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Gynecology > Oncology > Flashcards

Oncology Flashcards

1
Q

What are concerning features of adnexal masses?

A 
>10cm
irregular outline or cyst wall
papillary excrescences
solid components
ascites
thick septations
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2
Q

Tumor markers: dysgerminoma

A

LDH (V HIGH)

bHCG

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3
Q

Tumor markers: immature teratoma

A

AFP

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4
Q

What are the genes involved in Lynch syndrome?

A

MLH1 (uterine + ovarian), MSH2 (uterine + ovarian), MSH6 (uterine) , PMS2 (uterine)

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5
Q

What is the genetic inheritance of Lynch syndrome?

A

Autosomal dominant

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6
Q

What is the risk of Lynch syndrome in women with endometrial cancer?

A

5-9% if <50 years old

2.3% if >50 years old

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7
Q

What is the risk of uterine carcinoma in patients with EIN on biopsy/D&C?

A

40% risk of carcinoma on hysterectomy.

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8
Q

Lynch syndrome cancers

A

ovarian (4-12%), endometrial (25-60%), colon (50-80%), stomach (6-13%). Small % (<5) urinary tract, CNS, HPB, small bowel

40-60% present with endometrial cancer first

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9
Q

STK11 mutation - assocaited cancers, specific gyn risks

A

Peutz-Jeghers syndrome
hamartomatous polyps of the GI tract and pigmented macules (P = pigemented, J = jejunum)
Associated with increased risk of colon/stomach/small intestine cancer, breast/uterine/sex cord stromal tumor of the ovary, adenoma malignum of the cervix

breast cancer risk 44-50%
ovarian cancer risk 18-21%
risk of adenoma malignum of cervix (rare adenocarcinoma)

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10
Q

PTEN mutation - risks and cancers

A

Cowden syndrome
Breast (25-50%), hitting age 30-40
Endometrial (5-28%)
Renal, colon, thyroid, and melanoma

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11
Q

TP53 mutation

A

Li Fraumeni

Associated with sarcomas - osteo/soft tissue, breast cancer, adrena tumors, CR cancer, ovarian

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12
Q

Her2/Neu

A

Associated with breast ca, ovarian ca, and serous endometrial cancer

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13
Q

What chromosomes are BRCA 1/2 on?

A

17q and 13q

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14
Q

What is the risk of breast and ovarian cancer in BRCA?

A

BRCA1 - breast cancer 75%, ovarian cancer 40% (39-46%; earlier onset)
BRCA2 - breast cancer 75%, ovarian cancer appx 20% (10-27%, later onset)

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15
Q

When is RRBSO performed?

A

BRCA1 - between 35 and 40yo
BRCA2 - between 40 and 45yo
In BRCA, reduces risk of ovarian cancer by 85-90%

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16
Q

Where do you ligate the IP in a RR BSO for BRCA?

A

2cm proximal to the ovary

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17
Q

Which BRCA has a higher risk of uterine cancer?

A

BRCA1

Higher risk of serous endometrial cancer

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18
Q

What is the breast screening for BRCA?

A

Age 25-29; semiannual breast exam, mri annually

Age 30 onwards; semi annual breast exam, breast mri and mammogram alternate q6 months

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19
Q

What are the risk reducing strategies for breast cancer in BRCA carriers?

A

bilateral mastectomy - 90-95%
RRBSO (if premenopausal) - 40-70% (maybe higher in BRCA2)
tamoxifen - 63% in BRCA2 - esp preventin contralateral breast cancer

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20
Q

Bethesda Guidelines for genetic testing for Lynch Syndrome

A
  1. Endometrial or colon cancer <50yo
  2. Endometrial/ovarian cancer + colon cancer
  3. Colon cancer w/ specific growth patterns <60yo
  4. Endometrial or colon cancer and 1st degree relative with HNPHH tumor <50yo
  5. Endometrial or colon cancer w/ 2+ 1st or 2nd degree relatives with HNPCC tumors regardless of age
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21
Q

Amsterdam Criteria for genetic stesting for lynch syndrome

A

3-2-1 rule
3 or more relatives with colon, endometrial, intestine, ureter, or renal pelvis cancer
2 or more successive generations affected
1 or more relatives diagnosed before age 50
1 patient is a 1st degree relative of other affected

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22
Q

Surveillance for lynch syndrome pts

A

Colonoscopy q1-2 years starting age 20-24
Annual pelvic exam
Endometrial biopsy yearly (or q1-2) years beginning age 30-35
TVUS and CA-125 yearly beginning 30-35
Annual UA starting 30-35
Endoscopy q2-3 years starting age 30-35

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23
Q

What factors preclude breast-conserving (lumpectomy) therapy?

