Prolog Gyn-Onc 7Th Ed

Front 1

Lynch syndrome (CEO - Colon, Endometrial, Ovarian) - the immunohistochemical staining tests for ________?

note - colon = stomach & small bowel

Back 1

MLH1, MSH2 overexpression (TQ answer)

PB says that the staining will show ABSENCE of these proteins

Lynch syndrome = defects in mismatch repair - the insertion or deletion of additional nucleotides leads to micro satellite instability

PRLG #1

PB #147

Front 2

What is the 2nd most common cause of inherited ovarian cancer?

Back 2

The MCC = BRCA, duh

2nd MCC = Lynch Syndrome (CEO - ovarian cancer risk 4-24%)

PRLG #1CO # 634

Front 3

overexpression of PTEN

Back 3

Cowden disease - AUT DOM

Mutation in PTEN gene, phosphatase/tensin gene which is involved in cell cycle control

Cancer: thyroid, breast & uterus

Papillomas, hamartomas

Risk of breast cancer 25-50%

Risk of endometrial 5-10%

PRLG #1

CO # 634 Hereditary Cancer syndromes

Front 4

TP53 mutations

Back 4

Li-Fraumeni syndrome

soft tissue sarcomas, leukemia, adrenocortical cancer, breast cancer, brain cancer

PRLG #1

CO # 634 Hereditary Cancer syndromes

Front 5

which syndrome?

Back 5

Peutz-Jeghers Syndrome

Aut Dominant

Mutations in serine/threonine kinase II (STK11) gene

Presence of 2/3 criteria:

1) 2+ hamartomatous polyps in GI tract

2) mucocutaneous hyperpigmentation (mouth, lips, nose, eyes, genitalia, fingers)

3) family history of PJ syndrome

Cancer: breast, ovarian, cervical, uterine, pancreas, lung, stomach, gastric, colon, ovarian sex cord tumors

PRLG #1, CO #634

Front 6

Which cancer syndrome DOES NOT include increased risk for breast cancer?

Back 6

Lynch syndrome

think CEO - Colon (50-82%), Endometrial (25-60%), Ovarian cancer (4-24%)

Well, there is very small risk of some types of breast cancer, but not compared to other syndromes

PRLG #1

CO # 634

Front 7

What syndrome?

Back 7

Cowden Syndrome

Aut Dominant

Mutation in PTEN gene, phosphatase/tensin gene which is involved in cell cycle control

Cancer: thyroid, breast & uterus

Papillomas, hamartomas

Risk of breast cancer 25-50%

Risk of endometrial 5-10%

CO #634

Front 8

45yo with diplopia, vertigo, dizziness found to have ovarian mass

Back 8

Paraneoplastic syndrome

Systemic manifestations that are NOT caused by direct (local or metastatic) effects of tumor

PRLG #3

Front 9

what is low risk vs high risk gestational trophoblastic disease (GTD) ?

Back 9

A factor that adds exactly 4 points is an interval from molar pregnancy to GTN diagnosis > 1 yr

see graph

PRLG #4 & PB #53

Front 10

42yo with personal history of breast cancer at age 38, 1st degree relative with ovarian cancer - what is her risk of having BRCA mutation?

Back 10

> 20%

PRLG #2, PB #103

Front 11

At what age should risk-reducing BSO be considered in women with BRCA1 or BRCA 2?

Back 11

age 40 or when childbearing is complete

PB #103

Front 12

Explain when to use single-agent chemo vs multi-agent chemo for GTD

Back 12

single agent (either MTX or actinomycin) = stage I & low risk (score <7) stage 2/3

Multi-agent = stage 4 or high risk (score>7) stage 2/3

multi-agent = etoposide, MTX, actinomycin, cyclophosphamide + vincristine

or MTX, actinomycin + vincristine

PRLG #4, PB #53

Front 13

POD #2, 65yo with SOB & tachycardia after radical vulvectomy, bilateral inguinal node dissection.

Next step?

Back 13

CT- pulmonary angiography to r/o PE

SN/SP both as high as 95% AND can detect other pulmonary abnormalities that could explain the clinical presentation

IF pt has bad kidneys or allergy to contrast, then V/Q scan can be used

PRLG #5

Front 14

Topic: advance directives

76yo undergoes TAH, BSO, pelvic node dissection for endometrial cancer. POD #2 she suffers a stroke with neurologic deficit. Her 78yo husband is at bedside. After discussion, she states that she does not want to pursue additional treatment.

Most appropriate action?

Back 14

assess her decision making competence (before signing DNR paperwork)

PRLG #6

Front 15

70yo BMI 40 undergoes ovarian cancer TAH/BSO + debulking, frozen path shows malignancy.

What should you use for post-op DVT prophylaxis?

Back 15

SCDs + LMWH

you need DUAL prophylaxis for VTE prevention in gyn cancer patients

LMWH has several advantages over heparin

(1) ease of use once a day

(2) predictable pharmacodynamics

(3) greater anti-factor Xa activity

(4) less thrombin activity

(5) reduced risk of thrombocytopenia

PRLG #7

Front 16

52yo h/o breast cancer on tamoxifen with postmenopausal bleeding. TVUS shows stripe 4mm

Next step?

Back 16

Endometrial biopsy, duh.

Any pt that has AUB while on tamoxifen needs EMB

there is only risk for endometrial cancer in POST-menopausal women

TVUS not useful b/c all women with tamoxifen will have thickened endometrium

Both PRE- and POST- menopausal women will develop polyps with tamoxifen

If you find polyp on sonohysterography -> OR (some polyps have been cancer, duh)

If you find hyperplasia -> hysterectomy. You can restart tamoxifen for breast cancer prophylaxis after the hyst

NOTE: there is a risk of uterine SARCOMA - RARE, 17 per 100,000 patient years versus none in placebo group

PRLG # 8 CO #601

PB #126 (breast cancer)

Front 17

The most common side effect of tamoxifen is:

Back 17

hot flush

PRLG #141 CO #601

Front 18

Cervical cancer in pregnancy

38yo @ 16wks with 3cm SCC of cervix. After clinical staging, tumor confined to cervix. Pt wants definitive treatment of cancer, if that means terminating pregnancy. Next step?

Back 18

Stage IBI (tumor <4cm)

Radical hysterectomy with fetus in situ and pelvic lymphadenectomy

PRLG #9

Front 19

most common GYN cancer in pregnancy

Back 19

Cervical

PRLG #9

Front 20

evaluation of palpable breast mass

52yo, annual visit, normal mammography 2 yrs ago. Note a firm, contender, fixed 1cm mass in R breast (upper outer quadrant) with no palpable axillary lymphadenopathy. Next step?

