Gynaecology Pg No 21 -30
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Questions and Answers

What is the most common type of cancer found in the Bartholin gland?

  • Squamous cell carcinoma
  • Adenocarcinoma (correct)
  • Melanoma
  • Carcinosarcoma

    • A solid mass in the Bartholin gland is not an indication for biopsy.

    False

    What is the most common symptom of Bartholin cancer?

    Vulval mass

    A recurrent Bartholin cyst in a female aged _____ years or older is an indication for biopsy.

    <p>40</p> Signup and view all the answers

    Match the following indications for biopsy with their criteria:

    <p>Recurrent Bartholin cyst = ≥ 40 yrs female Enlarged Bartholin gland = Post menopausal female Solid mass = Criteria for biopsy Cyst lining = Fixed to surrounding structure</p> Signup and view all the answers

    What is the primary function of the Bartholin gland?

    <p>Produce alkaline secretions during intercourse</p> Signup and view all the answers

    A Bartholin cyst is typically painful.

    <p>False</p> Signup and view all the answers

    What is the recommended management for a symptomatic Bartholin cyst larger than 3cm?

    <p>Incision and drainage plus insertion of a word catheter</p> Signup and view all the answers

    A Bartholin abscess typically presents with __________ and tenderness.

    <p>pain</p> Signup and view all the answers

    Match the features to the corresponding condition-related management:

    <p>Chronic, recurrent cyst under 40 years = Marsupialisation Asymptomatic cyst over 3cm = Incision and drainage + word catheter Abscess = Incision and drainage + word catheter Cyst in a patient over 40 years = Excision of cyst + biopsy</p> Signup and view all the answers

    What is the first choice of surgery for Stage 1 vulval cancer with lymph node involvement?

    <p>Radical partial vulvectomy</p> Signup and view all the answers

    For palpable lymph nodes that are positive for vulval cancer, ipsilateral inguinofemoral lymph node dissection is required.

    <p>True</p> Signup and view all the answers

    What procedure is used for a visible area of vulva that is hypopigmented, hyperpigmented, or atrophied?

    <p>Vulvoscopy</p> Signup and view all the answers

    For stage 4 vulval cancer, the recommended management is __________.

    <p>chemoradiation</p> Signup and view all the answers

    Match the management steps with their corresponding requirements:

    <p>Stage IA = No lymph node dissection required Stage 1 = Radical partial vulvectomy Stage 2-4 = Ipsilateral inguinofemoral LN dissection/SNL biopsy Positive lymph nodes = Contralateral inguinofemoral LN dissection</p> Signup and view all the answers

    Which of the following is NOT considered a risk factor for vulval cancer?

    <p>Extra mammary Paget's disease</p> Signup and view all the answers

    The keratinising type of squamous cell cancer of the vulva has a higher incidence than the warty type.

    <p>True</p> Signup and view all the answers

    What is the main diagnostic procedure used to assess the depth of cancer in vulval cancer?

    <p>Biopsy</p> Signup and view all the answers

    Vulval cancer stage 2 involves the tumor spreading to the lower __________ of the urethra, vagina, or anus.

    <p>1/3rd</p> Signup and view all the answers

    Match the following types of VIN with their characteristics:

    <p>Differentiated VIN = Unifocal Undifferentiated VIN = Multifocal</p> Signup and view all the answers

    What structure is located at the anterior boundary of the vestibule?

    <p>Clitoris</p> Signup and view all the answers

    The introitus is responsible for the outflow of menstrual blood.

    <p>True</p> Signup and view all the answers

    Name one type of cyst found in the vulva.

    <p>Bartholin's cyst</p> Signup and view all the answers

    The opening covered by a thin membrane in the vestibule is called the ______.

    <p>hymen</p> Signup and view all the answers

    Match the following types of hymen with their descriptions:

    <p>Annular = A simple ring-like shape Imperforate = Does not allow the outflow of menses Septate = Divided into two or more parts</p> Signup and view all the answers

    Which of the following is true regarding Vulvar Intraepithelial Neoplasia (VIN)?

