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MRCOG Part 2 > Gynaeonc > Flashcards

Gynaeonc Flashcards

1
Q

What is the percentage of women who develop bowel fistula as consequence of treatment for cervical Ca?

A

8%

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2
Q

Which patients qualify for additional cervical screening?

A

HIV positive - yearly
End stage renal disease - at diagnosis
Renal transplant - within 1 year of transplant
When starting cytotoxic rheum drugs

NOT Tamoxifen

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3
Q

Which conditions predispose to Vulval Ca?

A

Lichen sclerosus - differentiated VIN
Risk of invasive disease with Lichen Sclerosus is 4%
HPV (16 and 18) - undifferentiated VIN

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4
Q

What are primary prognostic indicators of Vulval Ca?

A

Nodal status
Primary lesion diameter (<2cm)

Lymph node involvement 5 year survival
No LN involvement >80%
Inguinal LN involvement <50%
Iliac and other Pelvic LNs 10-15%

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5
Q

What are risk factors for molar pregnancy?

A

Extremes of age (above 40 higher than less than 15)
Previous molar

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6
Q

What score is used for assessing gestational trophoblastic disease?

What cut off is used for treatment?

A

FIGO 2000
Based on: Age, previous pregnancy, HCG, interval from last pregnancy, largest tumour size, site and number of mets, previous chemo

Score 6 or under - Methotrexate and folonic acid alternate days
Cure rate nearly 100%

7 or more - multi agent chemo
Cure rate 95%

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7
Q

What time of Ovarian tumour is associated with Endometrial Ca?

A

Granulosa cell tumour (stromal) - secretes Oestrogen
Blood tests: inhibin and estradial

Causes endometrial hyperplasia, polyps, ca

Approximately 1 in 3 women with granulosa tumour of the ovary will have endometrial hyperplasia.

Approximately 1 in 10 women with granulosa tumour of the ovary will have endometrial cancer.

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8
Q

What is the major risk factor for Endometrial Ca?

A

Obesity

Background lifetime risk 3%
Obesity increases to 10%

An endometrial thickness with TVS of less than or equal to 4mm reduces probability of endometrial carcinoma to <1%

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9
Q

What is lifetime risk of Ovarian Ca in general population?

A

1.4%

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10
Q

Describe FIGO staging of Vulval Ca

A

Stage 1 and 2 - negative nodes

Stage 1 - no invasion of other tissues
1a - <2cm and <1mm stromal invasion

Stage 2 - Tumour of any size with extension to adjacent perineal structures (lower 1/3 urethra; lower 1/3 vagina; anus)

Stage 3 - Tumor of any size with extension to upper part of adjacent perineal structures, or with any number of nonfixed, nonulcerated lymph node
IIIA Tumor of any size with disease extension to upper two-thirds of the urethra, upper two-thirds of the vagina, bladder mucosa, rectal mucosa, or regional lymph node metastases ≤5 mm
IIIB Regionalb lymph node metastases >5 mm
IIIC Regionalb lymph node metastases with extracapsular spread

IV Tumor of any size fixed to bone, or fixed, ulcerated lymph node metastases, or distant metastases
IVA Disease fixed to pelvic bone, or fixed or ulcerated regionalb lymph node metastases
IVB Distant metastases

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11
Q

What treatments for Breast Ca are safe in pregnancy?

A

Breast Ca affects 1 in 3000 pregnancies

Surgical treatment at any trimester
Chemotherapy in middle trimester
Radiotherapy contraindicated until after delivery
Tamoxifen and Herceptin contraindicated
Women on Tamoxifen should not breast feed
Women should have 2 week interval between chemotherapy and breastfeeding (neonatal lymphopaenia)

Should have stopped Tamoxifen for 3 months before trying to conceive

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12
Q

What is the effect of chemotherapy for gestational trophoblastic disease on menopause?

A

Single agent chemo - advance by 1 year

Multi-agent - advance by 3 years

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13
Q

When is repeat excision for CIN3 with incomplete margins on histology not indicated?

A

Age <45 years
No glandular abnormality
No invasive disease

These patients should have follow up at 6 months

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14
Q

What is the accuracy of OP endometrial biopsy in diagnosing endometrial hyperplasia?

A

Systematic review found likelihood ratio of 12 for positive and 0.2 for negative result

2% women will have negative EB and have hyperplasia

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15
Q

What is the medical treatment of endometrial hyperplasia?

A

Continuous progesterone should be used

1st line - progesterone coil
2nd line - medroxyprogesterone 10–20 mg/day or norethisterone 10–15 mg/day

Alternative - observation
Beware contraindications of high dose progesterone similar to those of COCP

If on HRT
- consider stopping
-change from sequential to continuous
-change to coil if not already using

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16
Q

What is the length of of follow up for endometrial hyperplasia?

A

At least 6 months of treatment
At least 2 x negative biopsies 6 months apart
Consider annual biopsy in those at high risk of relapse

If tolerable to patient recommend coil stays in situ for full 5 years

If no regression by 12 months then counsel towards hysterectomy (offer TLH BSO if post menopausal)

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17
Q

What is the risk of a symptomatic ovarian mass being malignant in a pre-menopausal woman?