A. Screening mammography of both breasts

B. Ultrasound of right breast

C. MRI of both breasts

D. Diagnostic mammography of right breast

Back 20

D. Diagnostic mammography of R breast

- lack of tenderness is characteristic of cancer

- Mammography vs ultrasound depends on age:

<30 yrs without risk factors = ultrasound

>30yrs = diagnostic mammography

Get MRI in cases of:

- silicone implants

- breast-conserving surgery

- known carcinoma for whom disease must be ruled out

- an axillary mass and no identifiable primary tumor

- extensive post-operative scarring

- extremely dense breasts

PRLG #10

Front 21

Most common benign breast mass is ______

Most common malignant breast mass is _______

Back 21

benign = fibroadenoma

malignant = invasive DUCTAL carcinoma

PRLG #10

Front 22

Laparoscopic complications

You are dissecting left sidewall for obturator lymph nodes during robotic case, morbidly obese pt, suddenly end-tidal CO2, SaO2 and BP have dropped. Heart murmur (mill-wheel) heard while Lungs clear.

Most likely diagnosis?

Back 22

Gas embolism

- intravascular injection of gas may follow direct needle or tracer placement into a vessel, or it may occur as a consequence of gas insufflation into abdominal organ.

- can also occur later in procedure, i.e. when dissecting tissue causes venous bleeding with open sinuses, allowing for venous accumulation of CO2

- sxs of embolism = tachycardia, cardiac arrhythmias, hypotension, increased central venous pressure, alteration in heart tones (mill-wheel murmur), cyanosis, EKG shows right heart strain

PRLG #11

Front 23

Treatment of gas embolism during laparoscopy

Back 23

(1) release of pneumoperitoneum

(2) steep trendelenburg with turn to left side (Durant position)

(3) place on 100% fraction of inspired oxygen

PRLG #11

Front 24

Next step for bowel obstruction from recurrent ovarian cancer

A. NG T

B. percutaneous endoscopic gastrostomy tube

C. endoscopic colorectal stent

D. ileostomy

E. cecostomy tube

Back 24

C. endoscopic colorectal stent

PRLG #12

Berek's 6th ed pg 902

Front 25

Breast surveillance in pts who are BRCA (+)

35yo healthy woman comes for annual. Her mother was BRCA2 (+) with ovarian cancer at age 50.

How should she be screened for breast cancer?

Back 25

Annual breast MRI alternating with semi-annual mammography

"semi-annual"?? every 6 months they need a screening test, alternating MRI and mammo

PRLG #13

PB #122 breast cancer screening

PB #103 BRCA

Front 26

62yo comes to office for post-op check 2 weeks s/p exp lap, debulking for stage IIIC serous ovarian cancer. Tachycardic, CT shows PE.

What is the preferred initial tx of PE?

Back 26

LMWH

Cochrane review comparing LMWH vs heparin showed that LMWH was a/w decreased risk of recurrent DVT, decreased mortality, and decreased risk of hemorrhage

In case of renal insufficiency, heparin is the 1st line therapy

PRLG # 14

Front 27

HPV vaccination

- given to what age group?

- do you test for HPV prior to giving the vaccine for a sexually active 24yo?

- if a 24yo had HPV testing with pap and it was positive, should she get the vaccine?

- do you give vaccine to HIV (+)?

- do you give vaccine to pregnant pt?

Back 27

1. Target age is 11-12 yrs for girls & boys

2. vaccine approved age 9 - 26yrs

3. DON'T do HPV testing until age 30 with pap

4. If 24yo is HPV(+), she can still get the vaccine

5. give to HIV pts

6. do NOT give during pregnancy

PRLG # 15

CO # 641

Front 28

28yo POD #4 s/p C/S with fever (103F), P 125, uterus tender, ext 1+ edema. Abdominal incision is erythematous & edematous, leaking cloudy serous discharge, EXQUISITELY tender. Preg complicated by T2DM needing insulin.

Next step?

Back 28

Dx: necrotizing fasciitis

Next step: (after antibiotics) DEBRIDEMENT of wound

Clues "dishwater fluid" - due to serous fluid and lysed inflammatory cells being produced in an area of facial necrosis, myositis, myonecrosis

PRLG #16

Front 29

Results of mammogram for 47yo: fibrocystic changes and small mass that, on biopsy, is c/w ductal hyperplasia without atypia

Next step?

Back 29

Observation

PRLG # 17

(need to read the explanation, no PB or CO about this)

Front 30

Blood product selection after massive hemorrhage

70yo with stage III ovarian cancer undergoing surgery with bleeding, EBL 1500cc, tachycardic 140's, BP 96/64, Hg 6.8.

Next step?

Back 30

pRBCs + FFP + platelets, balanced as 1:1:1 units transfused

note - stay away from options that give lots of crystalloid fluids. "a study of pts undergoing extensive debunking, with anticipated large blood loss and RBC transfusion requirements, demonstrated that early FFP with RESTRICTIVE crystalloid resuscitation reduced overall pRBC units transfused"

PRLG #18

Front 31

Topic: human chorionic gonadotropin (hcg)

47yo referred to you for amenorrhea x 2 yrs and recurrent CIN 3 by colposcopy. Plan for LEEP, but hCG level of 10 on two separate occasions. FSH & LH levels are 75mIU/mL.

Next step?

Back 31

prescribed OCPs and recheck hCG level

Why? some peri-menopausal women will have (+) hCG at very low levels, due to FSH/LH cross-reaction and possibly benign low-level pituitary hcG production

if pituitary in origin, the hCG titer can be suppressed with small dose of OCPs over 1 week period

PRLG # 19

Front 32

Most important test for pre-op cardiac clearance

70yo with 10cm complex pelvic mass, PMHx T2DM, HTN. Can walk 4 blocks before stops for leg cramps. No CP or SOB

Choices: EKG, Echo, Exercise stress test, CXR

Back 32

EKG

* She only has one risk factor - T2DM

* The leg cramp = think peripheral vascular disease

* when to get ECHO? for dyspnea of unknown origin or congestive heart failure (CHF) if test has not been performed in the past year
* when to get STRESS TEST? active "cardiac conditions" - i.e. angina, recent MI, AV block, arrhythmias, aortic or mitral stenosis OR 2+ risk factors
PRLG #20

Front 33

What's the recommended antibiotic prophylaxis?

36yo healthy woman scheduled for total laparoscopic hysterectomy (TLH)

Back 33

cefazolin

prlg #154

Front 34

What's the recommended antibiotic prophylaxis?

38yo with BMI 45 and echocardiogram confirmed MVP scheduled for total vaginal hysterectomy

Back 34

cefazolin

prlg #155

Front 35

What's the recommended antibiotic prophylaxis?

43yo with endometrial cancer and 18wk size uterus scheduled for total abdominal hysterectomy. She has a PCN allergy not caused by immediate hypersensitivity

Back 35

cefazolin

prlg #156

Front 36

What's the recommended antibiotic prophylaxis?

38yo with suspected cystic teratoma undergoing laparoscopic oophorectomy

Back 36

no antibiotic prophylaxis

prlg #157

Front 37

SIRS vs sepsis - what's the dx?

45yo postop pt with RR 27, HR 100bpm, plasma glucose 150, T38.4C, normal physical exam

Back 37

SIRS

prlog # 151

Front 38

SIRS vs sepsis - what's the dx?

