Wallach's Interpretation of Diagnostic Tests: Pathways to Arriving at a Clinical Diagnosis (262 page)

References

1.  Saraiya M, Ahmed F, Krishnan S, et al. Cervical cancer incidence in a prevaccine era in the United States, 1998–2002.
Obstet Gynecol.
2007;109:360–370.

2.  Solomon D, Nayar R (eds).
The Bethesda System for Reporting Cervical Cytology
, 2nd ed. New York: Springer Science and Business Media, LLC; 2004.

3.  Committee on Practice Bulletins—Gynecology. American College of Obstetricians and Gynecologists Practice Bulletin No. 131: screening for cervical cancer.
Obstet Genecol.
2012;120:1222–1238.

CANCER OF THE ENDOMETRIUM

   Definition

Endometrial carcinoma is the most common invasive gynecologic cancer in North America (cervical carcinoma is most common worldwide). There are two types recognized. Type 1 is estrogen or tamoxifen related, is usually a low-grade endometrioid type, and is preceded by endometrial intraepithelial neoplasia.

   Clinical Presentation

Cancer of the endometrium is associated with PTEN mutations, obesity, and hereditary nonpolyposis colonic cancer syndrome. Concurrent ovarian carcinoma may occur in 10–20%. Type 2 is unrelated to estrogen or tamoxifen, is usually a highergrade papillary serous or mixed type, and is associated with p53 mutations without a preceding in situ component. The progression of type 2 disease is usually rapid, and the prognosis is poor
¹
. Patients with endometrial carcinoma present with a history of abnormal vaginal bleeding, especially if postmenopausal.

   Laboratory Findings

The diagnosis of endometrial carcinoma is made on endometrial biopsy or curettage (positive in 95% of patients) and rarely is identified on Pap test (see eBook Figure 8-8). A negative Pap test does not rule out carcinoma. Blood tests may show anemia if bleeding is chronic or severe, but otherwise are noncontributory.

Reference

1.  Crum CP, Lee KR (eds).
Diagnostic Gynecologic and Obstetric Pathology
. Philadelphia, PA: Elsevier Saunders; 2006.

CANCER OF THE OVARY

EPITHELIAL OVARIAN CARCINOMA

   Definition

Cancer of the ovary may derive from the epithelium (95% of cases) or from the stromal supporting cells or germ cells. This section will deal with the epithelial carcinomas arising from the surface of the ovary that are contiguous with the peritoneum and include low-grade serous carcinomas, serous tumors of low malignant potential, high-grade serous carcinomas, mucinous carcinoma, endometrioid carcinomas, clear cell tumors, Brenner (transitional cell) tumors, and undifferentiated carcinomas.

   Clinical Presentation

Patients may present with either acute symptoms such as bowel obstruction or pleural effusion or subacute symptoms such as adnexal mass, pain, bloating, urinary frequency, or early satiety. Patients with a positive family history of breast or ovarian cancer or who have BRCA1 or BRCA2 mutations or Lynch syndrome may be at increased risk (see Hereditary and Genetic Diseases, Chapter
10
).

   Laboratory Findings

The diagnosis of ovarian cancer is made on histologic examination of tissue or cytology of peritoneal or pleural fluid if present (see eBook Figure 8-9). Rarely abnormal glandular cells may be seen on Pap test, which on further workup are found to originate from the ovary.

Imaging is the most important tool for identifying an adnexal mass. Surgical excision of the intact mass with intraoperative frozen-section diagnosis is performed whenever possible as transabdominal FNA or biopsy of ovarian tumors has been shown to increase the risk of seeding the malignant cells into the peritoneum by rupture or incision of the mass.

Screening tests for ovarian carcinoma have been sought to aid in finding these patients before symptoms occur. These include the following:

   
CA-125
is elevated in approximately 50% of patients with early-stage disease and in >80% of patients with advanced disease. It may also be elevated in normal women and in patients with endometriosis, leiomyoma, cirrhosis, PID, or other malignancies. Following serial CA-125 levels over time may be more beneficial as a screening tool.

   
Human epididymis protein 4
(HE4) is helpful in diagnosing recurrent or progressive disease or in the evaluation of a suspicious adnexal mass.

   
Carcinoembryonic antigen
(CEA) is nonspecific. Levels may be elevated in malignancies (particularly mucinous carcinomas) of the ovary, GI tract, breast, pancreas, thyroid, and lung. It is also elevated in patients who smoke, or who have mucinous cystadenoma, cholecystitis, cirrhosis, pancreatitis, pneumonia, and diverticulitis and IFD.