Gyne Onc Flashcards
What is the 5 year overall survival rate of ovarian cancer?
40 %
What is the lifetime risk of developing HGSC of the ovary, fallopian tube or peritoneum with BRCA1 ?
60 %
What is the lifetime risk of developing HGSC of the ovary, fallopian tube or peritoneum with BRCA2 ?
30 %
What is the % risk reduction of prophylactic BSO in BRCA + patients for ovarian ca?
80 - 90 %
What is the ovarian cancer risk reduction per year associated with OCP use ?
And lifetime risk reduction ?
Risk reduction per year: 5 - 8 %
Lifetime risk reduction: 50 % (in women taking OCP > 10 years)
What are the two typical mutations of HGSC
p53
Ki-67
What is the frequency of BRCA mutations in HGSC
30 - 50 %
What is the ovarian cancer yearly risk reduction with OCP?
And life time risk reduction?
Yearly : 5-8 %
Lifetime risk: 50 % if taken > 10y
What types of ovarian cancers are reduced with OCP use?
Serous and endometrioid
Mucinous is increased
What is the effect of opportunistic oophorectomy ?
↑ All call mortality (12%)
↑ risk of stroke and CVD (x2 for CVD)
↓ Ovarian cancer death by 94 %
Does progestin only pills have an impact of ovarian cancer risk?
NO
What is the % risk reduction of prophylactic BSO in BRCA + patients for breast ca?
40 - 50 %
What is the life time risk of getting endometrial ca?
(#291)
2.6 %
When and how should you screen a patient with HNPCC?
(#291)
Yearly endometrial biopsy
Start at :
- Age 30-35 or
- 5-10 years before the youngest age at which a familly member was diagnosed
Screen for ovarian cancer as well
What percentage of endometrial cancers are sporadic?
Hereditary ?
(#291)
s: 90 %
h: 10 %
What is the most common genetic predisposition to endometrial cancer?
(#291)
HNPCC
Other cancers:
Breast
Ovarian
Colon
What is the incidence of vulvar cancer ?
(#370)
1-2/ 10 000
Younger: HPV related
Older: non HPV related - Lichen
What is the most important prognostic factor in vulvar cancer?
(#370)
Lymph node status
Describe an appropriate vulvar biopsy
(#370)
Minimum 4 mm diameter
Full thickness skin
Some underlying subcutaneous fat
Describe stage 1A vulvar cancer
(#370)
Tumor confined to vulva / perineum
= 2 cm in size
= 1 mm stromal invasion
What is the treatment of stage 1A vulvar cancer?
(# 370)
WLE with macroscopically clear margins
NO LN assessment necessary
What is the treatment for stage 1B vulvar cancer?
(#370)
Radical WLE including urogenital fascia
Ipsilateral LND if > 1cm from mi
What are the conditions to perform sentinel LND vs complete LND in vulvar cancer
Unifocal tumor
< 4 cm tumor in widest diameter
SCC
No clinically suspicious / palpable nodes
What is the detection rate of inguinofemoral sentinel LN with a combination of radioactive and blue die?
87 %
What are the indication for adjuvant RTx in vulvar cancer?
(#370)
1- Inguinofemoral lymph node involvement:
Any macrometastasis (>/= 5 mm)
> 2 micrometastases (< 5mm)
Any capsular involvement
2- Close or positive margins if re-operation impossible/ morbid
=10 mm on fresh pathology OR = 8 mm on fixed
Pelvic and inguinal RTx
What is the most important predictor of local recurrence of vulvar SCC ?
(#370)
Positive margins
(< 8 mm in formalin and 10 mm in fresh)
What are the names of the chemos used for Vulvar SSC?
(# 370)
Cisplatin
Mitomycin C
5- Flurouracil
Paclitaxel
Isosfamide
What chemo can cause pulmonary fibrosis and what is it used for?
(# 370)
Bleomycin
Used for SCC of vulva, germ cell tumors and
Hodgkin lymphoma
What is the recurrence rate of SCC of the vulva?
(# 370)
12- 37 %
When does SCC of vulva relapse?
(#370)
Most in the first 2 years
35 % after 5 years
In SCC of the vulva, LN status is the strongest predictor of : (3)
What are other recurrence RF (6)
(# 370)
Overall survival
Disease site recurrence
Metastatic disease
Clinical cancer stage
Tumor size
Depth of invasion
LVSI
Advanced age = poor prognosis
HPV related disease = better prognosis
In SCC of the vulva, does HPV + confer a better or worse prognostic?
(#370)
Better
List germ cell tumors (5)
- Dysgerminoma
- Yo lk s a c
- Embryonal carcinoma • Choriocarcinoma
- Teratoma
List sex cord stromal tumors (6)
- Granulosa cell
- Thecoma
- Fibroma
- Sertoli cell
- Sertoli-Leydig
- Steroid
Most common germ cell tumor?
