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Gynae, Breast & Sexual Health > Gynaecology and Oncology screening > Flashcards

Gynaecology and Oncology screening Flashcards

1
Q

What is the order of most common gynae cancers in the world?

A
  1. Endometrial cancer is most common gynae cancer in the devleoped world
    • incidence risen in last 20 years by 40% - with obesity
    • presents early: peak 65-75yrs
  2. cervical cancer is the 3rd most common cancer worldwide, and THE most common in woman <35y/o
    • 50% cases are <47 y/o
    • peak = 25-29yrs
  3. ovarian cancer is the leading cause of death from gynae malignancy in the uk. 50% of cases are over 65 (but half are under 65?)
    • poor prognosis as late presenting (30% 5 year survival, all statges)
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2
Q

A patient with PMHx cervical glandular intraepithelial neoplasia can develop what type of cervical cancer?

A
  • ADENOCARCINOMA e.g. as glandular intraepithelial neoplasia –> from endocervical e.g. ectropion
  • high risk HPV is also important
  • adeno carcinomas = 15% cervical cancers (mixed = 15%; SCC = 70%)
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3
Q

A patient has a suspicious cervical lesion which is biopsied and sent for histology. On histology keratin pearls are seen.

What is this indicative of?

A

Squamous Cell Carcinoma (70% of cervical cancer)

  • progression from CIN (CERVICAL intraepithelial neoplasia) - occurs over 10-20yrs
  • (not all cases of CIN progress to cancer)
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4
Q

A patient presents with post-coital bleeding. What is the causative agent you most want to rule out?

A

HPV - post coital bleeding is cervical cancer until proven otherwise. (even if STIs is probably more common).

99.7% of cancerous cells contiain HPV DNA; most infections of HPV clear within 2 years but persistent cases can cause malignant chagnes

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5
Q

Which HPV are low risk and cause genital warts?

A

HPV 6 &11

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6
Q

Which HPV are high risk and can cause cervical cancer (although most infections clear within 2 years, but persistent cases can cause malignant changes)?

A

HPV 16, 18 & 33

HPV16 –> E6 gene –> inhibits P53 tumour supressor

HPV 1–> E7 gene –> inhibits RB supressor gene

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7
Q

What type of cancer is endometrial and what is its precancerous state?

A

endometrial cancer = andenocarcinoma (e.g. ectroption is this too as its the glandular tissue coming out)

the pre-cancerous state = endometrial hyperplasia = increase in number of endometrial glands relative to stroma

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8
Q

the pre-cancerous state = endometrial hyperplasia = increase in number of endometrial glands relative to stroma

What hormone causes the endometrial glands to grow and so what RFs are there for endometrial cancer?

A

Stimulation of the endometrium by unopposed oestrogen (e.g. in the follicular phase)

TF RFs:

  • early menarche, late menopause - at extremes of menstrual age cycles inc. likely to be anovulatory
  • anovulation (as P produced by CL after ovulation
    • low parity (foetus >24w)
    • PCOS
  • oestrogen
    • HRT with oestrogen only
    • tamoxifen - selective oest receptor modulator; antagonist in breast, agonist in endometrium)
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9
Q

What staging system is used for gynae cancers?

A

FIGO!

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10
Q

A patient has cervical cancer (SCC, 70% w/keratin pearls seen on histology, progressed from CIN) that is seen beyond the cervix but nor on the pelvic sidewall or lower 1/3 vagina. There is parametrial involvement (located near the uterus).

What FIGO stage is this?

A

Stage 2 B - 2A would be no parametrial involvement

the figo staging for cervical cancer starts at stage 0 = carcinoma in situ (CIS), S1 = confined to cervix A)microscopically, B) gross lesions, clinically identifiable

Stage 3 = extends to pelvic sidewall/lower 1/3 of vagina or hydronephrosis not explained by anther case; A) no extension to sidewall, B) extension to sidewall and/or hydronephrosis

S4 = extends to bladder or rectum of mets, A) Bladder/rectum B) Distant organs

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11
Q

A patient has cervical cancer that affect the lower 1/3rd of the vagina but no extension to the pelvic sidewall.

What FIGO stage is this cervical cancer?