A

1 in 1000

This rises to 3 in 1000 by age of 50

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18
Q

What is risk of Endometrial Ca when presenting with PMB by age?

A

Overall 10%
Women >80 years old 25%
Women <50 years old 1%
Women with PMB and obese 18%
Women with PMB and diabetes 21%
Women with PMB, obesity and diabetes 29%

19
Q

How do you calculate RMI?

A

RMI 1 recommended by NICE

Ca-125 x menopausal status (1 or 3) x Ultrasound features (0, 1 or 3)

Ultrasound features: multilocular cysts, solid areas, metastases, ascites and bilateral lesions

20
Q

What is the cut off for RMI for referral to MDT?

A

250

21
Q

In terms of Ovarian Ca, who is offered adjuvant chemotherapy?

A

High grade (3)
Or Stage 1c and above

Also offer to lower stages if they have not have full surgical intervention (hysterectomy)

22
Q

What is the incidence of uterine sarcoma?

A

Around 400 cases a year in the UK

23
Q

What are 2 main risk factors for uterine sarcoma (when assessing risk in uterine mass)?

A

Age
Menopausal status

24
Q

What is the endometrial cancer with worst prognosis?

A

Most common - endometrioid
Worst prognosis - clear cell

25
Q

What is the lifetime risk of ovarian cancer in a woman who has a first degree relative that has been affected?

A

5%

26
Q

What tumour markers are indicated in an ovarian cyst in a premenopausal woman?

A

CA-125
AFP
HCG
LDH

27
Q

The risk of clear cell adenocarcinoma of the genital tract following in-utero exposure to diethylstilboestrol (DES)…

A

0.1%
Hence increased surveillance and screening in this group.

28
Q

What is the risk of atypical hyperplasia developing into endometrial cancer over time?

A

5-10% by 5 years
27.5% by 20 years

29
Q

When should patients with Lynch syndrome be offered risk reduction TLH BSO?

A

From age 35-40 in those with MLH1 MSH2 MSH6

30
Q

What is risk of ovarian and breast Ca in BRCA 1 and BRCA 2?

A

BRCA 1

Breast 85%
Ovary 65%

BRCA 2

Breast 84%
Ovary 20-30%

Ovarian tumours associated with BRCA 1 or 2 mutations tend to be high-grade serous and endometrioid carcinomas that are typically aggressive and present in advanced stage (mainly papillary serous cystadenocarcinomas).

31
Q

At what stage of Endometrial cancer is pelvic node sampling indicated?

A

1b and above (>50% invasion into myometrium)

32
Q

What is the follow up for CIN following hysterectomy?

A

Individuals who have had a hysterectomy with CIN present are potentially at risk of developing vaginal intraepithelial neoplasia (VaIN) and invasive vaginal disease

If no previous CIN and normal histology - no further follow up

CIN completely excised on histology -
vaginal vault sample at 6 months +18 months; if they have a negative HPV result they can be discharged

Completely excised CIN, and are hrHPV positive cytology negative at 6 months: refer to colposcopy; if there is no evidence of VaIN at colposcopy the individual can be discharged

Incompletely excised CIN (or uncertain excision):
CIN 1: vault sample at 6, 12 and 24 months
CIN 2/3: vault samples at 6 and 12 months followed by 9 annual vault samples

Follow up for incompletely excised CIN continues to 65 years or until 10 years after surgery (whichever is later)

33
Q

What tumour types are associated with BRCA mutations?

A

High-grade serous and endometrioid carcinomas that are typically aggressive and present in advanced stage
Mainly papillary serous cystadenocarcinomas

34
Q

How do you subgroup patient response to platinum based chemotherapy (in the context of Ovarian Ca)?

A

Platinum-refractory - do not respond to platinum-based therapy and show progression during the course of the therapy

Platinum-resistant - less than 6 months of remission following chemotherapy. Clinically, these patients will show initial response to chemotherapy but experience relapse within 6 months of the last round of chemotherapy, a time course often described as platinum-free interval or treatment-free interval

Platinum-responsive - For patients who initially respond to platinum-based therapy, there is a spectrum of response that lasts from a little over 6 months to several years.

35
Q

What is the FIGO staging of Cervical Cancer?

A

Stage IA1: <3mm
Stage IA2: >3mm <5mm

Stage IB1:>5mm depth
<2cm
Stage IB2: >5mm depth
2-4cm w
Stage IB3: >4cm >5mm depth

Stage IIA:The tumour is limited to the upper two-thirds of the vagina. I
Stage IIB: Parametrial spread but not pelvic sidewall

Stage IIIA: The tumor involves the lower third of the vagina, but it has not grown into the pelvic wall.
Stage IIIB: The tumor has grown into the pelvic wall and/or affects a kidney. Hydronephrosis.

