ONC Flashcards
when to stop mammograms?
Consider stopping at 75. If otherwise healthy, can continue
Breast screening for BRCA, PTEN and P53 mutations, lifetime risk of 20%
twice yearly clinical breast exam
annual mammo at 10 years before earliest dx, but not before 25
annual breast MRI
Breast screening for hx of thoracic rads
start at 25 years old
clinical breast exam q6-12 months
annual mammo
annual breast MRI
What percentage of mammo miss breast cancer?
20%
Concerning features on mammo
mass
calcfications- 5 or more clustered is concerning
architectural distortion-skin changes
Patient has a breast cyst and FNA is performed. What features would require further work via bx?
mass is solid and you get no fluid.
fluid is bloodly
mass is persistent after aspiration,
lifetime risk of breast cancer
1 in 8
most common breast cancer histology
second most common
most common location of breast cancer
ductal carcinoma
infiltrating lobular carcinoma
upper outer quadrant
Risk factors for breast cancer
65+ yrs BRCA, Li-fraumeni, Cowden 2 or more 1st degree relatives with breast cancer dx at an early age biopsy confirmed atypical hyperplasia nulliparity menarhe <12, menopause >55 no breastfeeding post-menopausal obesity recent long term use of estrogen and progestin EtOH askenazi jewish heritage
inflammatory breast disease is what stage?
stage 3
Which patients are NOT candidates for breast conservation surgery
stage 3 and 4 dz his of rads pregnancy persistent margins family hx tumor greater than 5cm diffuse calcifications
Good prognostic factors for breast cancer
small tumor size, negative node, ER or PR positive
Breast CA adjuvant Therapy
- positive lymph nodes?
- Negative nodes, tumor <1cm?
- negative nodes, tumor >1cm?
- chemo, plus tamoxifen (if receptor positive), if post menopausal (tamoxifen plus aromatase inhibitor)
- consider tamoxifen if receptor positive. or nothing further
- tamoxifen if receptor positive with or without chemo, chemo is must if receptor negative.
What is DCIS?
treatment?
precursor to invasive breast cancer
mastectomy vs wide local excision with rads
How do you counsel patients on tamoxifen?
Risks: VTE, uterine cancer, fatty liver disease, vasomotor symptoms
Benefits: reduced risk of invasive breast cancer, but not in cancer deaths,
-reduced hip, radius, spine fractures
Can BRCA patients get HRT after having BSO?
yes! so long as they don’t have a history of breast cancer.
Letrozole inhibits the conversion of what to what?
workup before starting letrozole
androsteindione to estrone
BMD assessment with FRAX or DEXA and continue annual DEXA while on letrizole
Gest Troph Dz is comprised of GTN and benign molar pregnancy. What percentage is molar?
Of them, what percentage is partial vs complete?
Of GTN, name to metastatic types of disease?
80% benign mole
90% are complete mole, 10% partial
choriocarcinoma
placental site troph tumor
epitheliod troph tumor
Symptoms of a complete mole
hyperthyroidism, theca-lutein cyst
Preop molar pregnancy workup
Hcg TSH pelvic sono CBC PT/INR Type and screen CMP-renal and liver functions CXR- to rule of GTN as lung is the most common site of mets
What are the differences between partial and complete mole?
- Partial mole has fetal parts (normal ovum, fertilized with two sperm or diploid sperm).
- Complete mole-two sperm fertilize empty egg or one sperm fertilizes empty egg and duplicates it s DNA
- partial mole has focal villous edema abd trophoblastic hyperplasia
Partial mole is triploid
Partial mole has lower risk of GTN. Complete mole has 19% chance of invasive mole (aka nonmetastatic GTN)
Post op Molar follow up
HCG 48hrs after evacuation
weekly while elevated then monthly for 6 months
contraception to reduce the risk of a normal pregnancy causing a rise in hcg vs GTN
You are following a molar pregnancy. What hcg findings would make you suspicious for GTN?
- hcg plataeu over 4 values over 3 weeks (day 1, 7, 14, 21) +/- 10%
- > 10% rise over 3 values (day 1, 7, 14).
- Hcg +more than 6 months
rule out new pregnancy.
When to suspect phantom hcg?
low level plataeu hcg in blood
due to heterophilic antibody, check urine hcg to rule it out. antibody is not excreted in the urine
Which BRCA patients should get tamoxifen?
BRCA2 bc they are ore estrogen dependent
Risk of cancer with EIN?
40%
need ONC present for possible lymph node dissection
GTN workup
HCG CXR CBC CMP CT Head chest abd pelvis
Type of trophoblasts for Placental site trophoblastic tumor?
