Gyn Onc Flashcards
Management of early stage cervical cancer in general
- Early stage cervical cancer.
Upfront surgery (cervical conization vs. modified radical vs. radial hysterectomy depending on stage) - ***Adjuvant chemoradiation if path indicates intermediate or high-risk of recurrence
Surgical management of stage I cervical cancer
IF IA1, conization w/ no further management if margins negative
IF IA2,
modified radical hysterectomy (removal of uterus, cervix, upper ¼ of vagina, and paramteria)
simple hysterectomy w/ lymphadenectomy (can get away with simple hysterectomy)
IF IB1, radical hysterectomy w/ lymphadenectomy
IF IB2, radical hysterectomy
First line for MMR deficient advanced endometrial
carbo/taxol/durvalumab w/ maintenance durvalumab until progression (DUO-E - PFS HR 0.42 in dMMR, OS immature)
*or dostarlimab w/ maintenace dostarlimab
Size threshold for surgery vs. CRT
4 cm (greater than 4 cm requires CRT)
CRT for cervical
weekly cisplatin w/ EBRT + brachytherapy
Indications for adjuvant chemoradiation in localized cervical
- positive margins
- node positive
- parametrial invasion
Metastatic cervical mgmt
IF PD-L1 positive, platinum/carboplatin + paclitaxel + pembro +/- avastin
IF PD-l1 negative, platinum/taxol and bev
endometrial cancer presentation
- pelvic pain
- change in bowel habits
*vaginal bleeding - discharge
endometrial cancer RF’s
- obesity
- HRT
- tamoxifen
- older age
- infertility
*endometrial hyperplasia
*PCOS
Management of complex atypical hyperplasia
hysterectomy
Lynch recommended endometrial cancer screening
- transvaginal US annually starting at age 30
*Risk reducing hysterectomy with BSO at 35 or after completing childbearing
endometroid significance with endometrial
- bread and butter, more common endometrial cancer
- nonendometroid is higher risk
Uterine serous cancer significance
- aggressive, “serious”
Stage 1A endometrial management in woman wishing to preserve fertility
- IF G1-2, hormone therapy with medrestol (oral progestin) can be used to preserve fertility
Stage II endometrial mgmt
upfront surgery / adjuvant full pelvic EBRT
Stage III-IV endometrial mgmt
- upfront surgery
- adjuvant chemo
*CRT also an option followed by chemo for Stage III
clear cell significance in endometrial
- aggressively behaving, requires systemic therapy
serous HER2+ endometrial cancer mgmt
- add herceptin to carbo/taxol
recurrent metastatic endometrial mgmt
IF treatment free interval of >6 months, retreat with carbo/taxol
Systemic therapy for uterine carcinosarcoma
ifosfamide or platinum-based therapy or taxol
low grade endometrial stromal sarcoma mgmt
- hormonal therapy medregstrol
leiomyosarcoma mgmt
surgery if resectable
stage IB cervical cancer mgmt
surgery with adjuvant brachytherapy (not full pelvic EBRT)
ovarian cancer presentation
- bloating
- pelvic or abdominal pain
- early satiety
- urinary symptoms
ovarian cancer RF’s
- obesity
- ## estrogen exposure (later pregnancy after age 35)
When germline BRCA testing is indicated in ovarian
All high grade ovarian
Ovarian cancer biomarker
CA-125
Stage I ovarian cancer mgmt
IF wishing to preserve fertility, salpingo-oophorectomy
general management of ovarian
upfront cytoreductive surgery w/ salpingo-oophorectomy and hysterectomy w/ adjuvant chemo
management of ovarian in nonsurgical patient
upfront systemic therapy
When adjuvant chemo is indicated in ovarian
1) Stage IC or higher (positive ascites or peritoneal washings)
2) G3
3) clear cell histology
Role of maintenance in ovarian
*Essentially PARP + avastin for anyone regardless of BRCA status if high risk for recurrence
*PARP if not high risk for recurrence
*So PARP maintenance for all and avastin if high risk for recurrence
niraparib SE
thrombocytopenia
Recurrent metastatic ovarian management
IF platinum sensitive, carbo/taxol +/- bev
*second cytoreductive surgery if possible
IF platinum resistant, liposomal doxorubicin + avastin
IF no trial, alternative chemo - docetaxel, pemetrexed, doxorubicin
sensitivity to immunotherapy in ovarian
- not very effective
serous ovarian low grade management
