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Boards - Ovarian Cancer
OBGYN Qualifying Exam
181
Other
Post-Graduate
02/23/2020

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Cards

Term
what percent of torsion in adolescents do not involve an ovarian mass
Definition
46%
Term
what percent of torsion is not identified on laparoscopy
Definition
50%
Term
what size pelvic mass increases the risk of torsion
Definition
5cm
Term
what are the 2 pelvic masses that cause torsion in adolescents
Definition
simple cyst, benign teratomas
Term
what side has more torsion and why
Definition
64% on right side, left is protected by colon
Term
symptoms of torsion and incidence (3)
Definition
pain 88%, nausea 62%, vomiting 67%
Term
signs of torsion on ultrasound (7)
Definition
enlarge edema ovary, echogenic stroma, free fluid, whirlpool sign, asymmetric ovaries x12, multiple peripherial follicles, decreased flow (60% have flow)
Term
signs of torsion on CR (4)
Definition
asymmetric ovaries, uterine deviation towards pathologic side, free fluid, fat stranding
Term
signs of torsion on MRI (4)
Definition
decreased enhancement with contrast, asymmetric ovaries, deviation of uterus toward pathologic side, multiple peripherial follicles
Term
risk factors for torsion (4)
Definition
ovarian mass, congenitally long ovarian ligaments, laxity of pelvic ligaments, small uterus
Term
what percent of toarsed ovaries will heal and be fine
Definition
90% in 3mo
Term
when should you oopexy a torsed ovary
Definition
recurrent torsion, absent contralateral ovary, generally insufficient evidence
Term
what are general concepts when doing laparoscopy in adolescents
Definition
use lower pressures
higher risk of injury on entry
dont do cystectomy may compormise ovary
close all fascia even 5mm
opiates <3d post op
Term
when pressures should be used in adolescent laparoscopy
Definition
20kg+ start with 12 with 3-6L flow, <20kg use lower pressures
Term
if you dont do a cystectomy in an adolescent what is the follow up
Definition
TVUS in 6-12wk
Term
what percent of torsion is associated with malignancy
Definition
0.4-5%, dont do oophorectomy for this, malignant stuff is usually stuck and does not toarse
Term
what is the recurrence rate for torsion
Definition
2-12%, higher if toarsed spontaenously without mass
Term
what is the incidence of adnexal masses in general for PMP women
Definition
20%
Term
what is a normal CA125
Definition
<35 PMP, <200 pre-menopause
Term
how can you determine if CA125 is of GYN origin or GI origin
Definition
CA125:CEA 25:1 likley GYN
Term
what percent of ovarian cancer has an elevated CA125
Definition
80% of epithelial, but only 50% of all stage 1 disease patients, rarley elevated in germ cell, stromal, serous
Term
what benign things can cause CA125 elevations
Definition
endometriosis, pregnancy, PID, non-GYN cancer, fibroids, SLE, IBD, uterine horns non communicating, ovarian fibroma, torsions peritonitis, cirrhosis
Term
what are the parts of a multivariate index assay (6)
Definition
CA125, prealbumin, apolipoprotein A1, B2-microglobulin, transferrin, menopausal status
Term
why do we do a multivariate index assay
Definition
it is positive in 70% of malignancies when CA125 alone was negative, perdicts malignancies in 91% of cases compared to 65% CA125 alone
Term
what is better a multivariate index assay or ROMA
Definition
ROMA 83% vs 55% more specific, 93% of ovarian cancers were correctly called high risk before surgery
Term
what are the parts of OVA-1 (5)
Definition
CA125, transferrin, prealbumin, apolipoprotein A1, B2-microglobulin
Term
how is OVA-1 scored abnormal
Definition
pre-menopause >5
post-menopause >4.4
Term
what are the symptoms of ovarian cancer
Definition
fixed, irregular, nodular, firm, ascites, bloating, urinary symptoms, difficulty eating, early satiety, pelvic pain, abdominal swelling
Term
what are the signs of ovarian cancer on ultrasound
Definition
>10cm, solid components, papillary components, irregularity, ascites, flow (15%), thick walls, septations (worse >2-3mm), mural nodularity, bilaterality
Term
what is the worst sign of ovarian cancer on ultrasound
Definition
mural nodularity
Term
what do papillary projections on ultrasound indicate
Definition
borderline until proven otherwise