65yo postop pt with BP 85/45 (after IVF boluses), T 37.0C, HR 115, RR 30, WBC 12.5 Hg 11

Back 38

Septic shock

prlg #152

Front 39

SIRS vs sepsis - what's the dx?

34yo postop pt with RR 26, HR 92, T38.4, BP 130/80. Purulent drainage is present with erythema at wound site

Back 39

sepsis

prlg #151

Front 40

Which GTD subtype has risk of persistence after D&E of ~20%

Back 40

complete mole

PRLG #144

Front 41

Which GTD subtype - fetal vessels often are seen on hematoxylin & eosin stain

Back 41

Partial mole

PRLG # 145

Front 42

Which GTD subtype - systemic metastases occur frequently

Back 42

Gestational choriocarcinoma

PRLG #146

Front 43

Which GTD subtype - histology characterized by proliferation of intermediate trophoblastic cells

Back 43

Placental-site trophoblastic tumor

PRLG # 147

Front 44

What type of hysterectomy for moderate sized fibroid uterus in multip?

57yo menopausal G3P3 with new-onset pelvic pressure & urinary frequency. No VB or discharge. Exam shows enlarged 11-wk size uterus, US shows 12cmx7cmx5cm with 5 cm fundal intramural leiomyoma and normal ovaries. No prior h/o fibroids or pelvic sxs. The preferred surgical treatment?

Back 44

vaginal hysterectomy

(you want to avoid morcellation)

PRLG #21

Front 45

cytoreductive surgery - the best intraaoperative management

63yo with no co-morbidities, CC bloating +pelvic mass, BMI 33, Ca 125 2,400, U/S with ascites, paracentesis shows adenocarcinoma c/w primary ovarian tumor. Intra-op findings confirm ascites, mental caking, bilateral ovarian masses, 1cm mass to be invading sigmoid colon.

Back 45

complete resection with bowel resection

PRLG #22

Front 46

33yo, pap with atypical glandular cells, +HPV

In addition to colposcopy, next step is:

(a) repeat pap

(b) EMB

(c) ECC

(d) ultrasound

Back 46

endoCERVICAL sampling (ECC)

Note: endometrial biopsy is NOT needed if they are UNDER 35yrs, unless they have risk factors (AUB, chronic anovulation)

PRLG # 23

Front 47

How to calculate PPV:

New ovarian cancer test, used with 503pts, 151 received diagnosis of cancer, 352 were benign.

Of 223 predicted to have cancer by the test, 134 are confirmed to have cancer.

Of 280 with negative test, 17 are found to have cancer.

Back 47

PPV = 60.1% (134 / 223)

PRLG #24

Front 48

Next step - stage IIIC uterine carcinosarcoma

(a) whole abdominal radiation therapy

(b) brachytherapy

(c) adjuvant chemotherapy

(d) tamoxifen

Back 48

Adjuvant chemotherapy

PRLG # 25

Front 49

Bone marrow toxicity from chemo:

stage IIIC primary peritoneal cancer, with IV carboplatin/paclitaxel - found to have ANC 2000/mm, Hg 11, plts 70,000. She is afebrile

Next step?

Back 49

delay chemo until recovery of her platelets

Note: it's best to delay the next dose of chemo rather than decrease the dose.

transfuse platelets if < 10,000

PRLG #26

Front 50

What's the most common manifestation of bone marrow suppression from cytotoxic chemotherapy drugs?

Back 50

Neutropenia = ANC < 1,500

treatment: colony-stimulating factor (CSF) for febrile neutropenia

Front 51

the most likely primary site of pseudomyoma peritonei?

Back 51

appendix

prlg #27

Front 52

the best initial treatment for chemotherapy induced anemia?

Back 52

iron sucrose

prlg # 28

Front 53

what is the most likely primary site if the stain is (+) for CDX2, CK 20, CA 19-9 and negative for CK7, WT1, PAX8 and vimentin?

Back 53

gastrointestinal primary

prlg #29

Front 54

what is the most appropriate next step for pt who has gastric obstruction caused by carcinomatosis?

Back 54

percutaneous endoscopic gastrostomy tube placement

topic: palliative care

prlg #30

Front 55

malignant ovarian germ cell tumor

the best post-operative management is:

Back 55

observation

prlg #31

Front 56

the first step in management of hyperkalemia:

Back 56

calcium

prlg #32

Front 57

The NEXT STEP in management of uterine smooth muscle tumor of uncertain malignant potential

Back 57

Surveillance

prlg #33

Front 58

For prevention of chemotherapy-induced emesis, you can prescribe

Back 58

dexamethasone + selective type three 5-hydroxytryptamin (5HT-3) receptor antagonist

prlg #34

Front 59

What is the next step s/p TLH, BSO, staging for stage IA1 endometrial adenocarcinoma?

Back 59

3-6 month f/u with pelvic examination

prlg #35

Front 60

In addition to AGE, the prognostic factor common to most clinical prognostication models for breast cancer is

Back 60

tumor SIZE

prlg #36

Front 61

40yo women with (+)HPV - the most compelling reason to discuss the option of anal cytology is

Back 61

CD4 ct < 200cells/mm3

prlg #37

Front 62

worried about ureteral injury during TLH, next step?

Back 62

transurethral cystoscopy

#50

Front 63

If you identify a ureteral injury intra-operatively, what is the next step?

Back 63

placement of ureteral stents

#50

Front 64

In contrast to endometrioid adenocarcinoma of the endometrium, the factor which uterine papillary serous carcinoma is a/w:

Back 64

TP53 mutations

Also: HER2/neu gene amplification

#51

Front 65

type I endometrial cancer (endometrioid type) is associated with what molecular profile?

Back 65

inactivation of the PTEN tumor suppressor gene

mutations in beta-catenin and KRAS (Kirsten rat sarcoma viral oncogene)

and defects in DNA mismatch repair resulting in micro-satellite instability

#51

Front 66

most likely side effect of aromatase inhibitor

AI = anastrozole, exemestane, letrozole

Back 66

joint aches

#52

Front 67

FDA approved AIs for use in post-menopausalwomen with hormone receptor (+) breast cancer in 3 situations:

Back 67

POST-menopausal women

(1) instead of tamoxifen for 5 years

(2) Sequentially after 2-3 yrs of tamoxifen

(3) Sequentially for 3-5 years after 5 yrs of tamoxifen use in women who remain disease free (extended adjuvant strategy)

#52

Front 68

best method to screen for colon cancer

Back 68

colonoscopy

#53

Front 69

Initial chemotherapy for ovarian cancer

Back 69

IV carboplatin and placlitaxel

Note: carboplatin, not cisplatin (load up with carbs first!)

Note: IP only for pts who are optimally debunked

#54

Front 70

pt who is 61yrs, BMI 62, menarche age 10, in utero exposure to DES.

What is the greatest risk factor for developing breast cancer in this patient?

What is the greatest risk factor in general?

Back 70

BMI is this pt's greatest risk

Age is otherwise the greatest risk factor, RR 18 if older than 70yrs

#55

Front 71

Is IVF a risk factor for ovarian cancer?

