial hyperplasia
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In what conditions is incidence of EM carcinoma
-increased -decreased |
-Increased in ovarian tumors that secrete estrogen
-Decreased in castration or ovarian agenesis |
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What increases the risk of endometrial carcinoma in perimenopausal women?
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Use of estrogen for menopause symptoms
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Why does obesity increase the risk of endometrial carcinoma?
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Bc fat has aromatase and it makes more estrogen
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What gene inactivation is associated with increased risk of endometrial carcinoma?
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PTEN
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Do ALL patients with EM carcinoma have hyperestrinism?
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No there is a subset that doesn't
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How does EM carcinoma NOT associated w/ hyperestrinism compare to that which is?
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-Not preceded by EM hyperplasia
-More aggressive |
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In what age of women is Endometrial carcinoma not due to estrogen more likely?
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Older
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How does endometrial carcinoma usually present clinically?
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As abnormal bleeding
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What kind of gross tumor can endometrial carcinoma appear as?
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-Localized polypoid
-Diffuse involving most of the endometrial surface |
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Which type of tumor is EM carcinoma usually and how does that affect diagnosis?
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-Most often diffuse (anterior and posterior surfaces)
-Harder to see |
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Once you cut into the specimen of an EM carcinoma what do you need to look for?
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The degree of extension into the Myometrium.
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What will you see in myometrial extension of endometrial carcinoma?
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Subserosal nodules
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Why is it important to determine the depth of myometrial extension?
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For staging (1a,b, or c)
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What is the most common pattern of spread of endometrial carcinoma?
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To the periuterine structures like the broad ligaments
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What is a more aggressive but fortunately more rare pattern of EM carcinoma spreading?
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Via the lymph nodes
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What TYPE of carcinoma are >85% of endometrial carcinomas?
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Adenocarcinoma - glands
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How are endometrial adenocarcinomas graded?
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Based on degree of differentiation
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What are the 3 grades of EM adenocarcinomas and what % of each is solid area?
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G1 = well diff <5% solid
G2 = mod diff <50% solid G3 = poorly diff >50% solid |
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How else are endometrial tumors graded?
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Based on nuclear atypia
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Do the grades of EM carcinoma tumors for nuclei and differentiation always match up?
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No; tumors can be well differentiated (G1) but with nuclear atypia (G3)
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What grade overall would a two-tiered tumor be?
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G2
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What % of endometrial cancer is endometrial adenocarcinoma?
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85%
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What are the 4 uncommon types of endometrial cancer that make up the other 10-15%?
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-Clear cell carcinoma
-Papillary serous -Mucinous -Secretory |
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Which of the uncommon EM carcinomas are the most common?
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-Clear cell
-Papillary serous |
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What grade are Papillary serous and Clear cell carcinomas automatically?
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Grade 3 - highly aggressive
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What do endometrial Papillary serous carcinomas and Clear cell carcinomas resemble?
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Their ovarian counterparts
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Why do endometrial Papillary serous carcinomas and Clear cell carcinomas have the tendency to disseminate fast?
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Because of papillae which can break off and go into the lymphatic channels
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What is highly important for determining prognosis in endometrial carcinoma?
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STAGE
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How is grading done?
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Based on histology (differentiation)
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How is STAGING done? How many stages are there for endometrial carcinoma?
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-Based on how much of the genital tract is involved
-4 stages (1-4) |
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What is Stage I EM carcinoma?
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-Limited to the corpus of the uterine body
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What are 3 subsets of stage I endometrial carcinoma?
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Ia - limited to endometrium
Ib - invades <1/2 myometrium Ic - invades >1/2 myometrium |
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How does degree of invasion into the myometrium affect prognosis?
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It changes the ability of the cancer to invade the lymphatics
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What is stage II EM carcinoma?
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Extension into the CERVIX
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What is stage III EM carcinoma?
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Spread outside of the uterus, but confined to the true pelvis
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What is stage IV EM carcinoma?