A
  • multifocal disease
  • large tumor size
  • hx radiation to chest wall
  • diffuse calcifications
  • persistently positive margins
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24
Q

What is the treatment for cervical cancer by stage?

A

IAI - simple hyst or CKC
IA2-IBI - rad hyst and lymphadenectomy

Locally advanced IIB-IVA - chemotherapy and radiation

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25
Q

Who gets tamoxifen?

A

Premenopausal women with HR+ breast cancer

5 years of tamoxifen reduces recurrence by 45% and mortality by 32%

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26
Q

Who gets aromatase inhibitors after breast cancer?

A

Post-menopausal women only (for now)

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27
Q

What’s the biggest risk factor for post-operative sexual dysfunction in vulvar cancer?

A

Patient age, depression, performance status, and pre-operative sexual dysfunction

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28
Q

What is primary treatment for basal cell carcinoma of the vulva?

A

Wide local excision

negative margins 4-5mm

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29
Q

Women with endometriosis are at increased risk of what cancer?

A

Clear cell carcinoma of the ovary

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30
Q

What is the treatment for IBI small cell carcinoma of the cervix?

A

rad hyst + bl pelvic lymph node dissection

CHEMO next - cisplatin-etoposide

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31
Q

What is the recommended post-surgical surveillance in advanced stage ovarian cancer?

A

Physical exam and CA-125
No imaging
q3 months for 2 years, q6 months for 3 years, then annually

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32
Q

Gross hematuria after radiation therapy for cervical cancer

A

Radiation cystitis / hemorrhagic cystitis (5% in 5 years, 7% in 10 years, 9% in 20 years)
mean interval 4 years s/p radiation
tx bladder irrigation, evacuation of clot, embolization and transfusion prn

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33
Q

What is the main risk factor for IP chemotherapy catheter infection?

A

left colon/colorectal resection at time of placement (contamination)

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34
Q

What does surveillance after endometrial cancer entail?

A

History and physical. No imaging. No CA-125.

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35
Q

Which patients with vulvar cancer need nodal evaluation?

A

Depth of invasion >1mm

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36
Q

Which patients with vulvar cancer meet criteria for sentinel nodal mapping

A

Lesions <4cm
No palpable node / localized disease without obvious node involvement
Squamous histology

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37
Q

What is the preferred screening for women of average breast cancer risk but dense breast?

A

Digital mammography

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38
Q

In what kinds of cancer patients can you use menopausal hormone therapy?

A

Hematologic
Colorectal
Cervical
Vaginal/vulvar

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39
Q

What are benefits of transdermal estrogen over oral estrogen?

A

Decreased risk of blood clots (avoids liver stimulation with first pass effect; oral estrogen risk OR =4)
Decreased elevation in triglycerides (first pass liver)

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40
Q

What hormone therapy can you use in breast cancer survivors?

A

Vaginal estrogen
DHEA
Ospemifene (SERM)

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41
Q

What are the two vaginal estrogen rings and what is the difference?

A

Estring - no significant systemic absorption

Femring - does give systemic levels

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42
Q

Ospemifene

A

Block at Breast
Agonist at Bone
Agonist at vaginal mucosa
dose 60mg/day

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43
Q

What is the dose of estrogen replacement for a young woman <45?

A

0.1 patch

2mg oral estradiol

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44
Q

What is the chance of having a germline BRCA mutation in a woman diagnosed with high-grade ovarian cancer?

A

10-24%

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45
Q

What are the BRCA founder groups?

A

Ashkenazi Jews, French Canadians, Icelanders

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46
Q

What is the usual histology for BRCA- associated ovarian cancer?

A

serous or endometrioid

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47
Q

What is the risk of ovarian cancer in BRCA1?

A

39–46% by age 70 years

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48
Q

What is the risk of ovarian cancer in BRCA2?

A

by age 70 years is 10–27%

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49
Q

What is the risk of finding malignancy in risk-reducing salpingectomy for BRCA?

A

1-6%

Mostly STIC lesions

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50
Q

What is the risk reduction associated with bilateral tubal ligation?

A

24% lower risk of ovarian cancer in Nurses Health Study

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51
Q

Swedish risk reduction study - what is the risk reduction of BTL vs salpingectomy?

A

BTL - 28%
Salpingectomy - 60-65%

Reduced risk compared to women who did not undergo these proceures

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52
Q

Where is the most common location for a STIC lesion?