Back 71

NO

there is controversy but studies do not show link

#56

Front 72

34yo G0 undergoing IVF foranovulation (failed clomid) – she is obese, h/o 6yr OCP use, famhx of maternal aunt with gastric cancer & sister with melanoma. Her most significant RF for ovarian cancer

Back 72

nulligravidity

Greastest RFs:­ age, endometriosis, famhx of ovarian cancer, BRCA mutation, early menarche, latemenopause, nulligravidity, infertility

#56

Front 73

Does pre-op bowel prep have advantages?

Back 73

NO change in outcomes

it was hypothesized (and extrapolated from colorectal) that a pre-op bowel prep would decrease infectious post-op complications such as anastomotic leaks, surgical site infections andsepsis others presume it could improve visibility and bowel handling. But it does NOT

#57

Front 74

have hemorrhage from uterine artery pedicle - next step?

Back 74

ligate hypogastric artery (internal iliac)

#58

Front 75

FSS for 26yo G0 with fungating, friable 2cm lesion confined to cervix with no parametrial or vaginal involvement. Biopsy confirmed SCC

Back 75

stage IB1

vaginal trachelectomy + pelvic lymphadenectomy

note: some investigators havesuggested that pre-op MRI should be mandatory – data has suggested that MRI isthe most reliable modality to assess extent of cervical involvement

#59

Front 76

Hemorrhage during hysterectomy, you have cell savor set up, have irrigated with 1L saline and placed fibrin sealant for bleeding, what bloodproducts to give?

Allogenic, salvage product or autologous

Back 76

Allogenic products only (NOT salvage product, because you irrigated with saline & used hemostatic agent)

Allogenic = homologous = donor

Autologous = cell savor (salvage)

#60

Front 77

19yo with acute LLQ pain,u/s shows 18cm complex mass, take her back for laparotomy & mass issuspicious with solid components, frozen path of LSO shows malignant germ cell tumor - next steps?

Back 77

leave the right ovary (ONLY USO) but perform staging with washings, omentectomy, pelvic & para-aortic nodes,staging biopsies

#61

Front 78

64yo with persistent vulvar itching, 2x2cm raised right labial lesion

Biopsy sent

Treatment?

Back 78

Dx: Vulvar intraepithelial neoplasia (VIN) 3

Tx: wide local excision

#62

the picture on the front is from Melinda's: Carcinoma in situ of the vulva. There is full-thickness alteration in the architecture with elongation and distortion of the rete pegs. At arrow, there is intraepithelial pearl formation

Front 79

if the patient requires prolonged intubation, the best feeding system is

parenteral (TPN) vs enteral

Back 79

enteral nutrition (OG or NG tube)

= lower risk of infections

= maintains function & structural integrity of the gut and mucosal immunity, decreases oxidative stress, and down-regulates systemic immune response

#63

Front 80

Path shows placental-site trophoblastic tumor from D&C; next step?

Back 80

total hysterectomy

note: after surgery, then imaging to see if disease extensive - if stage II - IV, then EMACO (Etoposide, Methotrexate, Actinomycin, Cyclophosphamide, Vincristine/Oncovin)

#64

Front 81

ovarian cancer recurrence – the best surveillance duringremission is

Back 81

physical examination

#65

Front 82

30yo G0 undergoes surgery for complex ovarian mass; frozen path shows serous tumor of low malignant potential with noninvasive bladder implant; do you stage? Do you take both ovaries?

Back 82

No, just unilateral oophorectomy and removal of any gross disease

#66

Front 83

71yo, last pap 6 yrs ago was normal, new relationship for past 2 years, only gynecological problem is vaginal dryness with intercourse. What is the most appropriate cervical cancerscreening?

Back 83

no screening

(stop age 65 if history of normal paps)

#67

Front 84

Screening for ovarian cancer

58yo, asymptomatic, 70yo cousin diagnosed with ovarian cancer, would like to be screened – best management?

Back 84

NO screening "counseling and review of ovarian cancer symptoms"

Only screen high risk (BRCA & Lynch II) - start age 30-35 or 5-10 yrs before earliest age of diagnosis of ovarian cancer in family with Ca-125 + TVUS (if they do not have RR BSO)

#68

Front 85

C. Diff infection

62yo POD #7 s/p TAH, BSO,staging for ovarian cancer. Comes to office with diarrhea; T39.1C, WBC 22, Cr2.4 (up from 1 at discharge), stool study (+) for c diff

next step?

Back 85

vancomycin alone

this is a severe C diff infection based on the WBC >15 and Cr (>1.5x baseline)

#69

Front 86

Cervical cancer, colposcopy shows 2mm depth.

Stage?

Next step?

Back 86

Stage IAI

cone biopsy

for definitive tx of Stage IAI - extrafascial hysterectomy

#70

Front 87

How to correct injury to dome of bladder

Back 87

primary repair

use synthetic absorbable suture, running fashion, either 1 or 2 layers

#71

Front 88

Post-treatment surveillance in cervical cancer – 54yo with stage 3B SCC s/p chemo 3 months ago with new leg pain & swelling, pelvic pain.

In addition to pelvic exam, what’s the next step?

Back 88

PET-CT Scan

While the organizations have different recommendations, this question makes a point that NCCN recommends PET-CT scan at 3-6 months after chemo

#72

Front 89

How to treat Heparin induced thrombocytopenia (HIT)?

Plts: 210 - 85 - 55 in 5 days with pt on heparin post-op.

Back 89

stop unfractionated heparin and initiate argatroban

two tx rec of ACC - ARGATROBAN (direct thrombin inhibitor, ok if renal insufficiency)

OR DANAPAROID (ok in pts with liver dysfunction or pregnant - does not cross placenta)

#73

Front 90

What is the mechanism of Type II HIT?

Back 90

immune-mediated disorder; IgG attacks heparin platelet factor 4 complex

leads to platelet activation & micro particle release with subsequent arterial & venous thrombosis

#73

Front 91

Pathology shows low-grade serous ovarian cancer after laparoscopic USO.

At time of surgery, there was a <1cm nodule in the omentum

Next step?

Back 91

cytoreductive surgery

low-grade serous cancer is relatively chemoresistant

#74

Front 92

activation in "mitogen activated protein kinase" pathway by mutations of BRAF or KRAF are seen in what type of cancer?

Back 92

Low-grade serous ovarian carcinoma

#74

Front 93

ovulation induction therapy is a risk factor for what type of ovarian cancer?

Back 93

low-grade serous ovarian cancer

#74

Front 94

Tx of recurrent platinum sensitive ovarian cancer

Back 94

carboplatin

sensitive = interval >6 most

resistant = < 6 months

refractory = disease progresses during primary therapy

#75

Front 95

In performing TAH pt hassevere endometriosis; beforeremoving adnexa, what’s your first step?

Back 95

identify ureter

# 76

Front 96

What's the incidence of ureteral injury in gynecological procedures?

Back 96

0.5 - 2%

only 1/3 are identified at time of surgery

#76

Front 97

what is the most common site of ureteral injury during routine hysterectomy with BSO?

most common site during laparoscopic surgery for endometriosis?

most common site during vaginal surgery?

