Gyn Onc Flashcards
What is the lifetime risk of breast ca?
1 in 8 (12%)
What is an example of a non-proliferative breast mass?
Breast cyst
What is an example of a proliferative breast mass without atypia?
Fibroadenoma, intraductal papilloma
What is an example of a proliferative breast mass with atypia?
Atypical ductal hyperplasia, atypical lobular hyperplasia (4x risk of breast cancer in either breast)
What is the work up of a breast mass?
- Mammogram (if positive…)
- Ultrasound (if a mass…)
- Aspiration (if bloody or mass fails to resolve…)
- Excision/biopsy
What are the criteria for a breast biopsy/excision?
- Suspicious solid palpable mass
- Non palpable suspicious mammo findings
- Aspiration with bloody fluid or persistent mass
- Bloody nipple discharge or ulceration
What are some skin findings that warrant evaluation for inflammatory breast cancer?
Thickening, edema, peau d’ orange, erythema, nipple excoriations, skin ulcerations
How do you manage BIRADS 1-3 with clinical inflammatory breast findings?
Punch biopsy of skin
How do you manage BIRADS 4-5 with clinical inflammatory breast findings?
Punch biopsy of skin
Core needle biopsy
What is the management of atypical ductal hyperplasia, lobular carcinoma in situ?
Annual MRI if > 30yo
Clinical breast exam q 12 mo
Breast self awareness
Riks reduction (Tamoxifen)
What are some positives associated with ER/PR+ breast ca?
Better response to hormonal therapy (80% vs 10%)
Slower growing tumors, well-differentiated
What are the effects of Tamoxifen on breast, bone, uterus?
x breast
+ bone
+ uterus
What specific changes can Tamoxifen cause in the uterus?
Tamoxifen results in a spectrum of uterine abnormalities including benign alterations such as endometrial polyps, endometrial hyperplasia, endometrial cystic atrophy, adenomyosis, and uterine fibroid growth as well as malignant transformation into endometrial carcinoma and uterine sarcoma
What is the recommended uterine surveillance in patients who take Tamoxifen?
Per ACOG - none, unless symptomatic! However, this is controversial, as many providers do screen with EMB or US.
What are the effects of Raloxifene on breast, bone, uterus?
x breast
++ bone
x uterus
What are the effects of Anastraozole (AI) on breast, bone, uterus?
x breast via blocking peripheral conversion (but doesn’t block ovaries in pre-menopausal women)
x bone
x uterus
Used pre or post menopause?
- Tamoxifen (SERM)
- Raloxifene (SERM)
- Anastrazole (AI)
- Tamoxifene: both
- Raloxifene: post
- Anastrazole: both
How does Herceptin work?
Targeted monoclonal antibody therapy (trastuzumab) targeting Human Epidermal growth hormone Receptor+ cancer
Can be used pre- and post-menopause
What is the most common cause of bloody nipple discharge?
Benign intraductal papilloma
What is the most common cause of a solid breast mass?
Fibroadenoma
What cancer is associated with Paget’s disease of the breast?
Underlying intraductal and invasive breast carcinoma
What is the false positive rate of a mammogram?
10%
What are some indications for breast MRI?
- BRCA 1/2
- 1st deg relative wtih BRCA 1/2, pt not tested
- Lifetime risk breast ca > 20% (assessments)
- Chest radiation at 10-30yo
- Genetic syndromes such as Cowden
What defines Stage 1A cervical cancers (1A1, 1A2)?
1A1 = < 3mm depth of invasion
1A2 = 3-5mm depth of invasion
What defines Stage 1B cervical cancers (1B1, 1B2, 1B3)?
1B1 = 5mm-2cm greatest dimension
1B2 = 2-4cm greatest dimension
1B3 = >4cm greatest dimensiion
What defines Stage 2 cervical cancers (2A, 2B)?
2A = upper 2/3 vagina
2B = parametrial involvement
What defines Stage 3 cervical cancers (3A, 3B, 3C)?
3A = lower 1/3 vagina
3B = sidewall and/or hydronephrosis
3C = (a) pelvic, (b) para-aortic lymph nodes
What defines Stage 4 cervical cancers (4A, 4B)?
4A = Spread to adjacent pelvic organs (bladder, rectum)
4B = Spread to distant organs
What is the work up for cervical cancer staging?
PE - primarily clinical staging!
Cervical biopsy, ECC, cone
Endoscopy: hscpy, cysto, procto
Imaging: IVP, CXR, CT, MRI, PET (if available)
Pathology (if available)
What is the treatment of stage 1A1 cervical ca (provided no LVSI)?
Cone or simple hyst
What is the treatment of stage 1A2 - 1B cervical ca?
Rad hyst + nodes
What is the treatment of stage 2A-3B cervical ca?
Cisplatin + radiation
What is the treatment of stage 4 cervical ca?
Palliative chemo + radiation
In radiotherapy for cervical ca, what is Point A?
2cm above the external os and 2cm lateral to the midline (where the uterine artery crosses over the ureter) - deliver 7500 to 8500 rads
In radiotherapy for cervical ca, what is Point B?