    <p>VIN 3 shows dysplastic changes but no invasion.</p> Signup and view all the answers

    HPV is a related risk factor for VIN in older females.

    <p>False</p> Signup and view all the answers

    What is the primary risk factor for vulvar cancer in older females?

    <p>Lichen sclerosis</p> Signup and view all the answers

    The _____ lymph node biopsy is increasingly used for all gynecological cancers.

    <p>Sentinel</p> Signup and view all the answers

    Match the VIN category to its description:

    <p>VIN 1 = Lower 1/3rd dysplastic VIN 2 = 2/3rd epithelial involvement VIN 3 = Entire epithelium dysplastic, no invasion</p> Signup and view all the answers

    Which ultrasound technique requires a full bladder?

    <p>Trans-abdominal sonography (TAS)</p> Signup and view all the answers

    Hysteroscopy is a non-invasive procedure.

    <p>False</p> Signup and view all the answers

    What is the primary use of hysterosalpingography (HSG)?

    <p>To assess the patency of the fallopian tubes.</p> Signup and view all the answers

    The ________ technique uses higher frequency ultrasound waves to achieve better resolution.

    <p>trans-vaginal sonography (TVS)</p> Signup and view all the answers

    Match the following imaging techniques with their features:

    <p>Ultrasound = Non-invasive imaging CT Scan = Detailed cross-sectional images MRI = Magnetic resonance imaging PET Scan = Locates nodal metastasis in ovarian cancer</p> Signup and view all the answers

    Which of the following structures is NOT part of the female external genitalia?

    <p>Uterus</p> Signup and view all the answers

    The labia minora contains hair and sweat glands.

    <p>False</p> Signup and view all the answers

    What is the length range of the clitoris?

    <p>1.5 to 2 cm</p> Signup and view all the answers

    The area between the labia minora is called the __________.

    <p>vestibule</p> Signup and view all the answers

    Match the following conditions with their associated descriptions:

    <p>Clitoromegaly = Length of clitoris ≥ 4 cm Hidradenoma of vulva = Tumor of sweat glands Pubarche = Development of hair on the mons pubis Mons Pubis = Hair-bearing area above the pubic symphysis</p> Signup and view all the answers

    Which type of hysterectomy involves the removal of only the uterus while retaining the cervix?

    <p>Supracervical Hysterectomy</p> Signup and view all the answers

    Robotic hysterectomy provides 2-D views for surgeons.

    <p>False</p> Signup and view all the answers

    Name one disadvantage of laparoscopic hysterectomy.

    <p>Difficult to know the extent of thermal burns</p> Signup and view all the answers

    The return to normal activity after a vaginal hysterectomy is __________ than after an abdominal hysterectomy.

    <p>shorter</p> Signup and view all the answers

    Match the following types of hysterectomy with their characteristics:

    <p>Vaginal Hysterectomy = Shorter recovery time Abdominal Hysterectomy = Larger incision Laparoscopic Hysterectomy = Smaller incision Robotic Hysterectomy = Advanced instrument movement</p> Signup and view all the answers

    Which of the following features is not a disadvantage of robotic hysterectomy?

    <p>Small incision</p> Signup and view all the answers

    The size of the uterus can limit the approach taken for a vaginal hysterectomy.

    <p>True</p> Signup and view all the answers

    What is one indication for performing a supracervical hysterectomy?

    <p>Postpartum hemorrhage</p> Signup and view all the answers

    What is the primary purpose of a sentinel lymph node (SLN) biopsy in vulval cancer procedures?

    <p>To identify the first lymph node affected by cancer.</p> Signup and view all the answers

    Inguinofemoral lymph nodes do not usually require dissection in vulval cancer cases.

    <p>False</p> Signup and view all the answers

    What symptom is considered the most common in vulval cancer?

    <p>Pruritus (vulval itching)</p> Signup and view all the answers

    Structures that are less than 2 cm from the midline will require __________ dissection.

