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Abog oral boards > GYN ONC > Flashcards

GYN ONC Flashcards

1
Q

risk of vulvar SCC with untreated lichen sclerosus

A

2-5%

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2
Q

Fertility sparing management options for EIN

A

Need to have bx proven by hsc dc
LVNG 52 mg IUD
megace 40-200 mg/day
Provera 10-20 mg/day or cycline 12-14d/month
depo 150 mg IM every 3 months
vaginal progesterone 100-200 mg/day or cyclin 12-14d/month
serial EMB q3-6 months x2 years
Regression 80-90%
50% will have recurrence once medical therapy is stopped
risk of progression to cancer is 8% per year

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3
Q

Uterine CA staging

A

Stage 1A: <1/2 myometrium
Stage 1B : >1/2 myometrium
Stage II: cervical stromal involvement
Stage IIIa: uterine serosal or adnexal involvement
stage IIIB: vaginal or parametrial involvement
Stage IIIC: positive nodes; IIIC1: pelvic nodes; IIIC2: para aortic nodes
stage IVa: bladder and/or bowel mucosa
stage IVb: distant mets

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4
Q

what is comprehensive staging for uterine CA

A

remove uterus, adnexa (BSO), pelvic/para aortic nodes, pelvic washings
minimally invasive approach is standard

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5
Q

Chance of nodal spread that varies with stage and grade

A

3-5% with well differentiated, superficial disease
20% with poorly differentiated deeply invasive disease

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6
Q

When to do nodal dissection and peritoneal cytologies

A

at the time of hyst for preop dx of EIN
All cases of endometrial cancer
Especially when:
1) grade 2 or 3
2) more than 50% myometrial invasion
3) papillary serous or clear cell histology
4) tumors with lymphovascular space invasion

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7
Q

who can you medically manage endometrial cancer for

A

1) well differentiated grade 1 endometriod adeno verified by hsc d&c
2) no myometrial invasion
3) no extrauterine involvement
4) premenopausal
have to have consult with gyn onc

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8
Q

Surveillance after surgery after endometrial CA

A

H&P
pelvic, vaginal, rectal exam every 3-6 months x2 years, then every 6 mo for 3 years, then annually
no vaginal or pap smears
No annual CXR
CT/PET scan of chest, abdomen, pelvis should be used if concerned about recurrence

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9
Q

Tamoxifen use and endometrial CA

A

premenopausal women not known increased risk of uterine cancer with tamoxifen use, do not require additional monitoring beyond routine gyn care
associated with endometrial proliferation, hyperplasia, polyp formation, invasive carcinoma, or uterine sarcoma

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10
Q

borderline tumor staging procedure

A

hysterectomy, BSO, pelvic washings, omentectomy, diaphragm stripping, remove any visible disease
if you remove cyst and final pathology shows borderline, then you should consult gyn onc regarding possible reoperation to remove affected adnexa with possible staging vs surveillance

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11
Q

relapse rates of borderline with fertility sparing surgery

A

15% with unilateral oophorectomy
30% with unilateral cystectomy
Relapse is typically borderline not malignant

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12
Q

management of AGC (Atypical glandular cells)

A

Everyone gets colposcopy and ECC
endometrial sampling if : 35 and older, younger than 35 with risk factors for EIN/endometrial CA (obesity, chronic anovulation)

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13
Q

Colpo results for AGC/AIS
1) AIS or AGC/favor neoplasia
2) CIN2-3
3) <CIN2, no AIS
4) negative workup

A

1) CKC, ECC
2) manage via general guidelines - ckc preferred
3) co testing annually for 3 years
4) cytology and HPV in 12 and 24 months, then repeat co test in 3 yrs

if CKC and neg margins, fu in 12 and 24 months with cytology and HPV
if pos margins, hyst or repeat CKC (wants kids)

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14
Q

raloxifene and ospemifene and uterine cancer

A

raloxifene: not indicated in premenopausal women, does not increase risk of uterine cancer or bleeding
ospemifene: no increased risk at 52w of use, used for dyspareunia

