GINECOLOGÍA 2017 PRIMERA VUELTA FISIOLOGÍA Y ANATOMÍA GINECOLÓGICA DISTOPIAS AMENORRE AMENORREA A - SOP MENOPAUSIA FERTILIDAD ANTICONCEPTIVOS ITS HUA (ORGÁNICA Y FUNCIONAL) CA MAMA CA CUELLO OTROS CÁNCERES
“A la mujer hay que amarla, no comprenderla. Eso es lo primero que hay que comprender"
Dr.. Christ Dr Christiam iam Oc Ochoa hoa
ANAT A NATOMÍA OMÍA BÁ B Á SICA
DISTOPIAS 00 – 00 - 00
©2017 UpToDate®
FISIOLOGÍA BÁSICA
Molimina (breast tenderness, ovulatory
AMENORREA PRIMARIAS • GENITALES Disgenesia gonadal: Turner, pura, mixta. Rokitasnky. Himen imperforado. Feminización testicular o Morris. HSC o sd adrenogenital. Agenesia vagina.
• ANOREXIA/EJERCICIO • CENTRALES
Psíquica, lesión H-h, pubertad retrasada, hipo-hipog, neurogerminales: Kallman, Laurence Moon Bield, Alstrom, Progeria, Prader Willi.
SECUNDARIAS •
Uterino. Asherman (90% procedimientos – TBC genital)
• • • • • • • • • • •
Insuficiencia ovárico. Tumores ováricos. Hipo-hipog Hiperprolactinemia Sd. Sheehan Tumores hipofisiarios. Craneofaringioma Fármacos Enfermedades Psíquica Suprarrenal o tiroideo.
AMENORREA SECUNDARIA 1.bHCG gestación 2.TSH-PRL etiológico 3.Test progesterona anovulación 4.E/P Anatómica genital 5.FSH y LH falla ovárico 6.GnRh (hipotálamo e hipófisis)
Primary (absence of menarche by 15 years). Secondary (absence of menses 3R / 6IR) ©2017 UpToDate®
COMPARTIMIENTO
ENTIDAD
%
I: Canal genital.
Asherman
7
II: ovarios
Cromosomopatías
10
III: hipófisis anterior
Prolactinomas
7.5
IV SNC
Anovulación, anorexia, hipot
10
SOP
Rotterdam cr iteria 2003*[2] (two out of three required) Oligo- or anovulation Clinical and/or bi ochemical signs of hyperandrogenism Polycystic ovaries (by ultrasound)
AES definition 2008 [3] - (all required) Clinical and/or biochemical signs of hyperandrogenism Ovarian dysfunction – oligo-anovulation and/or polycystic ovaries on ultrasound Exclusion of ot her androgen excess or ovulatory disorders
©2017 UpToDate® - Proposed diagnostic criteria for polycystic ovary syndrome
NIH consensus c riteria 1990 [1] - (all required) Menstrual irregularity due to oligo- or anovulation
MENOPAUSIA ©2017 UpToDate®
Edad aproximada es de 50 años
INFERTILIDAD y ESTERILIDAD
SISTEMATICO • • • • •
Anamnesis y exploración física: temperatura basal. Hormonas: P, luego otras. Serología (rubeola, VIH). Ecografía transvaginal (2mm/día) Seminograma: 2-7ml, ph>7.2, 20-120millones, >50% progresivos o >25% rápidos. >15% normales. Histerosalpangiografia (OBSTRUCCION TUBARICA)
INDIVIDUALIZADO
ESTERILIDAD FEMENINA
INFERTILIDAD DEFECTOS CONGÉNITOS: ++fc. Cromosomopatías. Trisomias 50%: 13,16,18,21,22 precoces. 45XO 20% (el más aislado) FACTOR UTERINO: mioma submucoso o pólipos. Tabicado (segundo trimestre). Asherman. FACTOR CERVICAL: incompetencia cervical adquirida 95%, pasado semana 16. Dx: tallo Hegar en 2da fase. TTO: cerclaje 13-16s. FACTOR ENDOMETRIAL: baja calidad, sífilis, clamydias. FACTOR AUTOINMUNE, ENDOCRINO, MASCULINO, PSICOLÓGICO, SISTEMICO.
1.
2.
TUBARICA: 40%. Congenito, endometriosis, infecciones, otras. TTO: microcirugía, fecundación INVITRO si es bilateral. OVÁRICA: 25%. Insuficiencia lútea, SOP, endometriosis, tumores, congénitas. TTO: clomifeno 6 meses, progesterona 2da fase, bromocriptina. ORAL AGENTS: Clomiphene citrate, Metformin, Aromatase inhibitors (letrozole), Dopamine agonists. PULSATILE GnRH THERAPY. GONADOTROPIN THERAPY
3. 4.
UTERINA: 13% (infertil>esteril). Malformaciones. TTO: Qx. OTRAS: cervical 12%, vulvo vaginal 8%, inmunoligcas, psíquica, generales idiopáticas 10%.
