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GINECOLOGÍA 2017

PRIMERA VUELTA
FISIOLOGÍA Y ANATOMÍA GINECOLÓGICA
DISTOPIAS
AMENORREA - 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. Christiam Ochoa


DIRECTOR GRUPO QXMEDIC
ANATOMÍA BÁSICA
DISTOPIAS
00 – 00 - 00

©2017 UpToDate®
FISIOLOGÍA BÁSICA

Molimina (breast tenderness, ovulatory


pain, bloating)
Primary (absence of menarche by 15 years). Secondary (absence of menses 3R / 6IR)
AMENORREA ©2017 UpToDate®
COMPARTIMIENTO ENTIDAD %
I: Canal genital. Asherman 7
SECUNDARIAS II: ovarios Cromosomopatías 10
PRIMARIAS • Uterino. Asherman (90%
• GENITALES procedimientos – TBC genital) III: hipófisis anterior Prolactinomas 7.5
• Insuficiencia ovárico.
Disgenesia gonadal: IV SNC Anovulación, anorexia, hipot 10
• Tumores ováricos.
Turner, pura, mixta. • Hipo-hipog
Rokitasnky. • Hiperprolactinemia
Himen imperforado. • Sd. Sheehan
Feminización testicular o • Tumores hipofisiarios.
Morris. • Craneofaringioma
HSC o sd adrenogenital. • Fármacos
• Enfermedades
Agenesia vagina.
• Psíquica
• ANOREXIA/EJERCICIO • Suprarrenal o tiroideo.
• CENTRALES
Psíquica, lesión H-h, AMENORREA SECUNDARIA
pubertad retrasada, 1. bHCG  gestación
hipo-hipog, 2. TSH-PRL  etiológico
3. Test progesterona 
neurogerminales: anovulación
Kallman, Laurence 4. E/P  Anatómica genital
Moon Bield, Alstrom, 5. FSH y LH  falla ovárico
Progeria, Prader Willi. 6. GnRh  (hipotálamo e
hipófisis)
SOP

Rotterdam criteria 2003*[2] AES definition 2008[3] - (all required)


(two out of three required) Clinical and/or biochemical signs of
Oligo- or anovulation hyperandrogenism
Ovarian dysfunction – oligo-anovulation and/or
Clinical and/or biochemical signs of
polycystic ovaries on ultrasound
hyperandrogenism
Exclusion of other androgen excess or ovulatory
Polycystic ovaries (by ultrasound) disorders
©2017 UpToDate® - Proposed diagnostic criteria for polycystic ovary syndrome

NIH consensus criteria 1990[1] - (all required)


Menstrual irregularity due to oligo- or anovulation
Clinical and/or biochemical signs of hyperandrogenism
Exclusion of other disorders: NCCAH, androgen-secreting tumors
Edad aproximada es de
MENOPAUSIA 50 años
©2017 UpToDate®
SISTEMATICO
INFERTILIDAD y ESTERILIDAD • 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
1. TUBARICA: 40%. Congenito, Laparoscopia (ENDOMETRIOSIS) –
INFERTILIDAD endometriosis, infecciones, otras. Histeroscopia - Test poscoital (SIMS HUBNER) -
Anticuerpos antiespermatoide - Biopsia de
DEFECTOS CONGÉNITOS: ++fc. TTO: microcirugía, fecundación
endometrio
Cromosomopatías. Trisomias 50%: INVITRO si es bilateral.
ESTUDIO
13,16,18,21,22 precoces. 45XO 20% (el más 2. OVÁRICA: 25%. Insuficiencia lútea,
SOP, endometriosis, tumores, • Genética de pareja: cariotipo.
aislado)
• HSG o histeroscopia.
FACTOR UTERINO: mioma submucoso o congénitas. TTO: clomifeno 6 meses,
• Serología luética.
pólipos. Tabicado (segundo trimestre). progesterona 2da fase, • Anticardiolipina y anticoagulante lúpico.
Asherman. bromocriptina. ORAL AGENTS: Clomiphene • Estudio fase lútea.
FACTOR CERVICAL: incompetencia cervical citrate, Metformin, Aromatase inhibitors • OTROS:
(letrozole), Dopamine agonists. PULSATILE GnRH
adquirida 95%, pasado semana 16. Dx: tallo • Evaluación endocrina, Seminograma, tallo
THERAPY. GONADOTROPIN THERAPY
Hegar en 2da fase. TTO: cerclaje 13-16s. de Hegar, ecografía, urografía, cariotipo
3. UTERINA: 13% (infertil>esteril).
del aborto, Dx preimplantacional, meiosis
FACTOR ENDOMETRIAL: baja calidad, sífilis, Malformaciones. TTO: Qx. testicular, trombofilias.
clamydias. 4. OTRAS: cervical 12%, vulvo vaginal
FACTOR AUTOINMUNE, ENDOCRINO, 8%, inmunoligcas, psíquica,
MASCULINO, PSICOLÓGICO, SISTEMICO. generales, idiopáticas 10%.
ITS
ITS
DIAGNÓSTICO

