PROLOG: Gynecologic Oncology Flashcards
FIGO Staging: Vaginal Cancer
What are the two main types of endometrial cancer?
-
Estrogen driven
- Generally occurs in younger women
- Result of atypia 2/2 estrogen hyperstimulation in anovulatory women
- Tumor is identified in a lower stage and grade
-
p53
- Independent of estrogen exposure
- Generally occurs in older females regardless of BMI
- More aggressive such as papillary serous or clear cell
- Tumor is identified in a higher grade and stage
Stage 1 Ovarian Cancer
Divided into 3 subsets
- Stage IA: involves tumor limited to one ovary or fallopian tube and no involvement of the ovarian capsule or malignant cells in the peritoneal washings or ascites
- Stage IB: involves tumor spread to both ovaries or fallopian tubes with no involvement of “ “
- Stage IC: involves tumor to one or both ovaries and is further divided into three sections
- IC1: surgical spill
- IC2: tumor ruptured before surgery or tumor on the surface of the ovary
- IC3: tumor cells in the ascites or peritoneal washings
What percentage of mature teratomas will subsequently develop into squamous cell cancers?
1%
A 70 yo pt found to have SCC of the vagina. The tumor is located in the anterior/proximal two-thirds of the vagina along the anterior wall. What is the first site of LNM?
Internal iliac lymphatic chain
45 yo pt presents for follow up for Stage IIA SCC of the cervix, s/p radical hysterectomy followed by vaginal brachytherapy. Physical exam with a 2 cm mass palpable at the top of the vaginal cuff without sidewall fixation. PET CT confirms 2 cm mass located in the midline pelvis that was not previously present. No evidence of metastasis to lymph nodes or more distant sites. Biopsy of mass confirms recurrence. MOST appropriate treatment?
Pelvic exenteration: en bloc resection of uterus, tubes, ovaries, parametrium (if present), bladder, rectum, vagina, urethra, portion of levator muscles > resection with a clear margin is achieved in 75-97% of cases
Women who develop central recurrence (vaginal apex or pelvis without side wall involvement) after primary RT or after surgery followed by RT, pelvic exent represents the only potentially curative option for local recurrence or persistent disease
Those who successfully undergo exent (negative margins and no metastatic disease) have ~50% chance of being cured; the remainder die of recurrent cancer
What option exists for patients who are not candidates for surgical resection via exent for recurrent cervical cancer?
Chemotherapy (palliative) with cisplatin (50 mg/m2, given IV every 3 weeks)
Studies show response rate of 38%
Staging of GTN
- Confined to uterus
- Extends outside uterus but limited to genital structures (adnexa, vagina, broad ligament)
- Extends to lungs, with or without genital tract involvement
- Extends to distant sites, including brain and liver
Women diagnosed with FIGO stage I, II, or III GTN have a survival rate approaching 100%.
Patient is coming in to office for follow up after a suction curettage for a complete molar pregnancy. She is doing well but wants to know the risk of another molar pregnancy after having this one. What is the recurrence risk of a complete molar pregnancy?
10-fold increased risk
The risk of repeat molar pregnancy after 1 prior mole is ~1%, which is about 10-20 times the baseline risk for the general population.
What is the MOST common cell type of epithelial ovarian cancer?
Serous histology is, by far, the most common type, occurring in up to 80% of cases of advanced ovarian cancer.
Advanced stage (III/IV) is the most common stage at diagnosis, unfortunately, and is best treated with optimal cytoreduction (<1 cm of visible tumor after surgery) and postop platinum-based chemotherapy for 6 cycles
Most patients receiving external beam therapy for cervical cancer will experience what complication?