Laparoscopia (ENDOMETRIOSIS) – Histeroscopia - Test poscoital (SIMS HUBNER) Anticuerpos antiespermatoide - Biopsia de endometrio
ESTUDIO • • • • • •
Genética de pareja: cariotipo. HSG o histeroscopia. Serología luética. Anticardiolipina y anticoagulante lúpico. Estudio fase lútea. OTROS: • Evaluación endocrina, Seminograma, tallo de Hegar, ecografía, urografía, cariotipo del aborto, Dx preimplantacional, meiosis testicular, trombofilias.
ITS
ITS DIAGNÓSTICO
EPI
CRITERIOS HAGER
ANTIBIOTICOTERAPIA
MAYORES ➢Dolor espontáneo en
Infección del TGS FACTORES DE RIESGO • • • • • •
HISTORIA SEXUAL EDAD: 15-25 años Antecedente previo EPI Procedimientos: LU Usuaria de DIU (+++) ACO (---)
ETS DIU
1º Chlamidia 2º Gonococo Actinomices Israelii
abdomen inferior. ➢Dolor durante la movilización del cérvix. ➢Dolor anexial a la exploración. ➢Historia de actividad sexual reciente. ➢Ecografía no sugestiva de otra patología.
MENORES Temperatura > 38°C. Leucocitosis > 10.500. VSG elevada. Gram de exudado intracervical
A: AMBULATORIO B: HOSPITALIZACION
First-line regimens — The CDC recommends any of the following outpatient regimens, with or without metronidazole (500 mg twice a day for 14 days): ●Ceftriaxone (250 mg intramuscularly in a single dose) plus doxycycline (100 mg orally twice a day for 14 days) We prefer ceftriaxone plus doxycycline in patients with mild to moderate PID. Metronidazole should be added for patients with Trichomonas vaginalis or in those women with a recent history of uterine instrumentation. ©2017 UpToDate® DOLOR PELVICO CRÓNICO / INFERTILIDAD
HORMONAL Etinilestradiol + gestageno • • • • • • • •
• • • • •
ANTICONCEPTIVOS
T-2da: levonorgestrel Norgestimato T-3ra: gestodeno, desogestrel Pg: ciproterona, MDX Es: drospirenona
REDUCEN CA OVARIO Y ENDOMETRIO y COLON REDUCEN ECTOPICOS. REDUCEN EPI DISMINUYEN LA DISMENORREA. REGULAN CICLO. DISMINUYEN EL SANGRADO MENSTRUAL MEJORAN HIPERANDROGENISMO. MEJORAN PATOLOGÍA MAMARIA BENIGNA. CONTROL OSTEOPOROSOS
CONTRAINDICACIONES ABSOLUTAS • Pac con riesgo CV - HTA mal controlada-DM con afectacion vascular - Cardiopatias • Antec de TVP o TEP - Qx Mayor x inmovilizacion • Vasculitis - Discrasia sanguinea • Pac hepatopatas - Antecedentes de ictericia • Porfiria aguda intermitente - Embarazo • Ca mama - HUA no filiado
1.
2.
NATURALES a) Billings b) Ogino c) Sintotérmico d) MELA ARTIFICIALES a) Barrera b) Hormonales c) Intrauterino d) Quirúrgicos
CONTRAINDICACIONES ABSOLUTAS • Embarazo - EPI • SUA - Tumor Malig Cervix o uterino
DIU
INSERCION: cuando?, dolor, perforacion, migracion, infeccion (1m – Actinomices y polimicrobiano – sd shock toxico Sf). EVOLUCION: gestacion (1% endometrial, 5% ectopico). 50% riesgo aborto, no MAF,.RETIRAR / descenso y expulsion (control en la 1ra menstruacion). / sangrado anómalo 1m, salvo liberador de P. / dolor
HUA
Mas fc en no gestantes: uterino, anovulación, hemostasia (15-24%) y neo.
ASPECTOS GENERALES
PREVALENCIA: 53/1000 mujeres. calidad vida, productividad y servicios de salud. HUA POSTMENOPAUSICA: atrofia y pólipos endometriales. Cáncer de endometrio 5%.
