Monica’s Part 2 > Oncology > Flashcards

Oncology Flashcards

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1
Q

lifetime of EC with Lynch syndrome

A

25-60%

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2
Q

ET that is upper normal if postmenopausal , asymptomatic and on HRT

A

8mm

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3
Q

In symptomatic postmenopausal women with unscheduled vaginal bleeding whilst taking HRT or tamoxifen an endometrial biopsy should be taken if ET is ?

A

> 5mm

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4
Q

When to refer women if on HTR and bleeding

A

if persistent bleeding after 6 months of starting HRT

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5
Q

if new onset of PMB refer after stopping HRT

A

if persistent bleeding 6 weeks after stopping HRT

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6
Q

Tamoxifen is associated with?? fold increased risk of EC and therefore triggers a high level of clinical suspicion

A

three fold

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7
Q

what monitoring for women who have Lynch syndrome exists for EC?

A

should have annual TVS, hysteroscopy, endometrial biopsy after 35yrs

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8
Q

how much does end Ca increase with weight gain

A

every 5kg/m2 increase in BMI is linked to a 60% increase in endometrial cancer

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9
Q

how many times is a women with a BMI of 40 at increased of EC

A

10 times
giving her a lifetime risk of 10-15%

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10
Q

How many % of endo ca is attributed to obesity

A

40%

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11
Q

mirena is associated with how much reduction EC

A

54% reductions

increases to 75% if treatment is prolonged

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12
Q

how to treat Endometrial hyperplasia without atypia

A

norehisterone 10-15mg OD

or

Medroxyprogesterone 10-20mg one

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13
Q

Complete GCIN excision after cylinder loop FU?

A

6,18, then back to recall

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14
Q

1)Incomplete CGIN

2) Incomplete margins post hysterectomy for CIN 2 and 3

3) post LLETZ for 1A1

A

6, 12m, 9y

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15
Q

FU after incomplete excision of CIN 1 post hysterectomy

A

6, 12, 24

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16
Q

if colp inadequate (TZ 3) HPC + and low grade then repeat smear in colp in

A

12 months

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17
Q

if incomplete margins of CIN

A

depends on age, if under 50- no evidence of glandular abnormality,
no evidence of invasive disease=
NO repeat FU

if over 50 , and incomplete excision of CIN3 - repeat excision performed to try to obtain clear margins

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18
Q

if glandular neoplasia

A

need endometrial sampling

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19
Q

can you have conservative management of CIN II

A

yes if colposcopes examination is adequate and has excluded CIN3

CIN lesion occupies no more than 2 quadrants oc the cervix

they agree to 6 monthly smears in colp

treatment must be offered within 24 months if CIN not resolved- needs MDT

needs 6 monthly FU for 2 years +MDT

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20
Q

Cervical screening during pregnancy

A

if abnormal screening can have colp in late

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21
Q

If CIN 2 or 3 suspected in preggo

A

repeat colp at the end of the second trimester
if pregnancy further than that, repeat 3 months following delivery