Mature cystic teratoma = dermoid cyst
What is the most common ovarian malignancy detected in pregnancy?
Dysgerminomas
What are gonadoblastomas ?
Benign germ cell neoplasm that can undergo malignant transformation to dysgerminoma
Which type of germ cell malignancy can be bilateral and what is the % ?
Dysgerminomas - 15-20 %
What is patognomonic of yolk sac tumors?
Schiller-Duval bodies
Which tumor is the most immature of all teratomas?
Polyembryomas
Which malignant germ cell tumors have the best and the worse prognosis?
Best: dysgerminomas
Worse: Yolk sac tumors
In a mixed cell ovarian tumor, which component of the turmor determines the prognosis?
Non- dysgerminoma
What is the most common ovarian malignant germ cell tumor?
Immature teratomas
If a mature teratoma underwent malignant transformation, what histology would it be?
Squamous cell carcinoma
What is the only ovarian cancer that can benefit from excision of chemorefactory lesions?
Immature teratomas
What are the standard chemo agents used to treat germ cell tumors?
(BEP)
- Bleomycin
- Etoposide
- Cisplatin
How do you calculate the RMI score and what score is high?
(#230)
US score x menopausal status x Ca125
> 200
Describe the US features used in the RMI score
- Multilocular cyst
- Solid areas within the cyst
- Bilaterality
- Presence of ascites
- Presence of abdominal metastases
How do you surgically stage ovarian cancer?
(#230)
- Hyst + BSO
- PLND + PaLND
- Infracolic omentectomy
- Pelvic washings
- Resection of peritoneal implants / Bx of peritoneum
- Diaphragmatic scraping bilateral
What percentage of serous ovarian cancer are caused by a hereditary mutation?
10 - 15 %
What percentage of breast cancers are caused by a hereditary mutation?
5 - 10 %
% chance of breast Ca with BRCA1?
36 - 53 % lifetime risk
% chance of breast Ca with BRCA2?
11 - 25 %
% chance of ovarian cancer in general population?
1.5 - 1.8 %
For which hereditary breast cancer is pregnancy and lactation protective?
BRCA1 only
At what age should RRSO be done in BRCA 1 and BRCA2 patients?
BRCA1: 35 - 40 yo
BRCA2: 40 - 45 yo
If diagnosed post menopause, still so RRSO
* BRCA2, for breast Ca reduction: before age 50
I which population with hereditary breast cancer diagnosed, is RRSO beneficial?
What is the effect?
(#366)
BRCA1
Specifically in triple negative BRCA1
Mortality reduction by 73%
What is the risk of endometrial cancer in a 70yo with PMB?
(#291)
50%
What are the technical aspects of an RRSO?
(#366)
- Tube transected at the intramural portion of the cornua, and the remnants cauterized
- IP taken 2 cm away from ovary
- Specimen removed in an endoscopic bag to prevent seeding
What is the strongest risk factor for endometrial cancer ?
(#291)
Lynch syndrome (22-50% lifetime risk)
Obesity (RR = 10)
Unopposed estrogen replacement (RR 2-10)
Tamoxifen use (RR 6-8)
390: BMI > 30
What is the rate of concurent endometrial cancer in patients with atypical hyperplasia = EIN?
(#291)
40 %
What percentage of EMB pre-operative grade 1 endometrial tumors are upstaged with final pathology?
(#291)
30 %
What are the indications of a D+C rather than an EMB for assessment of the endometrium ?
(#291)
- Non diagnostic office EMB in high risk patients when underlying cancer is suspected
- Benign EMB and persistent bleeding
- Insufficient material on EMB and thickened endometrium on US
- Impossibility of doing office EMB
What is the significance of atypical endometrial cells on a PAP smear?
(#291)
Up to 25 % have concomittent endometrial cancer
May be prognostic for nodal metastases
Describe the minimum investigations required pre-op endometrial cancer (8)?
(#291)
CBC
Coagulation (Clotting time)
Electrolytes
Creatinine
Liver function test
Urinalysis
CXR
EKG
What is the rate of progression to endometrial cancer of endometrial hyperplasia without atypia ?
(#390)
1-3%
Which of the 2 confer the highest risk for endometrial cancer
- Abnormal uterine bleeding
- Intermenstrual bleeding?
(#390)
Intermenstrual bleeding
What are the indications for EMB (4) ?
(#390)
PMB
Age > 40 with AUB
AUB not responding to treatment
Age < 40 with risk factors
What are the medical options for treatment of non-atypical hyperplasia?