Back 97

with BSO = at the level of the pelvic brim when attempting to ligate the ovarian vessels

Laparoscopy = level of uterosacral ligaments

Vaginal = near the trigone - can not only the ureter but also the bladder

#76

Front 98

Describe the path of the ureter

Back 98

The ureter enters the pelvis at the level of the bifurcation of the common iliac artery and runs under the IP ligament.

Retroperitoneal location at this point is essential before ligating the ovarian vessels and can be accomplished by following the external iliac artery cephalic from the pelvis and exposing the medial broad ligament.

The ureter then runs retroperitoneal along the pelvic side wall before it passes under the uterine artery ("water under then bridge") and enters the paracervical tunnel.

At this level, the average distance from the ureter to the cervical edge is 2.3cm. (decreased in obese and <0.5cm in 12% of pts)

#76

Front 99

does pre-operative stents decrease ureteral injury

Back 99

NO

they make it easier to identify ureters, but research has shown that it doesn't decrease incidence of injury

#76

Front 100

Tx of ARDS (s/p TAH, staging for ovarian cancer)

SaO2 75%, 4L oxygen, CXR shows bilateral patchy infiltrates & no evidence of pleural effusions, negative spiral CT scan

Back 100

mechanical ventilation

#77

Front 101

Next step for PMB (BMI 50, TVUS shows stripe of 9mm)

Back 101

endometrial biopsy, duh

#78

Front 102

Is irritable bowel syndrome (IBS) a risk factor for colon cancer?

Back 102

NO

but Inflammatory bowel disease (IBD), Crohn's disease and ulcerative colitis are RFs

#79

Front 103

What is the "highest risk" factor for colon cancer

Back 103

Family history / inheritable susceptibility

Lynch Syndrome = the most common syndrome a/w colon cancer

Familial adenomatous polyposis

#79

Front 104

endometriosis is a risk factor for which types of ovarian cancer?

Back 104

clear cell & endometrioid types

#80

Front 105

What is the important molecular change seen with clear cell carcinoma of the ovary?

Back 105

loss of the ARID1A gene

loss of BAF250a, encoded by ARID1A gene

#80

Front 106

The agent responsible to the most common blood transfusion-associated infections in the US is

Back 106

gram (+) bacteria - typically staphylococcus (from the skin)

highest risk occurs with bacteria-contaminated platelet transfusion because they are stored differently

#81

Front 107

What is the risk for HIV, Hep B & C to be transmitted in a blood transfusion?

Back 107

#1 Hep B 1 / 277,000

#2 Hep C 1 / 1.9 million

#3 HIV 1 / 2.1 million

#81

Front 108

Next step

23yo pap with HGSIL, Colp CIN 2

Back 108

colposcopy & cytology in 6 months

if <25 for CIN 2 = repeat colp & pap in 6 month intervals for 12 months

if CIN 2 persists > 2 yrs, CIN 3, or inadequate colposcopy then LEEP

**HPV testing is not needed at age 23

#82

Front 109

What is the most commonly diagnosed STD in the US?

Back 109

HPV

#82

Front 110

Treatment of hot flashes in 40yo s/pTAH, BSO, staging for stage IA, grade II endometrioid adenocarcinoma

Back 110

estrogen

there is a long explanation about the controversy, but the bottomline is that it's the most effective for vasomotor sxs and there aren't any cases of recurrent endometrial cancer in women given HRT

#83

Front 111

The prognostic factor thatmost consistently predicts poor outcome after pelvic exenteration for cervicalcancer that recurred after pelvic radiation

Back 111

time to recurrence

also poor prog factor = (+) para-aortic nodes (NOT pelvic lymph nodes)

#84

Front 112

how to monitor for recurrence of endometrial cancer at the vaginal cuff?

Back 112

physical exam

NOT pap smear!

#85

Front 113

What is the prognosis for stage I endometrial cancer?

Back 113

>95% 5 yr survival

#85

Front 114

Cervical cancer screening for women > 30

Back 114

neg cytology & neg HPV = q 5 yrs

neg cytology (+) HPV = repeat cytology & HPV testing in 1 yr or reflex testing for HPV 16/18

if reflex testing (+) 16 or 18 = colposcopy

if neg 16/18 = contest in 12 months

#86

Front 115

Sepsis – 60yo PMHx ovariancancer, DM, HTN, pOD #7 s/p TAH BSO staging with T38.8, P130, BP 90/40, UOP15/hr, hypoactive bowel sounds, purulent drainage from vagina, WBC 17.5; nextstep?

Back 115

IV fluids and broad spectrum antibiotics

#87

Front 116

most effective method of risk reduction for 42yo with BRCA1 mutation, completed childbearing, smokes 1/2 PPD

Back 116

BSO

#88

Front 117

What are options to decrease risk of ovarian cancer in women who carry BRCA but are not ready to have ovaries removed?

Back 117

frequent surveillance with TVUS, physical exam, Ca-125

OCPs

#88

Front 118

28yo G0 with CIN3 undergoesLEEP, negative margins but AIS extending to deep margin of the specimen. Nextstep?

Back 118

re-excision via cervical conization

if she were done with childbearing, then next step is radical hyst for AIS

FSS option = repeat cone for negative margins. Cold knife cone procedure better than LEEP

if negative margins, then pap + HPV testing + colp with ECC in 6 months for surveillance

#89

Front 119

During abdominal hysterectomy, you see large amount of clear fluid filling up in the abdomen after identifying the IP ligament; next step?

Back 119

IV indigo carmine or methylene blue is the best way to investigate integrity of the ureters intra-operatively

#90

Front 120

45yo with endometrial cancer

Family history of 1st degree relatives with breast, lung, colon cancer

What syndrome? What genetic testing?

Back 120

Lynch II Syndrome, (HNPCC) "CEO"

testing = immunohistochemistry - MLH1, MSH2, MSH6, PMS2

breast cancer was a distractor?

#1

Front 121

54yo comes to you after finding out she has Lynch Syndrome. Both her father & brother had colon cancer

What do you recommend for her - i.e. RR surgery or screening?

Back 121

most effective choice is Hysterectomy with BSO (esp since she is post-menopausal)

#91

Front 122

73yo with vulvar pruritus & burning

exam: red, velvety, inflamed

biopsy: large cells with prominent nuclei & coarse chromatin

Dx? Next step?

Back 122

Dx: Paget disease

next step: screening for cervical, breast, colon cancer with pap, mammography, colonoscopy - (15-30% have co-malignancy)

#92

Front 123

What is the stage of cervical cancer:

on exam see 5cm friable mass, extends to upper 1/3 vagina

all other workup negative, except CT scan shows enlarged nodes

Back 123

Stage IIA2

#93

Front 124

Stage IB papillary serous uterine cancer

next step after surgery?

What is the recurrence rate?

Back 124

Papillary serous = Type II endometrial cancer

Chemotherapy, specifically carboplatin - paclitaxel then brachytherapy

recurrence rate = 60%

#94

Front 125

POD #3 after LAVH pt with SOB

Pt with morbid obesity, poor dentition, HTN, DM, HIT

See CT scan picture

Dx? Tx?

