Study guide Flashcards
optimal treatment of dermoid cyst
cystectomy with only inspection of contralateral ovary
Most important prognostic factor for endometrial, cervical, vulvar and breast cancer is:
node status
hydrops tubae profluens is a classic sign of :
fallopian tube carcinoma
bleomycin MOA
inhibits synthesis of DNA; binds to DNA leading to single and double strand breaks
topotecan
inhibits topoisomerase I - stabilizes the cleavable complex so that religation of cleaved DNA strand cannot occur - S phase of cell cycle
5 fluorouracil MOA
pyrimidine analog antimetabolite that interferes with DNA and RNA synthesis - inhibits thymidylate synthetase
5 fluorouracil adverse reaction
Neutropenia, mucositis, diarrhea, dermatitis
carboplatinum adverse reaction
thrombocytopenia
What is Meig’s syndrome
triad of ovarian fibroma, hydrothorax, ascites
most common sites of ureteral injury
at cardinal ligaments and infundibulopelvic ligaments
Vulvar stage IVb
pelvic nodes, distant mets
Vulvar stage IIIc
with positive nodes with extracapsular spread
most important predictor of local recurrence of vulvar cancer after resection
tissue margin (>8mm on fixed tissue)
doxorubicin adverse effect
cardiotoxicity
vicristine adverse effect
neurotoxicity
How many stages in vulvar cancer?
Ia Ib II IIIa IIIb IIIc IVa IVb
2 plant alkaloids
vincristine
vinblastine
attributes of plain and chromic catgut
intense inflammation, absorbed quickly by phagocytosis
methotrexate MOA
folate antimetabolite that inhibits DNA synthesis, repair, and cellular replication - inhibits dihydrofolate reductase - cell cycle specific for S phase
dermoid with mostly thyroid tissue, benign
struma ovarii
treatment for vulvar cancer if positive inguinal nodes
adjuvant pelvic radiation
Lugol’s iodine MOA
glycogen stain; negative stain
most superior and medial inguinal node, considered sentinel node for spread to pelvic nodes
Cloquet’s node
BRCA2 on chromosome __
13
cisplatinum (cisplatin) MOA
inhibits DNA synthesis by formation of DNA cross-links, denatures double helix, covalently binds DNA
antidose to ifosfamide
mesna
treatment for vulvar cancer for well-lateralized lesions <2 cm
radical local excision of vulva with unilateral inguinal-femoral lymphadenectomy
chemo drug from the pacific Yew tree
Taxol
after transection the broad ligament, the ureter is where?
on medial leaf
cause of dyspereunia after radiation is usually:
atrophic vaginitis
paclitaxel (Taxol) adverse reaction
Alopecia, immediate hypersensitivity, neutropenia, bradycardia
carboplatinum MOA
alkylating agent - covalently binds to DNA, interstrand DNA cross-links; not cell-cycle specific
acetic acid MOA
dehydrate cells
Vulvar stage Ia
≤ 2 cm, ≤1 mm invasion, no nodes
heritability of BRCA mutations
autosomal dominant
Taxol is __ phase speicific
M phase
lymphatic drainage of uterus
iliac and paraaortic
cells found in Krukenburg tumors
signet ring cells
lymphatic drainage of upper vagina
iliac (pelvic)
p53 & Rb are examples of __ genes
tumor suppressor
cyclophosphamide MOA
alkylating agent – prevents cell division by cross-linking DNA strands and decreasing DNA synthesis
BRCA1: __% risk of breast cancer and __% risk of ovarian cancer
85% risk of breast cancer and 40% risk of ovarian cancer
treatment for endometrial hyperplasia
TAH vs progestin therapy (any progestin will do); premalignant potential directly related to degree of cellular atypia and to a far less extent the degree of architectural complexity; microscopically has crowded glands but no invasion
Vulvar stage IVa
mucosa of bladder or rectum, urethra, bone bilateral inguinal nodes
plant alkaloids are __ phase specific
M phase
Which HPV strains linked to VIN & invasive SCC?
