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RCPSC > Oncology > Flashcards

Oncology Flashcards

1
Q

lifetime risk of endometrial cancer

A

2.6%

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2
Q

preferred initial investigation for ?endo ca

A

biopsy + TVUSS

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3
Q

most common gynae ca in north america

A

endometrial ca

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4
Q

endo ca staging: IA

A

tumor confined to the uterus, <50% myometrial invasion

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5
Q

endo ca staging: IB

A

tumor confined to uterus, >50% myometrial invasion

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6
Q

endo ca staging: II

A

cervical stromal invasion but not beyond uterus

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7
Q

endo ca staging: IIIA

A

tumor invades serosa or adnexa

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8
Q

endo ca staging: IIIB

A

vaginal and/or parametrical involvement

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9
Q

endo ca staging: IIIC

A

IIIC1 - pelvic node involvement

IIIC2 - para-aortic nodes and/or pelvic nodes

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10
Q

endo ca staging: IVA

A

tumor invasion bladder/ and or bowel mucosa

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11
Q

endo ca staging: IVB

A

distant mets including abdominal, and/or inguinal nodes

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12
Q

80% of all endometrial cancer

A

Type 1 - endometriod (hormone related)

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13
Q

premenopausal patients endo ca prevalence

A

10-15%

  • 2-5% will be under age 40
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14
Q

screening for HNPCC

A

annual endometrial biopsies beginning at age 30 -35, or 5-10 years before the youngest age at which a family member was dx with ca

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15
Q

% of endo ca that is hereditary

A

10%

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16
Q

HNPCC risk of endometrial ca

A

10x higher than baseline rate

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17
Q

Risk factors for endo ca

A
  • diabetes
  • obesity/physical inactivity
  • tamoxifen
  • exposure to excess unopposed oestrogen
  • HNPCC
  • Prior pelvic radiation
  • estrogen producing ovarian tumors
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18
Q

physical activity: risk reduction in endo ca

A

30%

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19
Q

concurrent endometrial ca in patients with atypical EH

A

36%

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20
Q

indications for D&C

A
  • non-diagnostic office biopsy in high risk pt
  • benign bx and persistent bleeding
  • insufficient material on bx + thickened ET
  • office bx unobtainable
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21
Q

false positive and false negative rates for curettage

A

FP 25%, FN 10%

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22
Q

sensitivity & specificity ET <4mm

A

sensitivity 98%
specificity 36-68%

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23
Q

risk of cancer in ET <5mm

A

1% in postmenopausal woman

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24
Q

atypical endometrial cells on pap smear - risk of endo ca

A

up to 25% will have concurrent endo ca and require further diagnostic measures

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25
Q

pre-op investigation for endo ca

A
  • CBC, Clotting, Electrolytes, Renal panel, LFTs
  • Urinalysis
  • CXR
  • ECG
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26
Q

pre-op investigation for endo ca - CT may be helpful?

A

workup of papillary serous tumors,
or agressive types such as sarcoma

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27
Q

pre-op investigation for endo ca - MRI may be helpful?

A

in assessment of loco regional extension if clinically suspect.

also accurate in assessing extent of myometrial invasion and cervical invasion
(accuracy 91%)

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28
Q

incidence of endometrial hyperplasia

A

133/100 000 woman-years

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29
Q

peak ages for EH

A

50-54

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30
Q

EH with atypia subtypes

A
  • atypical hyperplasia
  • endometrial intraepithelial neoplasia
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31
Q

progression of EH without atypia to EC

A

1-3%

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32
Q

EIN: concomitant EC

A

up to 60%

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33
Q

AUB in pre-menopausal women: which patterns associated with higher risk of EC

A

IMB 0.52%

(vs. HMB 0.11%)

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34
Q

indications for pipelle biopsy

A
  • 40+ AUB
  • Women not responding to medical rx
  • younger women based on RFs
  • PMB
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35
Q

