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Home , Fallopian tube cancer, Gynecologic oncology

Reviewed July 2014 Clinical Curriculum: Gynecologic

Goal: The primary goal of the rotation at the University of Alabama at Birmingham is to train residents to have a general understanding of the evaluation and treatment of women with suspected gynecologic malignancies. At the completion of four years of training, our residents will be capable of appropriate workup and referral of patients with gynecologic malignancies.

Organization: Four residents are assigned to the UAB inpatient rotation (Green: PGY2 & 3; Gold: PGY1 & 4). One intern will be assigned to the outpatient rotation. Junior residents (PGY1, 2) will also attend the Colposcopy Clinic on Friday mornings.

Supervision: Residents are directly supervised by faculty members at all times. Gynecologic oncology faculty are in attendance in the operating rooms during the critical portion of all procedures. All admitted inpatients are seen by a faculty daily.

By the end of the rotation, 1st and 2nd year residents should be able to perform:

 Workup and management of patients with suspected gynecologic malignancies

 Minor gynecologic procedures such as D&C, cold knife cone, and CO2 laser ablations

 Basic laparoscopy

 Routine open and salpingo-oophorectomy

By the end of the rotation, 3rd and 4th year residents should be able to perform:

 Critical care of postoperative patients

 Robotic hysterectomy and salpingo-oophorectomy

 Complicated abdominal and pelvic such as endometriosis and adhesions

Reviewed July 2014 By the end of the rotation, residents should understand or perform the following procedures: Procedure Understand Perform Colectomy (partial or total) 1,2,3,4 Colostomy 1,2,3,4 Fistula repair 1,2,3,4 Hysterectomy:  Extrafascial (with or without bilateral salpingo-oophorectomy) 1,2,3,4  Radical (with or without bilateral salpingo-oophorectomy) 1,2,3,4 Lumpectomy of breast 1,2,3,4 biopsy/dissection:  Axillary 1,2,3,4  Inguinal 1,2,3,4  Para-aortic 1,2,3,4  Pelvic 1,2,3,4  Sentinel 1,2,3,4 Mastectomy  Radical 1,2,3,4  Simple 1,2,3,4 Paracentesis 1,2,3,4 Pelvic exenteration with or without reconstruction 1,2,3,4 IP port placement 1,2,3,4 Radiation  Brachytherapy 1,2,3,4  External beam 1,2,3,4  Interstitial 1,2,3,4 Resection of large and small bowel 1,2,3,4 Staging laparotomy  Biopsy of pelvic lymph nodes 1,2,3,4  Biopsy of peritoneal implants and cytologic washings of the peritoneal cavity 3,4  Exploration of abdomen 3,4  Infracolic omentectomy 3,4 Suction evacuation of molar pregnancy 1,2,3,4 Transverse rectus abdominis myocutaneous flap 1,2,3,4 Vaginal reconstruction  Gracilis flap 1,2,3,4  Martius flap 1,2,3,4 Reviewed July 2014 Skin graft 1,2,3,4 Venous access device placement 1,2,3,4 Vulvectomy 3,4