    <p>bilateral inguinofemoral</p> Signup and view all the answers

    Match the following types of vulval cancer with their histological types:

    <p>Squamous cell carcinoma = Most common type of vulval cancer Melanoma = Less common but more aggressive Adenocarcinoma = Originates from glandular tissue Basal cell carcinoma = Rare in vulvar sites</p> Signup and view all the answers

    What percentage of not enlarged lymph nodes carry a risk of micrometastasis during dissection?

    <p>25%</p> Signup and view all the answers

    The most common age range for vulval cancer patients is between 40-60 years.

    <p>False</p> Signup and view all the answers

    Name one example of a structure that requires bilateral inguinofemoral dissection if it is under 2 cm from the midline.

    <p>CA clitoris or CA fourchette or CA perineum or CA anterior part of labia minora</p> Signup and view all the answers

    Study Notes

    Bartholin Gland Biopsy Indications

    • Biopsy is indicated for Bartholin cysts in females aged 40 years or older.
    • Biopsy is also indicated for enlarged Bartholin glands in post-menopausal women.
    • Biopsy is recommended for solid masses and cysts that are fixed to surrounding structures.

    Bartholin Cancer

    • Adenocarcinoma is the most common type of Bartholin cancer.
    • Post-menopausal women are most commonly affected.
    • Honan criteria are used for diagnosis.
    • Vulval mass is the most common symptom.

    General Gynecological Biopsy

    • Key's forceps or wedge biopsy are used for biopsies.
    • Vulvoscopy is recommended if the vulva appears hypopigmented, hyperpigmented, or atrophied.

    Vulval Cancer Management

    • Stage 1:
      • Treatment of choice is surgery if lymph nodes are involved.
      • Management involves radical partial vulvectomy, removing the tumor and lymph nodes.
      • Wide local excision with a 2 cm tumor-free margin is recommended for stage 1a.
    • Stage 2, 3, 4:
      • Surgery is indicated.
      • Chemoradiation is used for stage 4.
    • Palpable Lymph Nodes:
      • Enlarged lymph nodes should be removed and examined on frozen sections.
      • If positive for vulval cancer, manage like non-palpable lymph nodes.
      • If negative for vulval cancer, manage like non-palpable lymph nodes.
      • Ipsilateral inguinofemoral lymph node dissection or sentinel lymph node biopsy is recommended for all stages except stage IA with no lymphovascular space invasion (LVSI).
      • If lymph nodes are not palpable, stage the cancer.
      • Ipsilateral inguinofemoral lymph node dissection or sentinel lymph node biopsy is recommended for all stages except stage IA.
    • Nodes (Positive or Negative):
      • If negative, inguinal dissection is only required if:
        • Tumor size is less than 2 cm.
        • Tumor is more than 2 cm from the midline.
        • There is no local extension.
      • If positive, contralateral inguinofemoral lymph node dissection (B/1 dissection) is required.
    • LVSI (Lymphovascular Space Invasion):
      • These management guidelines are meant for general guidance.
      • Individual treatment plans may vary based on the patient's condition.

    Bartholin Gland Anatomy

    • The Bartholin gland is located between the labia minora and majora in the superficial perineal pouch.
    • It is typically not palpable.
    • The ducts open in the vestibule, outside the introitus, at the 4 and 8 o'clock positions.
    • The glands produce alkaline secretions during intercourse.

    Bartholin Cyst

    • Bartholin cysts are typically located between the labia minora and majora, outside the introitus.
    • Common features include intermittent, painless mass, unilateral, and an increase in size during intercourse.
    • Difficulty or pain during intercourse may occur.
    • Management:
      • Symptomatic cysts: Incision and drainage with insertion of Word catheter (to prevent recurrence).
      • Asymptomatic cysts:
        • Cysts less than 3 cm: Observation.
        • Cysts greater than or equal to 3 cm: Incision and drainage with insertion of Word catheter.
    • Recurrent Bartholin's Cyst:
      • < 40 years old: Marsupialisation.