www.qxmedic.com
TRATAMIENTO
EPI CRITERIOS HAGER ANTIBIOTICOTERAPIA
MAYORES
➢Dolor espontáneo en abdomen inferior.
A: AMBULATORIO
➢Dolor durante la movilización del cérvix. B: HOSPITALIZACION
Infección del TGS ➢Dolor anexial a la exploración.
➢Historia de actividad sexual reciente. First-line regimens — The CDC
FACTORES DE RIESGO ➢Ecografía no sugestiva de otra recommends any of the following
patología. outpatient regimens, with or
• HISTORIA SEXUAL without metronidazole (500 mg twice a
• EDAD: 15-25 años MENORES day for 14 days):
●Ceftriaxone (250 mg intramuscularly
• Antecedente previo EPI Temperatura > 38°C.
Leucocitosis > 10.500. in a single dose) plus doxycycline (100
• Procedimientos: LU mg orally twice a day for 14 days)
VSG elevada.
• Usuaria de DIU (+++) We prefer ceftriaxone
Gram de exudado intracervical plus doxycycline in patients with mild to
• ACO (---)
moderate PID. Metronidazole should
be added for patients with Trichomonas
1º Chlamidia vaginalis or in those women with a
ETS recent history of uterine
2º Gonococo instrumentation. ©2017 UpToDate®
DIU Actinomices
DOLOR PELVICO CRÓNICO / INFERTILIDAD
Israelii
HORMONAL ANTICONCEPTIVOS
• T-2da: levonorgestrel 1. NATURALES
Etinilestradiol • Norgestimato a) Billings
+ b) Ogino
• T-3ra: gestodeno, desogestrel
c) Sintotérmico
gestageno • Pg: ciproterona, MDX d) MELA
• Es: drospirenona 2. ARTIFICIALES
a) Barrera
• REDUCEN CA OVARIO Y ENDOMETRIO y COLON b) Hormonales
• REDUCEN ECTOPICOS. c) Intrauterino
• REDUCEN EPI d) Quirúrgicos
• DISMINUYEN LA DISMENORREA. REGULAN
CICLO. CONTRAINDICACIONES