Gynecologic Oncology Objectives Basic science/mechanisms of disease PGY Genetics PC MK PBL ICS P SBP Level Describe the clinical relevance of oncogenes and tumor suppressor genes. 1,2,3,4 x Describe the inheritance patterns for malignancies of the pelvic organs and breast. 1,2,3,4 x Describe the current indications for screening for BRCA1, BRCA2, and hereditary 1,2,3,4 x nonpolyposis colorectal (HNPCC), also known as Lynch syndrome. Describe the cell replication cycle and identify the phases of the cycle most sensitive to 1,2,3,4 x and . Physiology Describe the ability of vital organ systems to tolerate cancer therapy and define the 1,2,3,4 x concept of therapeutic index. Describe the changes in cell and organ physiology that result from injury due to 1,2,3,4 x radiation therapy and chemotherapy. Embryology and developmental biology Describe the embryology of gonadal migration and its role in the pathogenesis of 1,2,3,4 x epithelial and germ cell . Describe the embryologic origins of cell types found in benign and malignant germ cell 1,2,3,4 x tumors. Anatomy Describe the anatomy of the anterior and posterior abdominal wall. 1,2,3,4 x Describe the anatomy of the pelvic floor retroperitoneal and para-aortic spaces. 3,4 x Describe the gross and histologic anatomy of the external genitalia, pelvic organs, and 1,2,3,4 x the breast. Describe the vascular, lymphatic, and nerve supply to the breast, external genitalia, 1,2,3,4 x and each of the pelvic organs. Describe the anatomic relationship between the reproductive organs and the 3,4 x nongynecologic abdominal and pelvic viscera (ie, bladder, ureters, and bowel). Describe the likely changes in the anatomic relationships of the pelvic and abdominal viscera created by surgical or radiation treatment for a malignancy of the pelvic 3,4 x organs. Pharmacology Reviewed July 2014 List the major chemotherapeutic agents used for treatment of malignancies of the 2,3,4 x reproductive organs and breast. Describe the principal adverse effects of these major chemotherapeutic agents. 2,3,4 x List supportive care methods/medications that can be used to ameliorate the following treatment complications: a. Marrow suppression b. Nausea and vomiting 2,3,4 x c. Hemorrhagic cystitis d. Peripheral neuropathy e. Renal toxicity f. Cardiac toxicity and neoplasia

Describe the role of viruses in the pathogenesis of gynecologic tumors. 1,2,3,4 x Describe the influence of on the risk of acquiring a type of gynecologic cancer. 1,2,3,4 x

Describe the effect of cancer and its on the immune system. 1,2,3,4 x List the principal consequences of immunosuppression in the cancer patient (eg, increased susceptibility to and poor wound healing). 1,2,3,4 x

Carcinoma of the breast PGY Epidemiology and risk assessment of breast cancer PC MK PBL ICS P SBP Level Evaluate a patient’s personal or family history of breast cancer, including the risk 1,2,3,4 x x associated with BRCA1 or BRCA2. Evaluate other epidemiologic factors to assess a woman’s risk of developing breast cancer, such as the following: a. Patient age b. Parity 1,2,3,4 x x c. Ethnicity d. Lactation e. Hormone replacement f. Alcohol consumption Counsel patients regarding breast cancer prevention strategies. 1,2,3,4 x x Counsel patients regarding the use of screening methods, such as mammography. 1,2,3,4 x x Refer patients appropriately for genetic counseling and testing. 1,2,3,4 x x Reviewed July 2014 Diagnosis of invasive of the breast Obtain a focused history and perform a physical examination in women with signs or 1,2,3,4 x x symptoms of breast cancer. Order and explain to the patient appropriate diagnostic tests for evaluating a 1,2,3,4 x x suspicious breast lesion. Describe the indications for and interpret the results of needle aspiration of a breast 1,2,3,4 x x and fine needle biopsy of a solid lesion for the patient. Describe the indications for and interpret for the patient the results of other diagnostic studies, such as the following: a. Mammography b. Ultrasonography 1,2,3,4 x x c. Magnetic resonance imaging d. Core-needle biopsy e. Excisional biopsy Management of invasive breast cancer Describe the staging of breast cancer and the prognostic significance of histologic type, regional lymph node , distant metastasis, and hormone receptor 1,2,3,4 x status. Describe the indications for lumpectomy compared with mastectomy. 1,2,3,4 x Describe the indications for adjuvant therapy with hormonal treatment, chemotherapy, 1,2,3,4 x or radiation therapy. Describe the effect of pregnancy on the treatment and prognosis of breast cancer. 1,2,3,4 x Breast cancer survivorship Describe the psychosocial effect of breast cancer on family dynamics, sexuality, and stress management and make appropriate referral to support groups and 1,2,3,4 x x x professionals. Manage the adverse effects of antiestrogen medications, such as tamoxifen and 1,2,3,4 x x aromatase inhibitors.