      • 40 years old/ post-menopausal: Excision of cyst with biopsy.

    Bartholin Abscess

    • Pain, induration, flatulence, and warm tender swelling are common features.
    • Management:
      • Incision and drainage with insertion of Word catheter.

    Vulval Cancer Risk Factors

    • Human papillomavirus (HPV): HPV 16 is more common than HPV 18.
    • Vulval intraepithelial neoplasia (VIN).
    • Smoking.
    • Conditions affecting the vulva:
      • Lichen sclerosis
      • Condyloma acuminata
      • Squamous cell hyperplasia
      • Paget's disease of the vulva.
    • Low socioeconomic status.
    • Poor hygiene.
    • Not risk factors:
      • Herpes simplex
      • Condyloma lata
      • Parity or gravidity
      • Extra mammary Paget's disease.

    Vulval Squamous Cell Cancer Types

    • Keratinizing type: 60% incidence.
    • Warty type: 40% incidence
    • Keratinizing type is typically diagnosed at an older age (65-70 years) compared to the warty type (55-60 years).

    Vulval Cancer Diagnosis and Management

    Staging:

    • Stage 1:
      • Tumor restricted to the vulva.
      • 1A: ≤2 cm and depth of invasion ≤1 mm.
      • 1B: >2 cm or depth of invasion >1 mm.
      • Biopsy is required to assess the depth of cancer.
    • Stage 2:
      • Tumor spreads to the lower third of the urethra, vagina, or anus.
    • Stage 3:
      • Tumor involves inguinofemoral lymph nodes.
    • Stage 4:
      • Tumor involves the upper two-thirds of the vagina or urethra, or the rectum.
      • Pelvic lymph nodes are involved.
      • Fixed or ulcerative nodes.
      • Distant metastasis.

    Risk Factors Table

    • Risk Factor: Number of Foci

    • Lichen sclerosis:

    • Not HPV:

    • Differentiated VIN: Unifocal

    • HPV:

    • Undifferentiated VIN: Multifocal

    • Lymph node involvement is a key prognostic marker. Having involved nodes indicates a poorer prognosis.

    Vulva - Vestibule

    • Boundaries:
      • Anterior: Clitoris
      • Posterior: Fourchette
      • Lateral: Labia minora
    • Openings: 6

    Vulva - Introitus

    • The opening of the vagina, located in the vestibule.
    • Covered by the hymen.
    • Permits menstrual blood outflow.
    • Imperforate hymen is a condition where the hymen is closed and does not allow menstrual blood outflow.

    Types of Hymen

    • Annular (Normal): Ring-like shape.
    • Imperforate Septate: A hymen that does not allow menstrual blood outflow.

    Vulva Openings

    1. Urethra. 2, 3. Paraurethral/Skene glands.
    2. Introitus.
    4. Bartholin duct.

    Vulval Cysts

    • Type: Location:
    • Paraurethral/Skene gland cyst: Adjacent to urethra.
    • Gartner's cyst: Lateral wall of vagina.
    • Bartholin's cyst: Between labia minora and outside the introitus.

    Vulva - Other Important Points

    • The Bartholin's gland and duct may become blocked and cause a cyst that may be located between the labia majora, in the vestibule.

    Vulval Cancer - Anatomy of Vulva and Lymph Node Involvement

    • Lymphatics:

      • Sentinel lymph node (SLN): The first lymph node involved in cancer.
      • In rare cases (0.5%), lymphatics can drain directly into pelvic nodes.
      • SLN biopsy is used in gynecological vulval cancer procedures.
      • Dye used: Isosulfan blue or technetium 99 (Tc99).

    • Deep Inguinal Lymph Node (DILN):

      • Pelvic (External iliac) lymph node.

    • Clitoral Lymphatics:

      • May bypass the sentinel and deep inguinal lymph nodes and directly enter pelvic nodes, which is relatively rare.
      • In rare cases, lymphatic bypasses sentinel and deep inguinal lymph nodes.

