Uwise Neoplasia

Front 1

T/F: There is a much higher incidence of molar pregnancies in whites v asians.

Back 1

false. 1/800 for asians v 1/2000 white people.

Front 2

Age ranges for molar pregnancies? Incidence areas?

Back 2

less than 20, over 40. incidence is higher in areas where people consume less beta-carotene and folic acid.

Front 3

OB Hx that make you concerned for a molar pregnancy?

Back 3

women w/ 2+ miscarriages

Front 4

What diet changes can a woman make to decrease her chance of having another molar pregnancy?

Back 4

increase folic acid intake before and after. etiology of molar pregnancy unknown. No factors have been specifically identified that may decrease the recurrence risk for a molar pregnancy.

Front 5

what would you expect to see on ultrasound of a woman w/ suspected molar pregnancy?

Back 5

snowstorm appearance. presence of hydropic villi.

Front 6

How do most molar pregnancy patient present?

Back 6

vaginal bleeding. exam will show S > D (25-50% of cases). extremely high hCG (over a million is diagnostic). May see HTN.

Front 7

What is the most appropriate exam/lab to obtain in order to r/i or out molar pregnancy?

Back 7

ultrasound. no single hCG value is diagnostic (is important though when deciding whether to do an ultrasound)

Front 8

standard management for molar pregnancies?

Back 8

suction curettage. can do a hysterectomy but risk > than risks fo D&C.

Front 9

compared to a complete mole (had 1 patient), how is a partial molar pregnancy different (you've never had a patient)?

Back 9

karyotype 69XX (dispermy v complete which is "empty" egg), fetal PARTs present. incomplete also present w/ larger uteri, higher risk of preeclampsia and decreased likelihood of post-molar GTD

Front 10

Define gestational trophoblastic disease?

Back 10

proliferative disorder of trophoblastic cells. histological types: hydatidiform moles, gestational trophoblastic neoplasia, choriocarcinoma, placental trophoblastic tumor

Front 11

Woman who just underwentD&C for partial molar pregnancy wants to get pregnant ASAP. recommendations?

Back 11

contraception until 6 months after negative beta-hCG levels. patient need serial hCG levels to ensure regression of mole. Contraception recommended to ensure no confusion in interpreting hCG levels. OCPs a good choice.

Front 12

Woman who just underwentD&C for partial molar pregnancy wants to get pregnant again. Whats her chances of a viable infant?

Back 12

Excellent. risk of developing another molar is 1-2% (though higher than women who never had a molar pregnancy). GTD is most curable gynecologic malignancy. even w/ chemo for choriocarcinoma or post molar GTD, pregnancy success rate is high. no known association b/w molar pregnancy and infertility.

Front 13

T/F: risk of developing post molar GTD is greater in incomplete moles versus complete molar pregnancy.

Back 13

false. complete molar pregnancies have a high risk of persistent post molar GTD.

Front 14

a diagnosis of metastatic choriocarcinoma requires what tests/procedures?

Back 14

recent history of pregnancy, imaging (CXR-lungs, CT-brain and liver) and beta-hCG. IUP and ectopic should be excluded, hCG and U/S should take care of that.

Front 15

T/F: U/S is a diagnostic test for choriocarcinoma

Back 15

False. w/o a hCG level it will provide no information. it can tell you if there is an IUP or ectopic present.

Front 16

T/F: like all other malignancies, tissue diagnosis is the standard for diagnosing choriocarcinoma.

Back 16

False. this is the exception because metastatic choriocarcinoma is very vascular, lesion should never be biopsied.

Front 17

88 yo G2P2 nursing resident is brought in because of blood in her diapers. Long standing hx of incontinence and hx of lichen sclerosus of the vulva. Elevated irregular lesion on left labia. next step?

Back 17

biopsy. don't treat because you need to r/o malignancy first. Lichen sclerosis is an inflammatory disease of w/ distinctive dermal changes, pruitus and pain.

Front 18

72yo c/o vulvar itching worsening x 6mo. 3.5cm irregular lesion. Punch bx reveals moderately differentiated SCC. Next step?

Back 18

radical vulvectomy and groin node dissection. ONLY microinvasive SCC of vulva can be treated w/ wide local incision (lesion <2cm, well differentiated, invasion < 1mm).

Front 19

MCC vulvar malignancy

Back 19

SCC (90% of vulvar cancers), may arise in the setting of chronic irritation (pruitus) from lichen sclerosus.

Front 20

vulvar skin appears thin, inelastic and white, with a "crinkled tissue paper" appearance. +pruitus, +mild pain. Dx

Back 20

lichen sclerosus of the vulva

Front 21

vulvar lesion white plaquelike, no discrete mass. Lacy white mottling of the surface.

Back 21

Paget's disease of the vulva.

