Gynae

Question 1

What is the acceptable margin according to guideline for vulva cancer resection?

Answer 1

8mm
But can be up to discretion if >5mm and has no other high risk feature

Question 2

What is stromal invasion when describing vulva cancer resection?

Answer 2

Stromal invasion occurs when cancer cells penetrate the basement membrane and infiltrate the dermis or deeper layers.
Layers:
Epidermis
Basement membrane
Dermis
Subcutaneous tissue

Question 3

What are germ line mutations associated with endometerial cancer?

Answer 3

Lynch syndrome. AD.
MLH1, MSH2, MSH6, PMS2
3% EC due to Lynch syndrome
MLH1 highest lifetime risk

Cowden Syndrome: breast, thyroid, EC
PTEN mutation
28% lifetime risk

Question 4

What are the 4 genomic subgroups of Endometerial Cancer?

Answer 4

POLE (ultramutated): favourable prognosis
Micro satellite instability (hypermutated)
Copy number low (endometriod)
Copy number high (serous-like): worst prognosis

Question 5

What are the lymphatic drainage for endometerial cancer?

Answer 5

2 pathways:
Upper para-cervical pathway
- along uterine artery draining in the external and obturator LN before crossing the external iliac artery to the lateral precaval and para-aortic

Lower para-cervical pathway
- along sacrouterine ligament to the presacral area medial to the internal iliac artery and it presacral nodes before continuing medial to the common iliac artery to the medial para-aortic and precaval areas

Question 6

What is the standard care of endometerial cancer ?

Answer 6

Total hysterectomy with bilateral salpingoophrectony

Question 7

How is sentinel lymph node assessment done for Endometerial Cancer?

Answer 7

Peritoneal and serosal evaluation and washings
Retroperitoneal evaluation: Excision of all mapped SLN with ‘ultrastaging’ ; Any suspicious node to be removed regardless of mapping
If there is failed or no mapping, a side-specific LND is performed
Para-aortic LND done at discretion

Question 8

When should lymphadenectomy be performed for Endometerial Cancer?

Answer 8

Considered for tumours >50% myometerial invasion, grade 3 or non-endometerioid histology

Question 9

When should LN assessment NOT be performed?

Answer 9

As per ESMO-ESGO-ESTRO, low grade, low risk disease, reserving it for medium or high risk disease

Question 10

What are the 3 histopathological grade for EC?

Answer 10

Grade 1: < 5% sp;od growth pattern
Grade 2: 6-50% solid growth pattern
Grade 3: >50% solid growth pattern

Question 11

What are the 4 patterns of myometerial invasion for endometerial cancer?

Answer 11

1. Single gland pattern (diffusely infiltrative)
   - poor prognosis, assoc higher grade, LVSI, tumour recurrence
2. Pushing/expansile, board front/pattern
   - good prognosis
3. Adenomyosis-like
   - good prognosis
4. Microcystic, Elongated and Fragmented pattern (MELF)
   - strongly associated with low-grade endometerioid endometerial carcinoma and mucinous differentiation
   - significantly increases the risk of regional LN and associated with deep myometerial invasion, LVSI and grade 3 tumour

Question 12

When is adjuvant therapy not required for Endometerial Cancer?

Answer 12

Adjuvant therapy is not required for Stage IA grade 1-2 EC without intermediate or high-risk factors based on 2 prospective trials.
Intermediate risk factors: age >60, focal LVSI, large tumour size
High risk factors: LVSI, no surgical nodal staging