DISMINUYEN EL SANGRADO MENSTRUAL
MEJORAN HIPERANDROGENISMO.
ABSOLUTAS
• Embarazo - EPI
DIU
• MEJORAN PATOLOGÍA MAMARIA BENIGNA. • SUA - Tumor Malig Cervix
• CONTROL OSTEOPOROSOS
o uterino
CONTRAINDICACIONES ABSOLUTAS
• Pac con riesgo CV - HTA mal controlada-DM con INSERCION: cuando?, dolor, perforacion,
afectacion vascular - Cardiopatias migracion, infeccion (1m – Actinomices y
polimicrobiano – sd shock toxico Sf).
• Antec de TVP o TEP - Qx Mayor x inmovilizacion
EVOLUCION: gestacion (1% endometrial, 5%
• Vasculitis - Discrasia sanguinea ectopico). 50% riesgo aborto, no
• Pac hepatopatas - Antecedentes de ictericia MAF,.RETIRAR / descenso y expulsion
• Porfiria aguda intermitente - Embarazo (control en la 1ra menstruacion). / sangrado
• Ca mama - HUA no filiado anómalo 1m, salvo liberador de P. / dolor
Mas fc en no gestantes: uterino, anovulación, hemostasia (15-24%) y neo.
HUA
PREVALENCIA: 53/1000 mujeres. calidad vida, productividad y servicios de salud.
ASPECTOS GENERALES HUA POSTMENOPAUSICA: atrofia y pólipos endometriales. Cáncer de endometrio 5%.
©2017 UpToDate® Reproductive-age
Usual causes of abnormal genital bleeding in women by age Ovulatory dysfunction
group - Adapted from: APGO educational series on women's health issues. Clinical
Pregnancy
management of abnormal uterine…
Cancer
Polyps, leiomyomas,
Neonates adenomyosis
Estrogen withdrawal Infection
©2017 UpToDate® - Normal menstruation parameters Premenarchal Endocrine dysfunction
Clinical Terms Normal limits Foreign body (polycystic ovary
Absent Trauma, including sexual syndrome, thyroid,
Frequency of menses Infrequent >38 abuse hyperprolactinemia)
(days) Normal 24 to 38 Infection Bleeding diathesis
Frequent <24 Urethral prolapse Medication related (eg,
Regularity (variation Regular Var ≤7 to 9 days* Sarcoma botryoides hormonal contraception)
defined as shortest to Ovarian tumor Menopausal transition
longest cycle length) Irregular Var >7 to 9 days*
Precocious puberty Anovulation
Normal ≤8 days
Duration of flow (days) Early postmenarche Polyps, fibroids,
Prolonged >8 days Ovulatory dysfunction adenomyosis
Heavy >80 (hypothalamic immaturity) Cancer
Volume of monthly blood
Normal 5 to 80 Bleeding diathesis Menopause
loss (objective)
Light <5 Stress (psychogenic, Endometrial polyps
Heavy Patient's
EJEMPLO: Adenomisis+sangrado exercise induced) Cancer
Volume of monthly blood irregular + leiomioma tipo 6:
loss (subjective)
Normal perception of Pregnancy Postmenopausal hormone
Light volume. HUA-A, Lo, -O Infection therapy
©2017 UpToDate® Women who should undergo evaluation for
HUA Causes of heavy or prolonged menses endometrial hyperplasia or endometrial cancer
Coagulopathy
DIAGNÓSTICO ABNORMAL UTERINE BLEEDING ©2017 UpToDate®
Neoplasm / Estructural
•POSTMENOPAUSAL WOMEN – Any uterine bleeding, regardless of volume
1. UTERO? Other (including spotting or staining) and/or further evaluation of a sonographic finding
2. EMBARAZADA? Endometritis of abnormal-appearing endometrium.
3. PREMENOPAUSICA? Hypothyroidism
4. PATRÓN SANGRADO? •AGE 45 YEARS TO MENOPAUSE – Any abnormal uterine bleeding, including
Intrauterine device intermenstrual bleeding in women who are ovulatory. Abnormal uterine bleeding
5. ENDOCRINO – FARMACOS? in any woman that is frequent (interval between the onset of bleeding episodes
6. AGUDO, INESTABLE? Hyperestrogenism is less than 21 days), heavy (total volume of >80 mL), or prolonged (longer than
Endometriosis seven days).
1. HUA-MASIVA
2. HUA-INTERMENSTRUAL Causes of intermenstrual •YOUNGER THAN 45 YEARS – Abnormal uterine bleeding that is persistent,
occurs in the setting of a history of unopposed estrogen exposure (obesity,
3. HUA-OVULATORIA (irregular) bleeding - * postcoital bleeding.
chronic anovulation) or failed medical management of the bleeding, or in women
4. AMENORREA (3 ciclos) Drugs: ACO at high risk of endometrial cancer (eg, tamoxifen therapy, Lynch syndrome,
5. HIPOMENORREA (ACO, Cowden syndrome).
Infection
estenosis cervical, Asherman) •In addition, endometrial neoplasia should be suspected in premenopausal
Benign growths
6. POLIMENORREA (<21 días). women who are ANOVULATORY AND HAVE PROLONGED PERIODS OF
Cervical polyps*
AMENORRHEA (SIX OR MORE MONTHS).
Causes of ovulatory dysfunction Endometrial polyps
CERVICAL CYTOLOGY RESULTS
Primary hypothalamic-pituitary dysfunction Ectropion*
•Presence of atypical glandular cells (AGC)-endometrial.
(VER AMENORREAS CENTRALES) - SOP Uterine fibroids
Medications Vulvar skin tags, sebaceous •Presence of AGC-all subcategories other than endometrial – If ≥35 years old
OR at risk for endometrial cancer (risk factors or symptoms).
Estrogen-progestin contraceptives cysts, condylomata
Progestins Vaginal Gartner's duct cysts, •Presence of benign-appearing endometrial cells in women ≥40 years of age
polyps, adenosis who also have abnormal uterine bleeding or risk factors for endometrial cancer.
Antidepressant and antipsychotic drugs
Cancer OTHER INDICATIONS
Corticosteroids
Chemotherapeutic agents Trauma (cesarea previa) •Monitoring of women with endometrial pathology (eg, endometrial hyperplasia).
•Screening in women at high risk of endometrial cancer (eg, Lynch syndrome).
DIFFERENTIAL
BLEEDING
HUA PATTERN
OTHER ASSOCIATED CLINICAL FEATURES DIAGNOSIS
COMMON
EVALUATION

