GYN ONC Flashcards
risk of vulvar SCC with untreated lichen sclerosus
2-5%
Fertility sparing management options for EIN
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
Uterine CA staging
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
what is comprehensive staging for uterine CA
remove uterus, adnexa (BSO), pelvic/para aortic nodes, pelvic washings
minimally invasive approach is standard
Chance of nodal spread that varies with stage and grade
3-5% with well differentiated, superficial disease
20% with poorly differentiated deeply invasive disease
When to do nodal dissection and peritoneal cytologies
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
who can you medically manage endometrial cancer for
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
Surveillance after surgery after endometrial CA
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
Tamoxifen use and endometrial CA
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
borderline tumor staging procedure
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
relapse rates of borderline with fertility sparing surgery
15% with unilateral oophorectomy
30% with unilateral cystectomy
Relapse is typically borderline not malignant
management of AGC (Atypical glandular cells)
Everyone gets colposcopy and ECC
endometrial sampling if : 35 and older, younger than 35 with risk factors for EIN/endometrial CA (obesity, chronic anovulation)
Colpo results for AGC/AIS
1) AIS or AGC/favor neoplasia
2) CIN2-3
3) <CIN2, no AIS
4) negative workup
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)
raloxifene and ospemifene and uterine cancer
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
Low risk vs high risk for radiation or now
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
what chemo regimen for endometrial CA
paclitaxel and carboplatin
Lynch syndrome genes
AD, defects in mismatch repair system
MLH1, MSH2, MSH6, EPCAM, PMS2
results in microsatellite instability
which cancers does lynch syndrome put you at risk for
Colon- 18-61%
Endometrial - 16-61%
Ovarian 5-10%
also gastric, small bowel, hepatobiliary, renal, ureter
colon cancer screening with lynch syndrome
colonoscopy q1-2 years at 20-25 yo, or 2-5 years before earliest diagnosis in family. Whichever is first
endometrial cancer screening with lynch syndrome
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
chemoprevention for colorectal CA for lynch
600 mg ASA daily x2 years decreases colorectal CA
BRCA 1 and BRCA2
associated cancers
inheritance
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
Breast cancer screening for BRCA carriers
25-29: clinical breast exam q6-12 mo, annual MRI with contrast
30+: annual mammogram and MRI, alternating every 6 months
ovarian CA screening for BRCA
TVUS or CA125 may be reasonable for short term surveillance at 30-35 yo until risk reducing surgery
other associated Cancers with BRCA1/2
Brca1: high grade histology for endometrial cancer
Brca2: pancreatic, melanoma, prostate
BRCA1 vs BRCA2
BRCA2: more associated with hormonal positive breast cancer. Tamoxifen more likely to reduce risk of in breast cancer. Onset of ovarian cancer also later
risk reducing agents for BRCA
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
Risk reducing BSO for BRCA
Age it should be done
rate of reduction
how to perform it
how to treat sx after
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
risk reducing BS for BRCA
doesn’t help decrease risk of breast cancer.
Can reduce risk of ovarian cancer by up to 65%
risk reducing mastectomy for brca
bilateral mastectomy reduces risk by 85-100%
evaluation of breast mass if
<30
>30
abnormal imaging results
<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
management of simple cyst, birads 2
observation, aspiration only if symptoms
management of non simple breast cyst
observation, aspiration or biopsy
core needle if birads 4-5
birades 1-3: punch biopsy
Examples of
non proliferative
proliferative without atypia
atypical hyperplasia
lobular carcinoma in situ
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
lifetime breast CA risk
1/8 (12%)
atypical ductal hyperplasia
risk reduction
Screening
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%
lobular carcinoma in situ
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)
MC cause of bloody nipple discharge
benign intraductal papilloma
MC solid breast mass
fibroadenoma
Repeat imaging in 3-6 months
Can do core bx
If increases in size or sx- excision
Paget dz of breast
associated with underlying intraductal carcinoma 85% of the time- invasive or in situ
outline BIRADS
Liklihood of CA and plan
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
partial vs complete mole
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
Management of suspected or confirmed molar pregnancy
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
suspected GTN after molar pregnancy
levels plateau
HCG, CBC, LFTs, TSH, type and screen US, CXR, CT abdomen and CT or MRI brain
if HCG is >100k, get TSH
what patients need what kind of chemo for GTN
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)
risk of molar pregnancy
baseline
one prior
two prior
baseline: 1:1000
1 mole: 1-2%
2 moles: 15-18%
how to diagnose GTN
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
risk factors for molar pregnancy
AMA, extremes of age
prior molar pregnancy
Asian ancestry
dosing schedule for HPV vaccine
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
when to perform ECC
colposcopy is unsatisfactory
contemplating ablative therapy
if pap shows ASUS-H, HSIL, AGS or AIS
Medical treatment options for endometrial cancer
Only by gyn Onc
Medroxyprogesterone or megestrol
Progesterone IUD
Emb every 3 months. Recurrence in 50% once treatment discontinued
Most common causes of cancer death in US women
Lung
Breast
Colon
Pancreas
Ovary
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
1) lunch
2) breast
3) cervix
4) uterus
5) ovary
poor prognostic factors for GTN
pre therapy HCG >40k
long duration (>4 mo) from antecedent pregnancy
antecedent preg was term preg
brain or liver mets
prior chemo
Types of gestational trophoblastic neoplasia (GTN)
invasive mole
choriocarcinoma
placental site trophoblastic tumor
epithelioid trophoblastic tumor
genetics of complete mole and partial mole
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.
Management for AIS
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
management of Stage 1A1 cervical CA
microinvasion, penetrates BM, little to no risk of nodal involvement
CKC if desires fertility
hyst if done with childbearing
trachelectomy if fertility is desired
management of stage Ia2 cervical CA
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
management of stage IB-IIA cervical CA
radical hyst + PLND + chemoradiation or primary chemorads
stage IIB-IVA cervical CA
curative intent chemoradiation
how does rupture of ovarian mass in surgery change management for ovarian CA
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)
chemotherapy for germ cell tumors
BEP
bleomycin
etoposide
cisplatin
types of germ cell tumors
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
types of sex cord stromal tumors
benign: fibroma, thecoma
malignant: granulosa cell (estrogen, inhibin B, call exner bodies)
steroli leydig (testosterone)