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22
Q

are exceptional treatment are in preggo

A

yes in the 1st and 2nd trimester

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23
Q

FU post 1a1 and 1a2 cervical ca treatment

A

3 Montly smears for 2 years then 6 montly for 3 years

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24
Q

Which stage is the last stage you could do a teachelectomy

A

1B1

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25
Treatment for 1b3 and 2a2 cervical ca
CCRT - chemo and brachytherapy Platinum based
26
Situation to not defer a smear
Hx of CGIN or hx of CIN 2, 3 with unclear margins -
27
When do you start to do LN dissection for Vulval CA at what stage
1B
28
If nodes are positive in inguinal/femoral positive in vulval CA
Adjuvant Chemo and radiotherapy should be offered for early stage disease
29
what is Paget disease of the vulva
rare and can affect apocrine gland of the vuvla there are two types : 1) Begins as an intraepithelial lesion but the secondary form is due to invasion from an underlying adenocarcinoma which may be anorectal urothelial or genial tract carcinoma , endocevical or endometrial Treatment - wide local excision or imiquimod has high recurrence rates **eczematoid weeping lesion** in post menopausal women
30
in whom does gadgets disease usually occur in what does is look like
Postmenopausal women, presenting with pruritus, pain and an eczmatoid weeping lesion is often seen
31
What is the lifetime risk of ovarian cancer
1.4% Median age is 57 If any hereditary cancer 25-60%
32
Overall 5 year survival rate for ovarian cancer
45%
33
What kind of cancer is associated with Endo
Clear cell carcinoma of ovary
34
What is a 2nd line imaging modality in possible ovarian CA
MRI
35
What is staging modality for ovarian CA
CT TAP
36
Criteria to consider conservative management in postmenopausal cysts in women - need to be > or equal to 1cm
simple Asymptomatic Unilateral Uniloculated <5cm
37
What does conservative management mean for postmeno ovary
USS in 4-6 months with CA 125 for a year
38
If RMI > or equal to 200
Do CT AP and MDT
39
RMI
For cyst 1 factor =1 point, 2 or more = 3 points Bilateral Solid Mets Ascites Mutlilocular
40
How often to rescan a premenopausal women if cyst 5-7cm
Once a year
41
Chemo for ovarian cancer what is it
Platinum based
42
How many ppl will relapse post 1st line chemo
70%
43
What do you add to chemo to improve progression freee survivial
Add PARP inhibitors, bevacizumab (VEGF A inhibitor) or both
44
What is Braca 1/2 cancer demonstrate sensitivity to what chemo
Platinum based chemo and PARPi
45
What is a PARP?
Poly ADP ribose polymerase enzymes are crucial in single strand DNA repair pathways PARP inhibitors are useful new therapeutic modality for HGSC high grade serous carcinoma Used for braca 1 and 2
46
What is the increase in all cause mortality and composite morbidlity following BSO between 50-54
10%
47
By how much does BSO before 45 Associate with a greater mortality from cardiovascualr disease by
1.5% HRT offered protection in this group
48
Tubal ligation alonę reducentów the risk of ovarian CA by
34%
49
When do you do a sentinel LN biopsy
-unifocal disease -Depth of invasion >1mm , Tumour <4cm in vivo - representative peri-lesional injection is possible Tumour should not involve urethra, anus or vagina - no cinical or radiological evidence of involved nodes
50
What is a peritoneal pseudomyxoma associated with- what type of tumor (10% of cases)
Mutinous borderline ovarian tumors - they can be classified into intestinal and Endocervical/mullerian types - depending on the nature of the lining
51
What does the histology looks like of borderline tumours
Borderline ovarian tumors have stratifies epithelium with varying degreees of nuclear atypia and increased mitiotic activity, their lack of stromal invasion distinguishes them from invasive carcinomas
52
What type of cancers does the COPC decrease the risk of
Endometrial Ovarian Braca 1 and 2 associated ovarian
53
Risk factors for endometrial CA - not obvious and protective factors
PCOS Lynch syndrome 40-60% of risk of endometrial ca Breast CA PROTECTIVE factors: Parity Use of COCP
54
IOTA M and B rules
M rules: Irregular solid Tumour Presence of ascites >= 4 papillary projection Irregular multilocular solid Tumour >=100mm Color score 4 (strong blood flow) B rules: Unilocular Tumour with largest solid component <7mm Acoustic shadows Smooth multilocular Tumour <100mm Color score 1 For Malignant, need one M feature and NO b features , and vice versa. If mixed features its inconclusive - 20%