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15
Q

Low risk vs high risk for radiation or now

A

Low risk:
grade 1/2, <50% myometrial invasion, <2 cm
High risk:
grade 2/3, outer 1/3 myometrial invasion (>50%), LVSI
if >70, radis if 1 RF, if 50+, 2 RF, all ages with all three

VAginal brachytherapy > whole pelvic radiation

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16
Q

what chemo regimen for endometrial CA

A

paclitaxel and carboplatin

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17
Q

Lynch syndrome genes

A

AD, defects in mismatch repair system
MLH1, MSH2, MSH6, EPCAM, PMS2
results in microsatellite instability

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18
Q

which cancers does lynch syndrome put you at risk for

A

Colon- 18-61%
Endometrial - 16-61%
Ovarian 5-10%
also gastric, small bowel, hepatobiliary, renal, ureter

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19
Q

colon cancer screening with lynch syndrome

A

colonoscopy q1-2 years at 20-25 yo, or 2-5 years before earliest diagnosis in family. Whichever is first

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20
Q

endometrial cancer screening with lynch syndrome

A

EMB every 1-2 years, beginning at 30-35yo (or 10 years before earliest lynch associated CA)
monitor for signs of AUB
consider hyst/bso when in mid 40s or done with childbearing

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21
Q

chemoprevention for colorectal CA for lynch

A

600 mg ASA daily x2 years decreases colorectal CA

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22
Q

BRCA 1 and BRCA2
associated cancers
inheritance

A

AD. Tumor suppression genes that encode proteins that function on DNA repair
BRCA1 or BRCA2: breast cancer 45-85%
BRCA1: ovarian cancer 39-46%
BRCA2: ovarian cancer 10-27%
Ovarian cancer is usually high grade serous or endometrioid

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23
Q

Breast cancer screening for BRCA carriers

A

25-29: clinical breast exam q6-12 mo, annual MRI with contrast
30+: annual mammogram and MRI, alternating every 6 months

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24
Q

ovarian CA screening for BRCA

A

TVUS or CA125 may be reasonable for short term surveillance at 30-35 yo until risk reducing surgery

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25
Q

other associated Cancers with BRCA1/2

A

Brca1: high grade histology for endometrial cancer
Brca2: pancreatic, melanoma, prostate

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26
Q

BRCA1 vs BRCA2

A

BRCA2: more associated with hormonal positive breast cancer. Tamoxifen more likely to reduce risk of in breast cancer. Onset of ovarian cancer also later

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27
Q

risk reducing agents for BRCA

A

OCPs reduce risk for ovarian cancer 33-80% in brca1, 58-63% in brca 2
Tamoxifen reduces risk of breast cancer in brca2 by 62%
Raloxifene - limited data for brca patients

28
Q

Risk reducing BSO for BRCA
Age it should be done
rate of reduction
how to perform it
how to treat sx after

A

BRCA1: 35-50 yo
BRCA2: 40-45 yo
Reduces risk of ovarian CA by 80%, breast cancer by 37-100%
(risk for breast CA is reduced only if premenopausal at time of surgery)
Look at all surfaces, get washings
isolate and ligate ovarian vessels 2 cm proximal to end of ovarian tissue. get tubes at cornua if no hyst, remove ovary at uteroovarian lig as close to uterus as possible
ok to use HRT (if no breast CA) to mitigate effects of early menopause for a few years, does not sig diminish protective effect of BSO. However long term effect on breast cancer is unknown

29
Q

risk reducing BS for BRCA

A

doesn’t help decrease risk of breast cancer.
Can reduce risk of ovarian cancer by up to 65%

30
Q

risk reducing mastectomy for brca

A

bilateral mastectomy reduces risk by 85-100%

31
Q

evaluation of breast mass if
<30
>30
abnormal imaging results

A

<30: breast US
-solid: tissue bx or US q6-12mo
-simple cyst: routine fu if asx or aspirate if sx
-complex cyst: observe, aspirate or bx
-no abnormality: observe, CBE q3 mo, or regualr imaging or dx mammo if suspicion is high
>30: diagnostic mammo, ultrasound if birads 1-3 or biopsy if birads 4-5
options for bx: FNA, core needle, excisional