A

FIGO stage 3 A of cervical cancer =>

Stage 3 – extends to pelvic sidewall or lower 1/3rd vagina or hydronephrosis not explained by another case, A) no extension to sidewall, B) extension to sidewall and/or hydronephrosis

(S0 = CIS, S1A = microscopic cervical cancer confined to cervix, S1B = gross lesions, clinically identifiable, S2 = beyond cervix a = no parametrial involvement, B = yes parametrial involvement (near uterus), S4 = extends to bladder or rectum or mets A)bladder/rectum B) = DISTANT)

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12
Q

What are the risk factors for cervical cancers?

A
  • Risk factors –
    • HPV infection
    • Smoking
    • Other STIs (early first intercourse, many sexual partners)
    • Long-term (>8yrs) COCP
    • Immunodeficiency e.g. HIV
    • Age 30-5Oyrs
    • High parity
  • Protective factors –
    • HPV vaccination programme (HPV6,11,16,18)
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13
Q

A patient has presented with post-coital bleeding, what are the differentials?

A

Post coital bleeding

  • cervical cancer
  • endometrial cancer (post-menopausal population)
  • STI,
  • cervical ectropion,
  • polyp,
  • fibroids,
  • pregnancy-related bleeding
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14
Q

A patient has presented with post-coital bleeding, what other symptoms may you want to ask about?

A

Post-coital bleeding = cervical cancer until proven otherwise (even if STIs probably more common)

  • Abnormal PV bleeding
    • – PCB, IMB, PMB
  • Vaginal discharge
    • – blood-stained, foul smelling
  • Pelvic pain, dyspareunia (late sign)
  • Advanced (signs invasion)
    • – weight loss, oedema, loin pain, rectal bleeding, radiculopathy (pinched nerve), haematuria
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15
Q

What is the difference in investigation for pre-menopausal and post-menopausal women in whom you suspect cervical cancer?

A
  • for both you do a speculum
    • (bleeding, discharge, ulceration),
  • bimanual
    • (mass?),
  • GI
    • (hydronephrosis, hepatomegaly, rectal bleeding, mass on PR)
  • Pre-menopausal –
    • test for chlamydia trachomatis first, if –ve, –> colposcopy & biopsy (grade)
  • Post-menopausal –
    • urgent colposcopy & biopsy
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16
Q

What agents are used in colposcopy to highlight abnormal tissue?

A

Iodine or acetic acid

highlights abnormal tissue “aceto-white”

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17
Q

a patient has aceto-white abnormal cervical tissue highlighted - what other ix than colposcopy needs to be done now?

A
  • Basic bloods,
  • CT Chest Abdo Pelvis (?mets)
  • MRI/PET (uses glucose to see metabolically active areas) (stage)
  • +/- examination under anaesthesia with further biopsies
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18
Q

A patient had a cervical cancer confirmed microscopically on biopsy but there were no gross lesions and it was confined to the cervix. What is the Rx?

A

This is a figo stage 1A lesion (if grossly identifiable then would be figo stage 1B)

TF the Rx of stage 1a cervical cancer =

  • Radical trachelectomy removing cervix & upper vagina to preserve fertility (stage 1a)
    *
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19
Q

A patient is has cervical cancer confiemed that has spread beyond the cervic but not pelvic sidewall or lower 1/3 vaginia, there is no parametrial involvement (the parametirum is the fibrous and fatty tissue surrounding the uterus).

What is the managment of this cancer?

A

this is stage 2a (stage 1a would be gross lesions on the cervix)

Rx: radical hysterectomy as its curative removing uterus, vagina and parametrial trissues to pelvic sidewall + lymphadenopathy (stage 1b/2a)

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20
Q

A patient has cervical cancer that extends to the bladder or rectum (found on CT CAP)

What is the Rx for this?

A

this is stage 4 - extends to bladder/rectum (A) and 4B if it has metastasised to distant organs

Rx: anterior/posterior/total pelvic exenteration

–> removing all pelvic adnexae plus bladder and/or bowel (stage 4A or recurrent)

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21
Q

What therapy can be used for SCC/adeno/mixed in frail elderly where surgery is unsuitable?

A

Hormonal progestogen therapy

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22
Q

What kind of chemotherapy base is used for cervical cancer?

A

cisplatin-based

Can be used BEFORE or AFTER surgery/radiotherapy;

cisplatin based chemotherapy is the mainstay of palliative treatment

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23
Q

What follow up is needed following cervical cancer?