Front 22

Vulvar "cauliflower" white lesions.

Back 22

Verrucous carcinoma

Front 23

Pigmented lesion of vulva. irregular borders and size.

Back 23

melanoma

Front 24

38 yo G3P3 c/o dark spots on vulva x 2y w/ occasional pruitus. Hx of laser therapy for CIN 10 y ago. no pelvic exam since. Multiple parters, uses condoms. BTL, 24y smoker. Hx of herpes, 2 recurrences/year. No induration of lesion or nodularity. Anatomy normal. dx?

Back 24

HPV related VIN3 (Vulvar intraepithelial neoplasia).

Front 25

chronic, unrelenting vulvar skin infection causing deep, painful scars and foul discharge.

Back 25

hidradenitis suppurativa

Front 26

What are the greatest risk factors for developing vulvar intraepithelial neoplasia grade 3 (VIN 3)?

Back 26

HPV and smoking. Remember cervical dysplasia implies exposure to HPV.

Front 27

After Bx reveals VIN 3. Next step in management.

Back 27

wide local excision.

Front 28

44 yo G2P2 c/o intermittent vulvar itching x 6mo. PMHx Lupus on prednisone and gential warts. Vuvla has diffuse, erythematous labia w/ thin white filmy discharge. subtle multi focal flat white lesions <1.0cm. wet prep negative. next intervention?

Back 28

colposcopy and directed biopsies of the vulva. Most likely HPV related condyloma or vulvar dysplasia. women on immunsuprresive are at higher risk. Her hx suggest most likley condyloma.

Front 29

Patient diagnosed w/ multfocal vulvar dysplasia (VIN2). warty-type lesions on labia, whitish raised papules on minor, major and cltoral hood. most appropriate treatment.

Back 29

CO2 laser ablation of multifocal vulvar dysplasia. skinning vulvectomy whould be the other choice, but its disfiguring and removes the clitoris.

Front 30

58 yo G2P2 c/o vulvar rash x 2y. Hx of breast cancer, on tamoxifen. Steroid cream did not help. vulva red w/ whitish hyperkeratotic ares. Dx?

Back 30

paget's disease of vulva. its an in situ carcinoma of the vulva. association w/ breast cancer is significant but not as high as paget's disease of the nipple.

Front 31

What connects all risk factors of cervical cancer?

Back 31

HPV exposure! These include early-onset sexual activity, multiple sexual partners (or a partner w/ multiple partners), history of HPV, immunosuppression, smoking, poor, lack of regular pap. Boom.

Front 32

T/F: women with HIV have similar rates of cervical dysplasia and invasive cancer than women w/o HIV

Back 32

False. its higher in HIV+.

Front 33

recommendation for pap smears in HIV+

Back 33

obtained twice in first year after diagnosis and if positive, can ressume annual surveillance. If abnormal, needs a colpo and directed biopsy if ASCUS, Low or high SIL or SCC.

Front 34

34 yo G3P3 presents for WWE. No complaints, BTL 6 years ago. hasn't seen doctor since. small white plaque found on cervix in 12 o'clock position. In addition to a pap

Back 34

Biopsy lesion. most likely leukoplakia.

Front 35

colposcopy of cervix is performed. Biopsy shows aytpical vessels. Why is this concerning?

Back 35

represent increased angiogenesis --> worrisome for cancer.

Front 36

Next step when endocervical speculum and colposcopy cannot fully visualize lesion?

Back 36

cervical conization. need to r/o dysplasia and cacner. cold knife cone biopsy is done to get pathology specimen.

Front 37

Indications for cervical conization.

Back 37

unsatisfactory colposcopy (inabilitty to visualize entire SCJ, positive endocervical curettage). Basically, if pap shows something far different than biopsies and the ECC.

Front 38

Define CIS through CIN3

Back 38

abnormal cells extending up to the full length of the squamous surface to the BM, but NOT BEYOND.

Front 39

Define microinvasive cervical cancer.

Back 39

extending less than 3mm beyond the BM.

Front 40

Cervical bx show CIN. Pap shows LSIL. ECC shows high-grade lesion. Next step?

Back 40

cervical conization. indicated if cervical bx show severe dysplasia, CIS or if patient has a postive ECC.

Front 41

What is symptom most commonly assoicated w/ fibroids?

Back 41

Menorrhagia 2/2 increase in uterine cavity size that leads to increased area for endometrial sloughing and/or an obstructive effect on vasculature that leads to endometrial venule etasia and proximal congestion.

Front 42

other than mennorrhagia, what are some other symptoms of fibroids?

Back 42

pain, pressure symptoms related to size of tumors as well as pressure against bladder, bowel and pelvic floor.

Front 43

appropriate treatment options for uterine fibroid on anterior uterus in 25 G1 @ 17w?