- PELVIC ULTRASOUND - SALINE INFUSION


ENLARGED UTERUS ON EXAMINATION, UTERINE
DIAGNÓSTICO DISCRETE MASSES MAY BE NOTED LEIOMYOMA
SONOGRAPHY OR HYSTEROSCOPY (IF
INTRACAVITARY)
REGULAR
MENSES THAT - DYSMENORRHEA
ARE HEAVY - ENLARGED, BOGGY UTERUS ON ADENOMYOSIS PELVIC ULTRASOUND
OR EXAMINATION
PROLONGED - FAMILY HISTORY - BLEEDING DIATHESIS BLEEDING
TESTING FOR BLEEDING DISORDER
- ANTICOAGULANT THERAPY DISORDER
RISK FACTORS FOR UTERINE MALIGNANCY ENDOMETRIAL SAMPLING
- PELVIC ULTRASOUND
ENDOMETRIAL
- SALINE INFUSION SONOGRAPHY OR
REGULAR POLYP
HYSTEROSCOPY
MENSES WITH
RISK FACTORS FOR UTERINE MALIGNANCY ENDOMETRIAL SAMPLING
INTERMENSTR
UAL RECENT HISTORY OF UTERINE OR
BLEEDING CERVICAL PROCEDURE OR CHILDBIRTH,
ENDOMETRIAL SAMPLING
PARTICULARLY IF INFECTION WAS
PRESENT
OVULATORY
DYSFUNCTION:
TOTAL TESTOSTERONE AND/OR OTHER
HIRSUTISM, ACNE, AND/OR OBESITY PCOS ANDROGENS (MAY NOT BE INCREASED IN
VARIABLE ALL WOMEN WITH PCOS)
HYPERPROLACTINE
GALACTORRHEA PROLACTIN
MIA
SD. TIROIDEO THYROID DISEASE THYROID FUNCTION TESTS
RISK FOR MALIGNANCY ENDOMETRIAL SAMPLING
- FOLLICLE-STIMULATING HORMONE-
HYPOTHALAMIC
POOR NUTRITION OR INTENSE EXERCISE LUTEINIZING HORMONE
AMENORRHEA
- ESTRADIOL

PREMATURE
SECONDARY HOT FLUSHES OVARIAN FOLLICLE-STIMULATING HORMONE
AMENORRHEA INSUFFICIENCY

ON PELVIC EXAMINATION, INSTRUMENT


RECENT HISTORY OF UTERINE OR CANNOT BE PASSED THROUGH INTERNAL
CERVICAL PROCEDURE OR CHILDBIRTH. CERVICAL OS
HYSTEROSCOPY
ACO / DIU IATROGENIC AUB
HUA
TRATAMIENTO

Table 2. Medical Treatment Regimens


Drug Suggested Dose Dose Schedule
Conjugated 25 mg IV Every 4–6 hours for 24
equine hours
estrogren
ACO Monophasic ACO that 3/D X 7D
contains 35
micrograms of ethinyl
estradiol
MEDROXI 20 mg orally Three times per day for
7 days
§
Tranexamic 1.3 g orally Three times per day for
acid 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 is a considered a


type of extra-uterine leiomyoma and
presents as peritoneal pelvic benign smooth-
muscle masses separate from the uterus.

Indications for myomectomy during


pregnancy or at delivery — Given the potential
DEGENERACION HIALINA for harm (hemorrhage, uterine rupture,
miscarriage or preterm delivery), myomectomy is
DEGENERACION QUISTICA
avoided during pregnancy and at delivery,
CALCIFICACION especially if an intramyometrial incision is
required, unless the procedure cannot be safely
INFECCION Y SUPURACION
delayed [2,21,29,41,67-73]. Uncontrollable
NECROSIS hemorrhage during myomectomy may necessitate
hysterectomy.
DEGENERACIÓN ROJA
Rarely, myomectomy of pedunculated or
DEGENERACION GRASOSA subserosal fibroids has been performed
antepartum for management of an acute abdomen
DEGENERACION
or obstruction, and myomectomy may be required
SARCOMATOSA
at cesarean delivery in order to close the
hysterotomy [74].
ENDOMETRIOSIS
DEFINICIÓN EPIDEMIOLOGÍA
CLÍNICA
• Endometrio fuera de la cavidad uterina. 10% mujeres. Feritles. Ciclos
(adenomiosis es endmetriosis cortos o menorragia. Tabaco
• DOLOR 95%. Dismenorrea progresiva.
miometrial – asintomática) protege.
Dispareunia.
• Alteracion menstrual 65%: poli+meno.
• Infertilidad 41%: multifactorial. TTO ETIOPATOGENIA
• Otros: distención abdominal,
• Laparoscopia: elección Desarrollo in situ. (Muller)
rectorragia, disuria, Ca125.
• Cirugía radical. Teoria inducción:
• Laparoscopía – lesión en • Medico: ACO, DIU levonorgestrel, mesénquima.
DX: quemadura de polvora. análogos GnRH, Danazol, gestágenos. Teoria implante:
menstruación retrógrada.

LOCALIZACIÓN
Ovario. Quiste achocolatado.
Ligamentos uterosacros, fosa
ovárica, Douglas.
HIPERPLASIA ENDOMETRIAL SANGRADO POSTMENOPÁUSICO
CLASIFICACION • 5% consultas ginecológicas. Ocurre en 4 a 11% de
postmenopausicas.
• SIMPLE S/ O C/ ATIPIA • 1-25% de HUA pueden tener cáncer de endometrio.
• COMPLEJA S/ O C/ ATIPIA • HUA mas fc es atrofia o pólipos endometriales. En primeros
años hiperplasia, pólipos y miomas submucosos son fc.
INCIDENCIA CANCER: • SIEMPRE DESCARGAR CANCER DE ENDOMETRIO –
HS – SIN : 1% biopsia es mejor que ECOTV.
HC – SIN: 3% • Requiere biopsia toda ECOTV con: >4mm, heterogena, no
HS – CON: 8% visualiza endometrio, sangrado persistente.
• TODAS DEBEN TENER UN PAPANICOLAU y BX si hay lesión.
HC – CON: 29%
©2017 UpToDate® - Risk factors for endometrial cancer