Stage IIIC1: Pelvic nodes
Stage IIIC2: Paraortic nodes

Stage IVA: Bladder/bowel
Stage IVB: Distant spread

36
Q

What margins are required at time of cone biopsy for Cervical Ca?

A

Cone should be at lease 2.5cm in depth with clear margins of 5mm or more otherwise a repeat cone biopsy should be performed.

37
Q

What margins are required in WLE for Vulval Ca?

A

15 mm

38
Q

What factors increase risk of recurrence in Vulval disease?

A

Residual lichen sclerosis
Lymphovascular space involvement and infiltrative growth pattern

39
Q

What is the role of immunohistochemistery in Paget’s disease?

A

Immunohistochemistry is valuable in differential diagnosis of Paget’s disease.
The neoplastic cells in primary vulval Paget’s disease are positive for CAM 5.2, CEA, EMA and CK7.

Diffuse CK20 positivity is suggestive of secondary vulval Paget’s disease.
This results from spread of an internal malignancy, most commonly from an anorectal adenocarcinoma or urothelial carcinoma of the bladder or urethra, to the vulval epithelium.

Paget’s disease may mimic melanoma on routine stains and immunohistochemistry for melan A, S100 and HMB45 may be used to confirm a melanoma.

40
Q

When is sentinel lymph node biopsy adequate in management of Vulval Ca?

A

In unifocal tumours of less than 4 cm maximum diameter where there is no clinical suspicion of lymph node involvement, patients can be safely managed by removal of the identified sentinel lymph nodes.

41
Q

What is the FIGO staging of Ovarian Ca?

A

1A Tumour limited to 1 ovary, capsule intact, no tumor on surface, negative washings.
1B Both ovaries
1C1 Surgical spill
1C2 Capsule rupture before surgery or tumor on ovarian surface.
1C3 Malignant cells in the ascites or peritoneal washings.

IIA Extension and/or implant on uterus and/or Fallopian tubes
IIB Extension to other pelvic intraperitoneal tissues

IIIA Positive retroperitoneal lymph nodes and /or microscopic metastasis beyond the pelvis
IIIB Macroscopic, extrapelvic, peritoneal metastasis ≤ 2 cm ± positive retroperitoneal lymph nodes. Includes extension to capsule of liver/spleen.
IIIC Macroscopic, extrapelvic, peritoneal metastasis > 2 cm ± positive retroperitoneal lymph nodes. Includes extension to capsule of liver/spleen.

IVA Pleural effusion with positive cytology
IVB
Hepatic and/or splenic parenchymal metastasis, metastasis to extra- abdominal organs (including inguinal lymph nodes and lymph nodes outside of the abdominal cavity)

42
Q

What is the FIGO staging of Endometrial Ca?

A

stage I: limited to the body of the uterus
Ia: no or less than half (≤ 50%) myometrial invasion
Ib: invasion equal to or more than half (≥ 50%) of the myometrium
stage II: cervical stromal involvement
endocervical glandular involvement only is stage I
stage III: local or regional spread of the tumour
IIIa: tumour invades the serosa of the body of the uterus and/or adnexa
IIIb: vaginal or parametrial involvement
IIIc: pelvic or para-aortic lymphadenopathy
IIIc1: positive pelvic nodes
IIIc2: positive para-aortic nodes with or without pelvic nodes
stage IV: involvement of rectum and/or bladder mucosa and/or distant metastasis
IVa: bladder or rectal mucosal involvement
IVb: distant metastases, malignant ascites, peritoneal involvement

43
Q

What depth of LLETZ is required depending on type of transformation zone?

A

Types of transformation zone

Type 1

Completely ectocervical fully visible; small or large
Excisional techniques should remove tissue to a depth of more than 7mm in ≥95% of cases, though the aim should be to remove <10mm in individuals of reproductive age

Type 2
Has endocervical component, fully visible, may have ectocervical component which may be small or large
Excisional techniques should remove tissue to a depth of 10 to 15mm in ≥95% of cases, depending on the position of the squamocolumnar junction within the endocervical canal.

Type 3
Has endocervical component, is not fully visible; may have ectocervical component which may be small or large
Excisional techniques should remove tissue to a depth of 15 to 25 mm in ≥95% of cases, depending on the position of the squamocolumnar junction within the endocervical canal.

44
Q

What type of Ovarian cancer is associated with Endometriosis?

A

Clear cell

Most clear cell ovarian tumors are malignant
Can be predominantly solid or cystic with one or more polypoid masses protruding into the lumen
4–5% of all malignant ovarian epithelial tumors
Typically present in the fifth decade of life
Two-thirds of all women with malignant clear cell tumors are nulliparous and 50–70% have endometriosis. Epidemiological studies have suggested a specific link with endometrioid and clear-cell ovarian cancers
25% arise in the lining of benign endometrioid cysts, 15–20% are bilateral, and 60% are Stage I tumors at diagnosis
Survival rates lower than for other epithelial ovarian carcinomas. 5-year survival rates are 69% for Stage I, 55% for Stage II, 14% for Stage III and 4% for Stage IV tumors

MRCOG Part 2 (10 decks)

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