©2017 UpToDate ® Usual causes of abnormal genital bleeding in women by age group - Adapted from: APGO educational series on women's health issues. Clinical management of abnormal uterine…
©2017 UpToDate ® - Normal menstruation parameters
Clinical Frequency of menses (days) Regularity (variation defined as shortest to longest cycle length) Duration of flow (days) Volume of monthly blood loss (objective) Volume of monthly blood loss (subjective)
Terms Absent Infrequent Normal Frequent Regular
Normal limits >38 24 to 38 <24 Var ≤7 to 9 days*
Irregular
Var >7 to 9 days*
Normal Prolonged Heavy Normal Light Heavy Normal
≤8 days
>8 days >80 5 to 80 <5 Patient's perception of
EJEMPLO: Adenomisis+sangrado irregular + leiomioma tipo 6:
Neonates Estrogen withdrawal Premenarchal Foreign body Trauma, including sexual abuse Infection Urethral prolapse Sarcoma botryoides Ovarian tumor Precocious puberty Early postmenarche Ovulatory dysfunction (hypothalamic immaturity) Bleeding diathesis Stress (psychogenic, exercise induced) Pregnancy
Reproductive-age Ovulatory dysfunction Pregnancy Cancer Polyps, leiomyomas, adenomyosis Infection Endocrine dysfunction (polycystic ovary syndrome, thyroid, hyperprolactinemia) Bleeding diathesis Medication related (eg, hormonal contraception) Menopausal transition Anovulation Polyps, fibroids, adenomyosis Cancer Menopause Endometrial polyps Cancer Postmenopausal hormone
HUA DIAGNÓSTICO 1. 2. 3. 4. 5. 6.
UTERO? EMBARAZADA? PREMENOPAUSICA? PATRÓN SANGRADO? ENDOCRINO – FARMACOS? AGUDO, INESTABLE?
1. 2. 3. 4. 5.
HUA-MASIVA HUA-INTERMENSTRUAL HUA-OVULATORIA (irregular) AMENORREA (3 ciclos) HIPOMENORREA (ACO, estenosis cervical, Asherman) 6. POLIMENORREA (<21 días). Causes of ovulatory dysfunction Primary hypothalamic-pituitary dysfunction (VER AMENORREAS CENTRALES) - SOP
Medications Estrogen-progestin contraceptives Progestins Antidepressant and antipsychotic drugs Corticosteroids
©2017 UpToDate® Causes of heavy or prolonged menses
Coagulopathy Neoplasm / Estructural Other Endometritis Hypothyroidism Intrauterine device Hyperestrogenism Endometriosis Causes of intermenstrual bleeding - * postcoital bleeding. Drugs: ACO Infection Benign growths Cervical polyps* Endometrial polyps Ectropion* Uterine fibroids Vulvar skin tags, sebaceous cysts, condylomata Vaginal Gartner's duct cysts, polyps, adenosis Cancer
Women who should undergo evaluation for endometrial hyperplasia or endometrial cancer ABNORMAL UTERINE BLEEDING
©2017 UpToDate®
•POSTMENOPAUSAL WOMEN – Any uterine bleeding, regardless of volume
(including spotting or staining) and/or further evaluation of a sonographic finding of abnormal-appearing endometrium.
• AGE 45 YEARS TO MENOPAUSE – Any abnormal uterine bleeding, including
intermenstrual bleeding in women who are ovulatory. Abnormal uterine bleeding in any woman that is frequent (interval between the onset of bleeding episodes is less than 21 days), heavy (total volume of >80 mL), or prolonged (longer than seven days).
•YOUNGER THAN 45 YEARS – Abnormal uterine bleeding that is persistent,
occurs in the setting of a history of unopposed estrogen exposure (obesity, chronic anovulation) or failed medical management of the bleeding, or in women at high risk of endometrial cancer (eg, tamoxifen therapy, Lynch syndrome, Cowden syndrome). •In addition, endometrial neoplasia should be suspected in premenopausal
women who are ANOVULATORY AND HAVE PROLONGED PERIODS OF AMENORRHEA (SIX OR MORE MONTHS). CERVICAL CYTOLOGY RESULTS •Presence of atypical glandular cells (AGC)-endometrial. •Presence of AGC-all subcategories other than endometrial – If ≥ 35 years old
OR at risk for endometrial cancer (risk factors or symptoms). •Presence of benign-appearing endometrial cells in women ≥ 40 years of age
who also have abnormal uterine bleeding or risk factors for endometrial cancer. OTHER INDICATIONS
HUA DIAGNÓSTICO
BLEEDING PATTERN
REGULAR MENSES THAT ARE HEAVY OR PROLONGED
OTHER ASSOCIATED CLINICAL FEATURES ENLARGED UTERUS ON EXAMINATION, DISCRETE MASSES MAY BE NOTED
DIFFERENTIAL DIAGNOSIS COMMON UTERINE LEIOMYOMA
- DYSMENORRHEA - ENLARGED, BOGGY UTERUS ON ADENOMYOSIS EXAMINATION - FAMILY HISTORY - BLEEDING DIATHESIS BLEEDING - ANTICOAGULANT THERAPY DISORDER RISK FACTORS FOR UTERINE MALIGNANCY
ENDOMETRIAL POLYP REGULAR MENSES WITH RISK FACTORS FOR UTERINE MALIGNANCY INTERMENSTR RECENT HISTORY OF UTERINE OR UAL CERVICAL PROCEDURE OR CHILDBIRTH, BLEEDING PARTICULARLY IF INFECTION WAS PRESENT OVULATORY DYSFUNCTION: HIRSUTISM , A CNE, A ND/OR OB ESITY
PCOS
VARIABLE GALACTORRHEA SD. TIROIDEO RISK FOR MALIGNANCY POOR NUTRITION OR INTENSE EXERCISE
SECONDARY HOT FLUSHES AMENORRHEA
RECENT HISTORY OF UTERINE OR CERVICAL PROCEDURE OR CHILDBIRTH.
