Reviewed July 2014 Clinical Curriculum: Gynecologic Oncology Goal: The primary goal of the gynecologic oncology 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 clinic 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 hysterectomy 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 surgery 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 Lymph node 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 therapy 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 cancer (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 radiation therapy and chemotherapy. 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 neoplasms. 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 Pathology and neoplasia Describe the role of viruses in the pathogenesis of gynecologic tumors. 1,2,3,4 x Describe the influence of immunosuppression on the risk of acquiring a type of gynecologic cancer. 1,2,3,4 x Describe the effect of cancer and its therapies on the immune system. 1,2,3,4 x List the principal consequences of immunosuppression in the cancer patient (eg, increased susceptibility to infection 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 carcinoma 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 cyst 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 metastasis, 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 health care 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 vagina 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. Melanoma b. Squamous cell carcinoma c. Basal cell carcinoma 1,2,3,4 x d. Paget disease e. Sarcoma f. Verrucous carcinoma g. Bartholin gland carcinoma Describe the clinical manifestations of invasive vulvar malignancies. 1,2,3,4 x Describe the differential diagnosis of vulvar cancer. 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 Obstetrics (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.