A pregnant 35-year-old patient is at highest risk for the concurrent development of which of the following malignancies?
Breast cancer is the most common type of malignancy detected during pregnancy, affecting approximately 1 in 3,000 pregnant women. This is thought to be at least partially due to the fact that more women are choosing to have children later in life, and the risk of breast cancer increases with age.
Stage Ia2 microinvasive cervical cancer is diagnosed based on cervical biopsy in a 34-year-old woman who is 12 weeks’ pregnant.
What is the best next step in management?
Cervical cancer is one of the more common malignancies found during pregnancy. Management of cervical intraepithelial lesions is complicated in pregnancy because of increased vascularity of the cervix and because of the concern that manipulation of and trauma to the cervix can compromise continuation of the pregnancy. A traditional cone biopsy is indicated in the presence of apparent microinvasive disease on a colposcopically directed cervical biopsy. Otherwise, more limited procedures such as shallow cervical biopsies are more appropriate. If invasive cancer is diagnosed, the decision to treat immediately or wait until fetal viability depends in part on the gestational age at which the diagnosis is made, and the severity of the disorder. Survival is decreased for malignancies discovered later in pregnancy. Radiation therapy almost always results in spontaneous abortion, in part because the fetus is particularly radiosensitive. Chemotherapy is associated with higher than expected rates of fetal malformations consistent with the antimetabolite effects of agents used. Specific malformations depend on the agent used and the time in pregnancy at which the exposure occurs.
A 54-year-old woman presents for well-woman examination. On pelvic examination you palpate an enlarged, tender right adnexal mass. You order a pelvic ultrasound as the next step in this patient’s evaluation.
Which of the following sonographic characteristics of the cyst in this patient would warrant further evaluation for possible ovarian malignancy?
Most ovarian malignancies are not found until significant spread has occurred; therefore it is not unreasonable to further evaluate patients as soon as there is a suspicion of an ovarian neoplasm. Pelvic ultrasonography, tumor markers, and even surgical exploration may be part of the evaluation of a patient with an ovarian mass. Pelvic ultrasound findings of internal ovarian papillary vegetations, ovarian size greater than 10 cm, the presence of ascites, possible ovarian torsion, or solid ovarian lesions are indications for exploratory laparotomy in the postmenopausal patient. In a younger woman, a cyst can be followed past one menstrual cycle to determine if it is a follicular cyst, since a follicular cyst should regress after onset of the next menstrual period. If regression does not occur, then surgery is appropriate. Doppler ultrasound imaging allows visualization of arterial and venous flow patterns superimposed on the image of the structure being examined; arterial and venous flow are expected in a normal ovary.
A 70-year-old woman presents for evaluation of a pruritic lesion on the vulva. Examination shows a white, friable lesion on the right labia majorum that is 3 cm in diameter. No other suspicious areas are noted. Biopsy of the lesion confirms squamous cell carcinoma.
In this patient, lymphatic spread of the cancer would be first to which of the following lymph nodes?
An important feature of the lymphatic drainage of the vulva is the existence of drainage across the midline. The vulva drains first into the superficial inguinal lymph nodes, then into the deep femoral nodes, and finally into the external iliac lymph nodes. The clinical significance of this sequence for patients with carcinoma of the vulva is that the iliac nodes are probably free of the disease if the deep femoral nodes are not involved. Unlike the lymphatic drainage from the rest of the vulva, the drainage from the clitoral region bypasses the superficial inguinal nodes and passes directly to the deep femoral nodes. Thus, while the superficial nodes usually also have metastases when the deep femoral nodes are implicated, it is possible for only the deep nodes to be involved if the carcinoma is in the midline near the clitoris.
A 17-year-old girl is seen by her primary care physician for the evaluation of left lower quadrant pain. The physician felt a pelvic mass on physical examination and ordered a pelvic ultrasound. You are consulted because an ovarian neoplasm is identified by the ultrasound.
Which of the following is the most common ovarian tumor in this type of patient?
One half to two-thirds of ovarian neoplasms in young women in their teens and early twenties are of germ cell origin. Epithelial tumors of the ovary are quite rare in prepubertal girls. Papillary serous cystadenocarcinoma is an example of a malignant epithelial tumor and would be very uncommon in a girl of this age. Stromal tumors (such as fibrosarcoma) and Brenner tumors are not usually seen in this age group. Sarcoma botryoides, a tumor seen in children, is a malignancy associated with Müllerian structures such as the vagina and uterus, including the uterine cervix.