32
Q

management of simple cyst, birads 2

A

observation, aspiration only if symptoms

33
Q

management of non simple breast cyst

A

observation, aspiration or biopsy
core needle if birads 4-5
birades 1-3: punch biopsy

34
Q

Examples of
non proliferative
proliferative without atypia
atypical hyperplasia
lobular carcinoma in situ

A

non proliferative: simple cyst, mild hyperplasia, apocrine changes
proliferative: fibroadenoma, intraductal papilloma, sclerosing adenosis, radial scar
atypical ductal hyperplasia: atypical ductal hyperplasia, atypical lobular hyperplasia
LCIS

35
Q

lifetime breast CA risk

A

1/8 (12%)

36
Q

atypical ductal hyperplasia

risk reduction

Screening

A

increased risk of invasive cancer in affected breast and contralateral breast. or DCIS. 10-20% of time on surgical excision
risk reduction therapy strongly recommended
Tamoxifen (pre or post menopause)
raloxifene (post menopause)
aromatase inhibitors (post menopause)

annual mammo if >30
clinical breast exam q6-12 mo
breast self awareness
annual MRI if AH/LCIS and lifetime risk of breast ca >20-25%

37
Q

lobular carcinoma in situ

A

increased risk of invasive cancer in affected breast and contralateral breast. or DCIS. surgical excision.
rec risk reduction
tamoxifen (pre or post menopause)
raloxifene (post menopause)
aromatase inihibitors (post menopause)

38
Q

MC cause of bloody nipple discharge

A

benign intraductal papilloma

39
Q

MC solid breast mass

A

fibroadenoma
Repeat imaging in 3-6 months
Can do core bx
If increases in size or sx- excision

40
Q

Paget dz of breast

A

associated with underlying intraductal carcinoma 85% of the time- invasive or in situ

41
Q

outline BIRADS
Liklihood of CA and plan

A

0: incomplete, need additional imagig
1: negative, risk of CA 0%, routine
2: benign, risk of CA 0%, routine
3: probably benign, risk of cancer >0 but <2%, short interval (6 mo) fu
4: suspicious
4A: low, risk is 2-9%, tissue dx
4B: moderate, risk is 10-49%, tissue dx
4C: high risk, 50-94%, tissue dx
5: highly suggestive of CA, risk is 95-100%, tissue dx

42
Q

partial vs complete mole

A

partial: 69 XXX or XXY, fetal parts can be present, uterine size: SGA, GTN risk <5%, theca lutein cysts are rare
compelte: 46 XX or 46 XY (all [paternal), fetal parts absent, LGA, GTN risk 15-20%, theca lutein cysts are common

43
Q

Management of suspected or confirmed molar pregnancy

A

surgical evacuation (D&C, suction and sharp) or hyst if done with childbearing
rhogam if rh neg
iv oxytocin
contraception during monitoring period
HCG weekly until negative
partial mole: weekly until three consecutive neg, then monthly for one month
complete mole: weekly until three consecutive neg, then monthly three months

44
Q

suspected GTN after molar pregnancy

A

levels plateau
HCG, CBC, LFTs, TSH, type and screen US, CXR, CT abdomen and CT or MRI brain
if HCG is >100k, get TSH

45
Q

what patients need what kind of chemo for GTN

A

if high risk (score 7+, need combo chemo) EMACO (etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine)

if low risk (0-6) single agent chemo (MTX or actinomycin D)

46
Q

risk of molar pregnancy
baseline
one prior
two prior

A

baseline: 1:1000
1 mole: 1-2%
2 moles: 15-18%

47
Q

how to diagnose GTN

A

hcg plateau (within 10%) for 4 consecutive values over 3 weeks
hcg rise of>10% for 3 values over 2 weeks (day 1, 7, and 14)
hcg persistence for 6 months after molar evacuation
histopathology dx of choriocarcinoma
presence of metastatic dz