BMI cut off as RF for EH/EC

A

BMI 30

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36
Q

diagnostic sensitivity of pipelle device for EH and EC

A

81% EH
91% EC pre-MP,
99.6% EC PMB

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37
Q

blind approaches usually sample less than ___% of endometrial cavity

A

50%

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38
Q

hyperplasia with atypia associated with which mutations

A
  • microstatellite instability
  • PAX2 inactivation
  • PTEN, KRAS, CTNNB
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39
Q

EH without atypia - risk of progression at 20y

A

<5%

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40
Q

EH without atypia - spontaneous regression rates

A

75-100%

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41
Q

EH without atypia - regression with oral progestogens

A

67-72%

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42
Q

EH without atypia - regression with LNG-IUS

A

81-94%

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43
Q

EH without atypia - regression with Depo-Provera

A

92% at 6 months

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44
Q

treatment of choice for pts with EH without atypia

A

LNG-IUS

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45
Q

relapse rate of EH is higher in pts with BMI of ___

A

35 or greater - should extend follow-up

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46
Q

indications for surgical treatment of EH without atypia

A
  • progression to atypical or carcinoma
  • failure of regression at 12 months
  • persistent AUB
  • decline endometrial surveillance or medical rx
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47
Q

Initial management for EH without atypia

A

at least 6/12 of progestogens,
with biopsy every 3-6 months

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48
Q

Initial management for EH with atypia, or EIN

A

total hysterectomy with BSO

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49
Q

risk of EC (higher than stage) I for EH with atypia (ie when counselling for medical management/uterine preservation)

A

2%

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50
Q

risk of coexisting ovarian cancer for EH with atypia

A

4%

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51
Q

risk of death with uterine conversation/med management for EH with atypia

A

0.5%

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52
Q

conservative treatment options for EH with atypia

A
  • progestogens (PO or local)
  • aromatase inhibitors
  • GnRH agonists

Trial of 6 months is generally necessary - plateau at 12 months

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53
Q

Regression rates for EH with atypia

A

55-92%

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54
Q

Recurrence rates for EH with atypia (medical rx)

A

3-55%

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55
Q

endometrial surveillance for EH with atypia

A

every 3 months until at least 2 negative specimens obtained

after treatment cessation, every 6 months for 2 years and every year thereafter (until RFs corrected or surgical Rx completed)

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56
Q

fertility sparing options for EIN treatment

A
  • oocyte or embryo cryopreservation prior to TLHBSO
  • medical rx followed by ART
  • hysterectomy with ovarian conservation and surrogate use
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57
Q

live birth rate associated with conservative management of EIN approximates?

A

7-26%

Pregnancy is associated with a lower chance of disease recurrence

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58
Q

Surgical management for EH - who can keep their ovaries?

A

EH without atypia if <45yo

(but offer salpingectomy)

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59
Q

background risk/rate of EH if EH found in polyp

A

up to 52% of cases

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60
Q

risk of concurrent endometrial ca in patients found to have an atypical endometrial polyp

A

5.6%

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61
Q

incidence of ovarian cancer

A

9-17/100 000

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62
Q

proportion of ovarian cancer that is hereditary

A

15-20%

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63
Q

peak incidence of ovarian cancer

A

> 60y

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64
Q

lifetime risk of ovarian cancer

A

1/70

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65
Q

Stage 1A ovarian cancer

A

confined to ovaries:
1 tube or ovary affected

no tumor on ovarian or fallopian tube surface; no malignant cells in the ascites or peritoneal washings

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66
Q

Stage 1B ovarian cancer

A

confined to ovaries
2 tubes or ovaries

no tumor on ovarian or fallopian tube surface; no malignant cells in the ascites or peritoneal washings

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67
Q

Stage 1C1 ovarian cancer

A

Tumor limited to 1 or both ovaries or fallopian tubes, with:
Surgical spill

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68
Q

Stage 1C2 ovarian cancer

A

Tumor limited to 1 or both ovaries or fallopian tubes, with:
Capsule ruptured before surgery or tumor on ovarian or fallopian tube surface