    • Inguinofemoral Lymph Nodes:

      • The nodes to be dissected in vulval cancer.

    Lymph Node Involvement and Metastasis

    • Enlarged lymph nodes (with clinical suspicion of metastasis):

      • Positive for metastasis during dissection in 75% of cases.

    • Not enlarged lymph nodes (No clinical suspicion of metastasis):

      • Positive for micrometastasis in 25% of cases during dissection.
      • No need for dissection in 75% of cases.

    • Lymphatics from Midline Structures:

      • Structures less than 2 cm from the midline cross to the opposite side.
      • Requires bilateral inguinofemoral dissection.
      • Examples:
        • Cancer of the clitoris (CA clitoris)
        • Cancer of the fourchette (CA fourchette)
        • Cancer of the perineum (CA perineum)
        • Cancer of the anterior part of the labia minora (CA anterior part of labia minora).

    • Lymphatics from Lateral Areas:

      • Structures more than 2 cm from the midline do not cross.
      • Lymph node dissection may not be necessary in all cases.
      • Examples:
        • Cancer of the labia majora (Ca labia majora).

    Vulval Cancer Epidemiology

    • 3-4% of gynecological cancers.
    • Mean age: 65 years.
    • Most common age range: 50-70 years.
    • Most frequent histological type:
      • Squamous cell carcinoma (SCC)
      • Melanoma
      • Adenocarcinoma.
    • Most common site:
      • Labia majora
      • Labia minora.

    Vulval Cancer Symptoms

    • Pruritus (vulval itching): Most common symptom.
    • Lump, mass, or ulcer in the vulva.
    • Pain and urinary symptoms (due to urethral involvement).
    • Spread of Cancer: Primarily through the lymphatic system; sometimes via vascular system.

    Vulval Cancer Surgery

    • Post-operative Status: Large raw area, lymphedema, and vein thrombosis are possible complications.
    • Prolonged immobility increases the risk of distal vein thrombosis.

    VIN vs. Invasive Cancer

    • VIN:
      • Intact overlaying membrane.
      • Dysplastic cell spread.
    • Invasive Cancer:
      • Broken overlaying membrane.
      • Dysplastic cells invade surrounding tissue.

    VIN Categories

    • VIN 1: Dysplasia in the lower third of the epithelium.
    • VIN 2: Dysplasia in two-thirds of the epithelium.
    • VIN 3: Dysplasia in the entire epithelium, however, there is no lymphatic or vascular invasion.

    Vulval Cancer - Other Points

    • Young Female:

      • VIN is often HPV-related.
      • Approximately 90% of cases regress.

    • Older Female:

      • VIN is not HPV-related. Lichen sclerosis is a risk factor.
      • Vulval cancer progression to invasive cancer is more likely.

    Sentinel Lymph Node (SLN) Biopsy

    • Gynecology: SLN biopsy is used more often for vulval cancer than cervical cancer.
    • SLN biopsy is being used for all gynecological cancers now.
    • Used for breast cancer, penile cancer, and malignant melanoma.

    Hysterectomy Types and Comparison

    • Types:

      • Supracervical Hysterectomy (Sub-total Hysterectomy):

        • Only the uterus is removed. The cervix is retained.
        • Indication: Postpartum hemorrhage.

      • Vaginal Hysterectomy:

      • Abdominal Hysterectomy:

      • Laparoscopic Hysterectomy:

      • Robotic Hysterectomy:

      • Simple TAH:

    Hysterectomy Comparison

    Vaginal vs. Abdominal Hysterectomy

    • Feature: Vaginal Hysterectomy: Abdominal Hysterectomy:
    • Return to Normal Activity: Shorter. Longer.
    • Size of Uterus: Up to 16-18 weeks sized: Any size.

