CTgyn cheat sheet

The uterus is supported by the cardinal (Mackenrodt) ligaments, uterosacral ligaments, and round ligaments; the cardinal ligaments contain the uterine vessels.

The ovaries are supplied by the ovarian arteries (from the abdominal aorta) and the ovarian branches of the uterine arteries; lymphatic drainage parallels the ovarian vessels to para-aortic nodes.

The cervix has two epithelia: ectocervix is stratified squamous, endocervix is simple columnar; the squamocolumnar junction is the site of metaplasia and most cervical neoplasms.

The endometrium consists of functionalis (shed during menses) and basalis (regenerates); the basalis is supplied by straight arterioles, the functionalis by spiral arterioles.

The fallopian tube has four segments (interstitial, isthmus, ampulla, infundibulum); the ampulla is the most common site of ectopic pregnancy and the fimbriae are the site of serous tubal intraepithelial carcinoma (STIC).

The vulva is drained by superficial inguinal nodes; the clitoris and anterior labia may drain directly to deep femoral or pelvic nodes.

Normal vaginal pH is 3.8–4.5, maintained by Lactobacillus species producing lactic acid from glycogen.

The ovarian cycle is driven by FSH (follicular growth) and LH (ovulation); the corpus luteum secretes progesterone, and its lifespan is about 14 days unless rescued by hCG.

Endometrial cancer is the most common gynecologic malignancy in the US; risk factors include obesity, unopposed estrogen, nulliparity, diabetes, and Lynch syndrome.

Ovarian cancer has the highest mortality of gynecologic cancers; risk factors include nulliparity, early menarche, late menopause, BRCA1/2 mutations, and Lynch syndrome; oral contraceptive use and parity are protective.

Cervical cancer is caused by persistent high-risk HPV (types 16 and 18 cause ~70%); risk factors include early coitarche, multiple partners, smoking, and immunosuppression.

Vulvar squamous cell carcinoma has two pathways: HPV-associated (basaloid/warty) and HPV-independent (differentiated VIN, often associated with lichen sclerosus).

Uterine sarcomas are rare (<5% of uterine cancers); leiomyosarcoma and endometrial stromal sarcoma are the most common subtypes.

Gestational trophoblastic neoplasia includes choriocarcinoma, placental-site trophoblastic tumor, and epithelioid trophoblastic tumor; risk is higher after molar pregnancy.

Fallopian tube carcinoma is often grouped with ovarian high-grade serous carcinoma; many cases originate from STIC lesions.

Obesity is a risk factor for endometrial cancer (relative risk increases with BMI) but is associated with lower risk of premenopausal breast cancer and may be protective for ovarian cancer in some studies.

Endometrial cancer diagnosis requires endometrial biopsy or dilation and curettage; transvaginal ultrasound may show thickened endometrium but is not diagnostic.

Cervical cancer staging includes pelvic exam, colposcopy, biopsy, and imaging (MRI for local extent, CT/PET for nodal and distant disease); FIGO allows imaging and surgical findings in staging.

Ovarian cancer workup includes transvaginal ultrasound, CA-125, and CT of chest/abdomen/pelvis; diagnostic laparoscopy or laparotomy is needed for tissue diagnosis and staging.

Vulvar cancer diagnosis is by biopsy; staging includes clinical exam, imaging (CT/MRI) for nodal assessment, and sentinel lymph node biopsy for early-stage disease.

CA-125 is elevated in many ovarian cancers but is nonspecific; HE4 and ROMA may improve specificity.

Sentinel lymph node mapping is standard for early vulvar cancer and is increasingly used in endometrial cancer; indocyanine green is a common tracer.

PET/CT is useful for detecting occult nodal or distant metastases in cervical and ovarian cancers, but it does not replace histologic confirmation.

Tumor markers: beta-hCG for gestational trophoblastic disease, alpha-fetoprotein for yolk sac tumors, inhibin for granulosa cell tumors.

FIGO staging for endometrial cancer (2009): Stage I confined to uterus (IA <50% myometrial invasion, IB ≥50%); II cervical stroma involvement; III local/regional spread; IV bladder/bowel or distant metastasis.

FIGO staging for cervical cancer (2018): Stage IB includes measurable lesions; IB1 ≤2 cm, IB2 >2 to ≤4 cm, IB3 >4 cm; II involves upper vagina or parametria; III lower vagina, pelvic wall, hydronephrosis, or pelvic nodes; IV bladder/bowel or distant.

FIGO staging for ovarian cancer: Stage I ovaries; II pelvic extension; III peritoneal metastases outside pelvis or retroperitoneal nodes; IV distant metastases including pleural effusion with positive cytology.

FIGO staging for vulvar cancer: Stage I tumor ≤2 cm with negative nodes; II >2 cm with negative nodes; III positive inguinal nodes; IV upper vagina/urethra/bladder or fixed pelvic nodes or distant.

Prognostic factors in endometrial cancer include stage, grade, histologic subtype, myometrial invasion, and lymphovascular space invasion; p53 and POLE status are molecular prognostic markers.

In cervical cancer, stage, tumor size, lymph node status, and LVSI are key prognostic factors; HPV status and histologic subtype also matter.

Ovarian cancer prognosis depends on stage, residual disease after cytoreduction, histologic subtype, and BRCA mutation status.

Vulvar cancer prognosis is primarily determined by lymph node status (number and size of metastases) and tumor size.