Term
how long can you monitor a mass with solid components on US
Definition
never >1y
Term
how long can you monitor a mass without solid components on ultrasound
Definition
never >2y
Term
all malignancies demonstrated growth by ___ on US
Definition
7mo
Term
what is the #1 adolescent ovarian malignancy
Definition
germ cell tumors
Term
3 ovarian masses in pregnancy and their incidence
Definition
corpus luteum 17%, demoid 37%, cancer 1-7%, borderline 1-2%
Term
what is the rate of torsion for ovarian masses in pregnancy
Definition
7%
Term
how are ovarian masses in pregnancy managed
Definition
US in 4-6wk to see if resolution or progression, delay until PP unless concern for malignancy or torsion
if found during CD then resect and send for frozen if malignancy concern
Term
us signs of endometroma
Definition
low level echoes, round, homogenous
Term
us signs hydrosalpinx
Definition
tubular, sonolucent, cyst
Term
us signs simple cyst
Definition
smooth walls, thin, no flow
Term
when should a simple cyst be resected
Definition
>10cm
Term
how long should you observe an unchanging simple cyst
Definition
2y
Term
why dont we aspirate simple cysts
Definition
44% recurrence pre-menopause, 25% recurrence post-menopause
Term
ovarian cancer is the #__ cause of death in women
Definition
5
Term
what is the general population risk of ovarian cacer
Definition
1%
Term
what percent of ovarian cancer present at stage 3+
Definition
80%
Term
when do you do LND in ovarian cancer surgery
Definition
no ovbious metastasis, debulking
Term
suboptimal cytoreduction is associated with a CA125 level
Definition
>500
Term
what is the goldie coldman hypothesis
Definition
resistance of chemotherapy will develop in fraction to remaining viable cells
Term
how much does optimal cytoreduction improve survival
Definition
in stage 4 disease increases survival from 30 to 64mo
Term
how often does optimal cytoreduction require bowel resection
Definition
50%
Term
how often and what complications can occur form bowel resection
Definition
5%, infection, anastamotic breakdown, fistula
Term
how is ovarian cancer staged 1-2
Definition
1A - one ovary, capsule intact
1B - 2 ovary, capsule intact
1C1 - surgical spill
1C2 - capsule rupture before surgery
1C3 - malignancy in washings
2A - uterus/tubes or primary peritoneal
2B - other pelvic tissues
Term
how is ovarian cancer staged 4
Definition
A - pleural effusion with positive cytology
B - liver, spleen, inguinal nodes, nodes outside abodmen, distant mets
Term
what are the basic concepts of stage 3 staging for ovarian cancer
Definition
primary peritoneals included
positive nodes
mets outside pelvic brim but in abdomen not involving liver/spleen
Term
what is the chemotherapy used for ovarian cancer
Definition
carboplatin, paclitaxel
Term
what is the surveillence after ovarian cancer treatment
Definition
exam q2-3mo for 2y then q3-6mo for 3y, then annual x5y
CA125 if previously elevated
imaging if clinical symptoms
Term
what is the survival rate for stage 1 ovarian cancer for fertility and non fertility sparing
Definition
90-95% does not change if fertility sparing
Term
what stages of ovarian cancer could be observed, no chemo
Definition
stage 1A grade 2, stage 1B grade 2
Term
at what stage can you no longer consider fertility sparing management for ovarian cancer
Definition
1A-B ok, 1C-2+ not ok
Term
what is the 5y survival for stage 2, 3, 4 ovarian cancer
Definition
2 - 70%
3A - 40%
3B - 25%
3C - 20%
4 - 11%
Term
what are some options for prevention in patients for remission from ovarian cancer
Definition
olaparib, bevacizumab
Term
what is better neoadjuvant chemo or optimal debulking
Definition
optimal debulking, if you dont think you can achieve do neoadjuvant
Term
when should IP chemo be done
Definition
optimal debulked patients
Term
what are complications of IP chemo
Definition
increased pain, all the normal SE of the chemo, catheter issues #1 cause of DC (infection, leaking, blockage, access issues)
Term
what increases the risk of IP cath complications and how can this be reduced
Definition
left colon resection, can reduce by delaying placement until 1-2C of therapy complete to reduce risk
Term
what is better IV or IP chemo
Definition
IP improves survival per GOG
Term
define platinum sensitive vs resistant vs refractory