Acute cystitis
Treatment Options of Cervical Cancer by Stage
Stage I
Treatment for Stage IB2, IIA, IIB, stage III, and stage IVA cervical cancer
If no surgical lymph node evaluation, then whole pelvic exent + radiation therapy with brachytherapy and concurrent weekly cisplatin chemotherapy
Preferred initial effective regimen to treat high-risk GTN
Etoposide, MTX, dactinomycin (actinomycin D), alternating with cyclophosphamide and vincristine (Oncovin)
EMA-CO
Secondary treatment usually involves bleomycin, etoposide, and cisplatin (BEP)
The HPV E6 oncoprotein directly binds cell cycle regulatory proteins, especially ___.
p53
Karyotype of partial mole and sonographic features
One maternal haploid set and two paternal haploid sets of chromosomes
Presence of a fetus and a thickened placenta
Causes of postop fever
Histological hallmark of serous endometrial carcinoma
Psammoma bodies: concentric rings of calcifications
Present in serous cystadenocarcinoma of the ovary, serous carcinoma of endometrium, other tumors of lungs, thyroid, and kidney
GTN is defined by the FIGO in a specific manner following a molar pregnancy. One of the following criteria must be met.
Definition of optimal debulking in ovarian cancer
Disease smaller than 1 cm left in the abdomen
What is the most common side effect of radiation therapy for cervical cancer?
GI: N/V in acute phase and diarrhea in late phase (2-3 weeks after radiation)
These conditions are generally management with supportive treatment.
Cervical Cancer Stage: I and II
Cervical Cancer Staging: III and IV
Radical hysterectomies are reserved for which stage cervical cancers?
Stage IB1 and nonbulky stage IIA tumors
The surgery can shorten the vagina, but it maintains its pliability and lubrication; this may be desirable for younger patients.
What is gestational trophoblastic disease?
Group of tumors that arise from trophoblastic cells > usually the result of an abnormal fertilization event
Molar pregnancy
Choriocarcinoma
Placental site trophoblastic tumor (PSTT)
Epithelioid trophoblastic tumor (ETT)
A 36 yo P2 patietn has a known BRCA2 mutation. She recently underwent a prophylactic BSO. By how much is her risk of epithelial ovarian cancer reduced?
80%
In patients with HNPCC, a risk-reducing BSO may reduce the incidence of epithelial cancer by to ___%?
100%
What is the risk of choriocarcinoma after a normal pregnancy?
1 in 30,000
Specifically, it occurs 2/3 of the time after a term pregnancy and 1/3 of the time following a SAB or termination.
When does routine screening for colon cancer cease?
What is the MOST common gynecologic cancer worldwide?
Cervical cancer
70 yo P3 postmenopausal, no bleeding, EMB 6 mm. Next step?
Routine care.
Work-up for thickened endometrial stripe in an asymptomatic postmenopausal woman is not well-defined.
Pathology and appropriate plan of treatment for placental site trophoblastic tumor
Pathology: Intermediate trophoblasts with few syncytial elements
Management: hysterectomy (resistent to chemo)
** slight elevation of HCG and human placental lactogen relative to the tumor mass **
Which HPV strain has the highest risk of carcinogenic potential?
16 (accounts for 60% of all cases worldwide)
18 (accounts for 15% of cases)
Vaginal cancer is unique in that it can spread by direct extension, lymphatically, and hematogenously. The location of the cancer in relation to the upper or distal portion of the vagina determines which lymphatics will drain the site.
Breast Cancer Screening
Management of invasive cervical cancer in pregnancy
Neuronal injuries associated with pelvic surgery
- Ilioinguinal/iliohypogastic (L1–2)
- Genitofemoral (L1–2)
- Lateral cutaneous femoral (L2–3)
- Pudendal (S2–4)
- Obturator (L2–4)
- Femoral (L2–4)
- Peroneal (L4–5/S1–2)
surveillance recommendations for those with lynch syndrome
The most effective method to prevent gynecologic can- cer is risk-reducing hysterectomy and bilateral salpingo- oophorectomy. Lynch syndrome-associated endometrial cancer is more likely to develop in the lower uterine segment. Therefore, a total hysterectomy with removal of the cervix should be performed. Because cases are likely to occur before menopause, surgery is most effec- tive when performed at premenopausal ages or in women who have completed childbearing.
