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GOBBLERS 2023 > GTD/GTN and Cancer in Pregnancy > Flashcards

GTD/GTN and Cancer in Pregnancy Flashcards

1
Q

Patient with 1.4 mm melanoma at 23 weeks EGA s/p RLE and margins negative. What is the most appropriate next step in management?

A

Observation
(NOT interferon therapy or chemo)

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2
Q

Patient with late second trimester/early third trimester pregnancy, s/p USO c/w EST (endodermal sinus tumor) (unstaged). What is the most appropriate treatment?
A) observation
B) reoperation for staging
C) start BEP immediately
D) do MRI and start chemotherapy after delivery if no e/o disease on MRI
E) assess fetal lung maturity and start chemo after delivery

duplicate, and RED

A

C) start BEP immediately

  • any stage endodermal sinus tumor, embryonal tumor or nongestational choriocarcinoma requires chemo
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3
Q

What chemo drug is least teratogenic in 1st trimester?

A

Cyclophosphamide or doxorubicin
NOT: MTX, 5-FU

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4
Q

What chemotherapy is the most teratogenic ?

A

MTX (less so 5FU)

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5
Q

Radiation within the first two weeks of pregnancy causes what?

A

Embryonic death

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6
Q

Radiation at 2-16 weeks EGA causes?

A

Microcephaly, growth retardation

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7
Q

Radiation at 16-20wks EGA causes?

A

Same as 2-16, but less severe (microcephaly, growth retardation)

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8
Q

Radiation at >30 weeks EGA causes?

A

Causes few issues

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9
Q

41 yo patient presents with GTN characterized by 7 pulm mets (no size given), antecedent molar pregnancy, interval 8 months, HCG 1,000. What treatment is most appropriate?

A

Single-agent MTX

WHO score of 6
Stage 3 (lung mets)
WHO score
know WHO scoring

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10
Q

What is the genetic make-up of a complete mole?

A

46XX paternal origin most common
Rarely 46XY

46XX (90%) (monoandric with replication in empty ovum of a single sperm’s haploid chromosomes) and 46XY (10%) (diandric - diaspermic fertilization of empty ovum)

“Daddy’s little girl”

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11
Q

What is the common genetic make-up of a partial mole?

A

69XXY
Sometimes 69XXX
Biparental and diandric origin (two sperm fertilize one egg)

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12
Q

Pregnant patient at 10wks GA with breast microcalcifications. What is best next step?
A) biopsy
B) termination
C) ultrasound
D) mammogram

2018 red Q

A

Biopsy

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13
Q

Pregnant patient at 10wks GA with palpable breast mass, best next step?
A) biopsy
B) termination
C) ultrasound
D) mammogram

A

Ultrasound

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14
Q

If patient has elevated serum HCG but no clinical evidence of GTD what is next step?
A) Urine assay
B) repeat serum HCG
C) check free subunit

A

Urine Assay

  • if urine assay is. negative and serum levels do not decrease appropriately with parallel dilution, the molecule measures is likely a pseudogonadotropin or phantom hCG.
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15
Q

Which has the highest WHO score?
A) Liver mets
B) HCG 5000
C) mole as antecedent pregnancy

A

Liver mets

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16
Q

Stage IA G3 serous ovarian CA at 16wks preg?

A

6 cycles carbo/tax

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17
Q

WHO score - what has greatest impact?
A) HCG 10^4-5
B) interval >12 months from antecedent pregnancy
C) GI metastasis

A

Interval >12 months

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18
Q

What is the least likely cancer in a pregnant patient with no history of malignancy
a. lymphoma
b. melanoma
c. thyroid
d. colon
e. breast

A

Colon

most common
1 breast cancer
2 lymphoma
3 cervix
4 leukemia
5 melanoma

https://ascopubs.org/doi/10.1200/JCO.2009.23.2801#

ACS: The most common types of cancer found during pregnancy are, breast, cervical, thyroid, colon, and ovarian cancers, as well as melanoma, lymphoma, and leukemia

Other source: Thyroid cancer is the second most common malignancy during pregnancy, preceded only by breast cancer with an incidence of 14 per 100,000 live births
incidence of colorectal cancer (CRC) of 1 : 13,000

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19
Q

Tumor marker least likely to be affected by pregnancy
A) LDH
B) hCG
C) CA-125
D) inhibin