48
Q

risk factors for molar pregnancy

A

AMA, extremes of age
prior molar pregnancy
Asian ancestry

49
Q

dosing schedule for HPV vaccine

A

9-26 yo , approved to 45 yo now
3 shots (0, 2, and 6 months; if start before 15 yo, just 0 and 6 months)
contraindicated in preg, ok for nursing moms
covers HPV 6, 11, 16, 18, 31, 33, 45, 52, 58

50
Q

when to perform ECC

A

colposcopy is unsatisfactory
contemplating ablative therapy
if pap shows ASUS-H, HSIL, AGS or AIS

51
Q

Medical treatment options for endometrial cancer

A

Only by gyn Onc
Medroxyprogesterone or megestrol
Progesterone IUD
Emb every 3 months. Recurrence in 50% once treatment discontinued

52
Q

Most common causes of cancer death in US women

A

Lung
Breast
Colon
Pancreas
Ovary

53
Q

MC cause of cancer
1) death worldwide
2) gyn cancer death worldwide
3) pelvic cancer world
4) pelvic cancer US
5) pelvic cancer death ISA

A

1) lunch
2) breast
3) cervix
4) uterus
5) ovary

54
Q

poor prognostic factors for GTN

A

pre therapy HCG >40k
long duration (>4 mo) from antecedent pregnancy
antecedent preg was term preg
brain or liver mets
prior chemo

55
Q

Types of gestational trophoblastic neoplasia (GTN)

A

invasive mole
choriocarcinoma
placental site trophoblastic tumor
epithelioid trophoblastic tumor

56
Q

genetics of complete mole and partial mole

A

complete mole: fertilization of an empty egg by haploid sperm that then duplicates OR empty egg fertilized by two sperm. Completely paternal in origin.

partial mole: fertilization of an ovum (one set of haploid maternal chromosomes) by two sperm (two sets of haploid paternal chromosomes). triploid.

57
Q

Management for AIS

A

When diagnosed on colpo:
if done with childbearing- hyst preferred.
Or CKC (preferred bc of skip lesions)
if CKC returns invasive cancer- onc referral for hyst vs radiation

58
Q

management of Stage 1A1 cervical CA

A

microinvasion, penetrates BM, little to no risk of nodal involvement
CKC if desires fertility
hyst if done with childbearing
trachelectomy if fertility is desired

59
Q

management of stage Ia2 cervical CA

A

modified radical hysterectomy
(uterus, cervix, parametria (where uterine crosses ureter), upper 1/4 vagina) with plevic LN lymphadenectomy
-vaginal radical trachelectomy if desires fertility and pelvic lymphadenectomy

60
Q

management of stage IB-IIA cervical CA

A

radical hyst + PLND + chemoradiation or primary chemorads

61
Q

stage IIB-IVA cervical CA

A

curative intent chemoradiation

62
Q

how does rupture of ovarian mass in surgery change management for ovarian CA

A

1c1: surgical spill
1c2: capsule rupture before surgery
1c3: ascites or positive washings
Stage 1c or higher, high grade, get chemo
don’t need chemo if stage 1a or 1b or low grade (1-2)

63
Q

chemotherapy for germ cell tumors

A

BEP
bleomycin
etoposide
cisplatin

64
Q

types of germ cell tumors

A

dysgerminoma (LDH) - mc malignancy dx in pregnancy
teratoma (immature is CA) (AFP, LDH, ca125)
endodermal sinus (AFP, shiller duval bodies, rosettes)
choriocarcinoma (BHCG)
Embryonal carcinoma 9bHCG, AFP)
adolescent women

65
Q

types of sex cord stromal tumors

A

benign: fibroma, thecoma
malignant: granulosa cell (estrogen, inhibin B, call exner bodies)
steroli leydig (testosterone)

Abog oral boards (17 decks)

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