A 73-year-old woman comes to your office with a prolonged history of vulvar pruritus and burning. On examination, the vulva and perineum have a red, velvety, inflamed appearance (Fig. 92-1; see color plate). An office biopsy is performed, revealing large cells with prominent nuclei and coarse chromatin (Fig. 92-2; see color plate). The most appropriate next step in management is
(A) cervical cancer screening, colonoscopy, and mammography
(B) positron emission tomography scan
(C) topical corticosteroid cream
(D) topical imiquimod cream
A. cervical cancer screening, colonoscopy, and mammography
The vulva is the most common site of extramammary Paget disease, accounting for up to 65% of cases.
The median age at diagnosis of patients with Paget disease of the vulva is late 60s to early 70s. Paget disease usually presents as a red, scaly lesion and is associated with pruritus, burning, dysuria, and discharge.
The primary treatment of noninvasive Paget disease of the vulva is wide excision of the full thickness of the involved skin.
A 64-year-old woman underwent dilation and curettage for abnormal uterine bleeding and was diagnosed with leiomyosarcoma. She was referred to gynecology/oncology for surgical management and subsequently underwent an abdominal hysterectomy with surgical staging, which determined a diagnosis of stage I leiomyosarcoma. What is the best next step in this woman’s surveillance?
physical examination every three months for the first two years, followed by 6- to 12-month intervals.
A 64-year-old woman underwent dilation and curettage for abnormal uterine bleeding and was diagnosed with leiomyosarcoma. She was referred to gynecology/oncology for surgical management and subsequently underwent an abdominal hysterectomy with surgical staging, which determined a diagnosis of stage I leiomyosarcoma. What is the best next step in this woman’s surveillance?
physical examination every three months for the first two years, followed by 6- to 12-month intervals.
What can be given to a patient with epithelial ovarian cancer who is undergoing chemotherapy to reduce the degree of neutropenia?
Pegylated filgrastim is a long-acting granulocyte colony stimulating factor (G-CSF)
What can be given to a patient with epithelial ovarian cancer who is undergoing chemotherapy to reduce the degree of neutropenia?
Pegylated filgrastim is a long-acting granulocyte colony stimulating factor (G-CSF)
You are providing genetic counseling for a patient with breast cancer. She reports that her sister had osteosarcoma, and her mother had adrenocortical carcinoma. In which gene do you suspect a mutation is responsible?
A 64-year-old woman presents to your office for vaginal pruritus. Her history is significant for breast cancer that was treated, and she is currently in remission. On physical examination, you note that the vulva and perineum have a velvety red, eczematoid appearance. You perform a wide local excision of the lesion, and the histology is illustrated above. Margins are negative. Which of the following is the best next step in management?
Expectant management is recommended after WLE of the lesion.
It is important to note that 20% of patients with Paget’s disease will also have a nongenital tract malignancy, therefore, thorough evaluation and screening of other possible malignancies is recommended preoperatively, including pap smear, colonoscopy, and mammogram.
A 64-year-old woman presents to your office for vaginal pruritus. Her history is significant for breast cancer that was treated, and she is currently in remission. On physical examination, you note that the vulva and perineum have a velvety red, eczematoid appearance. You perform a wide local excision of the lesion, and the histology is illustrated above. Margins are negative. Which of the following is the best next step in management?
Expectant management is recommended after WLE of the lesion.
It is important to note that 20% of patients with Paget’s disease will also have a nongenital tract malignancy, therefore, thorough evaluation and screening of other possible malignancies is recommended preoperatively, including pap smear, colonoscopy, and mammogram.
A 43-year-old G0 woman presents to the office with the complaint of a lump in her right breast. On exam, you note some dimpling and nipple retraction, and a 3 cm mass is noted at the 11 o’clock position. The best next step in diagnosis would be which one of the following?
Diagnostic mammogram
A 26-year-old female presents for a screening Pap smear. The results demonstrate atypical squamous cells of undetermined significance. What is the best next step in evaluation?
HPV testing
Immediate colposcopy (C) is not the best next course of action for a woman less than 30 years of age with an unknown HPV status. It is acceptable to perform HPV testing, and if HPV is positive, colposcopy is then recommended.
A 26-year-old female presents for a screening Pap smear. The results demonstrate atypical squamous cells of undetermined significance. What is the best next step in evaluation?
HPV testing