A

Fimbriae

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53
Q

How often can opportunistic salpingectomy be performed during vaginal hysterectomy?

A

75-88% success

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54
Q

What is the risk of uterine serous carcinoma in BRCA?

A

BRCA1

1-2% risk

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55
Q

Should BRCA1 patients have risk reducing hysterectomy?

A

Not recommended by any clinical guidelines; may be offerred to patient, may simplify hormone therapy, consider if taking tamoxifen
- if does not change the route of hysterectomy

Can be a discussion with the provider and the patient

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56
Q

What is the cure rate for Stage III-IV ovarian cancer?

A

18%

57
Q

What’s the cure rate for Stage I ovarian cancer?

A

88%

58
Q

What is the screening for ovarian cancer in average risk women?

A

NONE TRICK QUESTION YA

59
Q

What are the outcomes of screening average risk women for ovarian cancer with TVUS?

A

No mortality benefit
10 women false positive for every 1 case detected

low PPV, harms related to false positives

60
Q

What symptoms should raise suspicion for screening for ovarian cancer?

A

> 12 days / month of new symptoms: bloating, pelvic/abdominal pain, early satiety; for <12 months

61
Q

What other cancers are BRCA carriers at risk for?

A

BRCA2- Pancreatic, Prostate, Melanoma

BRCA1- uterine

62
Q

What chromosome is BRCA1 on?

A

Ch 17

63
Q

What chromosome is BRCA2 on?

A

Ch 13

64
Q

What is recommended ovarian cancer screening in BRCA?

A

TVUS + CA 125 q6month
short term surveillance starting at diagnosis (annually before age 30) or age 30 until risk reducing surgery
No mortality data for this

65
Q

What are strategies for risk reduction in BRCA?

A

OCPs - 10 years of OCP use, 50-64% reduction of risk of ovarian cancer (Iodice et al); even 1 year of use shows significant reduction (Rosenthal et al)

Tamoxifen - mixed data, most useful in preventing contralateral breast cancer after h/o unilateral breast cancer. No impact on ovarian cancer

BSO (reduce by 80%)
Hysterectomy (BRCA1)

66
Q

What is the benefit of risk reducing OCPs?

A

reduction of ovarian cancer risk, 33-80% in BRCA1 nad 58-63% in BRCA2 with 1 year of use

67
Q

Are OCPs associated with breast cancer in BRCA?

A

No

68
Q

When should RR BSO be considered for other mutations, not BRCA?

A

45-50

BRIP1, RAD51C, RAD51D

69
Q

What is the risk reducing surgery for Lynch syndrome?

A

hyst-BSO

Age 40-45

70
Q

What is the effect of risk reducing BSO in BRCA?

A

reduces risk of ovarian, fallopian tube, or peritoneal cancer by 80%

decreased overall mortality

71
Q

What is the risk of developing ovarian cancer in BRCA1 by age 40? BRCA2 by age 50?

A

2-3% BRCA1

3% BRCA2

72
Q

What is the risk reduction of salpingectomy in the general population?

A

up to 65%

73
Q

What is the downside of risk reducing salpingectomy alone?

A

Second surgery

No protection against breast cancer

74
Q

What is recommended breast screening in BRCA?

A

25-29 years: clinical exam q6-12 months and MRI annually

30+ clinical exam, mammo, and breast MRI alternating q6 months

75
Q

Which has more false positive tests, breast MRI or mammography?

A 
Breast MRI (8-14%)
Mammography - 4-15%
76
Q

What meds are used for chemoprevention of breast cancer?

A

Tamoxifen

Raloxifene

77
Q

What is the risk reduction associated with tamoxifen use?

A

62% risk reduction in BRCA2

No risk reduction in BRCA1 (less ER+ breast cancer in this mutation)

78
Q

What are the risks of tamoxifen use?

A

VTE (RR 1.9) and endometrial cancer (RR 2.3)

79
Q

How much does BSO reduce breast cancer risk?

A

37%to 90+%

Only if premenopausal at rime of risk reducing surgery

80
Q

Where should the IP be ligated for risk reducing surgery?

A

2cm proximal to end of identifiable ovarian tissue

81
Q

What is the risk of primary peritoneal cancer? (even after risk reducing surgery) in BRCA

A

1-6%

82
Q

Frequency of BRCA in the US

A

1:345

83
Q

Frequency of BRCA in Ashkenazi Jews?

A

1:40

84
Q

Which BRCA is more common in patients with triple negative breast cancer?