A

LDH

*CA-125, apha fetoprotein and bHCG are affected
*Anti-mullerian and inhibin B are not affected

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20
Q

Sixteen week pregnant patient has adnexal mass removed which is consistent with yolk sac tumor what do you do
A. start chemo
B. observe
C. other options

A

Start chemo

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21
Q

Pt with UPT+, hyperglycos hCG neg, hCG plateaus after 3 cycles MTX at 145-150. Next step?
A) Observe
B) actD
C) multidrug chemo
D) hyst

A

Observe - quiescent

hCG-Hyperglycosylated (%) appears to reliably identify active trophoblastic malignancy. It is a 100% sensitive marker for discriminating quiescent GTD from active GTN/choriocarcinoma. It is also a marker for the early detection of new or recurrent GTN/choriocarcinoma

22
Q

Pt with elevated serum hCG no other signs of GTD, what is next step?
A) UPT
B) Repeat serum hCG
C) Measure free hcG

A

UPT - due to heterophilic antibodies that are not excreted in urine

23
Q

Pt on tamoxifen x 2 years, 8 weeks pregnant: what do you recommend

A

Discontinue tamoxifen for pregnancy and breastfeeding

  • while no specific congenital anomaly has been associated with tamoxifen and pregnancy, the following have been reported (Goldenhar’s syndrome, Pierre Robin sequence, ambiguous genitalia, clitoral hypertrophy). The medication should ideally be stoped at least 2 months before conception.
24
Q

Pregnant pt, cone bx stage IA1 squamous cervical cancer neg margins. What next?

A

Observe

25
Q

Pregnant pt cone bx CIS, + margins, pos ECC - what to do?

A

Observe

26
Q

Characteristics of a PARTIAL MOLE

A
  • PARTLY paternal
  • triploid
  • fetal PARTs
  • focal PARTial edema (rather than diffuse)
  • rare med complications (such as hyperthyroid, toxemia) (think partial risk)
  • SGA
  • < 5% malignant sequelae (think partial risk)
27
Q

Most common ovarian tumor in pregnancy

A

Non-malignant teratoma
(tumor not cancer)

28
Q

Most common ovarian cancer in pregnancy

A

Dysgerminoma - germ cell tumors make up 40% ovarian tumors in pregnancy

29
Q

Quiescent vs active GTN

A

Persistent, unchanging low levels < 200 of real hcG for at least 3 months with hx of GTD or SAB but no detectable disease.

6-25% will develop active disease (increase in hyperglycosylated hCG with cytotrophoblastic invasion) and total hCG.

Only tx once sustained rise or overt clinical disease detected.

30
Q

AGC-NOS during pregnancy, colpo neg at 22 weeks, what next?

A

Postpartum pap

31
Q

41 yo with choriocarcinoma 7 months from pregnancy with pulm mets too numerous to count. How do you treat?

A

EMACO - high risk WHO score (7+)

Stage 3 (pulm mets)

32
Q

32 weeks pregnant, 7 cm cystic adnexal mass - what do you do?

A

Ultrasound after delivery

33
Q

14 weeks with ASCUS HPV +, no gross lesions, what do you do?

A

Colpo NOW

34
Q

12 weeks pregnant, endodermal sinus tumor, next step?

A

Immediate chemo with BEP
* any stage endodermal sinus tumor, embryonal tumor or nongestational choriocarcinoma requires chemo

35
Q

Do complete or partial moles have villous capillaries present?

A

Partial mole have villous capillaries intact

36
Q

Which type of GTN is typically treated with hysterectomy?

A

Placental site trophoblastic tumor PSTT - because it is chemoresistant

*test for human placental lactogen, intermediate size cytotrophoblast is noted on pathology

37
Q

Common cancers during pregnancy include?

A

Breast, cervix, lymphoma, ovary, melanoma, leukemia, thyroid, colorectal (most to least common)

38
Q

Blood type associated with GTD?

A

Type A or AB

39
Q

Common clinical features of GTD?

A

Vaginal bleeding
Excessive uterine size
Prominent theca lutein cysts
Toxemia (preeclampsia)
Hyperemesis
Hyperthyroidism
Trophoblastic emboli

40
Q

Does p57/kip2 stain positive in partial or complete moles?