Definition
sensitive - recurrence >6mo after platinum therapy
resistant - recurrence <6mo
refractory - progression during initial therapy
Term
what do you use for chemo in a platinum resistant patient
Definition
IV cystplatin with doxyrubicin or gemcitabine
Term
what percent of ovarian cancer is a mets from another cancer and what are the common types (3)
Definition
10%
1- endometrial
2- colon
3- breast
Term
what is the name for bilateral ovarian masses caused by metastatic gastric cancer
Definition
krukenberg tumors
Term
what are the types of ovarian tumors and their incidence (4)
Definition
epithelial - 90%
metastasis - 10%
germ cell
sex cord stroma - 1%
Term
what are the types of benign epithelial ovarian tumors (6)
Definition
serous
mucinous
endometrotic
clear cell
brenner
seromucinous

all can be adenoma, adenofibroma
Term
what are the types of malignant epithelial ovarian tumors (11)
Definition
borderline - 15%
endometroid -
serous - high and low grade
clear cell - 5%
mucinous - 15%
brenner
seromucinous
undifferentiated
mesenchumal
adenosarcoma
carcinosarcoma
Term
risk factors for ovarian cancer (7)
Definition
age, genetic, nulliparity, infertility (not the drugs), endometriosis, PCOS, enviromental
Term
protective factors for ovarian cancer (7)
Definition
parity, OCPs, breastfeeding, salpingectomy 0.7%, hysterectomy, oophorectomy, pregnancy before 25yo
Term
how much do OCPs decrease risk of ovarian cancer
Definition
50%, >6y 60%
Term
how much does salpingectomy decrease risk of ovarian cancer
Definition
0.7%
Term
how much does oophorectomy decrease risk of ovarian cancer
Definition
97%
Term
average age of borderline ovarian tumor
Definition
50% <40yo
Term
histology of borderline ovarian tumor (5)
Definition
nuclear atypia, epithelial stratification, papillary tufting, no stromal invasion, micropapillae
Term
when a borderline tumor has micropapillae what does this increase the risk of (2)
Definition
bilaterality, invasive implants, does not change survival
Term
what is the #1 and 2 varient of borderline ovarian tumors
Definition
1 - serous aka atypical proliferative serous tumor
2- endometroid aka atypical proliferative endometroid tumor
Term
how is a borderline tumor managed
Definition
USO if fertility sparing, TLH/BSO if not, omentectomy (upstages 30% of patients), no LND
if invasive implants treat as low grade serous, adjuvant chemo only if in omentum
Term
what is the surveillence after borderline tumor
Definition
exam q3-6mo for 5y then annually
CA125 if initially elevated
imaging as indicated
Term
what is the recurrence rate for borderline ovarian tumor
Definition
50%, 75% being low grade serous
x6 if did cystectomy rather than oophorectomy
x5 if gross residual disease after surgery
Term
what are the tumor markers for low grade serous tumors (7)
Definition
KRT7, CK7, BRAF/KRAS 85%, CA125, PAX8, WT1
Term
histology of low grade serous tumors (4)
Definition
oval/round nuclei, uncommon nucleoli, <12 mitotic figures per 10 HPF, stromal invasion
Term
management of low grade serous tumors
Definition
TLH/BSO/omentum/debul
1 - observe
1C - +/- chemo +/- AIs
2+ chemo + AIs
Term
what mutation has the best prognosis for serous low grade
Definition
BRAF/KRAS
Term
what is the rate of resistant low grade serous tumors to chemo
Definition
60%
Term
what are the mutations associated with high grade serous tumors (2)
Definition
p53 in 100%
BRCA in 25%
Term
what are the mutations associated with high grade clear cell tumors (8)
Definition
loss of ARIDA1 in 50%
loss of BRAF250
upregular of SICA2 and CCL14
downregulation of TGDF1
PTEN
KRAS
MMR
Term
risk factors for clear cell tumors
Definition
asian x2, endometriosis 50% (27% increased risk), endometriosis surgery
Term
management of clear cell tumors
Definition
everyone gets chemo after surgery
Term
what is pseudomyxoma peritoneii
Definition
rupture of mucinous tumor
Term
what mutations are associated with mucinous tumors (2)
Definition
CK20, KRT20, CEA, CDX2
CEA/CK20 more indicative of GI primary
PAX5 more indicative of ovarian primary
Term
what is the average age of mucinous tumors
Definition
44
Term
what percent of mucinous tumors are bilateral, if not what side are they on
Definition
80%, right
Term
how are mucinous tumors managed