A

BRCA1

85
Q

How can you test for BRCA?

A

Single site testing
Targeted multisite testing
Comprehensive gene sequencing

86
Q

UK-FOCSS study results

A

Monitor q4 months with CA-125 and TVUS annual
Cancers diagnosed were more often early stage
No survival data - study not mature yet

87
Q

What is the counseling for fertility options in BRCA?

A

oocyte or embryo cryopreservation
pre-implantation genetic diagnoses
BRCA1 may be at risk for decreased ovarian reserve

88
Q

Who should be offered BSO for risk reducing surgery?

A 
BRCA
BRIP1
RAD51C
RAD51D
Lynch (with hyst)
89
Q

Steps of risk reducing BSO?

A 
Laparoscopic approach
Inspect diaphragm and abdominal survey
Washings and biopsy
Divide tube at insertion of cornua
remove 3-4 m of IP ligament
remove ovaries separately in bag
Serial sectioning on pathology
90
Q

How much does mastectomy reduce risk of breast cancer by in BRCA?

A

85-100%

91
Q

What’s the risk of contralateral breast cancer in BRCA, if has a h/o unilateral breast cancer?

A

30%

92
Q

Which BRCA patients can have HRT?

A

Women with BRCA s/p RRBSO if do not have a breast cancer

Does not diminish RRBSO protective effect

93
Q

Cowden syndrome

A

PTEN tumor suppressor
major criteria
minor criteria

Risk of endometrial cancer 19-28%
Risk of breast cancer 25-50% (usually age 30-40)

94
Q

Peutz-Jeghers

A

STK11
18-21% of ovarian cancer (sex cord stromal tumor)
44-50% risk of breast cancer

95
Q

What are STIC lesions?

A

Serous tubal intraepithelial carcinoma

Pre-invasive lesions

96
Q

What is seen on STIC path?

A

p53 overexpression or no expression
increase in the nucleus/cytoplasm ratio, enlarged nuclei with prominent nucleoli, reduction of ciliary cells, loss of polarity, but with no penetration through the basal membrane

97
Q

What is the risk of primary peritoneal cancer with isolated STIC lesions found in BRCA?

A

5%

98
Q

How would you manage a STIC lesion found after BSO?

A

Consider genetic testing if not already done (if BSO done for other indications)
Discuss completion of staging

appx 15% get chemotherapy, but this is not established
no established role for surveillance

99
Q

What’s the incidence of STIC in BRCA carriers?

A

0.6-7%

100
Q

What is the rate of occult leiomyosarcoma in surgery for presumed fibroids?

A

1 occult malignancy per 2000 surgeries

(based on meta analysis)

Previously estimated 1 in 500

101
Q

What are the risks of premature surgical menopause without HRT?

A

increased overall mortality (total and coronary heart disease)
quality of life
increased osteopenia/osteoporosis
early onset dementia

102
Q

What are the risks of HRT in BRCA?

A

HRT does not alter breast cancer risk and does not alter ovarian/breast cancer risk reduction benefuts

103
Q

What kind of HRT is preferred in BRCA?

A

estrogen-alone
or intermittent progestin withdrawal or progestin IUD
mild non-significant possible increased breast cancer risk with E+P HRT

104
Q

What is WHO endometrial schema based on?

A

glandular complexity
nuclear atypia

has poor intra-observer reproducibility

105
Q

What is the risk of malignancy with EIN on biopsy?

A

40%

106
Q

Asymptomatic woman, what EMB thickness do you sample?

A

> 11mm

107
Q

What is the risk of a high-risk uterine cancer (high grade, deep invasion, aka needs staging) in a patient with EIN?

A

10%

108
Q

Can a benign gynecologist do a MIS hyst for EIN?

A

Yes. No need for intra-operatively frozen pathology if no gyn onc available for staging. No routine PPALND for EIN

109
Q

How effective are LNG-IUDs for EIN or grade 1 endometrial cancer?

A

88-95% in 2 years

110
Q

How do you manage EIN medically?

A

Treat for 6-12 months

Sample q3-6 months until resolution of disease

111
Q

What is fertility-sparing treatment for endometrial cancer?

A

D&C if needed to confirm G1 disease
MRI to r/o myometrial invasion
progesterone therapy, resample q3-6 month
If progression, hysterectomy

112
Q

What are EIN criteria?

A

Size >1mm
Architecture, grands >55% vs stroma
Cytology - architecturally crowded focus

113
Q

How much of the uterus does a blind D&C sample?