Back 125

Dx: Aspiration Pneumonia

Tx: Piperacillin with Tazobactam

Imaging shows infiltrates in dependent regions of the lungs (posterior segments of the upper & superior segments of the lower lobes)

#95

Front 126

35yo with 1cm breast mass, needle biopsy shows Invasive ductal carcinoma

treatment?

Back 126

lumpectomy with sentinel lymph node biopsy

Distractor: sentinel node, not axillary node dissection!

#96

Front 127

Lumpectomy vs mastectomy -

What factors preclude a patient from breast-conserving treatment (lumpectomy)?

Back 127

#96

Front 128

Cervical cancer:

40yo, G2P2

4.5cm fungating cervical mass with extension to left pelvic side wall

Stage? Next step?

Back 128

Stage IIIB

Tx: chemo + radiation (cisplatin most common)

She is NOT a candidate for surgery - surgery alone would not be curative

chemo + radiation should be recommended b/c it improves progression-free survival and overall survival compared to radiation alone

#97

Front 129

40yo undergoes lumpectomy, axillary node dissection:

Diagnosed with stage I breast cancer (1cm in size) and negative nodes. +ER/+PR, but considered low risk.

Next step?

Back 129

Radiation therapy then tamoxifen

note: Aromatase inhibitors only shown benefit in postmenopausal

#98

Front 130

74yo with vulvar cancer undergoing hemivulvectomy & lymphadenectomy.

What is the greatest risk factor for long-term post-operative sexual dysfunction?

options: age, extent of surgery, lymphadenectomy, HTN

Back 130

patient age

studies show that increasing age is negatively associated with sexual function

the extent of surgery and type of vulvectomy did NOT correlate with degree of sexual dysfunction in a study

Other factors that increase risk for sexual dysfunction: age, depression, worsening performance status, pre-operative hypoactive sexual dysfunction

#99

Front 131

Basal cell carcinoma of labium minor (1cm in size, 1.5cm from urethral meatus)

Next step?

Back 131

Wide local excision (margin 4-5mm)

do NOT need nodes - considered small (cut-off ~2cm)

#100

Front 132

What is the best screening option to assess for lymph node involvement for cervical cancer

Back 132

PET-CT scan - high sensitivity in detecting retroperitoneal nodal involvement

MRI is most sensitive to determine tumor extensive to lower uterine segment or vagina and to provide objective measure of tumor size

so, depending on what they ask for, this could be tricky (ugh)

#101

Front 133

31yo, received HPV vaccination, had normal pap.

What is the preferred next screening test?

Back 133

cytology + HPV cotesting q 5 years

Why not cytology alone q 3 yrs? the increased sensitivity of contesting compared with cytology alone achieves slightly lower cancer rates with less screening and few colposcopy.

#102

Front 134

65yo with malignant ascites, family history of father with colon cancer at age 70.

Most likely cancer?

Back 134

ovarian

malignant ascites in pts with ovarian cancer is thought to be attributed to lymphatic obstruction, increased vascular permeability, release of inflammatory cytokines and direct increase of fluid production by cancer cells in peritoneal cavity

#103

Front 135

Endometriosis associated with what type of cancer?

Back 135

clear cell carcinoma

# 104

Front 136

You are going to operate on a patient with HIV, obesity, asthma & 30 pack yr smoking history with emphysema

the factor most likely to cause a reduction in functional residual capacity (FRC) is?

Back 136

obesity

FRC = volume of gas remaining in the lungs at passive end expiration

things that decrease FRC = mechanical factors - pregnancy, obesity, pleural effusion, posture

# 105

Front 137

49yo undergoes TAH, BSO, nodes for stage IB1 cervical cancer. Final path shows small cell cancer

margins negative

Next step?

Back 137

Chemotherapy, even for early stage disease (stage IB) because metastasis is common with small cell neuroendocrine tumors

cisplatin - etoposide regimen preferred

#106

Front 138

Back 138

papillary projections

why? with laparoscopy you worry about spilling contents that may be malignant during removal. Worried about spillage, you don't want to do something with papillary projections laparoscopically

#107

Front 139

What are the cut-off levels for Ca-125 to refer removal of adnexal mass to gyn onc?

Back 139

Pre-menopause >200

Post > 35

#107

Front 140

32yo with BMI 51 with grade I endometrial cancer.

No evidence of mets on MRI

Wants children

Trying to lose weight

Next step?

Back 140

IUD

IUD was better choice than high dose progestin therapy b/c oral progestin at high dose will hinder this patient's weight loss efforts

#108

Front 141

Needlestick injury, patient with HIV on HAART, last titer 800 RNA copies/mL

What drugs for post-exposure prophylaxis?

Back 141

Emtricitabine, Tenofovir, Raltegravir

#109

Front 142

What is the risk of HIV transmission from needle-stick of HIV (+) pt?

with Hep B (+) pt?

Back 142

HIV: 0.3% after percutaneous exposure to HIV infected blood

2 - 60% after exposure to Hep B infected blood

#109

Front 143

What is the most appropriate, evidence-based treatment recommendation for contraception while following beta-hCG levels for GTD?

Back 143

OCPs

#110

Front 144

42yo with recurrent stage IIB SCC of cervix. Undergoing 3rd course of chemo. On exam skin & sclera are jaundiced, abdomen distended with fluid wave, abnormal LFTs, imaging shows extensive liver mets, pulmonary nodules.

Admitted for pain control, requiring large doses of IV analgesics

Next step?

Back 144

Palliative care

#111

Front 145

What's the best way to fix an abdominal hernia from laparotomy for large fibroid uterus?

Back 145

Laparoscopic repair with mesh

#112

Front 146

What are the recommendations for observation of stage IIIC ovarian cancer?

Back 146

No imaging!

Surveillance is pelvic exam + Ca125 level

Imaging only when indicated (symptomatic)

#113

Front 147

Stage IIB cervical cancer, s/p radiation therapy and chemo.

c/o hematuria 5 yrs after treatment. Most likely cause?

Back 147

radiation hemorrhagic cystitis (5.8% in 5 yrs, 7.4% in 10 yrs) is more likely than recurrence (cure rate 50%)

Perform cystoscopy to confirm diagnosis of hemorrhagic cystitis

#114

Front 148

68yo s/p optimal debulking surgery for ovarian cancer. You are considering placing an IP catheter for adjuvant chemo. This patient's most significant risk factor for catheter-related complications is:

Back 148

segmental rectosigmoid resection

Note: the primary reason for dc'd IP chemo is complications related to the catheter - infection is the most common

left colon- rectosigmoid resection is the procedure that has the highest risk for infection/ complications

#115

#115

Front 149

Most important part of surveillance of stage IB grade 3 endometrial cancer is

Back 149

history & physical examination

SGO guidelines specifically address the lack of evidence behind pap tests, CA-125, CXR, CT scanning in surveillance of survivors - these tests only increase cost & anxiety without improving detection

# 116

Front 150

65yo POD #3 s/p bowel resection, anastomosis for SBO. She had index procedure for endometrial cancer 2 yrs ago.

