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Drexel Midterm Nurs 534 - Breast and
OBGYN Ca Test With Solution
Common ca - ANSWER Vulvar cancer Vaginal cancer Cervical cancer Endometrial cancer Ovarian cancer vulvar ca etiology and occurrence - ANSWER Occurrence: uncommon, 5% of gyn cancers, most often seen in postmenopausal women, <1% lifetime risk Etiology: 90% of squamous cell histology vulvar ca risk factors - ANSWER smoking, HIV HPV infection, lichen sclerosis, immunosuppression, vulvar or cervical neoplasia and northern European ancestry early stage vulvar ca has - ANSWER favorable prognosis, approximately 40% of vulvar carcinomas will recur locally, with a median survival of 52 months vulvar ca clinical presentation - ANSWER Vulvar lump with or without associated pruritis, discharge, erythema, dyspareunia, dysuria or bleeding Dx/Tx of vulvar ca - ANSWER Examine patient for coexistent vaginal or cervical lesions (present in up to 50% of cases) Biopsy suspicious lesions for change over time and as many eventually become pathologic stage 1 vulvar ca - ANSWER tumors of >1mm invasion: surgical wide excision Larger Stage I and II tumors >2cm vulvar ca - ANSWER radical vulvectomy with IND vs radical wide excision, partial or complete vulvectomy with secondary inguinal incisions stage III & IV vulvar ca - ANSWER radical vulvectomy +/- radiation and chemotherapy
complications of vulvar ca tx include - ANSWER lymphedema, sexual dysfunction and depression vaginal ca occurrence & origin - ANSWER Occurrence: rare, accounts for only 3% of female genitourinary tract cancers Etiology: most are squamous cell carcinomas, but more rarely melanoma, adenocarcinoma and sarcoma Majority of vaginal malignancies are metastatic, often arising from the endometrium, cervix, vulva, ovary and breast vaginal ca risk factors - ANSWER Risk factors: similar to cervical neoplasia (multiple sexual partners, early age at first intercourse, smoking) and most are mediated by HPV (highest prevalence subtypes 16 and 18) Vaginal Cancer Clinical Presentation and Diagnosis - ANSWER Vaginal bleeding (typically post-coital and/or postmenopausal) Possible vaginal mass Urinary symptoms (frequency, dysuria, hematuria) GI complaints (constipation, melena) Low occurrence of pelvic pain (less than 5%) and up to 20% asymptomatic Careful physical examination (speculum and rectovaginal exam) and cytology, colposcopy and/or biopsy of suspicious lesions Imaging is necessary only for staging purposes Stage 1 <2 cm vaginal ca - ANSWER tumor surgical excision Stage I >2-3cm vaginal ca - ANSWER radiation therapy is preferred as it is difficult to get adequate margins Surgical intervention ranges from excisions, to radical hysterectomy/vaginectomy/pelvic lymph node excision stage II/III vaginal ca - ANSWER frequently poor surgical candidates and are often treated with chemo/radiation
HIV
Herpes simplex Chlamydia CMV ASC-US - ANSWER atypical squamous cells of undetermined significance LSIL/LGSIL - ANSWER low-grade squamous intraepithelial lesion ASC-H - ANSWER atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion AGC - ANSWER atypical glandular cells HSIL+ - ANSWER high-grade squamous intraepithelial lesion or worse Cervical Intraepithelial Neoplasia (CIN): - ANSWER Cervical Intraepithelial Neoplasia (CIN): precursor to cervical cancer CIN1-3+ - ANSWER CIN 1+= mild dysplasia CIN 2+= moderate dysplasia CIN 3+= severe dysplasia AIS - ANSWER AIS: adenocarcinoma in-situ cerical ca facts - ANSWER 14th most common cancer in women in the US Mortality rates have fallen by 45% since 1970s due to pap testing if hpv screen type 16/18 pos then - ANSWER colposcopy if 12 other hrhpv+ then - ANSWER cytology and follow up in 12 mths if hpv neg then - ANSWER routine screen colposcopy - ANSWER direct visualization of cervical squamocolumnar junction with colposcope after application of 3%-5% acetic acid solution; suspicious areas will visually appear affected; lacks sensitivity to be used for universal screening, but is very useful as follow-up to abnormal pap