- AI
- MEK inhibitors
mucinous ovarian cancer mgmt
- GI regimens (platinum resistant), eg. mFOLFOX
ovarian dysgerminoma mgmt
- analogous to seminoma (BEP)
ovarian yolk sac (endodermal sinus) of ovary 1) characteristic path finding 2) mgmt
- schiller duval bodies
- adjuvant BEP
immature teratoma of ovary mgmt
- adjuvant BEP
granulosa cell tumor of ovary of mgmt
- upfront surgery
- BEP
sertoli-leydig tumor of ovary 1) presentation 2) mgmt
1) virilization (testosterone producing - opposite of male sertoli-leydig)
2) surgery w/ adjuvant BEP
Ethnicity with highest rising rate of endometrial cancer
Black
endometrial cancer RF’s
obesity
tamoxifen
Unopposed estrogen therapy
infertility
*PCOS (increased estrogen production)
Estrogen-producing ovarian tumors
Lynch genes mutated in majority of endometrial cancer pts
MLH1 + MSH2
Indication for MSI/MMR in endometrial cancer patients
All patients (universal screening)
Management of endometrial complex atypia
- treated as malignancy (high percentage have coexisting adenocarcinoma)
Management of endometrial in patients who aren’t surgical candidates
XRT
Adjuvant management stage I endometrial management
- indicated for high grade disease
- Brachytherapy vs. radiotherapy depending on depth of invasion (full pelvic if deep invasion)
Stage III endometrial mgmt
- cytoreductive surgery
- adjuvant chemo +/- XRT
Management of endometrial with isolated vaginal/pelvic recurrence
XRT
Later line for endometrial post chemo
Lenvatinib + pembro
When VEGF addition is indicated in endometrial
p53 mutation in recurrent metastatic disease
Targetable mutation for first line endometrial
HER2 for Serous endometrial
Localized carcinosarcoma mgmt
Surgery with adjuvant carbo/taxol (noninferior to ifosfamide and better tolerated)
Management of endometrial stromal sarcoma
Hormonal therapy (megestrol acetate) - hormone sensitive
Gyn malignancy assocaited with diethylstilbestrol (DES) exposure in utero
clear cell adenocarcinoma of the vagina and cervix
Preferred firstline systemic therapy for low grade endometrial stromal sarcoma
- AI
Olaparib SE to know
pneumonitis
Rucaparib SE to know
hepatotoxic
Management of ovarian cancer pt in surveillance with rising CA 125
- PET or CT
Components of surgical staging for ovarian cancer
- omentectomy, peritoneal biopsies, + lymph node sampling
Molecular profiling of endometrial
- MSI/MMR
*HER2
Status of HER2 in endometral
Added to systemic therapy in first line metastatic setting if HER2 positive
Management of stage II cervical cancer (extension beyond the uterus)
Concurrent chemoradiation (w/ EBRT), followed by brachytherapy
First line for low risk gestational trophoblastic neoplasm/choriocarcinoma
- single agent chemo with methotrexate or dactinomycin
first line for metastati uterine leiomyosarcoma
gemcitabine + docetaxel
Doxorubicine + trabectedin (Preferred)
1) RF’s for ovarian cancer 2) protective factor
1) Nulliparity and early menarche
2) OCP’s
Cervical cancer screening
High risk HPV test q 5 yrs (preferred) starting at age 25
- HPV + cytology cotesting q 5 years also an option
Management of locally advanced small cell carcinoma of the cervix
- CRT with cisplatin and etoposide, followed by 2 additional cycles of cisplatin/etoposide
*essentially the same as small cell of lung
Management of metastatic cervical with peritoneal carcinomatosis
- intraperitoneal cisplatin/taxol + IV taxol
Drug approved for ovarian with tumors expressing high levels of FOLR1
mivretuximab soravtansine
Tumor mutational profiling required for metastatic cervical cancer
PD-L1 (IO added to chemo for PD-L1 positive)
Gene mutation to know for granulosa cell tumors
FOXL2
Initial management of cervical cancer with pelvic wall extension and hydronephrosis
Concurrent CRT w/ platinum chemo followed by brachytherapy
Stage IA dysgerminoma management
Observation
Minimally invasive/robotic vs. open hysterectomy for small cervical tumors
open (minimally invasive associated with lower OS)
Recurrent metastatic cervical cancer management
same as de novo, platinum sensitivity doesn’t apply (CONFIRM)