SICU page re: RR 36, P 130, BP 90/55. SaO2 89% on 2L NC.

Next step for respiratory distress?

Back 150

Intubation

In the post-op period, most pts can be managed with O2 nasal cannula.

Indications for intubation: combination of a failure to adequately oxygenate, ventilate, or meet metabolic demands of a physiologically stressed patient

SaO2 <90% or PaO2/FiO2 less than 200-300mgHg

s/sxs to dx respiratory distress: tachycardia, arrhythmia, hypotension, tachypnea, use of accessory muscles, diaphoresis, cyanosis

#117

Front 151

After post-op patient is intubated what settings to know?

Back 151

FiO2 100% (1.0) - then titrated downward to maintain SpO2 at 92-94%

Tidal volume (TV) 8-10 mL/kg

RR 12-15 breaths/minute (target pH, not PaCO2)

if ARDS - then TV 4 - 6 ml/kg to prevent barotrauma, satisfy "air hunger"

whether to use volume- or pressure- controlled ventilation is generally at the discretion of the clinician (SIMV vs VC/AC, PC/AC)

#117

Front 152

57yo with vulvar cancer. 2.5cm raised lesion, biopsy shows grade 2 SCC with 2mm depth.

On exam, palpable inguinofemoral lymph node.

The factor that determines that the patient is NOT a candidate for sentinel node dissection is:

Back 152

palpable groin node

"the detection rate and sensitivity of sentinel node mapping is decreased in pts with clinically palpable nodes - the lymphatic system is obstructed by tumor cells that prevent radioactive isotope and dye from correctly identifying the sentinel node."

#118

Front 153

57yo with vulvar cancer; 2.5cm raised lesion, biopsy shows grade 2 SCC with 2mm depth. On exam, palpable inguinofemoral lymph node.

Does she need lymphadenopathy?

Back 153

Yes, depth > 1 mm needs lymphadenectomy.

Don't do sentinel node mapping when nodes are palpable, however

#118

Front 154

What are the ideal patients for sentinel lymph node mapping in treatment of vulvar cancer?

Back 154

Lesions < 4cm

squamous etiology

exam without palpable lymph nodes

#118

Front 155

Treatment of vulvar cancer:

Back 155

1A: <2cm in size, <1mm in depth

1A -> excision withOUT lymphadenectomy

IB - III = radical excision, with lymphadenectomy

if within 1cm of midline, need bilateral lymphadenectomy

#118 (but this is from perinatal resources)

Front 156

Tx of DCIS after excision + lymphadenectomy

Biopsy = 3cm in size, neg ER/PR, closest margin 1mm

She does not want surgery

Back 156

Next step: Radiation

Observation if surgical margin <3mm

If she wanted surgery, could do simple mastectomy

#119

Front 157

s/p TAH for endometrial cancer, BMI62. POD #2 difficulty walking - foot is limp & unable to dorsiflex.

What nerve?

What could have prevented this injury?

Back 157

Nerve: Peroneal nerve

Cause: prolonged malposition

To prevent: appropriate positioning of legs in stirrups

#120

Front 158

Sharp, burning pain over suprapubic area, labia, thigh

What nerve?

The common cause of this injury?

next steps?

Back 158

Ilioinguinal / iliohypogastric (L1-L2)

occurs during transverse abdominal incision or tracer site insertion

Tx: self- limiting

if persistent, then pain can be treated with gabapentin

severe pain - local nerve blocks

#120

Front 159

What nerve is commonly injured during SSLS?

S/Sxs?

Tx:

Back 159

Pudendal nerve

Typically entrapment injury

Sxs: pain

Tx: release of the entrapped nerve

#120

Front 160

What is the most common compression injury from retractors during hysterectomies?

sxs?

Back 160

femoral nerve (L2-L4)

sxs: sensory change of anteromedial thigh, motor weakness with hip flexion & knee extension

#120

Front 161

Best breast cancer screening option for healthy 45yo woman with dense breasts

Choices:

Ultrasound

MRI

Digital mammography

Film mammography

Back 161

digital mammography

Note: dense breast are a/w a modestly increased risk of breast cancer

#121

CO #593

Front 162

Next step for intra-operative rupture of malignant ovarian cyst

Path: high grade serous carcinoma grade 3

All other specimens including washings, are negative

Back 162

IV chemo because of high-grade histology

Note: chemo is needed not only because of the rupture, but also b/c of the high grade

#122

Front 163

What is the appropriate post-op treatment for patient taking methadone, to prevent withdrawal symptoms?

Undergoing TAH for fibroid uterus

Back 163

continue methadone

Note: in many patients, a fetanyl patch will be effective to treat persistent mod-severe chronic pain. The patch can be applied for up to 72hours for continuous pain relief. Fentanyl was not the right answer b/c it won't prevent withdrawal

#123

Front 164

The strongest scientific evidence for the benefit of acupuncture in cancer patients is for:

Back 164

chemo-induced nausea & vomiting

acupuncture's effect on pain is not well defined

#124

Front 165

Tx of CIN I in pregnancy

Back 165

reassess postpartum

#125

Front 166

Tx of CIN 2/3 in pregnancy

Back 166

pap & colposcopy every 12 weeks

deferral to postpartum is alternative option (not preferred)

#125

Front 167

42yo undergoes diagnostic laparoscopy for pelvic pain

Findings: 3cm right ovarian tumor, carcinomatosis with diffuse mental involvement and ascites.

Frozen path reveals serous carcinoma

The surgery-related complication this patient is most at risk for:

Back 167

port-site metastasis

Incidence 0.24%

#126

Front 168

Post-op DVT prophylaxis for 68yo s/p TAH, BSO, debulking for high grade serous ovarian adenocarcinom

Back 168

LMWH for 4 weeks postoperatively

#127

Front 169

42yo s/p surgical repair of bowel perforation attributed to bevacizumab therapy.

RR 24, BP 90/60, PaO2 70mmHg, FiO2 60%, SaO2 95%

Next step?

Back 169

Continue intubation

#128

Front 170

85yo with serous ovarian cancer, diagnosed after thoracentesis that removed 1L of ascites

h/o CAD, MI, CHF, wheelchair bound.

Work-up finds PE, massive ascites, mental caking, 8cm complex pelvic mass

best recommendations for management of her cancer is:

Back 170

IV chemo (NOT primary cytoreductive surgery)

#129

Front 171

54yo with 6cm ovarian mass, Ca-125 45.

Undergoes laparoscopic LSO, washings.

Frozen reveals grade 2 serous adenocarcinoma of ovary

Next step?

Back 171

hysterectomy, contralateral SO, omentectomy, lymphadenectomy, washings, peritoneal biopsies

#130

Front 172

What intervention has been shown most beneficial in decreasing post-operative ileum?

