Cancer

Question 1

Selective estrogen receptor modulators

Answer 1

DRUGS

• tamoxifen
• raloxifene

MAO

• competitive inhibitor of estrogen binding
• mixed agonist/antagonist effect

INDICATIONS

• prevention of breast cancer in high risk patients
• Tamoxifen: adjuvant treatment of breast cancer
• raloxifene: postmenopausal osteoporosis

ADVERSE EFFECTS

• hot flashes
• venous thromboembolism
• endometrial hyperplasia and carcinoma (tamoxifen only)

Question 2

Cervical cancer

Answer 2

CLINICAL

• most often asymptomatic
• vaginal discharge
• postcoital or intermenstrual bleeding
• cervical lesion

MANAGE
-cervical biopsy

ADVANCED STAGE

• large vascular cervical mass
• heavy vaginal bleeding

Question 3

choriocarcinoma

Answer 3

RISK

• advance maternal age
• prior complete hydatididiform mole

CLINICAL

• amenorrhea or AUB
• pelvic pain/pressure
• symptoms from mets: lungs, vagina
• uterine mass
• enlarged uterus
• elevated beta hCG

TREAT
-chemo

Question 4

Sertoli-Leydig cell tumor

Answer 4

PATHO

• sex cord-stromal tumor
• increased T

CLINICAL
-rapid onset virilization 
voice deepening
male pattern balding
increased muscle mass
clitoromeglay

• oligomenorrhea
• unilateral, solid, adnexal mass
• signs of estrogen deficiency

MANAGE
-surgery

Question 5

epithelial ovarian carcinoma

Answer 5

CLINICAL

• acute: shortness of breath, constipation, vomiting, abdominal distention
• subacute: pelvic/abdominal pain, bloating, early satiety
• asymptomatic adnexal mass

LAB
-increased CA-125

U/S

• solid mass
• thick septations
• ascites

MANAGE
-exploratory laparotomy

Question 6

Vaginal cancer

Answer 6

RISK

• over 60
• HPV
• tobacco use
• in utero DES exposure (clear cell adenocarcinoma only)

CLINICAL

• vaginal bleeding
• malodorous vaginal discharge
• irregular vaginal lesion

DIAGNOSIS
-vaginal biopsy

MANAGE
-surgery +/- chemoradiation

Question 7

Granulosa cell tumor

Answer 7

PATHOGEN

• sex cord-stromal tumor
• increased estradiol
• increased inhibin

CLINICAL
-complex ovarian mass
-juvenile type associated with precocious puberty
-adult subtype
breast tenderness
AUB
postmenopausal bleeding 

HISTOPATH
-call-exner bodies

MANAGE

• endometrial biopsy
• surgery

Question 8

HPV

Answer 8

ASSOCIATIONS

• cervical cancer
• vulvar/vaginal cancer
• anal cancer
• penile cancer
• oropharyngeal cancer
• genital warts

VACCINE INDICATIONS

• all girls and women 11-26
• all boys and men 9-21 (9-26 for MSM and HIV)

Question 9

vulvar cancer

Answer 9

ETI

• persistent HPV infection
• chronic inflammation

RISK

• tobacco use
• vulvar lichen sclerosis
• immunodeficiency
• prior cervical cancer
• vulvar/cervical intraepithelial neoplasia

CLINICAL

• vulvar pruritus
• vulvar plaque/ulcer
• AUB

DIAGNOSIS
-biopsy

Question 10

endometrial biopsy indications

Answer 10

AGE over 45

• AUB
• postmenopausal bleeding

AGE less than 45

• AUB PLUS
• unopposed estrogen: obesity or annovulation
• failed medical management
• lynch syndrome

AGE over 35
-atypical glandular cells on pap test

Question 11

Mammary paget disease

Answer 11

CLINICAL

• patient with no prior history of skin disease develops a breast rash
• persistent, eczematous ulcerating rash on nipple and areola
• vesicles, scales, blood discharge, nipple reaction
• pain
• itching
• burning
• no resolution with topic corticosteroids

CAUSES

• adenocarcinoma
• migration of neoplastic cells through mammary ducts to the nipple surface

WORKUP
-mammography and biopsy

Question 12

Mature cystic teratoma

Answer 12

PATHO

• benign ovarian germ cell tumor
• endoderm, mesoderm, ectoderm tissue

CLINICAL

• most asymptomatic
• ovarian torsion
• intermittent colickly abdominal pain
• struma ovarii subtype can cause hyperthyroidism
• unilateral adnexal mass
• us shows complex, cystic, calcifications
• gross appearance: sebaceous fluid, hair, teeth

MANAGE
-ovarian cystectomy or oophorectomy

Question 13

Risk factors for cervical cancer

Answer 13

• Infection with HPV
• history of STD
• early onset of sexual activity
• multiple or high risk sexual partners
• immunosuppression
• oral contraceptive use
• low SES
• tobacco use

Question 14

cervical conization

Answer 14

INDICATIONS
-cervical intraepithelial neoplasia grades 2 and 3

COMPLICATIONS

• cervical stenosis
• preterm birth
• preterm premature rupture of membranes
• second trimester pregnancy loss

Question 15

high grade squamous intraepithelial lesions

Answer 15

EVAL
-immediate colposcopy, even in pregnancy

• colposcopy evaluates cervix and vagina under magnification
• cervical neoplasia typically occurs at transformation zone or squamocolumnar junction
• if not visulalized, endocervcial curettage is performed to evaluate endocervical canal (not done during pregnancy)

Question 16

breast cancer risk factors

Answer 16

MODIFIABLE

• hormone replacement therapy
• nulliparity
• increased age at first live birht
• alcohol consumption

NON MODIFIABLE

• genetic mutation or breast cancer in first degree relatives
• white race
• increasing age
• early menarche or later menopause

Question 17

Adenomyosis

Answer 17

PATHOGEN
-abnormal endometrial tissue within uterine myometrium

RISK

• age over 40
• muliparity
• prior uterine surgery

CLINICAL

• dysmenorrhea
• heavy menstrual bleeding
• chronic pelvic pain
• diffuse uterine enlargement (GLOBULAR)
• +/- uterine tenderness

DIAGNOSIS

• clinical presentation
• MRI and ultrasound: thickened myometrium
• confirmation via pathology

TREATMENT
-hysterectomy

Question 18

Management of CIN3

Answer 18

If over the age of 25 and not currently pregnant

THEN

LEEP, Cold knife conization or cyroablation

THEN

Pap test with HPV 1 and 2 years post procedure

Question 19

Endometrial hyperplasia/cancer

Answer 19

RISK

• obesity
• chronic anovulation/PCOS
• nulliparity
• early menarche or late menopause
• tamoxifen use

CLINICAL
-heavy, prolonged, intermenstural and or postmenopausal bleeding

EVALUATION

• endometrial biopsy
• pelvic ultrasound (post menopausal women)

TREATMENT

• hyperplasia: progestin therapy or hysterecty
• cancer: hysterectomy