Risk factor (RR)


Increasing age (1.4% prevalence in women 50 to 70 years old) NA
Unopposed estrogen therapy 2 - 10
Early menarche, Estrogen-secreting tumor, Family history of
NA
endometrial, ovarian, breast, or colon cancer
Late menopause (after age 55), Nulliparity, DM, Tamoxifen therapy 2
SOP (chronic anovulation) 3
Obesity 2 to 4
SD.Lynch (hereditary nonpolyposis colorectal cancer), 22 to 50% risk
Cowden síndrome, 13 to 19% lifetime risk
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,
rápido crecimiento.
CÁNCER DE MAMA EPIDEMIOLOGÍA: 1ra muerte
mujer. 2da general. Riesgo en vida:
12%. 70% esporádicos, 15%
ASPECTOS GENERALES familiares, 5-10% hereditarios.
©2017 UpToDate® Low risk High risk RR
RISK FACTORS
Deleterious
PATOLOGÍA:
- + 3.0 to 7.0 EPITELIALES – METASTÁSICOS –
BRCA1/BRCA2
Mom or sis with MESENQUIMATOSOS.
No Yes 2.6
CAMAMA DUCTAL:
Age 30 to 34 70 to 74 18.0 LOBULILLAR:
Age at menarche >14 <12 1.5
ESPECIALES: DISEMINACIÓN:
Age at first birth <20 >30 1.9 to 3.5
• ENF PAGET: 2%: Eccematosa,
Age at menopause <45 >55 2.0
99% epidérmico del galactóforo.
INTRAMAMARIA: Duplica 2-9m. 5-8ª para
Use of ACO Never Yes 1.07 to 1.2 palpar. Invasión trae retracción fibrosa –Cooper.
• CA INFLAMATORIO 2%: Malaso!
HRT (E+P) Never Current 1.2
T4. 1/3 mama inflamada. LOCAL: Fascias, musculo, hueso, piel: edema,
Alcohol None 2-5 d/day 1.4 ulcera, ca en coraza, ca erisipeloide.
Carcinomatosis linfática de la
density on MAMRX % 0 ≥75% 1.8 to 6.0
dermis. LINFÁTICA: 40% al dx. Micrometastasis si
Bone density Q1 Q3 2.7 to 3.5
• CA MAM VARON 1%: 0.2% <2mm. GANGLIOS AXILARES (directo al tamaño,
Historia benign bx No Yes 1.7
pronostico + importante, niveles de BERG)
maligno del hombre, tumor
History of at / hyper No Yes 3.7
linfadenectomia? CADENA MAMARIA INTERNA.
indoloro retroaleolar. Tipo ductal
PROTECTIVE FACTORS INTERCOSTALES INTERNOS.
infiltrante. Mastectomía Madden.
Lactancia (meses) ≥16 0 0.73
En XXY o BRCA2 DISTANCIA: Émbolos, directo al tamaño y
Parity ≥5 0 0.71
• CA OCULTO DE MAMA: 1%: tiempo. No importa en sangre. PULMON, HIGADO
Recreational exercise Yes No 0.70
metastasis axilares. Tto cirugia (ductal), peritoneal (lobulillar), OSEA, SNC
Postmenopause IMC <22.9 >30.7 0.63
(leptomeninges lobulillar), OJOS.
radical de mama y axilas.
Qx ovario < 35 years Yes No 0.3
Aspirin ≥1/sX≥6 m + Nonusers 0.79
CÁNCER DE MAMA ©2017 UpToDate®
DIAGNÓSTICO