EVALUATION - PELVIC ULTRASOUND - SALINE INFUSION SONOGRAPHY OR HYSTEROSCOPY (IF INTRACAVITARY) PELVIC ULTRA SOUND TESTING FOR BLEEDING DISORDER ENDOMETRIAL SAMPLING - PELVIC ULTRASOUND - SALINE INFUSION SONOGRAPHY OR HYSTEROSCOPY ENDOMETRIAL SAMPLING ENDOMETRIAL SAMPLING
TOTAL TESTOSTERONE AND/OR OTHER ANDROGENS (MAY NOT B E INCREASED IN ALL WOMEN WITH PCOS)
HYPERPROLACTINE PROLACTIN MIA THYROID DISEASE THYROID FUNCTION TESTS ENDOMETRIAL SAMPLING HYPOTHALAMIC AMENORRHEA
- FOLLICLE-STIMULATING HORMONELUTEINIZING HORMONE - ESTRADIOL
PREMATURE OVARIAN INSUFFICIENCY
FOLLICLE-STIMULATING HORMONE ON PELVIC EXAMINATION, INSTRUMENT CANNOT BE PASSED THROUGH INTERNAL CERVICAL OS
HUA TRATAMIENTO
Table 2. Medical Treatment Regimens Drug Conjugated equine estrogren ACO
MEDROXI Tranexamic acid
Suggested Dose 25 mg IV
Dose Schedule Every 4 –6 hours for 24 hours
Monophasic ACO that 3/D X 7D contains 35 micrograms of ethinyl estradiol 20 mg orally Three times per day for 7 days § 1.3 g orally Three times per day for or 5 days (every 8 hours ) 10 mg/kg IV (maximum 600 mg/dose)
Surgical options include dilation and curettage (D&C), endometrial ablation, uterine artery embolization, and hysterectomy.
HUA - LEIOMIOMAS
POLIPO CERVICAL
A parasitic leiomyoma i s a c on si der ed a type of extra-uterine l ei om yo ma an d presents as peritoneal pelvic benign smoothmuscle masses separate from the uterus.
Indications for myomectomy during pregnancy or at delivery — Given the potential DEGENERACION HIALINA DEGENERACION QUISTICA CALCIFICACION INFECCION Y SUPURACION NECROSIS DEGENERACIÓN ROJA DEGENERACION GRASOSA DEGENERACION
for harm (hemorrhage, uterine rupture, miscarriage or preterm delivery), myomectomy is avoided during pregnancy and at delivery, especially if an intramyometrial incision is required, unless the procedure cannot be safely delayed [2,21,29,41,67-73]. Uncontrollable hemorrhage during myomectomy may necessitate hysterectomy. Rarely, myomectomy of pedunculated or subserosal fibroids has been performed antepartum for management of an acute abdomen or obstruction, and myomectomy may be required
ENDOMETRIOSIS DEFINICIÓN
CLÍNICA
• Endometrio fuera de la cavidad uterina.
• DOLOR 95%. Dismenorrea progresiva.
Dispareunia. • Alteracion menstrual 65%: poli+meno. • Infertilidad 41%: multifactorial. • Otros: distención abdominal, rectorragia, disuria, Ca125.
DX:
• Laparoscopía – lesión en
quemadura de polvora.
(adenomiosis es endmetriosis miometrial – asintomática)
TTO • Laparoscopia: elección • Cirugía radical. • Medico: ACO, DIU levonorgestrel,
análogos GnRH, Danazol, gestágenos.
EPIDEMIOLOGÍA 10% mujeres. Feritles. Ciclos cortos o menorragia. Tabaco protege.
ETIOPATOGENIA Desarrollo in situ. (Muller) Teoria inducción: mesénquima. Teoria implante: menstruación retrógrada.
LOCALIZACIÓN Ovario. Quiste achocolatado. Ligamentos uterosacros, fosa ovárica, Douglas.