    Laparoscopic vs. Abdominal Hysterectomy

    • Feature: Laparoscopic Hysterectomy: Abdominal Hysterectomy
    • Return to Normal Activity: Shorter: Longer.
    • Incision: Small: Larger.
    • Recovery: Shorter: Longer.
    • Other Disadvantages:
      • Laparoscopic Hysterectomy: Difficult to determine extent of thermal burns. Lack of haptic feedback.
      • Abdominal Hysterectomy: Bulky device limits assistant movement. Lack of haptic feedback. High cost.

    Robotic Hysterectomy

    • Advantages:

      • 3-D views.
      • Instruments offer 7 degrees of movement.
      • Scaling of movement.
      • More precise movement.

    • Disadvantages:

      • Bulky device limits assistant movement.
      • Lack of haptic feedback.
      • High cost.

    Abdominal Hysterectomy Ligament Clamping Order

    • Superior:

        1. Round ligament (if oophorectomy indicated, clamp at infundibulopelvic ligament).
        1. Uterine artery.
        1. Cardinal ligament.
        1. Uterosacral ligament

    • Inferior:

    Gynecological Investigations: Hysteroscopy and HSG

    • Investigation Modalities:
        1. Ultrasound
        • Trans-abdominal sonography (TAS).
        • Trans-vaginal sonography (TVS).
        1. Saline infusion sonography (SIS).
        1. MRI
        1. CT scan.
        1. PET scan: used to locate nodal metastasis in ovarian cancer.
        1. Hysterosalpingography (HSG).
        1. Hysteroscopy.
        1. Laparoscopy.

    Non-Invasive Procedures

    Ultrasound

    • Non-invasive and safe during pregnancy.
    • Visualizes the exterior and interior of the uterus, endometrial thickness, and all pelvic organs.

    TAS vs. TVS

    • Feature: TAS: TVS:
    • Full Bladder: Requirement: Not a requirement.
    • Frequency of wave: 3-5 Hz: 5-10 Hz.
    • Indication: Uterus palpable per abdomen (P/A): Uterus not palpable.
    • Note: Higher frequency ultrasound waves → better resolution, reduced depth of penetration.

    Ultrasound Images

    • Normal USG of the Uterus: Shows the endometrium, myometrium, and the uterus itself.
    • Normal USG of the Ovaries: Shows the ovary.

    Vulva and External Genitalia

    • Parts:
      • Fossa navicularis: Depression between the introitus and fourchette.
      • Fourchette: The point where the labia minora meet posteriorly.
      • Posterior commissure: The point where the labia majora meet posteriorly.
      • Labia majora: Outer lips of the vulva. Contains hair, sweat glands, sebaceous glands, apocrine glands, and subcutaneous fat. The round ligament attaches at the anterior 1/3rd.
      • Labia minora: Inner lips of the vulva. Contains only sebaceous glands. No hair, sweat glands, or apocrine glands.
      • Clitoris: Highly vascular, erectile tissue. Length: 1.5 to 2 cm.
        • Prepuce (above): The fold of skin covering the clitoris.
        • Frenulum (below): The fold of skin connecting the clitoris to the labia minora.
      • Mons Pubis: Hair-bearing area above the pubic symphysis.

    Applied Anatomy of Vulva & External Genitalia

    • Pubarche: Development of hair on the mons pubis due to androgens. Corresponds to Tanner stage 3.

    • Hidradenoma of the vulva: tumor of the sweat glands. Located on the labia majora.

    • Clitoromegaly: Length of clitoris ≥ 4 cm.

      • Causes:
        • At birth: Intrauterine androgen exposure.
        • At puberty: Excessive androgens.

    • Diagram:

      • Shows the female external genitalia, including labels for various parts.
      • Hart's line is shown, indicating the junction of keratinized and non-keratinized epithelium of the labia minora.
      • The medial side of the line is non-keratinized, and the lateral side is keratinized.
      • The labia majora is the most common site for vulval cancer, beyond Hart's line.

    Other Vulva Points

    • Vestibule: The area between the labia minora.

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