A

4 monthly after treatment for 2 years

then after 2 years…

6-12 monthly for the next 3 years

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24
Q

What type if carcinoma is most likely for cervical, endometrial and ovarian cancer?

A

Cervical = SCC (70%),

endometrial = adenocarcinoma

ovarian = epithelial/adenocarcinoma

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25
Q

Endometrial cancer is commonly adenocarcinoma on histology, what is the pre-cancerous state?

A

Endometrial hyperplasia –> endometrial adenocarcinoma

e.g. increase in the number of endometrial glands relative to stroma

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26
Q

The most common histology of cervical cancer is SCC (70%)

What is the precursor?

A

Cervical intraepithelial neoplasia - CIN

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27
Q

What is the aetiology of endometrial adenocarcinoma?

A

the stimulation of the endometrium by unopposed oestrogen

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28
Q

A patient presents with endometrial cancer (adenocarcinoma) which is in the myometrium but not cervix/beyond the uterus.

What FIGO Staging is this?

A

this is figo stage 1B -

carcinoma confined to body of uterus, A) endometrium, B) myometrium

S2 = extends to cevix but not beyond uterus, S3 = extends beyond uterus but confined to pelvis A) ovary, B vagina C lymph nodes. S4 = bladder or bowel or has metastasises to distant sites.

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29
Q

A patient presents with endometrial cancer that had extened beyond the uterus and is confined to the pelvis, it has invaded into the vagina?

What figo stage is this?

NB: figo staging goes from stage 1 - 4 in both cervical and endometrial cancer

A

this is figo stage 3 B - cancer extends beyond uterus but confined to pelvis A) ovary, B vagina C lymph nodes.

S1B = carcinoma confined to body of uterus, A) endometrium, B) myometrium; S2 = extends to cevix but not beyond uterus; S4; bladder or bowel or has metastasises to distant sites.

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30
Q

What are the risk factors for endometrial cancer?

A
  • oestrogen
    • oestrogen only HRT
    • tamoxifen - selective oestrogen receptor modulateor - SERM ; antagonist in breast, agonist in endometrium
  • anovulation (progesterone is produced by CL after ovulation - e.g. OPPOSES oestrogen)
    • e.g. early menarche, late menopause
      • BECAUSE at extremes of menstural age cycles are MORE likely to be anovulatory
    • low parity (not carried pregnancies to viable gestational age
  • age >50yrs
  • obesity - peripheral aromatisation of androgens e.g. increased oestrogen
  • diabetes, hypertension
  • genetics - HNPCC/lynch (so inc endometrial, CRC and ovarian also)
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31
Q

What cancers is the COCP protective for?

A

endometrial as the COCP shuts off the endometrium

COCP is also protective for OVARIAN cancer (as are the other combined methods)

32
Q

high parity is a RF for endometrial cancer y/n?

A

No! low parity is a RF

(in preg you get oestrogen and progesterone so its not unoppsoed oestrogen)

parity/high parity is a protective factor!

33
Q

What cancers does COCP increase the risk of?

A

Breast cancer and cerivcal cancer (.8yrs)

34
Q

doe high parity protect or increase the risk of cervical cancer?

A

it increases the risk of cervical cancer

as does immunodeficiencey (increases HPV infection risk, smoking, other STIs, long term COCP

35
Q

What type of bleeding is endometrial cancer until proven otherwise?

A

post-menopausal bleeding = endometrial cancer until proven otherwise

36
Q

If post menopausal bleeding = endometrial cancer until proven otherwise what are the DDx for post mentopausal bleeding?

also included in PMB is abnormal PV bleeding e.g. irregular or IMB

A
  1. Atrophic vaginitis
  2. HRT (e.g. combined with progesterone in women with a uterus = bleeds still)
  • Vulval = atrophy, pre- or malignant conditions,
  • cervical - polyps, cancer
  • endometrial - hyperplasia, polyps, atrophy
  • HRT
37
Q

A woman presents with clear or white vaginal discharge, previous abnormal cervical smears, abnormal PV bleeding and even abdominal mass, weight loss (advanced).

What couuld this indicate?

A

Endometrial cancer

(in cervical cancer they can get foul smelling discharge, pelvic pain and dysparenuna as late signs as well as loin pains and rectal bleeding as later signs of invasion)

38
Q

How should you examine someone with post menopausal bleeding?