(#390)
- IUD = first line (effectiveness and good side effect profile)
- Oral progestins
- MPA (Provera) – continuous or cyclic
- Progesterone (Prometrium) – continuous
- Megestrol acetate (Megace) – continuous
- NETA (Norlutate) – continuous or cyclic
- Depo-Provera
- Aromatase inhibitors (Letrozole) in pre + post menopausal
What percentage of the endometrial cavity does the pipelle sample?
(# 390)
Pipelle < 50 %
How should you follow a patient being treated for endometrial hyperplasia without atypia?
(#390)
Endometrial biopsy
- 3 months after onset of treatment
- 3 weeks after end of treatment
q 3-6 months if on treatment longer
Indications for surgical management of endometrial hyperplasia without/with atypia (6)?
(#390)
Progression to atypical hyperplasia or carcinoma during treatment (and no fertility issues)
Hyperplasia fails to regress after 12 months
Hyperplasia relapse after the end of treatment
Continue to have AUB despite treatment
Decline endometrial surveillance or medical treatment
How often is endometrial hyperplasia found in the background endometrium of a polyp with hyperplasia?
(#390)
52 % (with and without atypia combined)
If a polyp has atypical hyperplasia, what is the risk of concurent endometrial cancer?
(#390)
5.6%
Where does endometrial cancer metastasize?
(Figo corpus uteri)
Vagina
Ovaries
Lungs
What is the most important prognostic factor or endometrial cancer ?
(William p717)
Stage
Which immunochemical marker differentiates partial from complete mole ?
p57 positive in partial mole (throphoblast marker)
What is the risk of progression to GTN of partial and complete mole ?
(UpToDate)
Partial mole: 1 - 5%
Complete mole: 15 - 20%
How do you track beta in complete and partial molar pregnancies?
Partial mole:
- Weekly until 3 negative values
- Monthly x 1 negative value only
Complete mole:
- Weekly x 3 negative values
- Monthly x 3 months (vs previously 6 mo)
What are risk factors for complete and partial mole ?
Complete and partial
- Prior molar pregnancy (1 - 1.5% = 10-15 more than regular pop)
- SAB (> 2)
- Infertility
Complete mole only
- Extremes of age (<15, > 35)
- Deficiency of caroten (Vitamin A precursor)
What are the risk factors for GTN ?
(UpToDate)
Prior molar pregnancy
Age > 40
Asian or Indian ancestry
What are the risk factors for developing an invasive mole after a complete mole (3)?
(UpToDate)?
Pre D+C uterine size > dates
Beta hCG > 100 000
Bilateral theca lutein cysts
What is the most common clinical presentation of choriocarcinoma?
(UpToDate)
Bleeding from a metastatic site
Name the 4 most common metastatic sites for GTN
(UpToDate)
Pulmonary (80%)
Vagina (30 %)
CNS (10%) - Usually brain **
Liver (10%)
** Other CNS location = meninges
** All pts with CND mets have lung and vaginal mets
Which marker can be used to differentiate PSTT from ETT and in which entity is it higher?
(UpToDate)
Cyclin E
Higher in ETT
How do you follow low risk GTN and high risk GTN?
Low risk
- Weekly x until negative x 3
- Monthly x 12 months
High risk
- Weekly x until negative x 3
- Monthly x 24 months
What is the age distribution of Sex stromal tumors ?
(WG p 795)
Bimodal
- Pre pubertal → 30
- Age 50
What familial syndroms are sex cord tumors associated to?
Ollier disease –> multiple benign but disfiguring cartilaginous neoplasms
Peutz Jeghers syndrome –> Intestinal hartomatous polyps
Are sex cord tumors typically unilateral or bilateral ?
(WG p 797)
Unilateral
What are the 2 most common vulvar cancers
Squamous cell carcinoma (75)
Melanoma (2-10%)
What % of woment with PMB have endometrial Ca?
And PMB + endometrial thickness > 4 mm?
5-20 % (UpToDate)
20 %
List high risk oncogenic HPV
16 - 18
31- 35
45 - 51
56
What is the management of ASCUS or LSIL pap tests in pregnancy ?
(#284)
Repeat PAP test 3 months PP
(No referral to colpo needed according to SOGC. WG says ideal colposcopy)
What is the management of HSIL, AGC, ASC-H in pregnancy?
(#284)
Refer to colposcopy within 4 weeks
Take biopsies if suspicious
Monsel, silver nitrate, vaginal packing or suture are safe
What is the procedure after an unsatisfactory colposcopy in pregnancy?
(#284)
If done in T1 → repeat after 20 weeks (nature eversion of cervix)
Delay by 6-8 weeks (William’s OB)
How do you manage a confirmed CIN 2 or CIN 3 in pregnancy ?
(#284)
Delay management until 8-12 weeks PP (slow progression