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69
Q

Stage 1C3 ovarian cancer

A

Tumor limited to 1 or both ovaries or fallopian tubes, with:
Malignant cells in the ascites or peritoneal washings

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70
Q

Stage 1 ovarian cancer

A

Tumor confined to ovaries or fallopian tube(s)

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71
Q

Stage 2 ovarian cancer

A

Tumor involves 1 or both ovaries or fallopian tubes with pelvic extension (below pelvic brim) or peritoneal cancer

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72
Q

Stage 2A ovarian cancer

A

spread to gynae organs

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73
Q

Stage 2B ovarian cancer

A

extension to bladder or colon

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74
Q

stage 3 ovarian cancer

A

Tumor involves 1 or both ovaries or fallopian tubes, or peritoneal cancer, with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes

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75
Q

stage 3A1 ovarian cancer

A

Positive retroperitoneal lymph nodes only (cytologically or histologically proven):

  • IIIA1(i) Metastasis up to 10 mm in greatest dimension
  • IIIA1(ii) Metastasis more than 10 mm in greatest dimension
76
Q

Stage 3A2 ovarian cancer

A

Microscopic extrapelvic (above the pelvic brim) peritoneal involvement

with or without positive retroperitoneal lymph nodes

77
Q

Stage 3B ovarian cancer

A

Macroscopic peritoneal metastasis beyond the pelvis up to 2 cm in greatest dimension,

with or without metastasis to the retroperitoneal lymph nodes

78
Q

Stage 3C ovarian cancer

A

Macroscopic peritoneal metastasis beyond the pelvis more than 2 cm in greatest dimension,

with or without metastasis to the retroperitoneal lymph nodes (includes extension of tumor to capsule of liver and spleen without parenchymal involvement of either organ)

79
Q

Stage 4 ovarian cancer

A

Distant metastasis excluding peritoneal metastases

80
Q

stage 4A ovarian cancer

A

pleural effusion with positive cytology

81
Q

Stage 4B ovarian cancer

A

Parenchymal metastases and metastases to extra-abdominal organs

(including inguinal lymph nodes and lymph nodes outside of the abdominal cavity)

82
Q

Approximately______ of all epithelial “ovarian” cancers are Stage _____ at diagnosis

A

Approximately two-thirds of all epithelial “ovarian” cancers are Stage III or Stage IV at diagnosis

83
Q

staging laparotomy for ovarian cancer

A
  1. evaluation of peritoneal surfaces.
  2. Retrieval of any peritoneal fluid or ascites, or obtain washings.
  3. Infracolic omentectomy.
  4. Selective lymphadenectomy of the pelvic and para-aortic lymph nodes
  5. Biopsy or resection of any suspicious lesions, masses, or adhesions.
  6. Random peritoneal biopsies of normal surfaces
  7. TAHBSO in most cases.
  8. Appendectomy for mucinous tumors if the appendix appears abnormal.
84
Q

most important prognostic indicator in patients with advanced stage ovarian cancer is?

A

the volume of residual disease after surgical debulking.

85
Q

ovarian cancer - who should get chemo?

A

Stage 1C or high grade stage 1A/1B
All women Stage 2 or higher

86
Q

follow-up schedules for ovarian cancer

A

q3-4/12 for first 2y
q4-6/12 till 5 y
then annually

87
Q

ovarian cancer - chemo relapse categories

A

> 12/12 = sensitive
6-12/12 = partially
<6 = resistance
no response = refractory

88
Q

ovarian cancer is the ___ leading cause of cancer death in women

A

5th

89
Q

overall, ovarian cancer is the ___ most common cancer in women

A

8th most common

(second most common gynae)

90
Q

germ cell tumors account for ____% of all ovarian neoplasms (benign and malignant)