cryotherapy - ANSWER treatment of abnormal cells via freezing (nitrous oxide or CO thermal ablation - ANSWER uses heated probe to destroy abnormal cells LEEP (loop electrosurgical excision procedure) - ANSWER utilizes wire loop heated by electric current to remove abnormal cervical cells. cold knife conization - ANSWER removal of cone-shaped section of cervix with scalpel Laser conization: - ANSWER uses laser to remove cone-shaped section cervical ca tx - ANSWER Management depends on staging Hysterectomy with/without lymph node excision Possible adjunctive radiation therapy Fortunately, incidence of cervical cancer is decreasing with screening management! endometrial ca - ANSWER Most common GYN cancer, accounting for 50 % of all cases Accounts for 20 % of postmenopausal bleeding 5-year survival rate ranges from 78%-98% depending on detection and depth of invasion **Average age at diagnosis= 60 years **African American women at greater risk, and survival rates lower Combination OCPs have a protective effect against ovarian and endometrial cancers endometrial ca risk factors - ANSWER Unopposed estrogen (multiple etiologies: chronic anovulation, estrogen secreting ovarian tumor, older HT treatments, or Tamoxifen) Early menarche Advanced age High fat diet / obesity Nulliparity Hypertension
Hyperplasia without atypia (in premenopausal)= - ANSWER medroxyprogesterone acetate 10 mg daily for 12-14 days each month x 3-6 months Hyperplasia without atypia (postmenopausal not on HT) = - ANSWER hysteroscopy/D&C atypia-premaliginancy - ANSWER hysteroscopy/D&C, or preferably hysterectomy (if childbearing undesired) stage 1 endo ca - ANSWER confined to corpus luteum Total hysterectomy and BSO, +/- adjuvant post-surgical radiation stage 2 endo ca - ANSWER involves cervix Total hysterectomy and BSO Adjuvant post-surgical radiation stage 3- endo ca - ANSWER regional spread to pelvis Total hysterectomy and BSO Adjuvant post-surgical radiation and chemotherapy stage 4 - ANSWER spread to outside pelvis Total hysterectomy and BSO Adjuvant post-surgical radiation and chemotherapy endo ca follow up - ANSWER Review of symptoms and physical examination (speculum and bimanual pelvic exam) every three to six months for two years, then every six months or annually. The frequency of examinations depends upon the risk of persistent or recurrent disease. important regarding lynch syndrome & endo ca - ANSWER patients under age 50 with endometrial cancer are worth referring for genetic testing and family counselling. adnexal mass - ANSWER an enlarged structure in the ovaries, fallopian tubes or uterus that can be palpated on bimanual exam or seen on imaging 13-21% ovarian cancer
Clinical presentation can guide diagnostic approach adnexal mass diagnostic imaging - ANSWER Urine pregnancy Transvaginal ultrasound CA-125 in postmenopausal woman with abnormal U/S or if high suspicion of malignancy GYN causes adnexal mass - ANSWER Ovarian cyst Ovarian cancer Leiomyoma PCOS Ovarian dermoid Ectopic pregnancy Tuboovarian abscess Corpus luteum cyst non-GYN causes of adnexal mass - ANSWER Appendicitis Appendiceal abscess Diverticular abscess Ureteral diverticulum Bladder diverticulum Pelvic kidney Colon cancer Metastases ovarian cyst presentation - ANSWER Pain or discomfort in the lower abdomen Severe pain from torsion (twisting) or rupture Discomfort with intercourse, particularly deep penetration
pain, bloating, early satiety, urinary frequency/urgency Take comprehensive history of current complaint, bowel/bladder/menstrual/reproductive/social/family Objective: Mass on pelvic exam, decreased mobility of cervix/uterus, adnexal fullness
ovarian ca dx and testing - ANSWER Pelvic Ultrasound to evaluate size/shape/consistency CA-125 level If level is >35 greater likelihood of malignancy, but may be elevated in benign disease such as endometriosis, leiomyoma, PID, and cirrhosis of the liver Not an effective/sensitive screening tool TVUS can help distinguish benign/malignant IVP can evaluate impingement on ureters or bladder Barium enema can determine colorectal involvement CT/MRI not useful for diagnosis, but in looking for metastasis or other primary sites Biopsy is not recommended- may disseminate tumor cells into abdominal cavity Diagnosis is made by surgical investigation Recent mammography is useful for thoroughness of evaluation
stage 1 ovarian ca survival - ANSWER confined to ovaries 90% only 25% dx at this stage
stage 2 ovarian ca survival - ANSWER involves 1 or both ovaries, with pelvic extension or primary peritoneal cancer 40-60%