Vulvar and vaginal malignancies PGY Pre-invasive lesions PC MK PBL ICS P SBP Level Describe the epidemiology of vulvar intraepithelial neoplasia (VIN) and vaginal 1,2,3,4 x intraepithelial neoplasia (VAIN). Describe the clinical manifestations of VIN and VAIN. 1,2,3,4 x Describe the differential diagnosis of pigmented and nonpigmented vulvar and vaginal 1,2,3,4 x lesions. Perform and interpret the results of diagnostic procedures for VIN and VAIN. 1,2,3,4 x Reviewed July 2014 Perform surgical and/or medical treatment for patients with VIN and VAIN. 1,2,3,4 x Establish a posttreatment follow-up plan for patients with VIN and VAIN. 1,2,3,4 x x Describe the structural and histologic changes in the characteristic of in utero 1,2,3,4 x exposure to diethylstilbestrol. Invasive vulvar carcinoma Describe the epidemiology of invasive vulvar lesions, such as the following: a. b. c. Basal cell carcinoma 1,2,3,4 x d. Paget disease e. Sarcoma f. g. Bartholin gland carcinoma Describe the clinical manifestations of invasive vulvar malignancies. 1,2,3,4 x

Describe the differential diagnosis of . 1,2,3,4 x

Perform appropriate biopsies to diagnose vulvar carcinoma. 1,2,3,4 x Describe the staging of invasive vulvar cancer using the system adopted by the International Federation of Gynecology and 1,2,3,4 x (FIGO).

Counsel a patient about the evaluation and treatment (indications and complications) 1,2,3,4 x x of vulvar cancer. Describe the prognosis for invasive vulvar malignancies. 1,2,3,4 x Describe the effect of treatment of vulvar cancer on sexual function and manage/refer 1,2,3,4 x x x the patient appropriately. Provide psychosocial support and long-term follow-up for patients with vulvar cancer 1,2,3,4 x x x Invasive carcinoma of the vagina Describe the epidemiology of invasive , such as the following: 1,2,3,4 a. Squamous cell carcinoma x b. Clear cell 1,2,3,4 Describe the clinical manifestations of invasive vaginal cancer. x 1,2,3,4 Describe the differential diagnosis of invasive vaginal cancer. x 1,2,3,4 Perform appropriate biopsies to diagnose vaginal cancer. x Reviewed July 2014 1,2,3,4 Describe the staging of invasive vaginal cancer using the system adopted by FIGO. x Counsel the patient regarding the evaluation and treatment (indications and 1,2,3,4 x x complications) of vaginal cancer. Describe the prognosis for invasive vaginal cancer. 1,2,3,4 x Describe the effect of treatment of vaginal cancer on sexual function and manage/refer 1,2,3,4 x x x patients appropriately. Provide psychosocial support and long-term follow-up for patients with vaginal cancer. 1,2,3,4 x x x

Cervical disorders PGY Pre-invasive cervical disease PC MK PBL ICS P SBP Level Describe the epidemiology of cervical dysplasia. 1,2,3,4 x Obtain a pertinent history in a woman with an abnormal Pap test. 1,2,3,4 x x Interpret Pap test reports using the Bethesda classification system and determine 1,2,3,4 x appropriate follow-up. Perform and interpret the results of diagnostic procedures for cervical dysplasia. 1,2,3,4 x Develop an age-appropriate treatment plan for cervical dysplasia with modalities, such as the following: a. Cryosurgery b. Laser ablation 1,2,3,4 x c. Loop electrosurgical excision procedure d. Cold knife conization e. Observation/close follow-up Manage the complications that result from treatment of cervical dysplasia. 1,2,3,4 x Establish an appropriate follow-up plan for a woman who has been treated for cervical 1,2,3,4 x dysplasia. Describe the structural changes in the that are characteristic of in utero diethylstilbestrol exposure. 1,2,3,4 x