A
  • abdo
    • (endometrial mass?),
  • speculum
    • (vaginal atrophy, cervical lesions),
  • bimanual
    • (size & axis of uterus pre-sampling)
39
Q

What Ix should be done for someone with post menopausal bleeding?

A
  • TVUSS - to assess endometrial thickness
  • >4mm Pipelle biopsy (>5mm 96% have cancer, grade),
  • <4mm delay sampling as risk is low

Or biopsy by hysteroscopy

 

On confirmed dx – CT/MRI (stage)

40
Q

A patient has endometrial hyperplasia what is the management/surveillance?

A

if non-malignant endometrial hyperplasia = give progestogens e.g. mirena IUS + surveillance biopsies

in cases of atypical hyperplasia - 50% progress to malignancy –> TAH + bilateral salphingooophrectomy

41
Q

A patient has an endometrial carcinoma that is confined to the body of the uterus. What is the Rx?

A
  • Confined to the body of the uterus = Stage I(A)
    • [while in myometrium = 1B or extends to cervix but not beyond uterus = S2]
  • => TAH + BSO, peritoneal washings should also be taken (1c adjuvant radiotherapy)
42
Q

A woman presents with endometrial cancer that extends to the cervix but not beyond the uterus. What is the Rx?

A

Stage II Rx –

  • radical hysterectomy
    • (TAH + BSO + vaginal tissue surrounding the cervix also removed + supporting ligaments)
  • + lymphadenectomy,
  • adjuvant radiotherapy
43
Q

A woman presents with endometrial cancer that extends beyond the uterus but is confined to the pelvis, although it does affect the ovary, vagina and lymph nodes.

What is the Rx?

A

Stage III Rx:

–-> maximal de-bulking surgery,

neoadjuvant chemo prior to radiotherapy

(so s1 rx was just surgery w/peritoneal wahings +/- adjuvant radiotherapy; S2 was radical surgery + LN + ligaments and tissue + adjuvant radiotherapy; THIS one S3 is all 3, surg radio AND chemo)

44
Q

A woman presents with endometrial cancer that involves the bladder or bowel and has metastasised to distant sites. What is the Rx?

A

Stage IV

  • – maximal de-bulking surgery or palliative approach
    • palliative:
      • low-dose radiotherapy or
      • high-dose oral progestogens

  (progestogen therapy is also used for frail elderly where surgery is unsuitable for cervical cancer)

45
Q

What is the follow up period for endometrial cancer?

A

up to 5 years post-op

  • (for cervical its 4 monthly for 2 years after rx then 6-12monthly for 3 years = total 5 yrs too)
  • (ovarian cancer is also 5 years follow up with clinical exam and Ca125 levels and intervals between visits can become further apart by looking at risk of recurrence levels)
46
Q

A lady has been diagnosed with ovarian cancer.

What is the likely histology fo this cancer?

A
  • Commonly is epithelial/adenocarcinoma (glandular tissue as opposed to flat squamous cells)
  • 70% of ovarian cancers are serous cystadenocarcinoma
    • –> characterised by Psammoma bodies
    • there are also mucinous cystadenocardinoma
    • –> characterised by mucin vacuoles
      • also there are germ cell tumours (ova)
47
Q

What are the risk factors in line with the believed aetiology of ovarian cancer?

A

Ovarian cancers are believed to derive from surface epithelial irritation during ovulation

–> more ovulations that take place = increased risk of developing malignancy

RF’s TF include:

  1. Nulliparity (increased ovulations)
  2. Early menarche
  3. Late menopause
  4. HRT with oestrogen alone

Protective factors TF: multiparity (reduces ovulation), COCP/other combined methods, breastfeeding

48
Q

BEAT is an acronym for the symptoms of ovarian cancer

What does BEAT stand for?

A
  • Bloating
  • Eating less & feeling fuller
  • Abdominal pain
  • Trouble with bladder
    *
49
Q

Apart from bloating, eating less and feeling fuller, abdo pain and trouble with bladder. What other syx are indicative of ovarian cancer?

A
  • Abdominal distension (could be from bloating or ascites)
  • Ascites & pleural effusion (fluid overload)
  • Weight loss, fatigue
  • Change in bowel/ bladder habits (freq or constipation)
  • Chronic pain (2o to pressure on bladder & bowel)
  • Bleeding PV
  • Acute pain (bleeding, rupture or torsion)
50
Q

A female patient presents with ascites.