What is the tumor marker?
intermediate trophoblasts
human placental lactogen
Good prognostic factors in GTN
last pregnancy <4 months
low HCG titer <40k
no brain or liver mets
no prior chemo
WHO Staging system
What constitutes low risk?
= 6 which means they can have single agent chemo
GTN
- Patient has complete mole..You follow hcg but it plateaus over 4 values.
- you dx GTN.
- she gets CT H/A/P, CXR, CMP, CBC, Hcg.
- WHO score is <6 so she startes single agent chemo.
- HCG rises.
- What is our next step?
-change to other chemo agent
-consider TAH
-switch to EMA-CO
etoposide, methotrexate, actinomycin D, cyclophosphomide, vincristine
When to stop paps?
age 65, 2 prior negative HPV tests, 2 negative cotests, 3 negative cytology with the past 10 years. most recent test must be within the last 3-5 yrs
after total hysterectomy with no history CIN 2 or worse in the past 25 years
How do you manage ASCUS?
get HPV
If positive–> colpo
if negative–> repeat cotesting in 3 years
What should you do with the following results?
- cytology neg, HPV neg
- cytology neg, HPV pos
- repeat in 5 year
- cotest in 1 year or reflex to 16/18 and if positive-do colpo,
if negative for 16/18, retest in 1 year
You test for HPV alone, like the new guidelines say and your patient is HPV positive.
Next step?
get cytology
or if HPV 16/18 positive then do a colpo
How long do you keep doing cervical cancer screening in patients with a history of HSIL?
HPV with or without cytology every 3 years for 25 years
How to manage HSIL?
LEEP for everyone except if pregnant or age 21-24, then do colpo
ASCUS with +HPV and negative colpo.
next step?
repeat co test in 1 year.
if ASCUS with +HPV again, repeat in 1 year again.
if still ASCUS with +HPV for 2 years, then colpo again.
How to manage LSIL?
colpo, expect 21-24 then repeat cytology in 1 year
postmenopausal endometrial cells on pap?
Next step?
premenopausal endometrial cells on pap?
post-menopausal - EMB
pre-menopausal - do nothing
Atypical glandular cells
next step
<35
>35
Colpo/ECC for everyone
<35–>EMB if risk factors for endometrial cancer
>35–> EMB
Pap comes back with atypical endometrial cells.
next step?
emb and ecc, if negative, then do a colpo
Pap comes back with adenocarinoma in situ
next step?
colpo, ecc, emb
colpo comes back with adenocarcinoma in situ
next step?
refer to onc for CKC vs hyst.
colpo comes back with adenocarcinoma in situ.
CKC come back with positive margins.
next step?
simple hyst for those done with children
repeat cone with counseling for those who still want children, follow with Co-testing at 1 year
What are you looking for on colpo?
acetowhite changes,
abnormal blood vessels,
mosaicism (network of fine-caliber blood vessels),
area of punctation
How does lugols work?
stains glycogen so abnormal cells are pale
adequate colpo requires two things
see the whole cervix/lesion
see the squamocolumnar junction
What does LEEP stand for?
Loop electrosurgical procedure
Risks of preterm delivery after LEEP and CKC
CKC are 2.5 more likely to have Preterm delivery, low birth weight, and/or c/s.
LEEP 1.5 times more likely to have PTD.
LEEP path comes back with positive margins.
next step?
repeat pap and ecc in 4-6 months
Treatment options for cervical dysplasia
cryosurgery LEEP CKC Laser ablation Hysterectomy
How does gardasil work?
age for giving it?
how many doses?
can you get it while pregnant?
can you get it while breastfeeding?
vaccinates against the L1 virus like particles
9-45
2 dose if under 15, 3 if over 15
not while pregnant
okay while breastfeeding
Cervical Cancer staging
What stage can you do a cone?
1A1- nonvisible lesion with = 3 mm stromal invasion
simple hyst is okay as well.
Cervical Cancer staging
If the lesion is visible, it is at least what stage?
1B1
1B1 <2cm
1B3 >4cm
Cervical Cancer staging
If the patient has hydronephrosis, she is at least what stage?
3B
Cervical Cancer staging
What stages get rad hyst?
What if she wants future fertility?
IA2 thru 2A
nonvisible lesion with 3-5mm of invasion up through visible lesion in upper 2/3 of the vagina
radical trachalectomy for 1b1 and 1a2
Margins of a rad hyst
parametrial, pelvic lymph nodes, upper 2 cm of vagina
Who gets chemo/rads?
