Female Reproduc.ve System. Kris.ne Kra7s, M.D.

Transcription

1 Female Reproduc.ve System Kris.ne Kra7s, M.D.

2 Female Reproduc.ve System Outline Cervix Uterus Ovaries Breast

3 Female Reproduc.ve System Outline Cervix Cervical carcinoma

4 Cervical Carcinoma Once the most common cancer in women now not even in top 10. Decrease due to Pap test! At the same.me, precursor lesions are increasing (early detec.on)

5 Cervical Intraepithelial Neoplasia (CIN) Precursor to carcinoma Almost all carcinomas arise in CIN; but not all cases of CIN progress to carcinoma! Three grades: CIN I: mild dysplasia (half regress, 20% progress) CIN II: moderate dysplasia CIN III: severe dysplasia (30% regress, 70% progress) The higher the grade, the more likely the lesion will progress to carcinoma

6 Cervical Carcinoma Risk Factors Early age at first intercourse Mul.ple sexual partners A male partner with mul.ple previous partners Persistent infec.on with high-risk HPV Smoking Immunodeficiency

7 Cervical Carcinoma and HPV HPV is detectable in almost all CIN and cancer. High-risk types: 16, 18, 45, 31 Found in carcinomas Integrate into genome, inac.vate p53, RB Low-risk types: 6, 11 Found in condylomas (benign lesions) Do not integrate into genome

8 Transforma.on zone Normal cervix, young adult

9 Transforma.on zone

10 Spectrum of cervical intraepithelial neoplasia (CIN)

11 Normal turning into CIN

12 normal CIN I CIN II CIN III Cytology of CIN (Pap smear)

13 normal CIN I CIN II CIN III Low-grade dysplasia High-grade dysplasia Cytology of CIN (Pap smear)

14 Invasive Cervical Carcinoma Most cases are squamous, arising from CIN Small number are adenocarcinomas Peak age: 45 (10-15 years a7er CIN develops!) Spreads slowly Most cases are diagnosed early Mortality is related to stage Stage 0 (preinvasive): 100% 5 year survival Stage 4: 10% 5 year survival

15 Cervical carcinoma

16 Female Reproduc.ve System Outline Cervix Uterus Endometriosis Endometrial hyperplasia Tumors

17 Endometriosis Loca.on of endometrial glands outside uterus Usually peritoneum, rarely lymph nodes Endometrium undergoes cyclic bleeding Causes scarring, pain, some.mes sterility How does endometrium get out?

18 Endometriosis in ovary ( chocolate cyst )

19 Endometrial Hyperplasia Prolifera.on of endometrium due to estrogen excess Risk factors: anovulatory cycles, obesity, estrogenproducing ovarian tumors, exogenous hormone use Three categories: simple, complex, and atypical The more severe the hyperplasia, the greater the chance that it will evolve into carcinoma

20 Normal endometrium

21 Simple Complex Atypical Endometrial hyperplasia

22 Leiomyoma Fibroid Benign tumor of smooth muscle Common! S.mulated by estrogen Menorrhagia, metrorrhagia, or asymptoma.c

23 Leiomyosarcoma Malignant tumor of smooth muscle Necro.c, with atypical cells and lots of mitoses O7en recur a7er surgery Many metastasize, especially to lungs 5 year survival = 40%

24 Leiomyoma Leiomyosarcoma

25 Leiomyoma Leiomyosarcoma

26 Endometrial Carcinoma Peak age: (not before 40) Frequently arises in endometrial hyperplasia Risk factors: obesity, nulliparity, estrogen replacement Symptoms: leukorrhea, irregular bleeding Metastasizes late

27 Endometrial adenocarcinoma

28 Female Reproduc.ve System Outline Cervix Uterus Ovaries Tumors

29 Origin of Ovarian Tumors Surface epithelial tumors Cystadenoma Cystadenocarcinoma Germ cell tumors Teratoma Dysgerminoma Yolk sac tumor Choriocarcinoma Sex cord-stromal tumors Granulosa-theca cell tumor Sertoli-Leydig cell tumor

30 Cystadenoma Benign tumor derived from surface epithelium Repeated ovula.on, scarring, infolding of epithelium leads to cysts, which can undergo neoplas.c transforma.on Typically large, occasionally bilateral