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Distant metasasis outside the true pelvis
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What are the 2 most common symptoms of endometrial carcinoma?
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-Menorrhagia/abnormal bleeding
-Excessive leukorrhea |
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Why is endometrial carcinoma such a silent killer?
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Because it may remain asymptomatic for a long time and there is no screening test like the pap smear.
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What is the most common method of diagnosis for endometrial carcinoma?
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EM biopsy in dr office or if quantity insufficient for eval do a D/C; histologic exam
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So what are the 2 most important factors in determining prognosis in EM carcinoma?
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-Histologic grade
-Clinical stage |
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What are 80% of EM cancers at diagnosis?
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-Stage I (confined to EM)
-Grade 1 or 2 (well/med diff) |
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What is the 5-yr survival rate for
-Stage I EM carcinomas -Stage II -Stages III/IV |
Stage I = 80-90%
Stage II = 30-50% Stage 3/4 = 15-25% |
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Why does prognosis decline so quickly with increasing stage?
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Because there are more blood vessels the deeper the tumor invades so it can spread more easily
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What is the therapy for endometrial carcinoma?
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Surgery w/ or w/o adjuvant radiation
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What is chemoradiation done up front for in EM carcinoma?
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To make tumors that have spread beyond the true pelvis more resectable.
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So what structure of the endometrium is involved in most cancers?
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Glands
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What % of endometrial cancers involve the STROMA?
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<5%
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What are the 3 EM tumors with STROMAL differentiation?
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-Carcinosarcomas
-Adinosarcomas -Pure stromal neoplasms |
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What is an endometrial Carcinosarcoma?
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When there is malignancy of both the endometrial GLANDS and the STROMA components
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What is an endometrial Adenosarcoma?
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-Benign gland proliferation
-Malignant stromal proliferation |
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What are the 2 ways that pure stromal neoplasms can be?
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-Stromal nodules - benign
-Stromal sarcomas - malignant |
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What are Carcinosarcomas often called?
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Triple MT's
Malignant Mixed Mullerian Tumors |
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How do Carcinosarcomas develop?
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-Endometrial Adenocarcinoma is present
-Stromal differentiation into malignancy takes place |
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How are the 2 components of Carcinosarcomas (gland + stroma) related?
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They are derived from the same cell type stemline
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In what age group does Carcinosarcoma of the endometrium occur?
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Postmenopausal women (70's)
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And what are the malignant components of Carcinosarcoma?
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-Malignant glands (carcino)
-Malignant stroma (sarcoma) |
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What are the malignant components of Adenosarcoma?
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Just the stroma - that's why the glands are still adeno, not carcino.
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How do the doubly malignant Carcinosarcomas look grossly?
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Large bulky polypoid tumors that fill the EM cavity
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What do Carcinosarcomas consist of histologically?
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Mixed - malignant glands and stroma
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What can the stromal component of carcinosarcomas do?
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Differentiate into muscle, cartilage or osteoid
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So what is the most common clinical presentation of Carcinosarcoma?
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Vaginal bleeding in a POSTmenopausal woman
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How aggressive are adenocarcinomas and what is the 5-yr prognosis at diagnosis?
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-Highly malignant
-25-30% 5 yr survival |
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What are the 2 types of PURE stromal carcinoma?
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-Benign Stromal Nodules
-Malignant low grade Stromal Sarcoma |
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How do the low grade stromal sarcomas often present?
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-As a BULKY UTERUS due to mass
-Rarely with bleeding |
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Why does stromal sarcoma usually present after much growth has occurred to make a bulky uterus?
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Bc it is very infiltrative and invades the myometrium
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Because the stromal tumors tend to invade the myometrium, what do they often do?
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Penetrate lymphatic channels
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What % of endometrial stromal sarcomas recur after surgery?
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50%
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What % of stromal sarcomas metastasize to distant sites and cause death?