HPV 16,18, 31, 33
Vulvar stage Ib
> 2 cm or >1 mm invasion, no nodes
cyclophosphamide adverse effect
hemorrhagic cystitis
topotecan adverse reaction
profound neutopenia
most common tumor to metastasize to fetus
melanoma
Sentinal lymph node mapping in vulvar cancer
False negative rate is acceptably low (3.7%) such that patients can have SLN dissected and sent for frozen. If positive, full LN dissection on that side. Midline lesions need BILATERAL sentinel nodes.
the action of lasers is based on __
Water (cells heat and explode)
What is luteoma of pregnancy
solid, benign tumor requiring no treatment; regresses after pregnancy
What is the most common tumor in the broad ligament?
leiomyoma
cycle nonspecific alkylating agents
cyclophosphamide
chlorambucil
platinum compounds
doxorubicin MOA
inhibits topoisomerase II – inhibition of DNA and RNA synthesis, inhibition of DNA repair
Lymph node spread of vulvar cancer
- first to ipsilateral inguinal nodes, then pelvic (late)
- Well lateralized lesions ALWAYS spread to ipsilateral nodes before contralateral nodes
Main difference between tamoxifen and raloxifene is:
effect on endometrium (tamoxifen is proliferative)
bleomycin adverse effect
pulmonary fibrosis
methotrexate is __ phase specific
S phase
lymphatic drainage of cervix
iliac (pelvic)
paclitaxel (Taxol) MOA
inhibits microtubule disassembly, interfering with late G2 mitotic phase
metastatic tumore from stomach to ovary
Krukenburg tumors
ras, HER-2/neu are examples are __ genes
oncogenes
vincristine MOA
inhibits microtubule assembly - arrests cell at metaphase by disrupting formation of mitotic spindle (M & S phases)
BRCA1 on chromosome __
17
GROINS V Trial
False negative rate is acceptably low (3.7%) such that patients can have SLN dissected and sent for frozen. If positive, full LN dissection on that side. Midline lesions need BILATERAL sentinel nodes.
lymphatic drainage of vulva
inguinal
What are the steps of the cell cycle?
G1 - S (DNA replication) - G2 - M (mitosis)
lymphatic drainage of lower part of vagina
inguinal
Most likely histologies of vulvar cancer
- Squamous cell cancer most common (~85% of all vulvar cancers)
- melanoma (~9%)
- Basal Cell Carcinoma (2%)
- Paget’s disease, Bartholin’s adenocarcinoma, sarcomas, and neuroendocrine tumors all rare
cisplatin adverse reaction
nephrotoxicity, neurotoxicity, ototoxicity, emetogenic
Vulvar stage II
any size with adjacent spread (lower 1/3 vagina, lower 1/3 urethra, anus), no nodes
most important predictor of survival in vulvar cancer
+LN status (stage III disease)
methotrexate adverse reaction
Neutropenia, mucositis, nephrotoxicity
When doing omentectomy must ligate the __ arteries
gastroepiploic arteries
Vulvar stage IIIb
with 2 or more lymph node metastases (≥5mm) OR 3 or more lymph node metastases (
attributes of PDS & Maxon
monofilament, highest tensile strength for absorbables
treatment for vulvar cancer for lesions >2cm or midline lesion
radical local excision of vulva with bilateral lymphadenectomy
predictors of lymph node spread in vulvar cancer
Tumor diameter, grade, depth of invasion into stroma (most important!) and LVSI
attributes of Nylon & Prolene
monofilament, highest tensile strength of all sutures, nonabsorbable
Vulvar stage IIIa
with 1 lymph node metastasis (≥5mm) OR 1–2 lymph node metastases (
attributes of Vicryl and Dexon
polyfilament, absorbed by hydrolysis
What is treatment for microinvasive squamous cell carcinoma of vulva?
