GYN Oncology Flashcards
When should you stop ordering mammograms?
No consensus - most groups say after 70-75 reasonable to stop if patient wants, but should discuss with patient. You should still offer every year if patient has life expectancy of 10 more years and wants to do it
What are some high risk screening groups for breast cancer? When do you screen them?
BRCA1,2, PTEN mutation (Cowden), P53 (Li Frameuni), hx of thoracic/chest radiation, >20% lifetime hx of breast cancer
LCIS/atypical breast hyperplasia
Annual breast MRI + mammo, clinical breast exams twice per year, start 10yr before earliest relative OR 25yo
Describe the BIRADS classification system
0 - additional imaging needed 1 - negative 2 - benign 3 - likely benign but short term f/u needed usually in 6 months 4 - suspicious, should consider biopsy 5 - highly suggestive of malignancy
What are prognostic factors for breast cancer? What factors determine adjuvant treatment?
Nodal status and tumor size
Others: hormone receptor status, oncogene expression
Side effects of tamoxifen; when do you do US and endometrial biopsy?
VTEs, hot flashes, endometrial hyperplasia
REDUCTION of fractures
No benefit of surveillance US
All AUB/PMB should receive endometrial biopsy REGARDLESS of endometrial thickness
What are AIs? How do they work? What are some examples? Who are candidates? What are their side effects? Do they work better than tamoxifen
Aromatase inhibitors - block aromatase which converts androstenedione to estrone
Examples - letrozole and anastrazole
Patient NEEDS to be post-menopausal
Side effects: hot flashes, INCREASED fracture risk and arthralgias
NO VTE risk
**Patients on letrozole should have yearly DEXA scans
Yes, better survival than tamoxifen for ER+ breast cancers
What are the three broad categories of ovarian cancer?
- Epithelial –> Type 1 (papillary serous), Type 2 (endometrioid, clear cell)
- Sex cord (Leydig-Sertoli, granulosa)
- Germ cell (dysgerminoma, embryonal, yolk sac, choriocarcinoma, immature teratoma)
Differentiate between BRCA1 and BRCA2 (chance of cancer, chromosome location, recommendation of timing for BSO)
BRCA1 - chromosome 17, breast cancer 70%, ovarian cancer 40%, remove ovaries by 35-40yo after childbearing
BRCA2 - chromosome 13, breast cancer 70%, ovarian cancer 20%, remove ovaries by 40-45yo after childbearing
What are the various cancer risks for HNPCC? What are the screening/treatment guidelines?
Colon 70%, endometrial 40%, ovarian 10%
Start colonoscopies yearly at 25yo
Annual US, endobx, CA125 at 30-35yo
Hysterectomy/BSO in mid-40s when done w/ childbearing
GYN ONC referral guidelines for pre- and post- menopausal women
Pre-menopausal: CA125>200, first deg family relative w/ breast or ovarian cancer, ascites, evidence of mets
Post-menopausal: CA125>35, first deg family relative with breast or ovarian cancer, ascites, evidence of mets, fixed nodular pelvic mass
How do you treat an immature teratoma?
USO on affected side w/ surgical staging; stage IA grade I does not require adjuvant therapy, every other stage needs chemotherapy (BEP)
How do you perform correct surveillance on someone status post surgery for endometrial cancer?
Pelvic exam q3-6 months x 2 years, then every 6 months yearly (speculum and bimanual exam)
What are the Amsterdam criteria?
What are the Bethesda criteria?
Used to identify who should be screened for HNPCC
3 or more relatives with an HNPCC-associated cancer (colorectal cancer, or cancer of the endometrium, small intestine, ureter or renal pelvis);
2 or more successive generations affected;
1 or more relatives diagnosed before the age of 50 years
Bethesda - anyone with CRC under 50yo should be screened for Lynch syndrome
Differentiate a partial and complete mole (villous edema, fetal tissue presence, karyotype, risk of GTN cancer)
Partial - contains fetal tissue, 69-XXX, 69-XXY, or 69-XYY (TRIPLOID), lower risk of malignancy, focal/less villous edema
Complete - no fetal tissue, DIFFUSE villous edema, normal karyotype (46XX, 46XY - all chromosomes are paternally derived), has a very high malignant potential
What are some 4 point values for the WHO criteria?
What is considered a low risk and high risk number?
Interval of >13mo from index pregnancy, pre-treatment HCG of >100,000, brain/liver mets, mets > #8
Low risk score < 6; single agent chemo
High risk score >= 7, multi agent chemo
What three criteria can establish a post-molar pregnancy GTD diagnosis?
- HCG plateau of 4 values recorded over a 3 week duration
- HCG increase by >10% of 3 values over a 2 week duration
- Persistence of a detectable HCG for more than 6 months after molar evacuation
Which post-menopausal vulvar conditions have malignant potential?
Lichen sclerosus –> can become a squamous cell carcinoma (5% risk of malignancy)
Consider biopsy if resistant to treatment
How do you treat vulvar basal cell carcinoma? Vulvar melanoma? VIN? Paget’s disease of vulva?