stage 3 ovarian ca survival rate - ANSWER 1 or both ovaries, confirmed spread to peritoneum outside the pelvis, and/or metastasis to retroperitoneal lymph nodes
stage 4 distant metases ovarian ca survival rate - ANSWER <5%
ovarian ca management definitive, stage 1-2, stage 2-4 - ANSWER Total hysterectomy with bilateral salpingo-oophorectomy with pelvic and para-aortic lymph node dissection for staging
Early stage (I-II) most receive adjuvant chemotherapy
Later stages II ā IV may include intraperitoneal (IP) as well as IV chemotherapy
Post-treatment surveillance can include every 6-month CT scan for 2 years, and possible second-look surgical procedures
Role of serial CA-125 levels is still uncertain- no clear impact on overall survival rates
long-term effects in ovarian ca survivors - ANSWER Neurotoxicity from chemotherapy Muscle cramping, neuralgias in hands/feet, tinnitus or hearing deficit, etc
Cognitive dysfunction- few studies exist, related to diagnosis itself vs chemotherapy effects
Fatigue
most women have one or more areas of microcalcifications of various sizes
majority are harmless
small percentage can be precancerous or ca--> biopsy sometimes recommended
mastitis - ANSWER inflammation of the breast
puerpural mastitis - ANSWER develops in lactating or nonlactating breast after childbirth causes-disrupted breast tissue due to breast feeding milk stasis restriction of breast tissue from tight bras or sleep position
puerperal mastitis organisims - ANSWER 50% S auerus others are AB Strep and myobacterium TB
nonpuerperal - ANSWER rare occurrence in immune compromised patients ductal abnormality or local manifestation of a systemic problem
causes-squamous cell metaplastia of lactational ducts local manifestation of infection such as TB or syphilis reaction to silicone
periductal mastitis - ANSWER secretory disease of breast primarily affects peri and post menopausal women
causes-duct ectasia- dilation filling w keratin and obstruction *smoking is a RF
mastitis management - ANSWER continue breast feeding avoid milk stasis massage breast pump work on latching cold compresses between feedings
NSAIDS acetominophen
empirical abx therapy w oral broad spectrum- cephalexin/dicloaxacillin- 500 mg 4x/day augmentin 500 gm 3x/day 10-14 days bactrim or clindamycin with high suspicion for MRSA
Periductal mastitis management - ANSWER tx w empirical abx biopsy if mass is present
ACOG mammogram guidelines - ANSWER 40 no later than 50 annual or biennial mammo 75- may continue based on pt preference health status longevity
USPSTF mammogram recommendations - ANSWER 40-
- is recommended age biennial mammo
triple neg b ca 2 or more primary breast ca BRCA varian found in any type of tumor 1st or 2nd degree relative w b ca 2 or more relatives w breast ca primary rela w b ca <50 or 2 at any age
sub/obj b ca presentation - ANSWER subj lump w or wo pain orange peel texture red flag nipple discharge retraction ulceration
obj- dimpling retraction orange peel discharge lump
bca dx tools - ANSWER mammo ultrasound MRI if inconclusive above
Types of Biopies - ANSWER FNA-fine needle aspiration core needle aspiration-less invasive but less accurate results incisonal biopsy-done on large wedge to remove for histological exam lumpectomy-remove entire mass poor cosmetics compared to others
DCIS - ANSWER ductal carcinoma insitu
lower malignant potential 98% cure w local therapy
LCIS - ANSWER lobular carcinoma in situ 25-40% risk of developing invasive ca bilateral mastectomy chemprevention
invasive breast ca - ANSWER most adenocarinomas most are infiltrating ductal potential to disseminate via lymph and vascular system
prognostic factors - ANSWER histologic type tumor size lymph. node status histological differentiation are factors that guide oncologists in tx
breast ca general management, Stage 1/2, Stage3/4 - ANSWER refer to oncology tx choice guided by tumor factors surgical management of Stage 1/2 breast-conserving procedures possible w wide-ranging adjuvant therapy
Stage 3/4- modified radical mastectomy possibly radical mastectomy w or adjuvant therapy
mamogram 3-9 months following surgery
every 6 mths for 2 yrs-mammo annually possible CT scan bone density and liver function testing
annually- 5 years- continue annual mammo annual pelvic exam esp tamoxifen