wide local excision, NOT radical vulvectomy, NOT lymph node dissection
Define microinvasive squamous cell carcinoma of vulva
< 1 mm depth of invasion and <2 cm diameter - no risk of lymph node spread
In vulvar squamous cell carcinoma, if depth of invasion is 1.1 - 3 mm, likelihood of positive node is:
6 - 12% (need lymphadenectomy)
In vulvar squamous cell carcinoma, if depth of invasion is 3.1 - 5 mm, likelihood of positive node is:
15 - 20% (need lymphadenectomy)
second most common vulvar cancer
melanoma
survival with melanoma of vulva is related to:
Clark’s or Brewlow’s levels
treatment for melanoma of vulva with Clark level I or II (Breslow <1.5 mm)
wide local excision
treatment for melanoma of vulva with Breslow > 1.5mm
same as for squamous cell carcinoma, although nodes are only for prognosis
If nodes are positive in melanoma of vulva:
uniformly fatal
Paget’s disease of vulva may represent underlying __
adenocarcinoma (15%)
Cake icing effect of vulva
Paget’s disease
large clear cells at base of dermis
Paget cells
treatment of Paget’s disease of vulva
Wide local excision with clear margins of 2 cm
treatment of bartholin gland carcinoma
treat like squamous cell carcinoma
treatment of verrucous carcinoma
radical local excision without node dissection
verrucous carcinoma: __ rather than __ borders
pushing rather than infiltrative borders
Borders of femoral triangle
sartorius laterally
adductor longus medially
inguinal ligament superiorly
Where are the inguinal nodes?
In the femoral triangle, between superficial fascia (Camper’s) and deep fascia
Where are the femoral nodes?
In the femoral triage, deep to deep fascia
treatment for VIN I and II
observe
treatment for VIN III
wide local excision, CO2 laser ablation, Aldara (imiquimod)
most common symptom of VIN
pruritis
local recurrence __ after wide local excision of VIN III even with negative margins
20%
most common tumor in vagina
metastases from cervix or vulva, not primary vaginal cancer
most common histology of primary vaginal cancer
squamous cell carcinoma
lymphatic drainage of vaginal
upper: same as cervix
lower: same as vulva
vaginal cancer Stage I
mucosa
vaginal cancer Stage II
subvaginal/paravaginal tissue but not to sidewall
vaginal cancer Stage III
to pelvic sidewall
vaginal cancer Stage IVa
mucosa of bladder or rectum
vaginal cancer Stage IVb
distant mets
pelvic or inguinal lymph nodes in vaginal cancer mean stage __
stage III
treatment for vaginal cancer
Radiation for all stages: need external beam +/- brachy for lesions >2cm
Chemoradiation for locally advanced or metastatic
clear cell carcinoma of vagina is a subtype of __
adenocarcinoma
DES exposure in utero is associated with __
clear cell carcinoma of vagina
__% of patients with VaIN had or currently have either intraepithelial neoplasia or carcinoma of the cervix or vulva
50 - 90%
VaIN stage I
lower one third of epithelium
VaIN stage II
lower two thirds of epithelium
VaIN stage III
involves more than two thirds of epithelium
treatment of VaIN stage I
estrogen, follow; rare malignant potential
treatment of VaIN II/III
topical 5-FU, imiquomod, CO2 laser vaporization, partial vaginectomy, brachytherapy(Rare)
3 major risk factors for cervical cancer
1) age at first coitus
2) number of partners
3) Smoking
cervical cancer stage Ia1
cervix, diagnosed only by microscopy with invasion of <3 mm in depth and lateral spread <7 mm
cervical cancer stage Ia2
cervix, diagnosed with microscopy with invasion of >3 mm and <5 mm with lateral spread <7 mm
cervical cancer stage Ib1
clinically visible lesion or greater than Ia2, <4 cm in greatest dimension
How many cervical cancer stages are there?