55
What are poor prognostic factors in exenterative surgery for recurrent gynae cancer in irradiated patients
Obesity , poor patient performance status, psychological frailty, Short time to recurrence <2 years Mets in pelvic LNs Mets in para aortic LN POS peritoneal fluid Size of lesion >5cm in any dimension Histological margin R1 R2 Hisoltogical evidence of blood vessel infiltration or perineural disease Best age for exenteration is less than 70
56
What are common pipelle biopsy complications
Inadequate sample 31% Failure 11%
57
What to do if ca125 raised according to NICE - what imaging
USS ABDO and pelvis
58
What is the operative mortality rate for pelvic exenteration
15%
59
Doesn’t the OCP have protective factors for ovarian cancer
Yes
60
Risk of cancer from lichen planus and lichen sclerosis
3%
61
If the OCP protective of borderline tumors?
No
62
Is BRCA affiliated with borderline tumors
No
63
Can endometrial abnormalities be detected on a routine cervical smear
Yes
64
Risk factors for ovarian cancer
-Carrier BRCA1/2 or mismatch repair gene -untested 1st degree relative of someone with BRCA1/2 RAD51C, RAD51D or mismatch repair genes - untested second degree relative though an unaffected man of an individual with a mutation in BRACA1, 2, Rad51c, RAD51D or mismatch repair gene - first degree relative affected by cancer within a family that meets a lot of criteria …..
65
Do you need to do LN lymphadenectomy in ovarian cancer routinely
No
66
Which germ cell Tumour can be bilateral
Dysgerminoma - 10- 15%
67
Which genes does Lynch syndrome affect
MSH2, MSH6, MLH1 PMS2 They have a 25-60% lifetime risk of EC and present younger than sporadic EC
68
Random protective factors for endometrial CA
Smoking ever vs never Coffee drinking Increased animal fat intake Metformin bisphosphonate Bariatric op
69
What gene mutations are associated with borderline ovarian tumors
BRAF/Kras These are low grade tumors
70
Which mutation is associated with high grade serous ovarian cancer
P53
71
What is the most common indication for pelvic exenteration
Recurrent cervical cancer post radiotherapy Can be with or without chemo and with or without radical surgery Most recurrences occur within 3 years of primary treatment Less common indication include recurrent endometrial or vulval
72
How often do you check tumor marker after op for malignant ovarian germ cell tumors
Every 2 weeks for nondysgerminomas, **monthly for dysgerminomas** Every 2 weeks for first 6 months 7-12month = monthly 1-2 year — 2 monthly 2-3y — 3 monthly 3-4 y — 4 monthly 5-6 year — 6 monthly 7 years and over - one a year AFP has a half life of 6-7d, HCG 1-2 days Surveillance includes regular review, exam, imaging and tumor markers Tumor marker FU ragrdelss of initial value : AFP, hCG, LDH, Ca125
73
When does relapse usually occur in MOGCTs
2 years
74
What are malignant causes for elevated ca 125
Ovarian cancer Endometrial cancer Pancreatic cancer Primary peritoneal cancer Lung cancer Bowel cancer Breast Lymphoma Physiological causes for high ca125 -pregnancy -menstruation -age Other random benign causes Fibroids Pancreatitis TB Heart failure AF, pericardial disease
75
What is the best chemo for malignant ovarian germ cell Tumour
BEP - Bleomycin, etioposide, cisPlatin Platinum chemo is best for germ cell tumors BEP is administer for 3 cycles if complete resection or 4 cycles for macroscopic residual disease Bone marrow growth factors may be given Cisplatin should only be replaced by carboplatin if renal problems , peripheral neuropathy or ototoxicity
76
Which chemo for dysgermonoma
Adjuvant carboplatin and etoposide
77
Is pregnancy contraindicated for a smear test
Do smear in pregnancy if FU for : CGIN CIN 2 and CIN 3 All 3 with involved or uncertain margins - cytology should not be delayed until post pregnancy
78
What tumor marker will be elevated in immature teratoma
AFP
79
What are the most common MOGCTS
Dysgerminomas Immature teratomas Embryonal tumours Then Less common are endedermal sinus , chriocarcinomas, mixed cell types
80
What tumor marker is high in sex cord stromal tumors
Inhibin
81
When can you try to get preggo after fertility sparing surgery for early malignant germ cell tumours
After 2 years of surveillance
82
What is the indication for chemo in MOGCTs
Depends on the extent and type of disease at diagnosis For more advanced disese, stage II or greater, neoadjuvant combo chemo may be an option especially if fertility sparing surgery If stave IIIC or IV disease, then operate and then chemo