A

25%

but only for 5% of all malignant neoplasms

91
Q

most common malignant types of germ cell tumor of ovary

A

dysgerminoma and immature teratoma

92
Q

peak age for germ cell tumors of ovary

A

10-30y

93
Q

most common malignant ovarian tumor in pregnancy

A

dysgerminoma

94
Q

which tumor markers usually elevated in ovarian dysgerminom

A

LDH
ALP
bHCG

95
Q

what % of dysgerminoma will be bilateral

A

10-15%

the only germ cell tumor to have a significant bilateral rate

96
Q

recurrence rate of ovarian dysgerminoma

A

15-25%

97
Q

which is preferred chemo for ovarian germ cell tumors

A

BEP

98
Q

what is most important prognostic factor of immature teratoma

A

grade

99
Q

malignant transformation for mature teratoma/dermoid

A

1-2%

usually SCC

100
Q

endodermal sinus tumor - markers?

A

AFP

101
Q

embryonal carcinoma - markers?

A

hCG, AFP

102
Q

BEP is…

A

bleomycin, etopiside, cisplatin

103
Q

most common sex-cord stromal malignancy?

A

granulose cell tumor

104
Q

Call-Exner bodies are seen in

A

Granulose cell tumors

105
Q

Crystalloids of renke are seen in

A

ledyig tumors

106
Q

what is the most common ovarian sex cord stromal tumor

A

Fibroma

107
Q

most common MALIGNANT sex cord stromal tumor

A

granulose cell tumor

3% of all ovarian cancers

108
Q

metastatic tumors to the ovary proportion

A

4-8%

109
Q

RMI

A
  1. menopause status (1 or 4)
  2. Ca125
  3. USS features (1 or 4)
    - ascites
    - bilateral
    - cyst (multiloculated)
    - solid
    - extra (mets)
110
Q

most common histology of epithelial ovarian cancers

A

high grade serous

111
Q

BRCA mutation - personal risk of ovarian ca

A

BRCA1 - 40%
BRCA2 - 16-18%

112
Q

HNPCC/Lynch carriers - personal lifetime risk of ovarian ca

A

12%

113
Q

FHx of 1st degree relative with ovarian cancer (nonBRCA) - personal risk

A

3-5%

114
Q

RRSO when to do for BRCA1/2

A

BRCA1 - age 35-40
BRCA2 - age 40-45

115
Q

lifetime risk of HPV

A

80%

116
Q

which hrHPV account for majority of cervical ca cases?

A

16&18 = 71%

other high risk types (19% of cancer): 31, 33, 45, 52, 58

117
Q

bivalent HPV vaccine covers

A

HPV 16 & 18

118
Q

quadrivalent HPV vaccine covers

A

HPV 6, 11, 16, 18

119
Q

nonavalent HPV vaccine covers

A

HPV 6, 11, 16, 18
+
31, 33, 45, 52, 58

120
Q

anogenital warts caused by which HPV types

A

6 & 11

121
Q

invasive cervical cancer spread by

A
  1. direct extension
  2. lymphatic channels
  3. hematogenous (distant mets) late phenomenon
122
Q

cervical ca stage 1

A

ca confined to cervix

123
Q

cervical ca stage 1A

A

maximum depth =<5mm

1A1 =<3mm,
IA2 = 3-5mm

124
Q

cervical ca stage 1B

A

invasive ca with measured deepest invasion >5mm; but lesion limited to to cervix

1B1: 5mm -2cm
1B2: 2-4cm
1B3: >4cm

125
Q

cervical ca stage 2

A

ca invades beyond the uterus, but not extended onto lower third of vagina or pelvic wall

126
Q

cervical ca stage 2A

A

involvement limited to upper 2/3 of vagina without parametrial involvement

2A1 =<4cm
2A2 >4cm

127
Q

cervical ca stage 2B

A

with parametrial involvement but not up to the pelvic wall

128
Q

cervical ca stage 3

A

ca involves lower 1/3 of vagina,

and/or extended to pelvic wall,

and/or causes hydronephrosis or nonfunctioning kidney,

and/or involves nodes

129
Q

cervical ca stage 3A

A

lower 1/3 of vagina
with no extension to pelvic wall

130
Q

cervical ca stage 3B

A

extension to pelvic wall,
or hydronephrosis/nonfunctioning kidney

131
Q

cervical ca stage 3C

A

involvement of nodes:

3C1 pelvic nodes
3C2 para-aortic nodes

132
Q

cervical ca stage 4

A

extends beyond true pelvis or involved mucosa of bladder or rectum

133
Q

cervical ca stage 4A

A

spread to adjacent pelvic organs

134
Q

cervical ca stage 4B

A

spread to distant organs

135
Q

cervical ca: diagnosis of micro invasive disease (stage 1A1 and 1A2)

A
  • cone biopsy by LEEP or cold knife conization
  • trachelectomy or hysterectomy

if margins positive, then upstage 1B1

136
Q

cervical ca: diagnosis of invasive disease

A
  • punch biopsy or small loop or cone
  • imaging - MRI preferred for tumors >10mm
137
Q

cervical ca: detection of nodal metastasis greater than 10mm

A

PET-CT is more accurate than CT and MRI

FN 4-15%

138
Q

cervical ca: other imaging?

A

CXR and USS KUB if frank invasive carcinoma

139
Q

cervical ca: management of Stage 1A1

A

cervical conization
unless LVSI or tumor cells present at surgical margin

if childbearing complete, extrascial hysterectomy may also be recommended

140
Q

cervical ca: management of stage 1A2

A

lymphadenectomy + type B radical hysterectomy

if low risk (no LVSI, SNL negative), simple hysterectomy or trachelectomy with lymphadenectomy may be adequate

141
Q

cervicl ca stage 1A2: fertility sparing options

A
  1. cervical conization with pelvic lymphadenectomy
  2. radical trachelectomy with pelvic lymphadenectomy
142
Q

cervical ca Stage 1A - post treatment followup

A

if fertility sparing surgery, f/u 3/12 Pap smears for 2 years, then 6 monthly for 3 years.
Then return to normal screening schedule

143
Q

cervical ca Stage 1B1 - treatment

A

usually type C radical hysterectomy with pelvic lymphadenectomy

144
Q

cervical ca Stage 1B1/1B2 - fertility sparing options

A

radical trachelectomy with lymphadenectomy

145
Q

cervical ca stage 1B2 and 2A1 - treatment options

A

surgery or radiotherapy can be chosen

146
Q

cervical ca followup post-treatment

A

every 3-4/12 x 2-3y, then 6/12 until 5 y, then annually for life

147
Q

cervical ca, most recurrences happen within

A

3 y,
prognosis is poor

pelvis is most common site of recurrence; para-aortic lymph nodes is 2nd most common

148
Q

cervical ca in pregnancy - if dx after 20/40, can delay treatment for stages

A

1A2, 1B1, 1B2

usually delivery by classical c/s at 34/40 for radical hysterectomy. can have neoadjuvant Rx in the meantime.

149
Q

cervical ca: stage 1B3 and 2A2 treatment

A

CCRT

(concurrent platinum based chemoradiation)

150
Q

cervical ca: pelvic exenteration (primary surgery) can be considered for

A

stage 4A disease with only central disease
(without pelvic sidewall involvement or distant spread)