What are the DDx?

A
  • Liver cirrhosis,
  • Congestive Heart Failure,
  • cancer
    • peritoneal carcinomatosis (widespread dissemination of carcinoma in the body) –
      • Gynae
        • ovarian,
        • breast
        • endometriosis
      • GI
        • colorectal,
        • pancreatic,
  • infection e.g. bacteria, TB
51
Q

A patient has presented with weight loss, fatigue, ascites, PV bleeding and bloating, feeling full while eating less, abdo pain and trouble with bladder.

How do you proceed w/r to investigating this?

A
  • Exam – abdo, bimanual
  •  TVUSS – visualise ovaries
    • BIOPSY NOT ROUTINELY RECOMMENDED - can disseminate cancer cells into the peritoneal cavity *
  • On confirmed dx –
    • basic bloods (FBC, U&E, LFT, albumin),
    • CXR (can get pleural effusion from pleural cavity = most frequent extra abdo OC mets site),
    • CT Abdo Pelvis (staging, pre-operative planning) NB: staging for cervical and endometrial = MRI ( C = petmri too and E = CT/mri)
  • *surgery is definitive diagnosis
52
Q

What is RMI in ovarian cancer?

A

RMI = risk of malignancy index for ovarian cancer

(RMI = menopausal status e.g. Pre/post X USS features X serum Ca125)

53
Q

A patient has a high risk of malignancy index (RMI) for ovarian cancer. What is the first step in managment of this condition?

A

Surgery is the only definitive diagnosis and the RMI already takes into account TVUSS features

  • so #1 = staging laparotomy for those with high RMI w/attempt to debulk the tumour
  • High grade = TAH + BSO + omentectomy, para-aortic nodes

+ adjuvant/neo chemo + follow up

54
Q

What is the adjuvant chemotherapy used in ovarian cancer?

A

Caboplatin & paclitaxel - platinum bsed compounds (platinum based is also used for neo/adjuvant cervical cancer Rx too)

these as neoadjuvant or adjuvant are recommended for all patients except

from those with

  • early,
  • low grade disease
55
Q

What follow up is required for someone with diagnosed ovarian cancer?

A
  • 5 years of follow up
  • clinical examination and CA125 monitoring w/intervals between visits becoming further apart according to risk of recurrence
56
Q

What type of epithelium is the ectocervical epithelium made of?

A

Squamous

57
Q

What type of epilthelium is the endocervical epithelium made of?

A

Columnar (single layer of cells) up until the squamo-columnar junction

  • the S-C junction is not always at the os*
  • e.g. ectropion, nabothian cysts - filled with mucus secreted by cervical glands*
58
Q

What is the transformational zone of the cervix?

A

The endocervic columnar epithelium is pushed out of the external OS during puberty

–> physiological metaplasia to tougher, more resistant squamous epithelium

(the opposite of metaplasia in the oesophagus where the squamous –> columnar)

59
Q

What is the order of neoplasia, dysplasia and metaplasia?

A

metaplasia –> dysplasia –> neoplasia

60
Q

How is dysplasia defined in the cervix?

A

dysplasia in the cervix is caused by persistent HPV infection

= CIN 1-3; asymptomatic, not inevitable progression to carcinoma (only 10% progress)

–> treat at this dysplastic stage though

61
Q

What is the main carcinoma of the cervix?

A

Invasive squamous cell carcinoma!

as the columnar epithelium of the endocervix is pusched out of external os in puberty and TF has to undergo (physiological) metaplasia to be more tough (acidic vagina) SQUAMOUS epithelium –> SCC

62
Q
  • The UK has a well-established cervical cancer screening program - to detect & treat asymptomatic pre-cancerous lesions (CIN) & reduce the incidence of invasive squamous carcinoma - which is estimated to prevent 1,000-4,000 deaths per year.
  • It should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening (the main being SCC)

What is the timeframe for cervical screening?

A

3 yearly from ages of 25 - 49 y/o

5 yearly from ages of 50 - 64 y/o

63
Q

A woman is her T2 of pregancy & is due her cervical smear. What should you do?

A

Delay the smear until 3 months post partum if woman is pregnant

64
Q

A 38 y/o woman is newly diagnosed as HIV+ve.

What should happen regarding her smears?