83
What is the relapse rate for dysgerminomas
20% FU monthly for first 6 months
84
Do you give adjuvant chemo for early 1a1b dysgerminomas
No only surveillance due to chemo causing ovarian failure /infertiltiy
85
What is the prevalence of Lynch syndrome in women with endometrial cancer
3%
86
What kind of hereditary pattern does lynch syndrome have
AD , its highly penetrant (90%)
87
What DNA mismatch repair genes cause Lynch syndrome
There are 5 of them MSH2 MSH6 PMS1 PMS2 MLH1
88
What is the most common type of chemo used for ovarian cancer when adjuvant
Paclitaxel and carboplatin
89
Why do SLN biopsy in vulval cancer
Imaging is poor at excluding micro Mets so inguinal node surgery is recommenced is more than IA SCC if vulva
90
Can you do a fine needle aspiration of a inguinal LN in vulval CA
Yes if suspicious groin nodes on exam
91
When to do a CT TAP for staking
In vulval cancer if suspected or diagnosed with stage III disease or greater because further distant Mets will influence the extent of loco regional treatment options CONSIDER MRI- for Tumours with equivocal or clearn involvement of midline structures if this will directly surgical management
92
Is PET recommended for LN imaging
Not for routine vulval staging PET CT has limited value in detecting LN Mets <5mm and necrotic nodes and inflammatory nodes can be FP
93
What is also good for vulval CA inguinal LN evaluation
18F FDG PET CT
94
What number of breast CAs are due to BRCA
5%
95
What pathology tends to be in BRCA 1
Invasive ductal carcinoma with higher Tumour grade , lymphocytic infiltration and pushing margins Usually diagnosed at younger age and are triple negative In comparison BRCA 2 cancers have less distinct molecular phenotype consistently and there are no clear histopathological features that distinguish molecular phenotype and there are no clear histopath features that distinguish them from sporadic breast CAs with BRCA 2 tumours which tend to be more HER2 neg and ER POS
96
When to do Neo-adjuvant chemo NACT for ovarian cancer ?
When bulky supracolic omental disease is present or liver Mets that cannot be optimally resected
97
What is platinum resistant disease , define it
Patient who develop recurrent disease within 6 months of completing their last dose of platinum Platinum REFRACTORY disease - if patients develop resistance while receiving chemotherapy Platinum SENSITIVE= if develop recurrence beyond 6 months after completing their last platinum dose PARTIALLY SENSITIVE = recurrence occurs between 6 and 12 months ** importance is that retreatment with platinum has poor results even with non plat - like pegylated liposomal doxorubicin hydrochloride
98
How to excise suspicious cancer leasion initially?
Wedge biopsy
99
When to offer risk reducing op for Lynch syndrome if MSH2 pos
Hysterectomy and BSO by 35 MLH1 and MSH2 - at 35 years MSH 6 at 40 PMS 2 at 50
100
When to offer risk reducing op for Lynch syndrome if PMS2 post
Hyst and BSO at 50 MLH1 and MSH2 - at 35 years MSH 6 at 40 PMS 2 at 50
101
When to offer risk reducing op for Lynch syndrome if MLH1 & MSH2 pos
At age 35 MLH1 and MSH2 - at 35 years MSH 6 at 40 PMS 2 at 50
102
When to do groin node surgery in vulval CA
If more than stage 1A SCC Prior to SLNB examination and imaging is required of the grounds since obvious groin note disease would be contraindicated to SLNB USS is good for LN but very user dependent SO If suspicious groin notes on examination do USS guided fine needle aspiration or core biopsy where node positivity would change management.
103
When to do USS guided fine needle aspiration
In SCC of vulva If suspicious groin notes on examination do USS guided fine needle aspiration or core biopsy where node positivity would change management.
104
Survival rate for endometrial cancer for 5 years
Stage 1 = 95% Stage 2 = 75% Stage 3 = 50% Stage IV = 15%
105
What is the 1st line treatment for stage 1 dysgerminoma trying to preserve fertility
OPEN - unilateral SO , peritoneal washing, omental biopsy, selective removal of enlarged LNs Only open to prevent the cyst from breaking or rupturing more likely would happen if laparscopic
106
Can you have HRT post Lynch syndrome RR surgery
Yes - Estrogen only HRT - patch is best Estrogen has a protective effect against colorectal cancer and does not appreciably increase breast CA risk
107
What percentage of patients with ovarian CA respond to 1st line chemo