CLÍNICA TUMOR PALPABLE 75%, supero externo,


autoexamen no eficaz.
TELORREA: 10%hem. ECCEMA O
ULCERA PIEL: 2.7% retracción.
RX 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 >2% but <95%
4A: Low suspicion >2 to ≤10%
Tissue diagnosis
4B: Mod suspicion >10 to ≤50%
4C: High suspicion >50 to <95%
5: Highly suggestive Tissue diagnosis ≥95%
6: Known biopsy- Surgical excision when clinically
N/A
proven CA appropriate
METASTASIS
CÁNCER DE MAMA Pulmón (63%) – Hígado –Peritoneal - Huesos - SNC (cerebro)
ESTADÍO Y TTO
Primary tumor (T)*¶Δ ©2017 UpToDate®
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
Tis (DCIS)Ductal carcinoma in situ
Tis (LCIS) Lobular carcinoma in situ
Paget's disease (Paget disease) of the nipple NOT associated
Tis
with invasive carcinoma and/or carcinoma in situ (DCIS
(Paget's)
and/or LCIS) in the underlying breast parenchyma.
T1 Tumor ≤20 mm in greatest dimension
HER2+ HER2-
T1mi Tumor ≤1 mm in greatest dimension
T1a Tumor >1 mm but ≤5 mm in greatest dimension tumor >1 cm: HT, QT,
T1b Tumor >5 mm but ≤10 mm in greatest dimension Node-positive: HT and
and trastuzumab
T1c Tumor >10 mm but ≤20 mm in greatest dimension chemotherapy
Node-negative, tumor
T2 Tumor >20 mm but ≤50 mm in greatest dimension Node-negative or pN1mi,
0.6 cm to 1.0 cm: HT, ±
T3 Tumor >50 mm in greatest dimension ER/PR+ tumor >0.5 cm: 21-gene
QT, + trastuzumab
Tumor of any size with direct extension to the chest wall recurrence score assay•
T4
◊ Node-negative or
and/or to the skin (ulceration or skin nodules) or if not done: HT ±
pN1mi, tumor ≤0.5 cm
chemotherapy
Extension to the chest wall, not including only pectoralis or microinvasive: ± HT
T4a
muscle adherence/invasion
Ulceration and/or ipsilateral satellite nodules and/or edema tumor >1 cm:
T4b (including peau d'orange) of the skin, which do not meet the tumor >1 cm: chemotherapy
criteria for inflammatory carcinoma ER/PR- chemotherapy and Node-negative or pN1mi,
T4c Both T4a and T4b trastuzumab tumor 0.6 cm-1.0 cm:
§
T4d Inflammatory carcinoma "consider" chemotherapy
CÁNCER DE CÉRVIX
ASPECTOS GENERALES
High-risk (oncogenic or cancer-
associated) 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
•ADENOCARCINOMA
2011 IFCPC cervical colposcopy nomenclature: IFCPC:
CÁNCER DE CÉRVIX ©2017 UpToDate® International Federation for Cervical Pathology and Colposcopy.

GENERAL ASSESSMENT
DIAGNÓSTICO •Adequate/inadequate for the reason (ie, cervix obscured by inflammation, bleeding, scar)
Screening en: QxUtero •Squamocolumnar junction visibility: completely visible, partially visible, not visible
Inicio Fin HPV vac
Age 21 to 29 Age ≥30 benigno •Transformation zone types 1, 2, 3
Co-testing (pap test and
Pap test ever NORMAL COLPOSCOPIC FINDINGS
HPV testing) every five
y three years Same Original squamous epithelium Mature – Atrophic - Columnar epithelium Ectopy - Metaplastic
years (preferred)
recomm squamous epithelium Nabothian cysts - Crypt (gland) openings - Deciduosis in pregnancy
Can consider Pap test every three
Not endatio
ACOG † primary HPV years
21 65 indicate ns as Location of the lesion: inside or outside the T-zone, location of the
(2016) testing every General
Can consider primary d** unvacci lesion by clock position. Size of the lesion: number of cervical
three years principles
HPV testing every three nated quadrants the lesion covers, size of the lesion in %age of cervix
for
years for women ABNORM
women age ≥ Grade 1 Thin acetowhite epithelium Fine mosaic
women age ≥25 AL
25
COLPOS (minor) Irregular, geographic border Fine punctuation
Women who are infected with HIV (or otherwise COPIC
immunocompromised) should undergo cervical cancer screening twice Coarse mosaic - Coarse
FINDINGS Dense acetowhite epithelium
in the first year after diagnosis of HIV infection and then annually, punctuation
Grade 2 Rapid appearance of
provided the test results are normal. Sharp border -Inner border
(major) acetowhitening
For women with two consecutive normal cytological examinations, we sign
Cuffed crypt (gland) openings
recommend that annual follow-up Ridge sign
There is no consensus as to whether human papillomavirus (HPV)
testing should be performed routinely on HIV-infected women. Non- Leukoplakia (keratosis, hyperkeratosis), erosion
We recommend a screening colposcopy at initial evaluation. specific Lugol's staining (Schiller's test): stained/non-stained
SUSPICIO
CLASIFICACIÓN ANATOMO Atypical vessels - Additional signs: fragile vessels, irregular surface,
US FOR
PATOLOGÍA MEDIANTE BIOPSIA: exophytic lesion, necrosis, ulceration (necrotic), tumor/gross neoplasm
INVASION
RICHART
Stenosis - Congenital
NIC 1 O DISPLASIA LEVE - NIC 2 MISCELL Congenital transformation zone - Condyloma anomaly
MODERADA - NIC 3 y Ca in situ ANEOUS Polyp (ectocervical/endocervical) - Post-treatment
FINDING Inflammation consequence
Endometriosis
Primary tumor (T)
CÁNCER DE CÉRVIX TNM FIGO
categories stages
Definition

