Gyn Onc Flashcards
GTN stage I or low risk (score <7) stage II and III treatment
Single agent chemo with either methotrexate or actinomycin D
GTN high risk stage II/III (score 7 or more) or stage IV treatment
Multiagent chemo +/- surgery/radiotherapy
Etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine
Scores 4 points on GTN staging (WHO)
13 or more months from antecedent pregnancy
Pretreatment serum hCG 1,000,000 or more
Liver, brain mets
>8 metastases
Previously failed two or more chemo drugs
Recommended criteria for decision-making capacity
- Communicates choice between treatment options
- Understands treatment options
- Understands the information leading to the decision
- Understands consequences of treatment
Should a patient with PMB on tamoxifen get a biopsy?
Yes, regardless of endometrial thickness
Palliative option for treatment of large bowel obstruction in cancer patients
Colonic stent
Breast cancer screening in BRCA1 and BRCA2
Annual MRI alternating with semiannual digital mammography starting at 25-30 years
What do you do with a perimenopausal woman with low positive hCG?
1 week of OCPs and recheck hCG
If OCPs aren’t successful, do a CT chest/abd/pelvis
Ovarian cancer debulking should…
remove all visible disease, including bowel resection, as safely as possible.
Standard evaluation of all categories of AGC/AIS
ECC
If AGC and +HPV, likely…
cervical disease
AGC/AIS in women >35 (or younger with AUB or e/o chronic anovulation)
colposcopy + ECC + EMB
Table for statistics
DISEASE + DISEASE - T + a b E S - c d T
Next step after surgery of stage IIIC1 uterine carcinosarcoma
Adjuvant chemotherapy
Neutropenia < 1,500/mm3 on day of therapy
Delay until recovered
(if delay >7 days, reduce doses by 1 or add GCSF)
(if delay >14 days, reduce doses by 1 AND add GCSF)
Platelets 75,000-150,000 on day of chemotherapy
Delay until recovered
Platelets <75,000 on day of chemotherapy
Delay until recovered
If delay is >7 days, reduce doses by 1 level
Immature teratoma, surgically resected, stage IA, grade 1 management
Surveillance
Immature teratoma, surgically resected, stage IA, grade 2 or 3 management
Chemotherapy - bleomycin, etoposide, cisplatin
First line treatment of hyperkalemia to stabilize myocardium
IV calcium
can also use insulin with glucose
Greatest risk with oral conjugated equine estrogen use
Stroke
then DVT
Ovarian luteoma
Causes gestational hyperandrogenism
Benign
Usually regress and disappear 2-3 weeks after delivery
Risk of Ovarian Malignancy Algorithm
CA125
Human epididymis secretory protein 4
(In a woman with a pelvic mass)
International Ovarian Tumor Analysis
Classification of adnexal masses
Risk of Malignancy Index
CA125
Menopausal status
Ultrasound findings
(factors are multiplied together)
Risk of Ovarian Cancer Algorithm
Uses longitudinal increase in CA125 to determine risk
Ultrasound findings of pelvic mass consistent with malignancy
Irregular solid tumor
Ascites
At least four papillary structures
Irregular multilocular tumor with largest diameter 100mm
Very high color content on Doppler ultrasonography
After surgery for endometrial or colorectal cancer, first step to test for Lynch
Immunohistochemical TUMOR testing for MLH1, MSH2, MSH6, and PMS2 proteins
Ovarian cancer screening in BRCA1 or BRCA2
Periodic CA125 and transvaginal ultrasound starting at 30-35 or 5-10 years prior to earliest ovarian cancer diagnosis in the family
Prophylactic BSO in BRCA1 and BRCA2
Immediately after childbearing is complete or by 40
Managemnet of smooth muscle tumor of uncertain malignant potential
Surveillance for women desiring fertility
Hysterectomy for women not desiring fertility
Common prognostic prediction models use
Age
Comorbidities
Nodal status
Tumor size
Factors associated with abnormal anal cytology in HIV individuals
CD4 count of less than 200cell/mm3
History of STD other than HPV
Cervical cytology abnormality
Risk with St. John’s wort
Induces cytochrome P450 activity (doubles its metabolic activity)
(stop at least 5 days before surgery)
High risk patients with neutropenic fever
Neutropenia <100 cells/mm3
Anticipated duration of neutropenia >7 days
Significant comorbid conditions (hypotension, pneumonia, new abd pain, neuro changes)
Broad spectrum antibiotics for neutropenic fever
Cipro and augmentin
Mutation associated with uterine papillary serous carcinoma
TP53 mutations
Side effect associated with switching from tamoxifen to aromatase inhibitor
Joint aches
Recommended treatment for advanced ovarian cancer that has been suboptimally cytoreduced
IV carboplatin and paclitaxel
RIsk factors for ovarian cancer
Increasing age Endometriosis Family history of breast or ovarian cancer Nulligravidity Infertility Early menarche Late menopause
Benefit of mechanical bowel prep
None
Treatment of IB1 cervical cancer in patient desiring fertility
Radical trachelectomy with pelvic lymphadenectomy
Contraindication to salvage products
Any solution mixed with blood that results in red cell lysis:
Sterile water
Hydrogen peroxide
Alcohol
Indication for radical vulvectomy over wide local excision
Invasive carcinoma
Treatment of preinvasive lesions of the vulva
Wide local excision
Breast cancer risk reduction after 5 years of chemoprophylaxis with tamoxifen
50%
MLH1 immunohistochemical staining is absent, next test
Test sample for MLH1 methylation
20-30% of cases of endometrial cancer with absence of MLH1 are due to methylation
Best surveillance for ovarian cancer with previous complete response to treatment
Physical exam
Nulligravid with microinvasive cervical cancer on biopsy (not excision)
Do cone or LEEP for further diagnostic evaluation
Treatment for HIT
Stop heparin/LMWH
Start another anticoagulant to treat VTE (argatroban or danaparoid)
ARDS clinical criteria
Respiratory symptoms within 1 week of inciting event
Bilateral opacities on x-ray or CT that can’t fully be explained by other cause
Respiratory failure not explained by cardiac failure or fluid overload
Impairment of oxygenation (PaO2/FiO2)
Ovarian cancer associated with endometriosis
Endometrioid or clear cell
Most common transfusion-associated infection in the US
Staphylococcus (gram + cocci)
Less than 25 years old with HSIL –> CIN2 –> ?