75% (70-80%) initially respond to first line chemo Most responders eventually relapse (55% to 75% within 2 years). Responses to chemo can occur when 1st line chemo is repeated for a second and sometimes 3rd time. A complete response is defined as malignant disease not detectable for at least 4 weeks. Partial response is defined as tumour size reduzed by 50% for more than 4 weeks
108
What cancers can you use HRT post op
Endometrial Type 1- endometroid , stage 1 and II: **estrogen only** if no concern of possible occult foci, otherwise continuous combined Cervical- Squamous cell, stage I & II, - estrogen only if no concern with possible occult foci, otherwise continuous combined Vulval - squamous cell carcinoma, - estrogen only if prev hysterectomy otherwise continuous combined Vaginal -SCC - estrogen only if prev hysterectomy otherwise continuous combined Ovarian epithelial - limited data All other cancers and types- avoid or use cautiously
109
What cancers should you avoid using HRT post op
Ovarian - Germ cell, sex cord stromal = avoid Borderline =avoid/use with caution Endometrial, (Type 1) -stage III, IV = avoid Endometrial Type 2 = avoid Vulval, non SCC = avoid Vaginal nonSCC= avoid Cervical, SCC stage III, IV, = avoid / use cautiously Cervical Adenocarcinoma = avoid/ use cautiously
110
What is the response rate to second line chemotherapy after 9 months since completing last chemo
25- 30% Platinum free interval Platinum sensitive >12mont = 40 - 75% response rate Partially platinum sensitive 6-12 mo = 25- 30% Platinum resistant <6 months = 10 - 20% Platinum refractory = 10%
111
How to manage a preggo 18w with invasive suspisious disease at culposcopy
LLETZ - punch biopsy cannot reliably exclude invasion Risk of haemorrage with LLETZ is 25% need to be done in big clinics close to ORs
112
What is struma ovari
Ovarian goitre- a variant of an ovarian teratoma specifically with thyroid tissue constituting greater than half of the overall teratoma - about 2.7% of all dermis’s -usu in woman in 30s While most struma ovarii are benign thyroid-type malignancies- most often papillary carcinoma may arise within this subgroup of ovarina teratomas Most cases of struma ovarii present as any other mature teratomas Diagnosis is confirmed by radioactive iodine uptake seen in the pelvis Treat with antithyroid drugs and op - surgery carries a risk of thyroid storm . Laparoscopy is good for this
113
What is the rikitansky nodule associated with
Ovarian teratoma
114
What are mature ovarian teratomas associated with
Paraneoplastic encephalitis- secondary to neoplasticism processes Can be behavioral changes, to complex seizures. Paraneo encephalitis can subdivide into: two broad groups based on location of antigen which is the causative antibody - antibodies directed against intercellular neuronal proteins - antibodies directed against neuronal surface antigens The most notable is the antibody directed **against neuronal surface antigens** NMDAR NMDAR encephalitis is a disease of young women with median age of onset of 22 years or 15 with an MATURE OVARIAN TERATOMA - in up to 65% of cases
115
What is hypercalcemia, AKI and complex ovarian mass associated with
Small cell ovarian carcinoma but also in clear cell carcinoma Paraneoplastic hypercalcemia refers to elevated circulating Ca secondary to parathyroid hormone related protein, secreted by the tumour (humoral hypercalcemia of malignancy) causing renal calcium retention and increased osteoclast activity Small cell carcinoma of ovary - very agressive, in young women Patient will be dehydrated due to the AKI from kidneys resolving the Ca, patient will be in pain from bone respiration, renal failure, constipation, CNS disturbance , behavior changes Treatment is aggressive fluids , try to decrease Ca with bisphophonates and op
116
What is the lifetime risk of breast CA with BRCA 2
45% ovary/tube = 11-27% BRCA1- Boob Ca= 55-65% Ovary/tube ca = 59%
117
What is the lifetime risk of ovarian cancer with BRCA 1
59% BRCA1- Boob Ca= 55-65%- say 65% Ovary/tube ca = 59% BRCA2 Boob= 45% ovary/tube = 11-27%
118
What is the incidence of Paraneoplastic syndrome is all of gynaecology
8% approx
119
What is Paraneoplastic cerebella degeneration associated with
Anti-yo antibody - account for 50% of all PCD cases MC ovarian and breast cancer , vaginal melanoma is rare with this
120
What is the lifetime risk of endometrial cancer with lynch syndrome
60% (or 40-60%) - 57% Ovary 17% Colon 45%
121
What genetic mutation is small cell carcinoma of the ovary related to