Ia1 Ia2 Ib1 Ib2 IIa1 IIa2 IIb IIIa IIIb IVa IVb
cervical cancer stage Ib2
clinically visible lesion, >4 cm in greatest dimension
cervical cancer stage IIa1
vaginal but no parametrial involvement
involvement of the upper two-thirds of the vagina, <4 cm in greatest dimension
cervical cancer stage IIa2
vaginal but no parametrial involvement
involvement of upper 2/3 vagina, >4 cm in greatest dimension
cervical cancer stage IIb
with parametrial involvement
cervical cancer stage IIIa
lower 1/3 vagina
cervical cancer stage IIIb
parametria to sidewall or hydronephrosis
cervical cancer stage IVa
mucosa of bladder or rectum
cervical cancer stage IVb
distant
cervical cancer staging and 5 year survival
I 90%
II 70%
III 30%
IV 10%
most common histology in cervical cancer
80% squamous cell carcinoma
20% adenocarcinoma – also HPV-related, tend to be endophytic and larger
cervical cancer treatment for stage Ia1
simple hysterectomy
cervical cancer treatment for stage Ia2 - IIa
radical hysterectomy and bilateral pelvic lymphadenectomy OR chemoradiation
-Surgery has higher immediate complication rate BUT better preservation of sexual fnx and ovarian fxn
-Radiation has fewer contraindications BUT long term complications
-They are equally effective
Worst is surgery then radiation
cervical cancer treatment for stage IIb and beyond
chemoradiation
most common complication after radical hyst and b/l pelvic lymphadenectomy
bladder atony
In radical hyster and b/l pelvic LA, uterine artery is taken at its origin from the __
hypogastric
Name 3 scenarios requiring chemoradiation in cervical cancer
- Stage IIb and beyond
- Bulky Ib (>3-4cm)
- Adjuvant treatment following radical surgery (positive nodes, positive margins, parametrial involvement)
treatment for cervical cancer in first trimester of pregnancy
treat as usual; e.g. gravid radical hysterectomy and pelvic lymphadenectomy or radiation (fetus will die)
treatment for cervical cancer in second trimester of pregnancy
can wait for maturity or treat, depending on how early, patient preference
treatment for cervical cancer in third trimester of pregnancy
wait for maturity and treat (Cesarean delivery and then radiation, or Cesarean radical hysterectomy with pelvic lymphadenectomy)
Significance of microinvasion in cervical cancer:
is that there is no risk of lymph node metastasis
Cervical cancer microinvasion requires __ to diagnose
LEEP or cone bx
Definition of microinvasion in cervical cancer
less than 3 mm invasion with no lymphovascular space invasion (LVSI)
treatment for microinvasion in cervical cancer
TAH OR LEEP/cone bx
spread of cervical cancer
Locally
Pelvic lymph nodes - most common is obturator
Paraaortic lymph nodes
most common cause of death in cervical cancer
bilateral ureteral obstruction
treatment for cervical stump cancer
radiation or radical trachelectomy with nodes
Can stop cervical cancer screening at 65 if:
3 consecutive negative cytology tests or 2 consecutive negative co-tests within the previous 10 years, with the most recent test within the previous five years
bethesda system of glandular abnormalities of pap
AGUS (endometrioid v. endocervical)
adenocarcinoma in situ
adenocarcinoma
What kind of virus is HPV
double stranded DNA
E6 and E7 are HPV-encoded oncogenes whose protein products bind those of tumor suppressor genes __ and __, respectively
p53 and Rb
most common gynecologic cancer
endometrial cancer
risk factors for endometrial cancer
Estrogen excess - obesity, exogenous estrogen, chronic anovulation (type I)
How many stages of endometrial cancer are there?
Ia Ib II IIIa IIIb IIIc1 IIIc2 IVa IVb
endometrial cancer stage Ia
corpus, <1/2 invasion
endometrial cancer stage Ib
corpus, >1/2 invasion
endometrial cancer stage II
cervix, stromal invasion
endometrial cancer stage IIIa
adnexa or serosa
endometrial cancer stage IIIb
vagina or parametrial
endometrial cancer stage IIIc1
pelvic lymph nodes
endometrial cancer stage IIIc2
paraaortic lymph nodes
endometrial cancer IVa
bladder or bowel mucosa
endometrial cancer IVb
distant mets
3 scenarios in endometrial cancer requiring Adjuvant treatment with whole pelvic radiation OR vaginal brachytherapy
Deep invasion (>50%) High grade (3) Stage II (cervical involvement)
What studies showed that Radiation for endometrial cancer decreases local recurrences but does not improve survival?