SANGRADO POSTMENOPÁUSICO
HIPERPLASIA ENDOMETRIAL CLASIFICACION • •
•
SIMPLE S/ O C/ ATIPIA COMPLEJA S/ O C/ ATIPIA
• •
INCIDENCIA CANCER: HS – SIN : 1% HC – SIN: 3% HS – CON: 8% HC – CON: 29%
• • •
©2017 UpToDate ® - Risk factors for endometrial cancer
Risk factor Increasing age (1.4% prevalence in women 50 to 70 years old)
(RR) NA
Unopposed estrogen therapy
2 - 10
Early menarche, Estrogen-secreting tumor, Family history of endometrial, ovarian, breast, or colon cancer
NA
Late menopause (after age 55), Nulliparity, DM, Tamoxifen therapy
2
SOP (chronic anovulation)
3
Obesity
2 to 4
SD.Lynch (hereditary nonpolyposis col orectal cancer ), 22 to 50% risk Cowden síndrome, 13 to 19% lifetime risk
5% consultas ginecológicas. Ocurre en 4 a 11% de postmenopausicas. 1-25% de HUA pueden tener cáncer de endometrio. HUA mas fc es atrofia o pólipos endometriales. En primeros años hiperplasia, pólipos y miomas submucosos son fc. SIEMPRE DESCARGAR CANCER DE ENDOMETRIO – biopsia es mejor que ECOTV. Requiere biopsia toda ECOTV con: >4mm, heterogena, no visualiza endometrio, sangrado persistente. TODAS DEBEN TENER UN PAPANICOLAU y BX si hay lesión.
PAT. BENIGNA MAMA ASPECTOS GENERALES FUNCIONALES: Mastodinea, Galactorrea. Ginecomastia. INFLAMATORIOS : agudo, cronico y Mondor (tromboflebitis).
MASTOPATIA FIBROQUISTICA TIPOS: no proliferativos 68%, proliferativos sin atipia 26%, hiperplasia atipica 4%. DX: mastodinea premenstrual bilateral, áreas induradas, nódulos, telorrea. Patrón fibroso denso, nódulos diseminados. ECO! Tto: solo control. Otros hormonas, vitE
Pseudotumorales : Ectasia ductal, necrosis grasa. Tumoraciones : Mixtos( fibroadenoma 75%, Phyllodes), epiteliales (adenoma, papiloma), otros. FIBROADENOMA: NO DOLOR. TTO: >30ª, >2-3cm, rápid crecimient
CÁNCER DE MAMA ASPECTOS GENERALES ©2017 UpToDate ®
Low risk
High risk
RR
RISK FACTORS
Deleterious + 3.0 to 7.0 BRCA1/BRCA2 Mom or sis with No Yes 2.6 CAMAMA 30 to 34 70 to 74 18.0 Age >14 <12 1.5 Age at menarche <20 >30 1.9 to 3.5 Age at first birth <45 >55 2.0 Age at menopause Never Yes 1.07 to 1.2 Use of ACO Never Current 1.2 HRT (E+P) None 2-5 d/day 1.4 Alcohol ≥75% 0 1.8 to 6.0 density on MAMRX % Q1 Q3 2.7 to 3.5 Bone density No Yes 1.7 Historia benign bx No Yes 3.7 History of at / hyper PROTECTIVE FACTORS ≥16 0 0.73 Lactancia (meses) ≥5 0 0.71 Parity Yes No 0.70 Recreational exercise <22.9 >30.7 0.63 Postmenopause IMC
EPIDEMIOLOGÍA:
1ra muerte mujer. 2da general. Riesgo en vida: 12%. 70% esporádicos, 15% familiares, 5-10% hereditarios.
PATOLOGÍA: EPITELIALES – METASTÁSICOS – MESENQUIMATOSOS.
DUCTAL: LOBULILLAR: ESPECIALES: • ENF PAGET: 2%: Eccematosa, •
•
99% epidérmico del galactóforo. CA INFLAMATORIO 2%: Malaso! T4. 1/3 mama inflamada. Carcinomatosis linfática de la dermis. CA MAM VARON 1%: 0.2% maligno del hombre, tumor indoloro retroaleolar. Tipo ductal infiltrante. Mastectomía Madden. En XXY o BRCA2
• CA OCULTO DE MAMA: 1%: metastasis axilares. Tto cirugia di l de ila
DISEMINACIÓN: INTRAMAMARIA: Duplica 2-9m. 5-8ª para palpar. Invasión trae retracción fibrosa –Cooper. LOCAL: Fascias, musculo, hueso, piel: edema, ulcera, ca en coraza, ca erisipeloide. LINFÁTICA: 40% al dx. Micrometastasis si <2mm. GANGLIOS AXILARES (directo al tamaño, pronostico + importante, niveles de BERG) linfadenectomia? CADENA MAMARIA INTERNA. INTERCOSTALES INTERNOS. DISTANCIA: Émbolos, directo al tamaño y tiempo. No importa en sangre. PULMON, HIGADO (ductal), peritoneal (lobulillar), OSEA, SNC (lept inge lobulillar), OJOS