SMARCA4 Small cell carcinoma of the ovary, hypecalcaemic type is the most common undifferentiated ovarian malignancy in women under 40 It is distinguishable because of the dominant appearance of small hyperchromatic cell with scant cytoplasm and brisk mitotic activity - an early age of onset and the presence of hypercalcemia which discriminates it from the nueroendocirne type.
122
What genetic mutation is cowden syndrome related to
PTEN Cowden is AD, its part of phosphatase and tension homolog HAMRATOMA tumour syndrome Mucomutanous lesions 90-100% fibrocystic breast disease (76% of affected females, , thyroid stuff, multiple uterine leiomyomas, gastrointestinal polyps macrencepahy. Associated increased lifetime of several malignancies - breast, thyroid, endometrial cancers
123
Which genetic mutations is Lynch syndrome associated with
If you need to pick one - pick MSH2 Others are MLH1 MSH2 MSH6 PMS1 PMS2
124
What genetic condition is pests jeghers syndrome related to
STK11 A rare condition benign hamartomous polyps of the GI tract and melanosis of the lips and oral mucosa AD Malignancies of a young age - develop in colon, small intestine and stomach,
125
What is CGIN
Cervical glandular intraepithelial neoplasia is a precancerous condition that occurs when there are changes to the glandular cell of the cervix Usually in older women Concomitant CIN in approx 50% **if over 40 and smear done after 12th day of cycle with normal endometrial cells seen on the cervical sample- THIS could mean endometrial pathology or polyp or endometrial cancer. Woman need to be sent for colposcopy within 2 weeks and if pipelle done in the mean time and a USS to rule out ovarian CA/cyst!!!**
126
What is the genetic mutation assiciated with Muir- Torre syndrome
MLH1 Muir Torre syndrome AD rare \keratoachanthomas and visceral malignancy Colorectal, urothelial , endometrial
127
What to do if CGIN has been completely excised
Test of cure in 6 months , smear, either at GP or colp, MDT will decide If negative HPV , second TOC in 12 months or 18 months from treatment , if this is also negative for HPV, return to recall in 3 year If TOC positive for HPV at any point, needs cytology done to help colp If TOC just HVP pos but colp examination is normal - needs 2nd TOC 12 months later
128
What do you do if an individual is inadequate cytology at 24months
Refer to colp
129
Who goes to colp in 2 weeks
High grease dyskaryosis (moderate and severe) Suspected glandular neoplasia Borderline changes in endocervical cells
130
How to follow up LLETZ for CGIN
smear in 6 and then 12 months or 18 months from cure If at all hvp pos needs cytology and if HPV pos but cytology neg need FU smear in one year If all normal at 18 mo for routine renal back to 36 months If at all cytology abnormal for colp
131
How to treat cervical CA that goes into the parametrium but not into side wall
This is IIB Treat with chemo- radiotherapy consisting of external beam radiotherapy , intracavitary brachytherapy and concomitant chemo with cisplatin
132
How to treat cervical CA 1a2, 1b1, 1b2 in the standard way ie not wanted it fertility
Radical hysterectomy, BL salpingectomy, +/- BL oopherectomy BL pelvic lymphadenectomy
133
How to treat IVa vulval ca
Pallliative
134
How to treat multi focal disease of vulval ca ex 1B
Separate wide local excisions can be considered but But consider radical vulvectomy if large tumors or those demonstrating multi focal invasion with backround of vulval dermatosis
135
How to treat 1A1 cervical cancer
Simple hysterectomy
136
Up to what stage and which op to do for fertility spearing cervical ca treatment
Up to 1B1 Do a radical trachelectomy with cerclage and bilateral pelvic lymphadenectomy and or sentinel LN biopsy
137
how to treat stage 1B vulval squamous cell carcinoma
the management of these is determined by the location of the tumour - if the tumour is lateral of the midline with the edge of the tumour lying more that 1cm of the midline structures such as urethma, clitoris A RADICAL WIDE LOCAL EXCISION should be undertaken -if the tumour is peri-clitoral , an anterior vulvectomy may be required - if the tumour is close to the midline, surgery will often involve the contralateral side to ensure adequate margin is achieved and the defect can be closed without tension - If lesion is in the posterior part of the vulva and close to midline- perform a posterior vulvectomy
138
How to treat 1A vulval CA
wide local excision without lymphadenectomy
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