31 Pa.ent with ovarian cystadenoma

32 Pa.ent with ovarian cystadenoma

33 Ovarian cystadenoma

34 Ovarian cystadenoma

35 Ovarian cystadenoma

36 Teratoma Benign tumor with differen.a.on along all three germ cell layers (ectoderm, endoderm, mesoderm) Usually cys.c, with skin inside ( dermoid cyst ) Sebaceous material, majed hair, teeth, bone Malignant variant has immature.ssues

37 Teratoma

38 Teratoma

39 Ovarian Cancer 22,000 new cases / 14,000 deaths in th commonest, 5 th most deadly cancer in women Danger: no defini.ve signs un.l advanced Peak age: 50 Most are cystadenocarcinomas

40 Papillary cystadenocarcinoma

41 Papillary cystadenocarcinoma

42 Ovarian Cancer Symptoms Feeling of fullness or bloa.ng Pelvic pain Back pain Abnormal menses Risk factors Nulliparity Family history (BRCA gene muta.on) NOT using oral contracep.ves!

43 Ovarian Cancer Treatment: surgery, radia.on, chemotherapy Prognosis depends on stage Cancer confined to the ovary: 5y survival 70% Cancer through ovarian capsule: 5y survival 13%

44 Female Reproduc.ve System Outline Cervix Uterus Ovaries Breast Fibrocys.c change Tumors

45 Breast Many breast diseases present as lumps Most lumps represent benign things but a lump always needs to be evaluated Ultrasound, mammography, fine needle aspira.on, and biopsy are the usual methods

46 Most breast lumps are benign

47 Fibrocys.c Change Two kinds: nonprolifera.ve and prolifera.ve change Cause: exaggera.on of normal breast cycles Rarely associated with increased cancer risk Very common (present in most women at autopsy) Called fibrocys.c change, not fibrocys.c disease

48 Fibrocys.c change

49 Normal breast

50 Nonprolifera.ve fibrocys.c change

51 Prolifera.ve fibrocys.c change

52 Fibroadenoma Most common benign breast tumor S.mulated by estrogen Peak incidence in 20s Solitary, discrete, moveable mass Fibrous.ssue with compressed ducts and lobules

53 Fibroadenoma

54 Fibroadenoma

55 Breast Carcinoma 233,000 new cases / 40,000 deaths in 2014 Most common, 2 nd deadliest cancer in women Life.me risk: 1 in 8 75% of pa.ents are >50 Rate was increasing but now stable

56 Breast Carcinoma Risk Factors Age Family history Increased estrogen exposure Obesity Alcohol consump.on High-fat diet

57 Breast Carcinoma Family History 5-10% of all cases are hereditary Worry if first degree rela.ve with breast cancer Most have BRCA-1 or BRCA-2 muta.ons Tumor suppressor genes; help repair DNA Gene.c tes.ng difficult Most carriers get cancer by age 70

58 Breast Carcinoma Clinical Findings If discovered by palpa.on Solitary, painless, moveable mass 2-3 cm in diameter Axillary nodes posi.ve in 50% of pa.ents If discovered by mammography 1 cm in size Axillary nodes posi.ve in only 15% of pa.ents As disease progresses Fixa.on to chest wall Adherence to overlying skin Peau d orange

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60 Advanced breast carcinoma: fixa.on to skin

61 Peau d orange

62 Breast Carcinoma Histologic Types Non-invasive Ductal carcinoma in situ (DCIS) Lobular carcinoma in situ (LCIS) Invasive Ductal Lobular Inflammatory Others

63 Normal breast

64 Lobular carcinoma in situ

65 Invasive breast carcinoma

66 Low-grade invasive ductal carcinoma

67 High-grade invasive ductal carcinoma

68 Inflammatory breast carcinoma

69 Breast Carcinoma Prognos.c Factors Size of tumor Lymph node involvement Distant metastases Grade of tumor Histologic type of tumor

70 Sen.nel node biopsy

71 TNM* staging system for breast cancer Stage T N M 5-year survival Stage 0 DCIS 0 M0 92% Stage I <2 cm 0 M0 87% Stage II <5 cm >5 cm <3 0 M0 M0 75% Stage III <5 cm 4+ M0 >5 cm Any T M0 M0 46% Any T Any N skin or chest wall Stage IV Any T Any N M1 13% * Tumor (size), nodes (# posi.ve), metastases