CÁNCER DE MAMA DIAGNÓSTICO
CLÍNICA
RX
TUMOR PALPABLE 75%, supero externo, autoexamen no eficaz. TELORREA: 10%hem. ECCEMA O ULCERA PIEL: 2.7% retracción. ADENOPATIA AXILAR. MASTODINEA
ECO – MAMO (PRIMARIOS Y SECUNDARIOS) - RMN
BX: Definitivo. A cielo abierto, BAG para BIRADS 3,4,5, palpables o axilar. Assessment
Management
CHANCES
0: Incomplete
Recall for additional imaging
N/A
1: Negative
Routine mammography
0%
2: Benign
Routine mammography screening
0%
3: Probably benign
Short-interval (6-month)
>0% but ≤2%
4: Suspicious 4A: Low suspicion 4B: Mod suspicion
>2% but <95% Tissue diagnosis
>2 to ≤10% >10 to ≤50%
4C: High suspicion
>50 to <95%
5: Highly suggestive Tissue diagnosis
≥95%
6: Known biopsy-
Surgical excision when clinically
©2017 UpToDate®
CÁNCER DE MAMA
METASTASIS Pulmón (63%) – Hígado –Peritoneal - Huesos - SNC (cerebro)
ESTADÍO Y TTO Primary tumor (T)*¶Δ ©2017 UpToDate® X Primary tumor cannot be assessed 0 No evidenceof primary tumor is Carcinoma in situ is (DCIS)Ductal carcinoma in situ is (LCIS) Lobular carcinoma in situ Paget's disease (Paget disease) of the nipple NOT associated is with invasive carcinoma and/or carcinoma in situ (DCIS (Paget's) and/or LCIS) in the underlying breast parenchyma. 1 Tumor ≤20 mm in greatest dimension HER2+ 1mi Tumor ≤1 mm in greatest dimension 1a Tumor >1 mm but ≤5 mm in greatest dimension tumor >1 cm: HT, QT, 1b Tumor >5 mm but ≤10 mm in greatestdimension and trastuzumab 1c Tumor >10 mm but ≤20 mm in greatest dimension Node-negative, tumor 2 Tumor >20 mm but ≤50 mm in greatest dimension 0.6 cm to 1.0 cm: HT, ± ER/PR+ 3 Tumor >50 mm in greatest dimension QT, + trastuzumab ◊ Tumor of any size with direct extension to the chest wall Node-negative or 4 and/or to the skin (ulceration or skin nodules) pN1mi, tumor ≤0.5 cm Extension to the chest wall, not including only pectoralis or microinvasive: ± HT 4a muscle adherence/invasion Ulceration and/or ipsilateral satellite nodules and/or edema 4b (including peau d'orange) of the skin, which do not meet the tumor >1 cm: criteria for inflammatory carcinoma ER/PR- chemotherapy and trastuzumab 4c Both T4a and T4b §
HER2Node-positive: HT and chemotherapy Node-negative or pN1mi, tumor >0.5 cm: 21-gene recurrence score assay • or if not done: HT ± chemotherapy tumor >1 cm: chemotherapy Node-negative or pN1mi, tumor 0.6 cm-1.0 cm:
CÁNCER DE CÉRVIX ASPECTOS GENERALES High-risk (oncogenic or cancerassociated) types. Common types: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 82 Low-risk (non-oncogenic) types Common types: 6, 11, 40, 42, 43, 44, 54, 61, 72, 81
CÉLULAS ESCAMOSAS •CÉLULAS ESCAMOSAS ATÍPICAS (ASC)
De significado incierto: ASC-US No se puede excluir lesión NIC de alto grado: ASC-H •LESIÓN ESCAMOSA INTRAEPITELIAL DE BAJO GRADO (LSIL): incluye VPH+, NIC1, displasia leve. •LESIÓN ESCAMOSA INTRAEPITELIAL DE ALTO GRADO (HSIL): incluye NIC 2-3, displasia moderada, severa y Ca insitu. •CARCINOMA ESCAMOSO
CÉLULAS GLANDULARES: •CEL. GLANDULARES ATÍPICAS (AGC) •CEL. GLAN. ATÍPICAS, POSIBLE NEOPLASIA •ADENOCARCINOMA “IN SITU” ENDOCERVICAL : AIS