PORTEC, GOG-99
Most common types of histology in endometrial cancer
Type 1: Most common is endometrioid endometrial carcinoma
Type 2: Clear cell, papillary serous carcinoma have poorest prognosis
Papillary serous - looks like ovarian (papillary serous), acts like ovarian (spreads intraperitoneally), treated like ovarian (chemotherapy)
normal endometrial stripe in postmenopausal women
<5mm
tamoxifen increases the risk of endometrial carcinoma by
2-4 fold
tumor marker for recurrence of endometrial cancer
CA125
Cancer incidence for endometrial hyperplasia: simple without atypia
1%
Cancer incidence for endometrial hyperplasia: complex without atypia
3%
Cancer incidence for endometrial hyperplasia: simple with atypia
8-10%
Cancer incidence for endometrial hyperplasia: complex with atypia
30-40%
treatment for endometrial hyperplasia, simple without atypia
progestins
treatment for endometrial hyperplasia, complex without atypia
progestins
treatment for endometrial hyperplasia, simple with atypia
surgery or progestins
treatment for endometrial hyperplasia, complex with atypia
surgery
What does simple endometrial hyperplasia look like
- glands are mildly crowded
- cystically dilated with only occasional outpouching
- Mitoses may or may not be present
What does complex endometrial hyperasia look like
- glands that are crowded (>50 percent gland to stromal ratio);
- disorganized and have luminal outpouching.
- Mitoses
- Not Grade I endo CA because residual endometrial stroma that separates all glands
What does atypia look like
nuclear enlargement, prominent chromatin
How many stages of uterine sarcoma are there?
Ia Ib IIa IIb IIIa IIIb IIIc IVa IVb
uterine sarcoma stage Ia
Tumor limited to uterus < 5 cm
uterine sarcoma stage Ib
Tumor limited to uterus > 5 cm
uterine sarcoma stage IIa
Tumor extends to the pelvis, adnexal involvement
uterine sarcoma stage IIb
Tumor extends to extra-uterine pelvic tissue
uterine sarcoma stage IIIa
Tumor invades abdominal tissues, one site
uterine sarcoma stage IIIb
Tumor invades abdominal tissues, more than one site
uterine sarcoma stage IIIc
Metastasis to pelvic and/or para-aortic lymph nodes
uterine sarcoma stage IVa
Tumor invades bladder and/or rectum
uterine sarcoma stage IVb
distant mets
risk factors for uterine sarcoma
prior radiation exposure, age, race, tamoxifen
treatment for uterine sarcoma
TAH/BSO; all adjuvant therapies unproven
ovarian stage Ia
tumor limited to one ovary or fallopian tube, surface not involved
How many stages of ovarian cancer are there?
Ia Ib Ic1 Ic2 Ic3 IIa IIb IIIa - IIIa1i , IIIa1ii , IIIa2 IIIb IIIc IVa IVb
ovarian stage Ib
tumor limited to both ovaries or fallopian tubes, surface not involved
ovarian stage Ic1
tumor limited to one or both ovaries/fallopian tubes with intra-operative tumor rupture
ovarian stage Ic2
tumor limited to one or both ovaries/fallopian tubes with pre-operative tumor rupture OR tumor on the surface/capsule
ovarian stage Ic3
tumor appears limited to one or both ovaries/fallopian tubes with positive cytology from ascites or washings
ovarian stage IIa
extension to gynecologic tissues beyond the primary organ (uterus, mets to fallopian tube, contralateral adnexa)
ovarian stage IIb
extension to other pelvic intraperitoneal tissues (e.g. – bladder peritoneum, rectum, cul-de-sac)
ovarian stage IIIa
positive LN or microscopic peritoneal metastases outside the pelvis
ovarian stage IIIb
Macroscopic metastasis outside the pelvis within the peritoneal space ≤ 2 cm
ovarian stage IIIc
Macroscopic peritoneal metastasis beyond pelvis > 2 cm in greatest dimension (includes extension of tumor to capsule of liver and spleen without parenchymal involvement of either organ), with or without positive retroperitoneal lymph nodes
ovarian stage IVa
positive pleural cytology (effusion)
ovarian stage IVb
parechymal metastasis to liver, spleen or extra-abdominal spread (thoracic or supraclavicular LN, pulmonary solid mets, etc.)