3cm lateral to Point A (position of obturator nodes) - deliver 5500 to 6500 rads
What HPV subtypes contribute to what % of cervical cancers?
HPV 16 50%
HPV 18 20%
HPV 31,33,43,52,58 20%
What is differentiated VIN?
Vulvar lesion not associated with HPV and associated with derm conditions such as lichen sclerosis
What is usual type VIN?
Vulvar lesion associated with carcinogenic HPV
What defines stage 1 ovarian ca (1A, 1B, 1C)?
1A Confined to one ovary
1B Both ovaries, capsule intact
1C spillage (1-surgical, 2-capsule rupture, 3-washings)
What defines stage 2 ovarian ca (2A, 2B)?
2A Spread to uterus
2B spread to other pelvic intraperitoneal tissues
What defines stage 3 ovarian ca (3A, 3B, 3C)?
3A retroperitoneal lymph nodes
3B Spread < 2cm beyond the pelvis
3C Spread > 2cm beyond the pelvis (capsule of liver or spleen)
What defines stage 4 ovarian ca (4A, 4B)
4A pleural effusion
4B distant disease (parenchyma of liver or spleen)
What features in an ovarian mass are concerning for malignancy?
Bilateral, solid, complex, papillations, excrescences, septations, bloody fluid, size > 6cm, persistent
What is the ddx of a solid ovarian mass?
Fibroid, thecoma, fibroma, brenner, granulosa cell, dysgerminoma
What is the ddx of a cystic ovarian mass?
Functional cyst, serous and mucinous tumors, mature cystic teratoma
What tumor markers are positive in a: dysgerminoma
HCG, LDH
What tumor markers are positive in a: yolk sac tumor?
AFP
What tumor markers are positive in a: choriocarcinoma?
HCG
What tumor markers are positive in a: immature teratoma?
AFP, LDH
What tumor markers are positive in a: embryonal carcinoma?
HCG. AFP
What ovarian tumor produces estrogen?
Granulosa cell tumor (also inhibin)
What ovarian tumor produces androgens?
Sertoli-Leydig tumor
What is conservative management of a dysgerminoma?
USO and limited staging, follow with serial tumor markers (rather than TAH/BSO and BEP chemo)
Which ovarian tumor is associated with Call-Exner Bodies?
Granulosa cell tumors (coffee bean nuclei)
What is breast cancer surveillance in patients with BRCA 1/2?
Age 25-29:
- Clinical breast exam q 6mo
- MRI annually
Age 30+
- Mammogram + MRI annually, alternating 6 mo
At what age is risk reducing BSO offered in BRCA 1/2?
BRCA1 age 35-40
BRCA2 age 40-45
What type of genes are BRCA 1/2 (inheritance, function)?
Autosomal dominant
Encode proteins that function as DNA repair
What type of gene is Lynch/HNPCC (inheritance, function)?
Autosomal dominant
Defect in mismatch repair gene
What cancers is Lynch/HNPCC asssociated with?
Colon, small bowel, endometrial, ovarian, gastric, liver, renal, ureter
What colon cancer screening is recommended in Lynch syndrome.
Colonoscopy q1-2 yrs beginning age 20-25, or 5 years earlier than age of diagnosis in family
What endometrial cancer screening is recommended in Lynch Syndrome?
Embx q1-2 yrs beginning age 30-35
Monitor for s/sx AUB
What chemoprophylaxis is recommended for BRCA 1/2 carriers?
COmbined OCPs
Tamoxifen can decrease breast ca risk in BRCA2
What chemoprophylaxis is recommended for Lynch carriers?
ASA 600mg qd x2 yrs - colorectal cancer
Progestin contraception - endometrial cancer
At what age should risk reducing TAH/BSO be discussed in Lynch?
Age 40-45yo
What are the two types of endometrial cancer?
Type 1: endometrioid adenocarcinoma
- More common, more global, assoc w EIN and estrogen, better prognosis
Type 2: papillary serous or clear cell
- High grade, more focal, poor prognosis
What are some treatment options for EIN?
Mirena
Megace 40-200mg/d
Provera 10-20mg/d
Depo Provera 150 mg q 3mo
Vaginal P 100-200 mg/d
What is the staging of endometrial cancer?
Stage 1A < 50% myometrium
Stage 1B > 50% myometrium
Stage 2 Stroma of cervix only
Stage 3A Serosal or adnexal involvement
Stage 3B Vaginal or parametrial involvement
Stage 3C Positive PPALN
Stage 4A Bladder or bowel
Stage 4B Distant mets
Qualities of partial mole
69XXX or XXY
Has fetal parts
Smaller uterine size
Rare theca lutein cysts
GTN risk 5%
Qualities of compelte mole
46XX or XY
No fetal part
Large uterine size
Assoc with theca lutein cysts
GTN risk 15-20%
What factors are accounted for in FIGO staging of GTN
Age
Type of antecedent pregnancy
Time since antecedent pregnancy
Beta HCG value
Tumor Size
Number of Mets
Location of Mets
Hx failed chemo
What are the four types of GTN?
Invasive mole
Choriocarcinoma
Placental site trophoblastic tumor
Epithelioid trophoblastic tumor