also can consider for local recurrence

151
Q

lifetime risk cervical cancer

A

1/135

152
Q

histological distribution of cervical ca

A

70% squamous
20% adeno

153
Q

vulvar cancer accounts for ___% of all gynae malignancies

A

4%

154
Q

most common subtype of vulval cancer

A

SCC

155
Q

HPV type related to HSIL and SCC of vulva

A

16

156
Q

lichen sclerosis is associated with which type of VIN

A

differentiated

157
Q

which VIN is associated with HPV

A

undifferentiated

158
Q

overall risk of progression of VIN to SCC

A

9-18%

159
Q

which VIN has a higher rate of progression to SCC

A

differentiated

160
Q

lichen sclerosis risk of progression to SCC

A

4%

161
Q

vulval cancer stage IA

A

Tumor confined to vulva:
=<2cm wide and =<1mm invasion

162
Q

vulval cancer stage IB

A

tumor confined to vulva:
>2cm size or >1mm stromal invasion

163
Q

vulval cancer stage II

A

tumor of any size with extension to lower 1/3 of urethra, vagina, or anus

negative nodes

164
Q

vulval cancer stage 3

A

extension to upper part of adjacent perineal structures,
Or with any number of non fixed, nonulcerated nodes

165
Q

vulval cancer stage 3A

A
  • extension to upper 2/3 of urethra, vagina,
  • bladder or rectal mucosa,
  • regional lymph mets =<5mm
166
Q

vulval cancer stage 3B

A

regional lymph node mets >5mm

Regional refers to inguinal and femoral lymph nodes

167
Q

vulval cancer stage 3c

A

regional lymph node mets with extracapsular spread

Regional refers to inguinal and femoral lymph nodes

168
Q

vulval cancer stage 4

A
  • tumor of any size fixed to bone,
  • fixed, ulcerated lymph node mets,
  • distant mets
169
Q

vulval cancer stage 4A

A

disease fixed to bone,
or ulcerated, fixed nodes

170
Q

vulval cancer stage 4B

A

distant mets

171
Q

vulval cancer - depth of invasion is measured from….

A

basement membrane of the deepest, adjacent, dysplastic, tumor-free rete ridge (or nearest dysplastic rete peg)
to
the deepest point of invasion

172
Q

vulval ca investigations

A
  1. cervical cytology, colposcopy of cx and vagina
  2. FBC, biochem, LFTs, HIV
  3. CXR
  4. CT or MRI of pelvis and groin may be helpful

+/- PET-CT to assess and detect nodes or with large tumors when mets suspected, or in recurrence if extenteration contemplated

173
Q

vulval ca: surgical margins for WLE

A

2cm
to achieve pathological margins of at least 8mm

174
Q

vulval ca: who should have inguinofemoral lymphadenectomy?

A

all women with Stage IB or resectable stage II cancers

175
Q

vulval ca: deep margin of excision in rWLE

A

inferior fascia of urogenital diaphragm

if necessary, the distal 1cm of the urethra can be removed to achieve an adequate margin without compromising urinary continence

176
Q

vulval ca - ipsilateral groin dissection is adequate for?

A

small lateral lesions (<4cm and >=2cm away from midline)

177
Q

vulval ca - bilateral groin dissection for?

A
  • close to (<2cm) or crossing midline
  • involving anterior labia minora
  • large lateral tumors (>4cm)
  • positive ipsilateral nodes
178
Q

indications for a sentinel node procedure (GROINSS-V study)

A
  • unifocal tumors confined to the vulva
  • tumors <4cm in diameter
  • stromal invasion >1mm
  • clinically and radiologically negative groin nodes
179
Q

vulval ca - if ipsilateral sentinel lymph node not detected - next step?

A

complete ipsilateral inguinofemoral lymphadenectomy must be done

if this is positive, then need to proceed to bilateral

180
Q

vulval ca - indications for pelvic and groin irradiation with positive nodes:

A
  1. extra capsular spread
  2. >=2 positive groin nodes
  3. positive sentinel lymph node
181
Q

vulval ca - only patient that does not require LN assessment:

A

=<1mm depth of invasion
and
=<2cm size

ie stage 1A

182
Q

vulval ca: what is a “close” surgical margin

A

<5mm

183
Q

follow-up for vulval ca

A

q3-6/12 for 2y
then q6-12/12 x 3 y

184
Q

BRCA1 risks

A

35-53% risk ovarian
65-80% risk breast

185
Q

BRCA2 risks

A

11-25% risk ovarian
45-85% risk breast

RCPSC (17 decks)

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