A

50%

114
Q

What is surgical management of EIN

A

hysterectomy
+/- oophorectomy
peritoneal washings

115
Q

What is the correlation between frozen adn final pathology for endometrial cancer?

A

Histology 97% concordant
Grade 88% concordant
Depth of invasion 98% concordant

116
Q

What progesterones can be used to medically treat EIN?

A

Provera (medroxyprogesterone acetate) (10-20mg daily)
Depo-Provera (150mg q3 months)
Micronized oral progesterone (200-300mg daily)
Megace (40-160mg daily)
Aygestin (5-15mg daily)
LNG-IUD

117
Q

What is the risk of endometrial cancer in Lynch synrome?

A

15-70% depending on mutation
PMS2 - 50%
MLH1 - 20-50%
MSH2/6 - 20-70%

118
Q

What is the risk of ovarian cancer in Lynch syndrome?

A

3-40% depending on mutation
MLH1 - 8-20%
MSH2 - 12-38%

Low risk in MSH6 (1-10%) and PMS2 (3-5%)

119
Q

What are features of Lynch associated endometrial cancer?

A

Dx young, age 40s-50s
Endometrioid histology
Higher % from lower uterine segment

120
Q

What are features of Lynch associated ovarian cancer?

A

Dx earlier, usually Stage I-II
Epithelial or endometrioid type
15-25% have synchronous cancers

121
Q

How many women with Lynch present with endometrial cancer?

A

40-60%

122
Q

What is screening for Cowden syndrome?

A

Clinical breast exam yearly from age 25
Annual mammogram from age 30
Annual breast MRI from age 30
Annual TVUS or embx from age 30

123
Q

What is the screening recommended for Peutz-Jeghers Syncrome?

A

Clinical breast exam q6-12 months from age 25
Mammogram annually
breast MRI annually
Annual pap and pelvic exam from age 20

124
Q

What are the benefits of RRBSO in BRCA?

A

Ovarian cancer risk redutcion 96%

Breast cancer risk reduction 50%, more for BRCA1 than BRCA2 (likely earlier, also higher overall risk in brca1)

125
Q

How do you manage endometrial hyperplasia without atypia?

A

Progestin therapy (IUD, oral progestin, OCPs)

126
Q

What is the risk of endometrial hyperplasia without atypica progressing to carcinoma?

A

less than 10%

127
Q

What is the median time of regression from endometrial hyperplasia without atypica to normal endometrium?

A

appx 3 years

128
Q

What is surveillance for endometrial hyperplasia without atypia being treated with progestins?

A

Endometrial biopsy q6 months x1 year
If normal endometrium - repeat biopsy not required, may consider continuing tx given risk factors
If persistent EH without atypia - increase dose, repeat biopsy q3-6 months

129
Q

What is the surveillance for EIN treated medically?

A

EMBx q3-6 months x2 years

130
Q

Which two progestins are actually approved for treatment of endometrial carcrinoma?

A

Provera (medroxyprogesterone acetate)

Megace

131
Q

What is the benefit of transdermal estrogen replacement?

A

Lower VTE risk
Lower migraine risk
Theoretically better for libido

132
Q

what is the appropriate dose of estrogen in hrt

A

0.625mg conjugated estrogen
1mg estradiol (median starting dose), about half physiologic
50mcg transdermal 17-beta estradiol

133
Q

What is the dose of progestin replacement for HRT

A

Provera (5-10mg/day)
Micronized progesterone / Prometrium 100mg/day continuous or 200mg/day cyclic (this is better for lower breast cancer risk, ? greater cardiovascular prevention)
IUD (though not approved)

134
Q

When can you use OCPs for HRT?

A

Low risk women in their 40s
bothersome bleeding / hot flashes
still need contraception

135
Q

What are non hormonal options for control of vasomotor symptoms?

A 
Venlafaxine
Fluoxetine 
Paroxetine
Clonidine
Gabapentin
136
Q

What are options for topical vaginal estrogen?

A 
Premarin cream
Vagifem tablet (second lowest dose)
Estring (lowest systemic dose)
137
Q

What kinds of breast cancer are more common in BRCA1 vs BRCA2?

A

BRCA1 - triple negative

BRCA2 - hormone sensitive

138
Q

What is the data on OCP use for chemoprevention for ovarian cancer?

A

OCPs reduce ovarian cancer risk in BRCA patients by 50% over 10 years
Systematic review shows reduction with even 1 year of use

139
Q

Risk reducing salpingectomy benefit?

A

reduce risk of ovarian cancer by ~60%

Gynecology (3 decks)

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