TRATAMIENTO TX Primary tumor cannot be assessed


T0 No evidence of primary tumor
Tis* Carcinoma in situ (preinvasive carcinoma)
T1 I Cervical carcinoma confined to uterus
¶ Invasive carcinoma diagnosed only by microscopy. Stromal invasion with a
T1a IA
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
T1a1 IA1
horizontal spread
Measured stromal invasion more than 3.0 mm and not more than 5.0 mm in
T1a2 IA2
depth with a horizontal spread 7.0 mm or less
Clinically visible lesion confined to the cervix or microscopic lesion greater
T1b IB
than T1a/IA2
T1b1 IB1 Clinically visible lesion 4.0 cm or less in greatest dimension
T1b2 IB2 Clinically visible lesion more than 4.0 cm in greatest dimension
Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower
T2 II
third of vagina
Tumor without parametrial invasion or involvement of the lower one-third
T2a IIA [1,2]
of the vagina
T2a1 IIA1 Clinically visible lesion 4.0 cm or less in greatest dimension
T2a2 IIA2 Clinically visible lesion more than 4.0 cm in greatest dimension
FIGO % 5 años IIA 73.4 ESQUEMA TTO: T2b IIB Tumor with parametrial invasion
•NIC 1: expectante – Tumor extends to pelvic wall and/or involves lower third of vagina, and/or
IA1 97.5 IIB 65.8 T3 III
citología semestral. causes hydronephrosis or nonfunctioning kidney
IA2 94.8 IIIA 39.7 Pronostico bueno. T3a IIIA Tumor involves lower third of vagina, no extension to pelvic wall
IB1 89.1 IIIB 41.5 •NIC 2 Y 3: conizacion Tumor extends to pelvic wall and/or causes hydronephrosis or
(elección) y/o T3b IIIB
IB2 75.7 IVA 22.0 nonfunctioning kidney
histerectomía. Tumor invades mucosa of bladder or rectum, and/or extends beyond true
©2017 UpToDate® IVB 9.3 •GESTANTE T4 IVA
pelvis (bullous edema is not sufficient to classify a tumor as T4)
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. GRADO DE INVASIÓN
MIOMETRIO Degree of differentation of the adenocarcinoma
2. EDAD AVANZADA
3. GRADO DE 5 percent or less of a nonsquamous or
DIFERENCIACIÓN G1
nonmorular solid growth pattern
TUMORAL: HISTOLÓGICO
PAPILAR SEROSO, CELULAS
6 % to 50 percent of a nonsquamous or
CLARAS, ADENOESCAMOSO G2
4. RECEPTORES HORMONALES nonmorular solid growth pattern
5. CITOLOGÍA PERITEONEAL
POSITIVA - TAMAÑO More than 50 %of a nonsquamous or
G3
TUMORAL > 2cm CA 125 nonmorular solid growth pattern
OTROS CÁNCERES CÁNCER DE OVARIO
RESUMEN ASPECTOS GENERALES
Extramammary Paget disease — Extramammary Paget disease, ©2017 UpToDate® Histopathology in 656 women
with a persistent adnexal mass
an intraepithelial adenocarcinoma, accounts for less than 1 percent PREVALENCE — 7.8 percent (prevalence Data from: Guerriero S, Alcazar JL,
of all vulvar malignancies [26]. Most patients are in their 60s and 70s of ovarian cysts 6.6 percent) [2]. Results of a European study.
and Caucasian. Gynecol Oncol 2001; 83:299.
• Pruritus is the most common symptom, Most common etiologies of
• The lesion has an eczematoid appearance; torsion in different populations Pathology #
• It is usually multifocal and may occur anywhere on the vulva, Endometrioma 152
mons, perineum/perianal area, or inner thigh. Fetus/neonate Serous cystadenoma 101
Differential diagnosis includes melanoma, leukoplakia, basal Mature teratoma 76
cell or squamous cell carcinoma, condyloma acuminata, Ovarian cysts Hemorrhagic cyst 44
hidradenitis suppurativa, psoriasis, fungal infection, seborrheic Mucinous cystadenoma 34
or contact dermatitis, and lichen sclerosis [27]. Premenarchal girls Paraovarian cyst 25
Cystadenofibroma 22
Incidence of histologic subtypes of
©2017 UpToDate® -
Ovarian cysts and neoplasms
Follicular cyst 13
primary vaginal cancer - Adapted from Berek JS, Hacker NF Elongated utero-ovarian ligament Ovarian fibroma 12
(Eds). Practical Gynecologic Oncology, 3rd ed, Lippincott Williams & Wilkins, Hydrosalpinx 12
Philadelphia, 2000.
Premenopausal women Tuboovarian abscess 8
Peritoneal cyst 8
Histology Incidence Undifferentiated 1.0
Ovarian cysts and neoplasms (includes Leiomyoma 4
Squamous cell 83.4 Small cell 0.7 ovarian hyperstimulation syndrome) Granulosa cell tumor 2
Adenocarcinoma 9.3 Lymphoma 0.3 Fibrothecoma 2
Pregnancy
Sarcoma 2.6 Carcinoid 0.1 Malignant ovarian
Postmenopausal women 122
neoplasm
Melanoma 2.6 Total 100.0
Ovarian tumor of low
Ovarian cysts and neoplasms malignant potential
19
CÁNCER DE OVARIO
ASPECTOS GENERALES
4% cáncer ginecológico FACTORES DE RIESGO
CLASIFICACIÓN Alta tasa de mortalidad 1. Edad avanzada
2. Nuliparidad
3. Endometriosis
4. Historia familiar
5. Oncogenes (BRCA 1-2)
EXTRAOVARIAN AND
OVARIAN TUBAL NONGYNECOLOGIC
EXTRATUBAL
BENIGN