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15%
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How does high grade EM stromal sarcoma compare to low grade, histologically?
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-Wide range of cell atypia
-Frequent mitoses |
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What are the 2 tumors of the myometrium? Which is benign vs malignant?
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-Leiomyomas (benign)
-Leiomyosarcomas (malignant) |
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What is the colloquial term for Leiomyomas of the uterus?
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Fibroids
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Why are fibroids clinically significant? (2 reasons)
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-Most common genital tumor in women!!
-Causes vaginal bleeding |
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What is the prevalence of fibroids/leiomyomas in women in active reproductive life?
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1/4
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In what ethnicity are leiomyomas more common?
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African americans
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What happens to leiomyomas after menopause usually?
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They regress
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What can leiomyomas do?
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Hemorrhage and/or Calcify
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Where do these leiomyomas originate?
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From the myometrium
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What are 3 subtypes of Leiomyomas based on location?
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-Subserosal
-Intramural -Submucosal |
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What subtype of Leiomyoma will cause most severe vaginal bleeding and why?
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Submucosal - bc it pushes into the endometrial cavity
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What is a good thing about the severe bleeding in submucosal leiomyomas?
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They will be picked up at relatively earlier stages
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What % of women >30 have leiomyomas? What is the peak age?
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30% of women >30
Peak: 40-50 |
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Why do leiomyomas regress after menopause?
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Bc there is an estrogen component of stimulation
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When can leiomyomas increase?
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In pregnancy
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What does clinical diagnosis and treatment of leiomyomas depend on?
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Location, location, location
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What DON'T leiomyomas commonly do?
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Transform into malignancy
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What is the gross appearance of a leiomyoma?
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Whorled
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What will you see on histology of a leiomyoma?
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Whorled bundles of smooth muscle cells
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What are the malignant tumors of myometrium?
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Leiomyosarcomas
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Define leiomyosarcoma:
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Malignant tumor with smooth muscle differentiation
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How common are leiomyosarcomas?
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Very rare
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How do leiomyosarcomas most often develop, if at all?
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De novo - NOT a malignant transformation from something benign.
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What are 2 gross patterns of development of leiomyosarcoma?
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-Polypoid mass in lumen
-Invasion of uterine wall |
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What 3 factors are important for diagnosing/determining prognosis of leiomyosarcomas?
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-Mitoses present
-Atypia (well diff to anapl) -Necrosis |
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What is usually the best way to confirm that a leiomyoma is malignant leiomyosarcoma?
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>10 mitoses per hpf
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At what age can leiomyosarcomas develop?
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Either BEFORE or AFTER menopause - they are equally common
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What is the peak age group of leiomyosarcoma?
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40-60 yrs
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What do leiomyosarcomas tend to do after surgical removal?
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Recur
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What is seen in >50% (!!!) of cases of leiomyosarcomas?
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Distant metastases
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What are the 3 commonest sites of metastasis from leiomyosarcomas?
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-Lung
-Bone -Brain |
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What is the 5-yr survival rate of leiomyosarcoma?
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40%
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What are the 4 methods of diagnosis of endometrial or myometrial cancer?
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-EM currettage (D/C)
-EM biopsy -EM aspirate -PAP smear |
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What will usually give an adequete sample for accurate diagnosis?
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D/C
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Which method of diagnosis is less accurate?
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EM biopsy
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Why is EM biopsy easier than EM curettage?
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EM Biopsy requires no anesthesia; D/C does
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What is NOT a good method of diagnosing endometrial malignancy? Why?
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EM Aspirate - this only shows cytology, and you need to see ARCHITECTURE (glands/stroma) to differentiate hyperplasia and malignancy
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Why isn't a PAP smear a good method of diagnosing EM neoplasms?
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-Very low yield
-High rate of false negatives |
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In what patients should EM biopsy always be done for any case of abnormal vaginal bleeding?
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Postmenopausal!!
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