Repeat colposcopy and cytology at 6 months
Okay to use estrogen postoperatively in patients with endometrial cancer?
Controversial but yes, estrogen not shown to increase recurrence
Prognostic factors for success of exenteration
Time to recurrence
Tobacco use
Age >70
Primary site of disease
LEEP with AIS extending to margin?
Re-excise with cone
Most effective method to prevent gynecologic cancer risk in Lynch syndrome
Hysterectomy and bilateral salpingoophorectomy
Vulvar biopsy with large cells with prominent nuclei and coarse chromatin
Paget’s disease
Management of vulvar Paget’s
Cervical cancer screen, colonoscopy, and mammography
Cervical cancer stage if tumor is limited to cervix >4cm
IB2
Cervical cancer stage if involvement of upper third of vagina
IIA2
Cervical cancer stage if tumor involves lower third of vagina
IIIA
Are lymph nodes included in cervical cancer staging?
No
Highest risk factor for long-term sexual dysfunction after vulvectomy
Age
Treatment for vulvar basal cell carcinoma
Wide local excision (without lymphadenectomy)
Postoperative treatment for small cell cervical cancer (neuroendocrine)
Chemotherapy
Most compelling reason to convert to laparotomy for adnexal mass removal
Mural nodule
Papillary projections
Size greater than 10
Best method for contraception during molar pregnancy postoperative surveillance
OCPs
IUDs haven’t been studied with regards to recurrences
Surveillance for first 2 years after IIIC high grade serous ovarian cancer surgery with no residual disease
History and physical
CA-125
(not CT)
Risk factors for intraperitoneal catheter related complications
Timing of catheter insertion Hysterectomy Appendectomy Small bowel resection Ileocecal resection Left colon-rectosigmoid resection
Precludes candidacy for sentinel lymph node dissection in patients with vulvar cancer
Palpable lymph node
DCIS treatment
Breast sparing surgery + radiation
Best imaging modality for dense breast tissue
Digital mammography
Risk of laparoscopic resection of ovarian tumor
Port site metastasis
Prophylaxis for patients that are at high risk for VTE (age, cancer, extent of surgery)
LMWH for 4 weeks
General prerequisites for weaning from intubation
Secretions <2.5mL/hr
Strong cough
FiO2 <50%, PaOw/FiO2 of at least 150-200mmHg
Manageable minute ventilation
Acceptable pulmonary mechanics
Alert
No CHF, sepsis, acid-base abnormalities, severe electrolyte imbalances, vasopressor requirements, need for ongoing plasma expansion, no planned general anesthesia the same day, etc
What is the minimum ovarian pelvic radiation dosage that has no effect on the ovaries in females younger than 40
1.5 Gy
Immunohistochemical markers indicative of ovarian cancer
PAX8
CA125
WT1
KRT7
Treatment of choice for VAIN III
CO2 laser
LEEP showing CIN III with positive margins
Repeat cytology/ECC and colposcopy in 4-6 months
ASCUS in a 16 year old?
Repeat cytology 1 year
Least important intraoperative step for stage 1 ovarian cancer
Biopsy of the diaphragm
Best to determine prognosis of breast cancer
Stage
Tumor marker that’s most reliable in pregnancy
LDH
What to do for concern of increased intraabdominal pressure
Monitor intraabdominal pressures
Treatment for stage II invasive carcinoma of the vagina
Radiation
Pseudomyxoma peritonei can be fatal if left untreated due to what
Bowel obstruction
NOT a treatment for EIN
Nexplanon
What part of the cell does ionization radiation effect
Nucleus
If upper ur
Placenta site trophoblastic tumors most commonly develop following
Term pregnancies
What tumor marker is most elevated in endometrial cancer
Ça 125
Serum levels of which hormone can support a clinical impression of ectopic but can’t distinguish ectopic from IUP
Progesterone
Does prophylactic BSO reduce the risk of breast cancer in BRCA1?
No
Paget disease of the breast is what type of carcinoma
Ductal carcinoma
BRCA 1
Pancreatic
Melanoma
Breast
Ovarian
Percentage of fibromas in miegs syndrome undergo malignant transformation
1%
Late effects of radiation in women with gynecologic cancer
Fistulas
Fibrosis stenosis of vaginal canal
Intestinal obstructions
Bladder stenosis
What can’t be treated with topical imiquimod?
VIN differentiated
Chemo that causes extravasation leading to skin necrosis and ulceration
Doxorubicin
Most favorable vulvar cancer
Basal cell