Definition
1 - observe after surgery
1C - +/- chemo
2+ chemo
Term
average age germ cell tumors
Definition
13-19yo
Term
what percent of germ cell tumors are stage 1 at diagnosis
Definition
60-70%
Term
signs of germ cell tumors (4)
Definition
unilateral, rapid enlargement, pain, hemoperitoneum
Term
survival rate for completely resected germ cell tumor
Definition
50-80%
Term
types of germ cell tumors (9)
Definition
dysgerminoma
endometrial sinus - yolk sac
mature teratoma - dermoid - benign
immature teratoma
strumi ovarii - benign
sebaceous adenoma - benign
stromal carcinoid - borderline
mucinous carcinoid - malignant
SCC - malignant
Term
#1 malignant germ cell tumor
Definition
dysgermanoma
Term
what percent of dysgermanoma are bilateral
Definition
10%
Term
risk factor for dysgermanoma
Definition
dysgenetic gonads
Term
serum markers for dysgermanoma
Definition
low hCG, LDH isoenzymes 1, 2, 3
Term
histology dysgermanoma
Definition
large vesicular walls, clear cytoplasm,
Term
percent of dysgermanoma with nodal spread
Definition
10%
Term
management of dysgermanoma
Definition
USO, no staging indicated, chemo rads sensitive, if stage 1 observe, if > stage 1 chemo BEP
Term
histology yolk sac tumor
Definition
schillar duval bodies
Term
varients yolk sac tumor (3)
Definition
polyvesicular vitelline, glandular, hepatoid
Term
management yolk sac tumor
Definition
USO, all require chemo BEP
Term
incidence of dermoid
Definition
15% BL, 20-45% of ovarian neoplasms
Term
what is strumi ovarii
Definition
dermoid with monodermal thyroid tissue that an cause hyperthyroidism
Term
what percent of dermoids have malignancy and what is it
Definition
1% SCC from ectoderm
Term
what percent of people with a dermoid that do expectant management will end of getting surgery
Definition
26%
Term
how do immature teratomas spread
Definition
IP implantation
Term
serum markers immature teratoma (3)
Definition
AFP, CA125, LDH
Term
management immature teratoma
Definition
USO, stage 1 grade 1 observe, everyone else gets BEP
Term
what is BEP
Definition
bleomycin, etoposide, cisplatin 3-4C
Term
what is the surveillence after germ cell tumors
Definition
exam and AFP q2-3mo for 1y -> q4mo 1y -> q6mo 3y -> annually

CT A/P q3-4mo 1y -> q6mo 1y -> annually 3y -> as indicated

if non-dysgernaoma do CXR with CT
Term
what are the benign sex cord stromal tumors (5)
Definition
thecoma
fibroma
leydig cell
stromal
lutenized thecoma
Term
what are the borderline sex cord stromal tumors (5)
Definition
cellular fibroma
gonadoblastoma
mixed germ cell
sertoli cell
sex cord with annular tubules
Term
what is a leutenized thecoma associated with
Definition
sclerosing peritonitis
Term
what is meigs syndrome
Definition
ovarin fibroma causing ascites and hydrothorax
Term
what is the average age of fibroma and thecoma
Definition
59yo, 84% PMP
Term
what are the malignant germ cell tumors (4)
Definition
fibrosarcoma
steroid cell tumor
granulosa cell
sertoli-leydig
Term
types of granulosa cell tumors and their incidence
Definition
adult 95%, juvenile 5%
Term
histology adult granulosa cell tumors
Definition
call exner bodies, cords, trabeculae, round cells, scant cytoplasm,, coffee-bean grooved nuclei
Term
histology juvenile granulosa cell tumors
Definition
solid, focal follicles, more cytoplasm than adult, round nuclei, hyperhcromatic, brisker mitotic activity, sometimes marked atypia
Term
serum markers granulosa cell tumor
Definition
estrogen, inhibin B > A
Term
signs granulosa cell tumor
Definition
endometrial pathology (25-50% hyperplasia), precocious puberty, large mass (mean 12cm), friable mass
Term
management granulosa cell tumor
Definition
USO, no LND
1 - consider chemo if high risk (poor differentiated, 1C, heterologous elements, ruptured)
>1 - platinum chemo
Term
prognosis granulosa cell tumor 1A and 1A+
Definition
1A - 95% survival 5y
>1A - 55% survival
juvenile better survival
larger tumor less favorable >10cm or ruptured
Term
signs of sertoli leydig tumor
Definition
virilization 10%
Term
serum markers sertoli leydig tumor
Definition
testosterone
Term
prognosis sertoli leydig tumor
Definition
5y 70-90%
Term
management sertoli leydig tumor
Definition
USO, no LND
1 - consider chemo if high risk (poor differentiated, 1C, heterologous elements, ruptured)