Basal cell - wide local excision 1cm margins
Melanoma - radical local excision depending on thickness of the lesion
Low grade VIN without concern for occult invasion - excision, laser, topical imiquimod
High grade VIN - always treat w/ wide local excision or partial simple vulvectomy
Paget’s disease - wide local excision
What do you do for the following pap results: Cytology negative (HPV unknown) ASCUS cytology alone ASCUS cytology and HPV negative Cytology negative and HPV negative Cytology negative and HPV positive
Screen in 3 years
Can repeat cytology in 1 year OR do reflex HPV testing
Cotest in 3 years
Cotest in 5 years
Can do HPV typing and if 16/18 do colposcopy OR cotest in 1 year
When do you continue paps after a hysterectomy? For how long?
If patient has history of CIN2/3 or AIS - continue paps for 25 years (CYTOLOGY ALONE, no HPV testing - not validated)
When do you start HIV+ pap screening? How often do you perform paps?
Within 1 year of sexual activity OR by age 21yo (whichever first). Need to perform q1 year cytology testing; if consecutively negative for 3 years then can f/u q3 year
Describe the new nomenclature for cervical cancer squamous cells and glandular cells
LSIL - HPV effect, ASCUS, LSIL
HSIL - ASC-H, HSIL, CIS
Glandular cells - AGC, AIS , adenocarcinoma
CIN2 is now LSIL if p16 neg and HSIL if p16 positive
Which genes are involved in HPV expression and how do they lead to cervical cancer?
E6 inhibits p53 which normally causes cell death
E7 binds to Rb protein and increases cell proliferation
Young women (21-24yo). How do you manage the following:
1) ASCUS
2) ASC-H
3) LSIL
4) HSIL
5) CIN2/3
Young women:
1) Repeat cytology in 1 year, colpo NOT recommended.
2) Colposcopy
3) Repeat cytology in 1 year, colpo not recommended
4) Colposcopy
5) Can observe with pap/colpo q6 months x 24 months
How do you manage AIS/AGC?
Would you prefer LEEP or CKC for these, and why?
Pap/ECC
Endometrial biopsy if >35yo
CKC preferred for management (fewer positive margins)
How do you manage LSIL?
LSIL for 25yo+ can go straight to colpo since >75% of LSIL is HPV+
For LSIL with cotest HPV neg - reasonable to repeat cotest in 1 year; if no cotest go straight to colpo
For 21-24yo, repeat cytology in 1 year (preferred) *high rate of regression
You perform a LEEP for CIN2/3 and margins are negative - what is the followup? What if margins are positive?
Negative - cotest in 6 months
Positive - colpo/ECC at 4-6 months OR consider re-excision
What is the dosing schedule for Gardasil? Is it recommended for breastfeeding and/or lactating moms?
<15yo two doses (0, 6-12mo)
>15yo three doses (0, 2, 6mo)
Not recommended in pregnancy but acceptable for lactating moms
What is is the definition of microinvasive cervical cancer? (IA1 vs IA2). How do you manage when patient wants to preserve future fertility?
Stromal invasion <3mm and lateral spread <7mm (IA1) - can manage with simple hysterectomy
(CKC for pregnant)
IA2 - stromal invasion 3-5mm and lateral spread <7mm - can manage with radical hysterectomy
(trachelectomy for pregnant)
When do you perform colposcopy in pregnancy? When is it not indicated?
LSIL, ASC-H, HSIL - needs colpo in pregnancy
ASCUS or HPV+ alone can defer until postpartum
Differentiate Type 1 vs Type 2 uterine cancers
Type 1 - endometrioid, younger age, ER/PR+, unopposed estrogen, PTEN mutation common
Type 2 - papillary serous, ER/PR neg, older age, worse prognosis, no relation w/ estrogen, P53 mutation
How do you define cytoreduction?(complete, optimal, suboptimal). What is the adjuvant treatment?
Complete - no residual disease
Optimal - <1cm residual disease
Suboptimal - >1cm residual disease
All get carbo/taxol however for optimal you can consider IP over IV chemo
Describe cervical cancer staging and treatment. What are the fertility sparing options for treatment?
IA1 - <=3mm stromal invasion IA2 - 3-5mm stromal invasion 1B1 - visible tumor <2cm 1B2 - visible tumor 2-4cm IB3 - visible tumor >4cm
IA1 can get simple hysterectomy, everything else needs radical hysterectomy
For fertility sparing - 1A1 can get CKC and 1A2 and 1B1 can get radical trachelectomy
How do you treat placental site trophoblastic tumors? What is the associated tumor marker?
Hysterectomy; human placental lactogen
How do you categorize ovarian cancer recurrence?
Platinum sensitive (>6mo disease free interval) Platinum resistant (<6mo disease free interval) Platinum refractory (progression of disease during primary treatment)
How do you treat C-diff infection?
Mild/moderate (WBC < 15K, Cr <1.5) - PO flagyl only
Severe (WBC >15K, Cr>1.5) - PO vanco
SEVERE and complicated (hypotensive, shock, megacolon, ileus, etc) - vanco + flagyl
What do you do in patients with AGC whose initial evaluation is all NEGATIVE
If AGC NOS - Cotest at 12 and 24mo
If AGC favor neoplasia - CONE
How do you manage AIS
Excise with CKC to rule out invasive cancer
- If patient has completed childbearing, ALWAYS perform hysterectomy (the CKC will help determine which kind of hysterectomy)
- If patient desires fertility and has negative margins and negative ECC, then can consider cotest/colpo and ECC in 6 months
- If patient desires fertility and has either positive margins or positive ECC, then re-excise