most common ovarian cancer histology
high grade serous - most common and most aggressive
ovarian cancer with +AFP
Endodermal sinus tumor (aka Yolk Sac), +/- immature teratoma, +/- embryonal carcinoma
ovarian cancer with +hcg
ovarian choriocarcinoma (rare); +/- dysgerminoma
name 2 types of sex cord stromal tumors
granulosa cell tumors, sertoli-leydig cell tumors
tumor markers for granulosa cell tumors
inhibins, estradiol
tumor markers for sertoli-leydig cell tumors
androgens
breast cancer stage 1
< 2 cm without nodes
breast cancer stage 2
> 2cm but < 5 cm with or without 1-3 ipsilateral nodes OR > 5 cm without nodes
breast cancer stage 3
Anything in between stage II and IV: direct extension to the chest wall and/or to the skin (ulceration or skin nodules), Inflammatory carcinoma
breast cancer stage 4
distant mets
underlying disease in Paget’s disease of breast
underlying carcinoma is ALWAYS present (unlike vulva)
risk factors for endometrial cancer
obesity, nulliparity, tamoxifen, unopposed estrogen, Lynch, DM, gallbladder
tamoxifen increases endometrial cancer risk by __
2-3 fold
pharm category of tamoxifen:
SERM
most COMMON pathology that results from tamoxifen
polyps
What screening should you do in women taking tamoxifen?
None
Are premenopausal women taking tamoxifen at increased risk of cancer?
No
Call Exner bodies mean:
granulosa cell tumors
Tumor markers for granulosa cell tumors
inhibin (A or B)
Tumor marker for dysgerminoma
LDH
3 types of ovarian cancer
epithelial (90%), germ cell, sex cord stromal
risk factors for ovarian cancer
HNPPC, Peutz Jeughers, age, nulliparity, P1>35yo
protective factors for ovarian cancer
OCPs, salpingectomy, breastfeeding
Schillar Duval bodies mean:
endodermal sinus (yolk sac) germ cell cancer
Oncogenes for cervical cancer in HPV
p53: E6
Rb: E7
cutoff for elevated Ca125 in postmenopausal
> 35
cutoff for elevated Ca125 in premenopausal
200
causes of elevated ca125 other than cancer
endometriosis, pancreatitis, hepatitis, diverticulitis, cirrhosis, menses, PID, pregnancy, fibroids
treatment for low risk GTN
methotrexate or dactinomycin (Act-D)
treatment for high risk GTN
EMACO
components of EMACO
etoposide, methotrexate, Act-D, cyclophosphamide, vincristine
cure rate for GTN with treatment
> 80%
How do you diagnose persistent GTN?
HCG plateaus for 4 measurements over 3w
HCG >10% over 3 measurements over 2w
HCG still persistent after 6 months
If you are doing a hyst for hyperplasia with atypia, what is the likelihood of finding endometrial ca?
42%
Risks for progression to endometrial ca from hyperplasia:
simple: 1
complex: 5
simple w atypia: 10
complex w atypia: 25
risk factors for cervical cancer
smoking! HPV, immunocompromised, HIV, multiple partners, 3+ SVDs
When do you start paps when +HIV
when she becomes sexually active
When do you start paps for DES exposure hx
menarche
next steps for 35yo negative pap, +HPV
16 or 18: colpo
low risk HPV: cotest 1 year
no HPV type: cotest 1 year
oncogene in endometrial cancer
K-ras
tumor suppressor gene in endometrial cancer
PTEN
indications for risk reducing BSO
BRCA age >40, Lynch, strong family hx, hx breast cancer
risk of primary peritoneal cancer after BSO in +BRCA
0.2%
What HPV is associated with SCC
16
What HPV is associated with adeno
18
Stage: cervical cancer side wall w hydro
IIIB