>1 - platinum chemo
Term
potential complications of oopexy - 1
Definition
interference with blood supply or function
Term
what can be used in patients with frequent torsion for prevention
Definition
OCPs
Term
what are the parts of a ROMA score - 3
Definition
CA125, HE4, PMP status
Term
% of time ascites is associated with cancer
Definition
10%
Term
#1 cancer associated with ascites
Definition
ovarian
Term
how is ascites related to prognosis of cancer
Definition
drops 5y survival to 40%
Term
what drug can help with ascites
Definition
bevacizumab
Term
#1 concerning sign in cancer
Definition
ascites
Term
when to refer to a GYN ONC - 4
Definition
1. PMP with elevated CA125 US suggestive of malignancy.
2. Pre-MP with CA125 >200 and US suggestive of malignancy.
3. Pre-MP or PMP with elevated risk assessment
4. family history of breast or ovarian cancer in a 1st deg relative with a suspicious mass
Term
rate of ovarian masses in pregnancy
Definition
0.5-3.2%
Term
why don't we use gadolinium in pregnancy - 5
Definition
increases fetal rheumatologic, inflammatory, and infiltrative skin conditions, still birth, neonatal death
Term
% of complex masses in pregnancy that are malignant
Definition
10%
Term
management of cystic teratoma in pregnancy
Definition
removal in 2T is optional, unilateral lymphadenectomy
Term
if a malignancy is found on an incidental mass at CD when do you do the staging
Definition
1-2wk PP
Term
2 predictors that an ovarian mass in pregnancy might not resolve
Definition
>5cm, complex
Term
ovarian cancer is the #__ GYN cancer and the #__ most deadly GYN cancer
Definition
#2, #1
Term
boundries for paraaortic node dissection
Definition
over the IVC/aorta between the renal and inferior mesenteric vessels
Term
boundries for pelvic node dissection 4
Definition
common iliac, external iliac, hypogastric, obturator nerve and fossa
Term
how do you treat a platinum sensitive recurrence
Definition
carboplatin until 2C past complete remission
Term
rate and timing of ovarian cancer relapse
Definition
75% in 18-24mo
Term
in a patient who is a poor surgical candidate how do you treat them
Definition
neoadjuvant chemo, if at the end they progressed they treat as platinum resistant, if they are stable or responded consider interval cytoreduction
Term
where does ovarian cancer metastasize
Definition
stomach, mesenteric nodes, bladder, bowel
Term
what do you do if a borderline tumor is not completely resectable
Definition
CT scan for residual disease, if none observe, if residual treat like low grade epithelial
Term
invasive mets in border line tumor increase the risk of - 2
Definition
SBO, death
Term
what injury during surgery for borderline tumor increases risk of recurrence
Definition
cystectomy x6
Term
what epithelial ovarian tumors are candidates for hormonal management in stages 1C+ - 2
Definition
endometroid, low grade serous
Term
in what 2 epithelial ovarian cancers can you fertility spare
Definition
borderline, low grade mucinous, potentially endometroid?
Term
low grade serous chemo response rate
Definition
50% respond, 60% stable
Term
what medical complication does pseudomyexoma peritonei increase the risk of
Definition
bowel obstruction
Term
#2 malignant germ cell tumor
Definition
endodermal sinus
Term
2 ovarian tumors that get largest up to 30cm
Definition
mucinous, endodermal sinus
Term
#1 most common germ cell tumor
Definition
mature teratoma
Term
how is immature teratoma graded
Definition
neuronal elements
Term
what do you do if a germ cell tumor is persistent after BEP or there is an incomplete or no response
Definition
TIP - paclitaxel, isofosfamide, cisplatin
Term
what do you do if a dysgerminoma recurs/does not respond
Definition
radiotherapy - ONLY RADIOSENSITIVE OVARIAN TUMOR
Term
what tumor gets meigs syndrome
Definition
fibroma
Term
how are seroli Leydig tumors managed
Definition
TAH/BSO/staging - if stage 1 observe, if Ic/ruptured/poor differentiation/heterologous elements do chemo, if 2+ do chemo
Term
what stages of Sertoli Leydig can do fertility sparing
Definition
1A-C
Term
what is a sign that a Sertoli Leydig tumor is more aggressive - 2
Definition
heterologous elements, endocrine changes
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