A

If someone is HIV +ve increase the smear test to yearly screening

(remember immunodeficiency e.g. HIV is a RF for cervical cancer ?inc. HPV infection risk)

65
Q

A patient has had radiotherapy for cervical cancer

[combination of external beam & intra-cavity brachytherapy; conjunction with chemo over 5-8wk course (gold standard for stages 1b to 3 – not hysterectomy) ??now guidance is TAH BSO with post op radio]

  What does this mean for her smear tests?

A

the cervical smear test is no longer valid after radiotherapy

66
Q

what is the first stage of the new (changed 1/3/19) cervical screening programme?

A

STEP 1 = HPV test

If +ve => continue to cytology…

-ve = routine recall (3yrly 25-49yrs; 5yrly 50-64yrs)

67
Q

What is step 2 of the new cervical screening programme?`

A

Step 2 = cytology (off the back of a positive hrHPV test)

On cytology:

  1. dyskaryosis seen e.g. abnormalities of the cell nucleus - the term only used on cervical smear reports, good predictor for CIN but only a SCREENING test
    • TF indicates –> COLPOSCOPY & BIOPSY
  2. normal: re-screen for HPV in 12 months
    • ​​If HPV keeps being +ve then cytology negative keep re-screening every 12 months with negative cytology
68
Q

What is step 3 of the new (1/3/19) cervical screening programme?

A

Step 3 = colposcopy and histology (off the back of S1 - HPV +ve and S2 - HPV -ve)

using colposcopy to get a sample for histology –>

  1. CIN = a diagnosis made on cervical BIOPSY = GOLD STD TEST (formal diagnosis)
    • colposcopy carefully examines cervic both before and after the application of acetic acid
    • certain abnormal colposcopic appearances are associated with CIN e.g. _acetowhite_ epithelium (= its abnormal tissue) - allows you to target site of biopsy
69
Q

CIN can be labelled as 1, 2 or 3 which affects the treatment of the dysplasia.

What is the treatment for CIN 1?

A

Watch and wait

  • repeat smear and HPV test
70
Q

CIN can be labelled as 1, 2 or 3 which affects the treatment of the dysplasia.

What is the treatment for CIN 2?

A
  • Generally treat with LLETZ = large loop excision of the transformation zone - diathermy under LA
  • excision of CIN w/LLETZ with clear margin is curative
71
Q

CIN can be labelled as 1, 2 or 3 which affects the treatment of the dysplasia.

What is the treatment for CIN 3?

A
  • LLETZ of transformation zone,
    • re-test at 6months/1yr depending on risk
  • – may have persistent HPV infection & need treatment
  • – if normal back to 3yrly screening follow up (may develop CIN again in future)
72
Q

When counselling a patient about LLETZ.

What are the early complications and the late complications?

A

Early

  • bleeding
  • infection

Late

  • Stenosis
  • dysmenorrhoea
  • inadequate smears
  • fertility
  • cervix incompetence
    • late miscarriage (also called 2nd trimester loss, 14-24wks
    • preterm labour
73
Q

What is the ovarian cancer risk of malignancy index threshold for referral to a specialist gynaecologist?

A
  • >250 as this = 75% risk of having cancer
  • RMI = U x M x CA125
  • M = menopausal status (pre = 1 pt, post-meno = 3 pts)
  • U = USS score - multi-locular cyst, solid areas, mets, ascites, bilateral lesions
74
Q

A patient with ovarian cancer presents with ischaemia and abdo pain, what acute presentation of ovarian cancer can occur?

A
  • Torsion (ishcaemia and abdo pain)
  • Rupture (especially mature cystic teratoma)
  • Haemorrhage (cystic masses haemorrhaging –> can cause hypovolaemic shock)
75
Q

Between ovarian and testicular cancer which one is

  1. more common
  2. more commonly benign
  3. more likely in younger pts
  4. has a better prognosis
A
  1. ovarian cancer is common (5th most common cancer in women overall); testicular cancer is uncommon (not in top 20 overall)
  2. benign ovarian tumours are common e.g. mature cystic teratoma; benign testicular tumours are rare
  3. germ cell testicle tumours are most common & typically in young men; ovarian carcinoma is most common in post menopausal women
  4. ovarian carcinoma has bad prognosis (presents at high stage and doesnt respond to chemoradiotherapy); germ cell tumours have good prognosis (present early, chemo-radio responsive)

Gynae, Breast & Sexual Health (7 decks)

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