Stage II-4B
Consequences of DES exposure
cervico-vaginal clear cell CA congenital GU tract anomalies infertility, PTL, PTD CIN Vaginal adenosis HIgher risk of breast ca
-mammo and pap recommendations for pts with DES exposure
annual mammo
annual pap and colpo of cervix and upper vagina
Pt in her 40% with bartholins. next step?
must excise to rule out adenoma carcinoma
Vulvar cancer
If pt has inguinal lymph node mets, what stage is that?
What is the stromal invasion cut off for performing a lymphadnectomy?
stage 3
1mm
Vulvar skin cancer
counseling and treatment
basal cell
localized, rarely mets
treat with wide local excision of 1cm margin
Vulvar skin cancer
malignant melanoma
ABCD
asymetry
irregular borders
color variation
diameter >5mm
Vulvar skin cancer
malignant melanoma
treatment
Radical local excision
>1mm–> 1cm margin
1-4mm –> 2cm margin
> 4mm –> 3cm margin
excellent chance for cure
if pregnant, send placenta due to mets!
Which class of vulvar dysplasia is associated with lichen sclerosis
VIN differentiated type (dVIN) —>treat like high grade
other types are low-grade, and high grade
postmenopausal woman presents with genital warts.
next step?
biopsy because it could be vulvar dysplasia
Vulvar skin cancer
treatment
excision, can consider laser, or topical treatments if no concern for occult invasion
Pagets dz of the vulva
appearance
- red and velvety
- white islands of hyperkeratosis, cupcake frosting appearance
pruritis, will always have postitive margins
Pagets dz of the vulva
histologic findings after biopsy
large, round cells, pale cystoplasm, cells may be clustered giving an acinar appearance
stain for CEA and CK-7 to differentiate from melanoma
Pagets dz of the vulva
what screening tests would you recommend to this patient?
I recommend mammogram, colonoscopy, CT looking for GU tumors
Pagets dz of the vulva
treatment
wide local excision
Pap comes back with VAIN I
next step?
slow progressing, retest in 1 year,
colpo after 2 years
if persistent, can extend to retest in 2-3 years or refer for treatment with laser
Pap comes back with VAIN 2/3
next step?
refer for treatment
Pagets dz of the vulva
Where else can it manifest?
perianal, axilla
Ovarian Cancer
Types
Epithelial-clear cell, high grade serous, low grade serous, endometrioid, mucinous
Germ cell-dysgerminoma, endodermal sinus, embryonal, polyembryoma, choriocarcinoma, immature teratoma, (DEEP CT)
Sex cord stromal-sertoli-laydig, granulosa
metastic-GI
Most common type of ovarian cancer
high grade serous
Sex cord stromal
Granulosa cell tumor
age range
tumor markers
<30 and >60
inhibin (A and) B, AMH
secrete estrogen, but not monitored with estrogen, need EMB
call exner bodies-rosettes
coffee bean nuclei
Sex cord stromal
Sertoli Leydig tumor
age
tumor markers
treatment
20s and 30s
testosterone
oophorectomy in reproductive age women
hyst BSO if postmenopausal
-high survival
Germ Cell Cancer
dysgerminoma
tumor markers
treatment
LDH bhcg
leave other ovary and uterus in place if they look normal for all germ cell.
most common malignant germ cell tumor
Which epithelial ovarian cancer patients should get referred for genetic testing?
ALL women with epithelial ovarian cancer except mucinous
Germ Cell Cancer
immature teratoma
tumor markers
treatment
AFP
Ca 125
at least unilateral BSO.
if stage 1A grade 1 then no adjuvent therapy (BEP)
immature neural components determine the grade
Lynch Syndrome patients
routine screening
- colonoscopy q1-2 year starting at age 25
- annual UA to screen for GU cancers
- hyst BSO in early 40s after EMB
Germ Cell Cancer
endodermal sinus (yolk sac)
histology
tumor markers
treatment
Schiller-duval bodies, aggressive, rupture in abdomen with hemorrhage
AFP
unilateral BSO, responds to chemo and every needs chemo
Germ Cell Tumor
chemo regimen
BEP
bleomycin
etopiside
cisplatnin
What is the OVA1 test?
screening tool as to whether or not GYN ONC referral is needed pre-operatively
combines CA 125, transferrin, prealbumin, apolipoprotein AI, and Beta2 microglobulin
pre-menopausal >5 and post >4.4 call ONC
Epithelial ovarian cancer
chemo regimen
carboplatin and paclitaxal
Borderline tumors are precursors to what type of ovarian cancer
low grade serous
EIN = complex atypical hyperplasia
What about endometrial hyperplasia without atypia? Management
Weight loss
D+C
MRI
Progestin therapy for example
IUD
provera 30mg daily
EMB q 3 months
then surgical management