Back 172

early post-operative feeing

#131

Front 173

What is the Dx & Tx:

38yo h/o stage IIB cervical cancer. Now 3 yrs s/p chemoradiation c/o abdominal pain, N/V. CT scan shows inflammation around the terminal ileum and proximal colon

Back 173

Dx: radiation enteritis

Tx: Bowel rest, IVF, correction of electrolytes, antiemetics, analgesics

#132

Front 174

Okay for HRT in BRCA pts?

37yo BRCA1 s/p BSO & bilateral mastectomy. C/o hot flashes, vaginal dryness.

The BEST therapy for her?

Back 174

hormone therapy

**if uterus is still in place, then progestin therapy should be included to decrease risk of developing endometrial cancer

#133

Front 175

The greatest risk factor for lymphedema?

55yo with stage I3C1 endometrial cancer treated with laparoscopic radical hysterectomy, BSO, pelvic & para-aortic lymphadenectomy. Then completed chemo and radiation. BMI 32.

Back 175

Answer: multimodality therapy

Lymphedema in GYN depends on type of cancer, extent of lymphadenectomy & location of nodes being removed.

Studies show age & BMI are NOT independent risk factors

**Vulvar cancer with highest incidence

**Lymphadenectomy alone increases risk

** but addition of radiation to lymphadenectomy increases risk more! (duh)

#134

Front 176

Treatment of Stage 4B cervical cancer

31yo with friable mass, extension to pelvic sidewalls, palpable supraclavicular lymph node, multiple lung lesions on imaging.

Back 176

chemotherapy alone

Stage 4B cervical cancer is NOT amenable to surgery or radiation - is a/w poor prognosis, and is rarely curable

Primary tx consists of systemic chemotherapy with the goal to prolong survival and improve quality of life

Combination chemo - cisplatin + (paclitaxel, topotecan or gemcitabine)

#135

Front 177

26yo s/p complete mole

beta-hCG 3,000 - 7000 - 13000 (over 3 weeks)

Exam: benign

CXR: normal

U/S: abnormal soft tissue hyper vascular lesion in the fundus, stripe 2cm

Next step:

Back 177

single-agent chemo

She has GTD (beta-hCG increase more than 10% over 2 weeks)

and low risk (memorize the chart!)

#136

Front 178

The step to reduce risk of wound infection

Back 178

use of chlorhexidine-alcohol surgical prep

**wound infxns comparable whether movie vs scalpel used for incision

**Chlorhexidine is the most effective skin cleasing agent and shown to be superior to povidone-iodine in reducing skin infections

*shaving skin can increase risk of skin infection, but clipping hair just prior to incision does NOT increase risk

*placing drains to reduce risk of infection is controversial

#137

Front 179

34yo wants FSS for ovarian cancer

Path: endometrioid ovarian cancer, grade I

no evidence of extra ovarian disease

Back 179

FSS = preserve uterus & contralateral ovary

So - USO, washings, omentectomy, pelvic & para-aortic nodes

*** should also perform endometrial biopsy to check for risk of synchronous primary cancer

in this age group, most common types of ovarian cancer are germ cell tumors or borderline ovarian tumors

#138

Front 180

Acute Kidney injury (AKI) - next step?

48yo POD #2 s/p TAH for fibroids. Hypotension during procedure - given salvaged rbcs, crystalloid, vasopressors. Cystoscopy at end of procedure normal. BP 120/70, P 90, R 18, UOP low but increased 1 mL per kg/ hr overnight. Hg 9.8 and Cr 2.3 (1 at baseline)

Back 180

maintenance IVF

AKI is pre-renal (hypotension) - vs postrenal (ureteral injury) because cystoscopy was normal

"management for post-op AKI not due to surgical urinary tract injury is mainly supportive and should be directed at making sure the volume is replaced until natural recovery occurs. Sepsis should be rule out. Hypotension and volume overload should be avoided because both affect perfusion)"

crystalloid fluids preferable

#139

Front 181

65yo G3P3 with grade 3 endometrial cancer. BMI 32

What's the procedure that she needs & the best surgical route (fewest complications)?

Back 181

TLH, BSO with pelvic lymph node dissection

(she needs lymphadenectomy - grade 3 - so vaginal route eliminated)

laparoscopic better than open (duh)

#140

Front 182

The most common adverse effect of tamoxifen

Back 182

hot flushes

#141

Front 183

Next step in management:

27yo with adenocarcinoma in-situ (AIS) on colposcopy, underwent conization, showed invasive adenocarcinoma with diameter 5mm and depth of 2mm, negative margins, no LVSI

Back 183

Final diagnosis = stage IAI

Next step: routine cervical cancer surveillance examinations

(does not need node dissection, hysterectomy or re-excision)

#142

Front 184

9yo has a complex adnexal mass and precocious puberty. The tumor marker most likely to assist in your pre-operative evaluation is

Back 184

inhibin B level (Granulosa cell tumor)

#143

Front 185

Which GTD -

Risk of persistence after D&C is ~ 20%

Back 185

complete mole

#144

Front 186

Which GTD -

Fetal vessels often are seen on hematoxylin and eosin stain

Back 186

partial mole

#145

Front 187

Which GTD -

systemic mets occur frequently

Back 187

gestational choriocarcinoma

#146

Front 188

Which GTD -

Histology characterized by proliferation of intermediate trophoblastic cells

Back 188

Placental-site trophoblastic tumor

#147

Front 189

Back 189

Hypovolemic shock - E

Septic shock - C

Cardiogenic shock - A

Front 190

Abx prophylaxis for:

38yo with suspected cystic teratoma who is scheduled for a laparoscopic oophorectomy

Back 190

none

#157

Front 191

Abx prophylaxis for:

36yo healthy women scheduled for TLH

Back 191

Cefazolin

#154

Front 192

Abx prophylaxis for:

38yo with BMI 45 and echocardiogram confirmed mitral valve prolapse scheduled for vaginal hysterectomy

Back 192

cefazolin

#155

"level I evidence supports the use of 1st generation cephalosporins for women who undergo TAH or total vaginal hysterectomy"

"Level III evidence supports prophylaxis for minimally invasive surgery - either TLH or LAVH"

Front 193

Abx prophylaxis for:

43yo with endometrial cancer and 18wk size uterus scheduled for an abdominal hysterectomy. She has a penicillin allergy not caused by immediate hypersensitivity

Back 193

Cefazolin

Front 194

Which hemostatic agent?

acidic plant-based extract that saturates with blood at the bleeding site and forms a brownish or blackish gelatinous mass, which aids in the formation of a clot via the intrinsic coagulation pathway

Back 194

Oxidized regenerate cellulose "Surgicel" - supplied as mesh, "Nu-Knit", "Fibrillar", "SNoW"

#158

Front 195

Which hemostatic agent?

Purified bovine-based agent that attracts platelets to a bleeding site, initiating the formation of a physiologic platelet plug

Back 195

microfibrillar collagen

#159

supplied as sheets "actifoam, Avitene, helistat"

Front 196

Which hemostatic agent?

Bovine or human extracted agent that converts fibrinogen to fibrin in addition to cross-linked granules that aid in platelet adhesion & aggregation

Back 196

flowable gelatin matrix with thrombin

#160

supplied as liquid, "thrombin - JMI"