A

p57/kip2 is IHC marker for PARTIAL mole

Nuclear staining in cytotrophoblasts and villous stromal cells

p57 is paternally imprinted, maternally expressed gene CDKN1C (p57KIP2)

Also >90% expression in Choriocarcinoma

41
Q

Risk factors for GTN?

A
  • Age >40
  • Prior molar pregnancy
  • Asian or American Indian ancestry
42
Q

Risk factors for Molar Pregnancy?

A
  • Extremes of maternal age (< 15 or > 35)
  • Prior molar pregnancy
43
Q

How do PSTT and ETT differ from choriocaricnoma?

A
  • consist predominantly of intermediate trophoblast
    — PSTT: neoplastic proliferation of intermediate trophoblasts at placental implantation site
    — ETT: neoplastic chorionic type intermediate trophoblasts
    [— vs choriocarcinoma, composed of syncytiotrophoblast, cytotrophoblast and intermediate trophoblast]
  • low HCG and HPL
  • tend to remain in uterus
  • chemoresistant

Surgical management, PLND if appears contained to uterus (5-15% risk nodal mets)

44
Q

GTN pretreatment evaluation

A
  • H&P
  • HCG level
  • Hepatic, thyroid, renal function tests
  • CBC, T&S (Rhogam if Rh-)
  • CXR
  • Pelvic US

If metastatic disease is found:
- CT chest/abd/pelvis
- MRI head

- can consider PET per UTD

  • CSF HCG level (if head imaging neg and still suspicious, normal value plasma to CSF ratio < 60:1)
45
Q

Young patient with an initial WHO score 5 being treated with MTX. Now with two weeks of rising HCG, what should you do?
A) switch to actinomycin-D
B) switch to EMA-EP or EMA-CO
C) CT scan
D) hysterectomy
E) D&C

A

Per NCCN: If HCG <1000, switch to weekly actinomycin-D. If HCG >= 1000, repeat workup to check for mets (i.e. CT scan)

NCCN: Pulse Act-D should not be used as secondary therapy for failed MTX, nor primary therapy for those with CCA (use fixed daily dose Act-D x5 days)

46
Q

Risks factors for GTD

A

extremes maternal age, OB hx prior molar pregnancy or SAB, diet low in animal fat/carotene/vitA, blood type A or AB

47
Q

Do complete or partial moles have villous capillaries present?

A

Partial moles

48
Q

Which is not associated with GTD risk?
A) Extremes of age
B) prior mole
C) low beta carotene
D) High animal fat intake
E) NLRP7 gene mut
F) Asian

A

D) High animal fat intake

Low animal fat intake is associated with increased GTD risk

49
Q

Cervical cancer and pregnancy - outcomes, stage at diagnosis?

A

Stage for stage, the course of disease and prognosis of cervical cancer in pregnant patients are similar to those of nonpregnant patients

Most patients are diagnosed at an early stage of disease. This is probably a result of routine prenatal screening, but it is also possible that advanced stage disease interferes with conception

Staging lymphadenectomy during pregnancy may provide the most definitive information on lymph node status. This information is important, as patients diagnosed with high-risk (node-positive) disease should be counseled about the importance of initiating immediate definitive therapy, including pregnancy termination.

Per UTD

50
Q

Patient with GTN with lung mets and otherwise no other significant risk factors - best treatment?

A

Single agent MTX (multi-day dosing)
(lung mets get 0 points)

51
Q

What are the subsequent pregnancy outcomes of patient with complete molar pregnancy followed by GTN that was treated with chemotherapy?

A

Expect normal reproduction (no increased risk of prenatal/intrapartum complications)

Increased risk of future molar pregnancy (1/100 patients will have at least 2 molar pregnancies)

So after 1 mole, risk of second is 1-2%
After 2 moles, risk of third is ~15%

Familial repetitive mole: missense mutation in NLRP7 on chromosome 19

52
Q

What confers a worse prognosis in PSTT?

A
  • advanced stage
  • older age
  • longer interval from previous pregnancy
  • previous term pregnancy
  • higher serum hCG level
  • higher mitotic rate
  • coagulative tumor necrosis
  • clear cytoplasm
  • PSTT is chemoresistant - so if distant metastasis outsie of uterus, this is bad because limited options.

70% PSTTs act in a benign manner and 30% are aggressive with distant mets

PSTT may have a higher free-beta subunit of HCG

GOBBLERS 2023 (32 decks)

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