CÁNCER DE CÉRVIX
©2017 UpToDate®
2011 IFCPC cervical colposcopy nomenclature: IFCPC: International Federation for Cervical Pathology and Colposcopy.
GENERAL ASSESSMENT •Adequate/inadequate for the reason (ie, cervix obscured by inflammation, bleeding, scar) •Squamocolumnar junction visibility: completely visible, partially visible, not visible QxUtero HPV vac benigno •Transformation zone types 1, 2, 3
DIAGNÓSTICO Inicio Fin
ACOG (2016)
21
65
†
Screening en: Age ≥30 Age 21 to 29 Co-testing (pap test and Pap test ever HPV testing) every five y three years years (preferred) Can consider Pap testevery three Not primary HPV years indicate testing every Can consider primary d** three years HPV testing every three for years for women age ≥ women age ≥25 25
NORMAL COLPOSCOPIC FINDINGS
Same Original squamous epithelium Mature – Atrophic - Columnar epithelium Ectopy - Metaplastic recomm squamous epithelium Nabothian cysts - Crypt (gland) openings - Deciduosis in pregnancy endatio ns as Location of the lesion: inside or outside the T-zone, location of the General unvacci lesion by clock position. Size of the lesion: number of cervical principles nated quadrants the lesion covers, size of the lesion in %age of cervix women ABNORM
Grade 1 AL COLPOS (minor) Women who are infected with HIV (or otherwise COPIC immunocompromised) should undergo cervical cancer screening twice FINDINGS in the first year after diagnosis of HIV infection and then annually, Grade 2 provided the test results are normal. (major) For women with two consecutive normal cytological examinations, we recommend that annual follow-up There is no consensus as to whether human papillomavirus (HPV) testing should be performed routinely on HIV-infected women. We recommend a screening colposcopy at initial evaluation.
CLASIFICACIÓN ANATOMO PATOLOGÍA MEDIANTE BIOPSIA: RICHART NIC 1 O DISPLASIA LEVE - NIC 2 MODERADA - NIC 3 y Ca in situ
Nonspecific
Thin acetowhite epithelium Irregular, geographic border
Fine mosaic Fine punctuation
Dense acetowhite epithelium Rapid appearance of acetowhitening Cuffed crypt (gland) openings
Coarse mosaic - Coarse punctuation Sharp border -Inner border sign Ridge sign
Leukoplakia (keratosis, hyperkeratosis), erosion Lugol's staining (Schiller's test): stained/non-stained
SUSPICIO Aty pical vess els - Add itio nal sig ns : fr agile vess els, ir regul ar sur face, US FOR exophytic lesion, necrosis, ulceration (necrotic), tumor/gross neoplasm INVASION MISCELL Congenital transformation zone - Condyloma ANEOUS Polyp (ectocervical/endocervical) -
Stenosis - Congenital anomaly Post-treatment
CÁNCER DE CÉRVIX TRATAMIENTO
Primary tumor (T) TNM FIGO categories stages
TX T0 Tis* T1 ¶
FIGO
% 5 años
IIA
73.4
IA1
97.5
IIB
65.8
IA2
94.8
IIIA
39.7
IB1
89.1
IIIB
41.5
IB2
75.7
IVA
22.0
ESQUEMA TTO: •NIC 1: expectante – citología semestral. Pronostico bueno. •NIC 2 Y 3: conizacion (elección) y/o histerectomía.
I
T1a
IA
T1a1
IA1
T1a2
IA2
T1b
IB
T1b1 T1b2
IB1 IB2
T2
II
T2a
IIA
T2a1 T2a2 T2b
IIA1 IIA2 IIB
T3
III
T3a
IIIA
T3b
IIIB
Definition
Primary tumor cannot be assessed No evidence of primary tumor Carcinoma in situ (preinvasive carcinoma) Cervical carcinoma confined to uterus Invasive carcinoma diagnosed only by microscopy. Stromal invasion with a maximum depth of 5.0 mm and a horizontal spread of 7.0 mm or less. Measured stromal invasion 3.0 mm or less in depth and 7.0 mm or less in horizontal spread Measured stromal invasion more than 3.0 mm and not more than 5.0 mm in depth with a horizontal spread 7.0 mm or less Clinically visible lesion confined to the cervix or microscopic lesion greater than T1a/IA2 Clinically visible lesion 4.0 cm or less in greatest dimension Clinically visible lesion more than 4.0 cm in greatest dimension Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of vagina Tumor without parametrial invasion or involvement of the lower one-third [1,2] of the vagina Clinically visible lesion 4.0 cm or less in greatest dimension Clinically visible lesion more than 4.0 cm in greatest dimension Tumor with parametrial invasion Tumor extends to pelvic wall and/or involves lower third of vagina, and/or causes hydronephrosis or nonfunctioning kidney Tumor involves lower third of vagina, no extension to pelvic wall Tumor extends to pelvic wall and/or causes hydronephrosis or nonfunctioning kidney Tumor invades mucosa of bladder or rectum, and/or extends beyond true
CÁNCER DE ÚTERO Incidence of endometrial hyperplasia was 133 per 100,000 woman-years. - age 50 to 54 years and rarely younger than age 30. Most common gynecologic malignancy in developed countries; for women through age 74 years, the incidence is 14.7 per 100,000 and mortality rate is 2.3 per 100,000. In developing countries, it is the second most common gynecologic malignancy (cervical cancer is more common).
©2017 UpToDate®
CÁNCER DE ÚTERO
1. 2. 3.
4. 5.