•FUNCTIONAL (PHYSIOLOGIC) CYST


•CONSTIPATION
•CORPUS LUTEAL CYST
•APPENDICEAL ABSCESS
•LUTEOMA OF PREGNANCY •PARAOVARIAN CYST
•DIVERTICULAR ABSCESS
•THECA LUTEIN CYST •PARATUBAL CYST
•ECTOPIC •PELVIC ABSCESS
•POLYCYSTIC OVARIES •UTERINE LEIOMYOMA
PREGNANCY •BLADDER DIVERTICULUM
•ENDOMETRIOMA (PEDUNCULATED OR
•HYDROSALPINX •URETERAL DIVERTICULUM
•CYSTADENOMA CERVICAL)
•PELVIC KIDNEY
•BENIGN OVARIAN GERM CELL TUMOR •TUBO-OVARIAN ABSCESS
TIPO < 20 20-50 > 50 •PERITONEAL CYST
(EG, MATURE TERATOMA)
•NERVE SHEATH TUMOR
•BENIGN SEX CORD-STROMAL TUMOR
EPITELIO CELOMICO 29% 71% 81%
MALIGNANT OR BORDERLINE
CELULAS GERMINALES 59% 14% 6%
•EPITHELIAL CARCINOMA
ESTROMA GONADAL 8% 5% 4% •EPITHELIAL •APPENDICEAL NEOPLASM
•EPITHELIAL BORDERLINE NEOPLASM
CARCINOMA •METASTATIC •BOWEL NEOPLASM
•MALIGNANT OVARIAN GERM CELL
•SEROUS TUBAL ENDOMETRIAL •METASTASIS (EG, BREAST, COLON,
MESENQUIMA NO 4% 10% 9% TUMOR
INTRAEPITHELIAL CARCINOMA LYMPHOMA)
ESPECIFICO •MALIGNANT SEX CORD-STROMAL
NEOPLASIA •RETROPERITONEAL SARCOMA
TUMOR
Primary tumor (T)
CÁNCER DE OVARIO TNM FIGO Definition
TX Primary tumor cannot be assessed
DIAGNÓSTICO Y TTO T0 No evidence of primary tumor
T1 I Tumor confined to ovaries or fallopian tubes
CLINICA Quiste folicular ECO DOPPLER Ca 125 Ca
Tumor limited to one ovary (capsule intact) or fallopian tube; no tumor
Asintomáticos Quiste cuerpo lúteo RMN/TAC 19.9, CEA,
T1a IA on ovarian or fallopian tube surface; no malignant cells in ascites or
Tumor palpable Tumores MARCADORES LDH, AFP,
peritoneal washings
Dolor pélvico inflamatorios DD TUMORALES
b HCG,
Tumor limited to both ovaries (capsules intact) or fallopian tubes; no
H. tir
Ascitis Quistes T1b IB tumor on ovarian or fallopian tube surface; no malignant cells in ascites
Sd. Meigss. endometriales or peritoneal washings
The following symptoms are much more likely to occur in Tumor limited to one or both ovaries or fallopian tubes, with any of the
IC
following:
women with ovarian cancer than in women in the general
[1,2] IC1 Surgical spill
population. These symptoms include : T1c
Capsule ruptured before surgery or tumor on ovarian or fallopian tube
IC2
• Bloating surface
IC3 Malignant cells in the ascites or peritoneal washings
• Pelvic or abdominal pain Tumor involves one or both ovaries or fallopian tubes with pelvic extension
T2 II
• Difficulty eating or feeling full quickly (below pelvic brim) or peritoneal cancer*
Tumor involves one or both ovaries or fallopian tubes, or peritoneal cancer,
• Urinary symptoms (urgency or frequency) T3 III with cytologically or histologically confirmed spread to the peritoneum outside
the pelvis and/or metastasis to the retroperitoneal lymph nodes

• CIRUGIA TTO
• CITORREDUCCION
• QUIMIOTERAPIA

METASTASIS
• Carcinomatosis
• Linfática
• Hematógena