Endometrial cancer: total hysterectomy with bilateral salpingo-oophorectomy is standard; lymphadenectomy or sentinel node biopsy is performed for staging in higher-risk cases.

Cervical cancer: radical hysterectomy with pelvic lymphadenectomy is an option for early-stage disease (e.g., stage IB1–IB2); fertility-sparing radical trachelectomy may be considered.

Ovarian cancer: primary debulking surgery aims for no visible residual disease; neoadjuvant chemotherapy followed by interval debulking is an alternative for advanced disease.

Vulvar cancer: wide local excision with 1–2 cm margins; inguinofemoral lymphadenectomy or sentinel node biopsy for nodal staging.

Operative reports should document tumor size, location, histology, grade, margins, lymphovascular invasion, and lymph node counts.

For ovarian cancer, residual disease should be recorded as microscopic, ≤1 cm, or >1 cm; completeness of cytoreduction is a key prognostic and quality metric.

Sentinel lymph node biopsy protocols require ultrastaging with cytokeratin immunohistochemistry to detect micrometastases and isolated tumor cells.

Minimally invasive surgery is acceptable for endometrial cancer but not recommended for cervical cancer radical hysterectomy based on the LACC trial.

Cervical cancer: concurrent cisplatin-based chemoradiation is standard for locally advanced disease (stages IB3–IVA); brachytherapy is an essential component.

Endometrial cancer: adjuvant radiation is considered for high-intermediate or high-risk disease; chemotherapy is used for advanced or serous/clear cell histologies.

Ovarian cancer: standard first-line is platinum-taxane chemotherapy; maintenance PARP inhibitors are used for BRCA-mutated or HRD-positive tumors; bevacizumab may be added.

Vulvar cancer: chemoradiation may be used for advanced disease or to avoid exenterative surgery; radiation is often combined with cisplatin or 5-FU.

Radiation therapy fields: pelvic radiation for cervical/endometrial cancer; extended-field radiation for para-aortic nodes; intensity-modulated radiation therapy (IMRT) reduces toxicity.

Brachytherapy for cervical cancer: high-dose-rate (HDR) is commonly used; dose is prescribed to point A or with MRI-based adaptive planning.

Systemic therapy for recurrent/advanced endometrial cancer includes carboplatin-paclitaxel; immunotherapy (pembrolizumab) is used for MSI-high tumors.

Treatment sequencing: surgery first for early-stage disease; chemoradiation first for locally advanced cervical cancer; neoadjuvant chemotherapy for advanced ovarian cancer when primary debulking is not feasible.

Casefinding sources include pathology reports, radiology reports, operating room logs, and tumor board lists; search terms include gynecologic cancer terms and procedure codes.

Abstracting requires capturing patient demographics, tumor site, histology, stage, treatment, and follow-up; use standardized coding manuals (e.g., ICD-O-3, AJCC).

Data quality checks include verifying stage consistency, treatment dates, and vital status; re-abstracting a sample of cases is a common quality assurance method.

For gynecologic cancers, abstract extent of disease (e.g., myometrial invasion, ovarian surface involvement) and record lymph node counts and status.

Timeliness standards: abstract within a defined period (e.g., 6 months) after diagnosis; follow-up should be updated annually.

Confidentiality: follow HIPAA and institutional policies; de-identify data before sharing or analysis.

Use of natural language processing (NLP) is increasing for casefinding and abstraction but requires validation against manual review.

Record treatment sequence and dates accurately, including neoadjuvant vs adjuvant settings, to support survival and quality analyses.

Survival is often reported as overall survival (OS), disease-specific survival (DSS), and progression-free survival (PFS); define start and end points clearly.

Kaplan-Meier method estimates survival curves; Cox proportional hazards model assesses prognostic factors.

Recurrence patterns: endometrial cancer recurs locally (vaginal cuff) or distantly (lung); cervical cancer recurs in pelvis or para-aortic nodes; ovarian cancer recurs in peritoneum.

Follow-up for endometrial cancer: physical exam and symptom review every 3–6 months for 2–3 years, then annually; routine imaging is not recommended for asymptomatic patients.

Follow-up for cervical cancer: pelvic exam and cytology annually for 3 years, then every 3 years; imaging for symptoms or suspected recurrence.

Ovarian cancer follow-up includes CA-125 and imaging; rising CA-125 may precede clinical recurrence.

Vulvar cancer follow-up: exam every 3–6 months for 2 years, then annually; monitor for local recurrence and second primaries.

Survival statistics should include stage distribution and treatment era; relative survival compares to general population.

Informed consent must include diagnosis, treatment options, risks, benefits, and alternatives; documentation is required.

Clinical practice guidelines from NCCN, FIGO, and ASCO provide standards of care; adherence is a quality metric.

Multidisciplinary tumor boards improve staging accuracy and treatment planning; documentation of discussion is recommended.

Ethical principles: autonomy, beneficence, nonmaleficence, and justice; apply to resource allocation and end-of-life care.

Conflicts of interest must be disclosed in research, publication, and clinical practice.

Patient privacy: HIPAA and GDPR regulations govern use of personal health information; data sharing requires de-identification or consent.

Research ethics: institutional review board (IRB) approval is required for human subjects research; informed consent must be obtained.

Quality improvement: participation in accreditation programs (e.g., Commission on Cancer) and reporting to cancer registries is expected.