Counsel patients regarding the use of vaccinations for the prevention of human 1,2,3,4 x papillomavirus-related diseases. Invasive Describe the epidemiology of cervical cancer. 1,2,3,4 x

Describe the typical clinical manifestations of cervical cancer. 1,2,3,4 x Describe the differential diagnosis of cervical cancer. 1,2,3,4 x Perform appropriate biopsies to diagnose invasive cervical cancer. 1,2,3,4 x Reviewed July 2014 Describe the staging of cervical cancer using the system adopted by FIGO. 1,2,3,4 x Counsel the patient about the evaluation and treatment (indications and complications) 1,2,3,4 x x of cervical cancer. Describe the prognosis for cervical cancer. 1,2,3,4 x Describe the effect of treatment of cervical cancer on sexual function and 1,2,3,4 x x x manage/refer patients appropriately. Provide psychosocial support and long-term follow-up for patients with cervical cancer. 1,2,3,4 x x x

Carcinoma of the PGY Endometrial hyperplasia PC MK PBL ICS P SBP Level Obtain a targeted history in patients who have abnormal uterine bleeding, including an assessment of risk factors, such as the following: a. Obesity b. Anovulation 1,2,3,4 x x c. Polycystic syndrome d. Glucose intolerance e. Estrogen or antiestrogen (tamoxifen) exposure f. Family history Perform a focused physical examination in women who have abnormal bleeding and 1,2,3,4 x risk factors for endometrial hyperplasia. Describe factors that influence the treatment of hyperplasia, such as the following: a. Classification and histology b. Age of patient 1,2,3,4 x c. Reproduction goals d. Risk of malignancy Treat endometrial hyperplasia medically and surgically. 1,2,3,4 x Describe and manage the potential complications of these interventions. 1,2,3,4 x Describe appropriate post treatment follow-up. 1,2,3,4 x Carcinoma of the endometrium Describe the epidemiology of , such as the following: a. Uterine adenocarcinoma 1,2,3,4 x b. Describe the clinical manifestations of endometrial cancer. 1,2,3,4 x

Describe the differential diagnosis of invasive endometrial cancer. 1,2,3,4 x

Perform biopsies to diagnose endometrial cancer. 1,2,3,4 x Reviewed July 2014 Describe the staging of invasive endometrial cancer using the system adopted by 1,2,3,4 x FIGO. Counsel the patient about the evaluation and treatment (indications and complications) 1,2,3,4 x x of endometrial cancer. Describe the prognosis for invasive endometrial cancer. 1,2,3,4 x Provide psychosocial support and long-term follow-up for women with endometrial 1,2,3,4 x x x cancer.

Ovarian and Tubal Carcinoma PGY Carcinoma of the ovary PC MK PBL ICS P SBP Level Describe the epidemiology of . 1,2,3,4 x Describe the inherited syndromes that increase a woman’s likelihood of developing 1,2,3,4 x ovarian cancer. Describe the screening protocols that may identify patients who have an inherited form 1,2,3,4 x of ovarian cancer. Describe the clinical manifestations of ovarian cancer. 1,2,3,4 x Describe the staging of ovarian cancer using the system adopted by FIGO. 1,2,3,4 x Describe the histology, staging, and prognosis for the following: a. Epithelial tumors b. Germ cell tumors c. Stromal tumors 1,2,3,4 x d. Sarcomas e. Metastatic tumors f. Tumors of low malignant potential Interpret for the patient the following tests to diagnose ovarian cancer: a. Ultrasonography b. Serum tumor markers 1,2,3,4 x x c. Cytology from thoracentesis or paracentesis d. Computed tomography scan Counsel the patient about the evaluation and treatment (indications and complications) 1,2,3,4 x x of ovarian cancer. Provide psychosocial support and long-term follow-up for women with ovarian cancer. 1,2,3,4 x x x Carcinoma of the 1,2,3,4 Describe the epidemiology of . 1,2,3,4 x Describe the typical clinical manifestations of fallopian tube cancer. 1,2,3,4 x Describe the staging of fallopian tube cancer using the system adopted by FIGO. 1,2,3,4 x Counsel the patient about the evaluation and treatment (indications and complications) 1,2,3,4 x x of fallopian tube cancer. Reviewed July 2014 Describe the prognosis of fallopian tube cancer. 1,2,3,4 x Provide psychosocial support and long-term follow-up for women with fallopian tube 1,2,3,4 x x x cancer.