GRADO DE INVASIÓN MIOMETRIO EDAD AVANZADA GRADO DE DIFERENCIACIÓN TUMORAL: HISTOLÓGICO PAPILAR SEROSO, CELULAS CLARAS, ADENOESCAMOSO RECEPTORES HORMONALES CITOLOGÍA PERITEONEAL AMAÑ
Degree of differentation of the adenocarcinoma G1
5 percent or less of a nonsquamous or nonmorular solid growth pattern
G2
6 % to 50 percent of a nonsquamous or nonmorular solid growth pattern More than 50 %of a nonsquamous or
C NCER DE OVARIO
OTROS CÁNCERES
ASPECTOS GENERALES
RESUMEN Extramammary Paget disease — Extramammary Paget disease, an intraepithelial adenocarcinoma, accounts for less than 1 percent of all vulvar malignancies [26]. Most patients are in their 60s and 70s and Caucasian. • Pruritus is the most common symptom, • The lesion has an eczematoid appearance; • It is usually multifocal and may occur anywhere on the vulva, mons, perineum/perianal area, or inner thigh. Differential diagnosis i nclu des melanoma, leukoplaki a, basal cell or squamous cell carcinoma, condyloma acuminata, hidradenitis suppurativa, psoriasis, fungal infection, seborrheic or c ontact dermatitis, and lichen sclerosis [ 27]. ©2017 UpToDate ® -Incidence
of histologic subtypes of primary vaginal cancer - Adapted from Berek JS, Hacker NF (Eds). Practical Gynecologic Oncology, 3rd ed, Lippincott Williams & Wilkins, Philadelphia, 2000.
Histology Squamous cell
Incidence 83.4
Undifferentiated 1.0 Small cell
0.7
Adenocarcinoma 9.3
Lymphoma
0.3
Sarcoma
2.6
Carcinoid
0.1
Melanoma
26
Total
100.0
©2017 UpToDate® PREVALENCE — 7.8 percent (prevalence of ovarian cysts 6.6 percent) [2]. Most common etiologies of torsion in different populations
Fetus/neonate Ovarian cysts Premenarchal girls Ovarian cysts and neoplasms Elongated utero-ovarian ligament Premenopausal women Ovarian cysts and neoplasms (includes ovarian hyperstimulation syndrome) Pregnancy Postmenopausal women
His topat hol og y i n 656 w omen with a persistent adnexal mass Data from: Guerriero S, Alcazar JL, Results of a European study. Gynecol Oncol 2001; 83:299.
Pathology Endometrioma Serous cystadenoma Mature teratoma Hemorrhagic cyst Mu ci no us c ys tad en om a Paraovarian cyst Cystadenofibroma Follicular cyst Ovarian fibroma Hydrosalpinx Tuboovarian abscess Peritoneal cyst Leiomyoma Granulosa cell tumor Fibrothecoma
# 152 101 76 44 34 25 22 13 12 12 8 8 4 2 2
Malignant ovarian neoplasm
122
CÁNCER DE OVARIO ASPECTOS GENERALES
CLASIFICACIÓN
4% cáncer ginecológico Alta tasa de mortalidad
FACTORES DE RIESGO 1. Edad avanzada 2. Nuliparidad 3. Endometriosis 4. Historia familiar 5. Oncogenes (BRCA 1-2) OVARIAN
TUBAL
EXTRAOVARIAN AND EXTRATUBAL
NONGYNECOLOGIC
BENIGN
TIPO
< 20
20-50
> 50
EPITELIO CELOMICO
29%
71%
81%
CELULAS GERMINALES
59%
14%
6%
ESTROMA GONADAL
8%
5%
4%
MESENQUIMA NO
4%
10%
9%
•FUNCTIONAL (PHYSIOLOGIC) CYST •CORPUS LUTEAL CYST •LUTEOMA OF PREGNANCY •THECA LUTEIN CYST •POLYCYSTIC OVARIES •ENDOMETRIOMA •CYSTADENOMA •BENIGN OVARIAN GERM CELL TUMOR
•ECTOPIC
PREGNANCY •HYDROSALPINX
•PARAOVARIAN CYST •PARATUBAL CYST •UTERINE LEIOMYOMA
(PEDUNCULATED OR CERVICAL) •TUBO-OVARIAN ABSCESS
(EG, MATURE TERATOMA) •BENIGN SEX CORD-STROMAL TUMOR
•CONSTIPATION •APPENDICEAL ABSCESS •DIVERTICULAR ABSCESS •PELVIC ABSCESS •BLADDER DIVERTICULUM •URETERAL DIVERTICULUM •PELVIC KIDNEY •PERITONEAL CYST •NERVE SHEATH TUMOR
MALIGNANT OR BORDERLINE •EPITHELIAL CARCINOMA •EPITHELIAL BORDERLINE NEOPLASM •MALIGNANT OVARIAN GERM CELL
TUMOR
•EPITHELIAL
CARCINOMA •SEROUS TUBAL
•METASTATIC
ENDOMETRIAL
•APPENDICEAL NEOPLASM •BOWEL NEOPLASM •METASTASIS (EG, BREAST, COLON,