Back 43

No further treatment is necessary. Most are asx and do not require treatment. rarely symptomatic in pregnancy 2/2 hemorrhagic changes (red degeneration). If fibroid is located below fetus, lower uterine segment or cervix or may cause soft tissue dystocia --> CS!

Front 44

MC solid pelvic tumors in women?

Back 44

fibroids.

Front 45

Why is removal of fibroid (myomectomy) contraindicated during pregnancy/at time of section?

Back 45

risk of increased blood loss.

Front 46

Which type of fibroid is more likely to cause subfertility? Best treatment?

Back 46

submucosa. presumed mechanisms: focal endometrial vascular disturbance, inflammation or secretion of vasoactive substances. Best treatment is hysteroscopic resection.

Front 47

Medical options for treating symptomatic uterine fibroids?

Back 47

GnRH agonists (constant NOT PULSATILE) --> (-) estrogen --> decrease size of fibroids. Commonly used 3-6 months prior to hysterectomy. this therapy is commonly used in women close to menopause.

Front 48

47yo G2P2 c/o recent weight gain 20lbs. She is concerned its 2/2 fibroids but w/o sx. BMI > , smoker. hCG negative. TVUS shows 4cm intramural fibroid. next step?

Back 48

lose some weight fatty! she isn't symptomatic. no indication for asymptomatic small fibroids.

Front 49

50 yo G3P3 c/o menorrhagia. Physical exam c/w 14w irregularly shaped uterus. Hct 35%. Next step in management?

Back 49

Age group (approaching menopause) and normal Hct is suspicious for hyperplasia or cancer. Get an endometrial biopsy prior to GnRH agonist or hysterectomy/myomectomy.

Front 50

What happens to the response of fibroids is a women stops her GnRH treatment?

Back 50

resume their former growth potential. maximal response of GnRH is achieved by 3mo.

Front 51

side effects of GnRH therapy for fibroids.

Back 51

post-menopausal sx --. hot flashes (>75% but resolve after max 2mo).

Front 52

48yo G2P2 c/o progressively heavier and longer menstrual periods x 12mo. +Fatigue. Irregularly shpaed 16w size uterus. Hct 28%. Dx?

Back 52

Uterine fibroids. DDx: hyperplasia/cancer.

Front 53

Patient c/o dysmenorrhea, menorrhagia. physical exam shows symmetric enlarged "boggy" uterus. Dx

Back 53

adenomyosis.

Front 54

31 yo G0 diagnosed w/ uterine fibroids. US show intramural (5 x 6cm and 2 x 3 cm) x 2 distorting cavity. h/o infertility x 2y. No etiology of infertility after work up. Most appropriate treatment?

Back 54

Myomectomy as patient still wants children. A cause may be due to mechanical distortion 2/2 fibroids. GnRH not indicated as patient would like to get pregnant still. artery embolization not indicated either.

Front 55

Of nulliparity, obesity, late menopause, HTN and exposure to unopposed estrogen, which confers greatest risk of developing endometrial cancer?

Back 55

obesity, especially when patient is more than 50lbs over ideal weight.

Front 56

Which confers a greater risk of endometrial cancer: obesity or Endo Bx positive for complex atypical hyperplasia.

Back 56

Complex atypical hyperplasia. 28% will progress to invasive cancer if left untreated.

Front 57

T/F: most women who are diagnosed w/ endometrial cancer are symptomatic.

Back 57

True. 5% are asymptomatic. Most present w/ VB or discharge as their only presenting symptom.

Front 58

Name top 5 cancers detected in women.

Back 58

In descending order: Breast, Lung, Colon, Uterine, Ovary

Front 59

Name top 5 gynecologic cancer

Back 59

uterine, ovary, cervix, vulva, vaginal

Front 60

72 yo G3P3 c/o abnormal discharge x 2 mo. Endorses VB x 2 over last year. Hx: HRT x 10 y (58-68yo). Tried antifungal creams. +abdominal discomfort. Exam: mucopurlent discharge from os, 10w size uterus. Which finding is most concerning for endometrial cancer?

Back 60

vaginal bleeding. this is MC presenting symptoms in postmenopausal women. Remember, be specific on HRT (unopposed v combined).

Front 61

65 yo G2P1 referred from internist 2/2 of persistent VB x 2mo. TVUS showed normal lining. from referral, an endometrial Bx: scant tissue w/ rare ayptia. next step in management?

Back 61

D&C. Bx has high detection rate, and atypia warrants further investigation w/ D&C.

Front 62

62 yo G0 had Endo Bx c/w FIGO grade 1 endometrial AC. No other significant hx and benign physical. Next test?

Back 62

CXR. Lungs are the most common site of distant spread. When there is a low suspcion of advanced disease, CT, MRI, PET and other invasive and costly tests are not indicated.