Gestational Trophoblastic Disease PGY Hydatidiform mole PC MK PBL ICS P SBP Level 1,2,3,4 Describe the epidemiology and genetics of hydatidiform mole. x 1,2,3,4 Describe the clinical manifestations of gestational trophoblastic disease (GTD). x Diagnose GTD and its manifestations using tests, such as the following: a. Ultrasonography b. Quantitative b-hCG titer 1,2,3,4 x c. Chest X-ray d. Thyroid function tests Distinguish between a complete and partial hydatidiform mole using histologic and 1,2,3,4 x cytogenetic findings. Provide surgical treatment for a patient with GTD. 1,2,3,4 x Provide the appropriate follow-up for a patient who has had suction evacuation of a 1,2,3,4 x molar pregnancy. Counsel the patient regarding recurrence risk of GTD. 1,2,3,4 x x Malignant gestational trophoblastic disease

Describe the risk factors for malignant GTD. 1,2,3,4 x Describe the histologic appearance of invasive mole versus versus 1,2,3,4 x placental site trophoblastic tumor. Describe the diagnosis of malignant GTD using a combination of physical examination, 1,2,3,4 x b-hCG, chest X-ray, computed tomography scan, and ultrasonography. Describe the features associated with low-risk versus high-risk GTD. 1,2,3,4 x

Counsel patients regarding risk of recurrence and prognosis for future pregnancies. 3,4 x x

Provide psychosocial support and long-term follow-up of patients with GTD. 1,2,3,4 x x x

Therapy PGY Radiation therapy PC MK PBL ICS P SBP Level Describe the general principles of radiation therapy. 2,3,4 x Reviewed July 2014 Describe the indications for radiation therapy in the treatment of gynecologic neoplasms and the factors that influence decisions regarding intervention, such as the following: a. Classification and FIGO staging of disease and histology b. Age of patient 2,3,4 x c. Underlying medical conditions d. Implications for future fertility e. Concomitant therapy with radiosensitizers or chemotherapy f. Previous abdominal procedures g. Need for palliative management Describe the potential complications of radiation therapy. 3,4 x Chemotherapy Describe the general mechanisms of action of chemotherapy. 2,3,4 x Describe the general indications for chemotherapy in the treatment of gynecologic 1,2,3,4 x neoplasms. Describe the most appropriate indication for chemotherapeutic agents, such as the following: a. Alkylating agents b. Antimetabolites c. Vinca alkaloids 2,3,4 x d. Antibiotics e. Hormonal agents f. Heavy metals g. Immunotherapy Describe the potential complications of chemotherapy. 2,3 x

Describe the long-term effects of chemotherapy on fertility. 3,4 x Terminal care Describe the basic principles of . 1,2,3,4 x Describe medical, radiation and operative modalities for palliation of symptoms in 1,2,3,4 x terminally ill patients. Describe the appropriate indications for a “do not resuscitate” order. 1,2,3,4 x Describe the medical, ethical, and legal implications of a “do not resuscitate” order. 1,2,3,4 x Describe the concept of therapeutic index when considering medical or operative 1,2,3,4 x intervention to improve patients’ quality of life. Describe the basic principles of and provide appropriate pain control 1,2,3,4 x for terminal patients.