Front 63

Treatment for FIGO grade 2 endometrial cancer in premenopausal woman?

Back 63

TAH/BSO, bilateral pelvic and para-aortic lympahdenectomy, pelvic washings. Can also do a lap-hys, BSO and staging.

Front 64

patient w/ multiple risk factors for endometrial cancer. In tolerance found in speculum and bi-man exam as patient is a virgin. Next step?

Back 64

D&C. intolerant to office procedures like endometrial bx, would make D&C next best choice to get cause of bleeding.

Front 65

What are common causes of post-menopausal bleeding?

Back 65

atrophy of endometrium (60-80%), HRT (15-25%), endometrial cancer (10-15%), polyps (2-12%) and hyperplasia (5-10%).

Front 66

65yo G2P2 hx of stage I endometrial CA returns for routine surveillance. c/o dry cough x several months refractory to abx. elevated CA 125 and CXR: multiple nodules. Next step?

Back 66

refer to oncologist.

Front 67

T/F: Tamoxifen is known to increase risk of endometrial cancer.

Back 67

True. remember, ultrasound isn't helpful because tamoxifen is known to cause changes in endometrium (thickening).

Front 68

35 yo G0 has FHx +Ov CA in mother @ age 50. Onset of menarche at 14, OCP x 10y, 1 pack/wk smoker, hx of GC and herpes and LEEP 2/2 cervical dysplasia. Which places greatest risk of developing ovarian cancer?

Back 68

FHx. events leading to the development of ovarian cancer are unknown. endocrine, environmental and genetic factors are importnant in carcinogenesis.

Front 69

T/F: smoking is an associated risk factor for increased risk of ovarian cancer.

Back 69

False. Nulliparity, fhx, early menarche, late menopause, white people and increase age.

Front 70

What are some protective measures an 18yo G0 woman can take to minimize risk for developing ovarian cancer?

Back 70

Start OCPs until ready to have a baby. OCPs cause anovulation.

Front 71

25 you G0 wants to assess her risk for ovarian cancer. MGM + Ov CA, Mom +Breast CA w/ mets. Next step in management?

Back 71

BRCA1 and 2 mutations should be checked on patient's mother. These mutations are seen in cases of hereditary ovarian cancer. There are no routine screening tests available.

Front 72

25 yo G1P1 c/o LLQ discomfort. Regular menses. LMP 3 weeks ago. Exam + mass; 3 x 5 cm Left adnexal mass. U/S shows unilocular cyst. Most likely diagnosis?

Back 72

functional ovarian cyst. US shows unilocular cyst w/o evidence of blood or excresences. Serous cystadenomas are generally larger than functional cysts

Front 73

Describe how the following appear on ultrasound: functional ovarian cyst, muscinous cystadenoma, serous cystadenoma and dermoid.

Back 73

functional ovarian cyst is a simple cyst on ultrasound. Serous appears similar to functional just larger. Mucinous tend to be multiloular and large. Dermoid tumors tend to have solid components or appear echogenic: teeth, cartilage, bone, fat and hair

Front 74

72 yo G3P2 c/o of abdominal bloating and early satiety. Large pelvic mass identified on U/S. elevated CA125. What is most helpful in assessing extent of disease?

Back 74

CT scan abdomen + pelvis. No SOB or sx so no CXR at this time.

Front 75

Describe steps in surgical staging of apparent advanced ovarian cancer.

Back 75

vertical skin incision, sampling ascites, inspection of entire peritoneal cavity, TAH/BSO, omentectomy, pelvic and para-aortic lymph node dissection.

Front 76

When is neoadjuvant chemotherapy an viable option in treatment of cervical cancer?

Back 76

when patient has unresectable disease or is a poor surgical candidate, at which point paracentesis for cytologic confirmation.

Front 77

What information is most helpful in determining long term prognosis of papillary adenocarcinoma of the ovary.

Back 77

Tumor stage. 5 year survival of patients w/ epithelial ovarian cancer is ~ stage.

Front 78

44 yo G0 is POD 21 s/p surgical procedure 2/2 Stage IIIB endometroid AC of the ovary. MHx significant for DM, HTN, HLD and depression. Most appropriate treatment at this time?

Back 78

chemotherapy. in patients w/ advanced ovarian cancer, post-op chemo is standard of care.

Front 79

30 yo G1P1 p/w left sided abdominal pain. Physical exam + 5 x 6cm mobile mass. U/S: left ovarian mass w/ solid and cystic components. Most likely Dx?

Back 79

dermoid tumor. may contain differentiated tissue from all three embryonic germ layers. Look for teeth, har, sweat and sebaceous glands, cartilage, bone and fat. 80% occur during reproductive years.