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.

40 Signup and view all the answers

Match the following indications for biopsy with their criteria:

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

What is the primary function of the Bartholin gland?

Produce alkaline secretions during intercourse Signup and view all the answers

A Bartholin cyst is typically painful.

False Signup and view all the answers

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

Incision and drainage plus insertion of a word catheter Signup and view all the answers

A Bartholin abscess typically presents with __________ and tenderness.

pain Signup and view all the answers

Match the features to the corresponding condition-related management:

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 Signup and view all the answers

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

Radical partial vulvectomy Signup and view all the answers

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

True Signup and view all the answers

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

Vulvoscopy Signup and view all the answers

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

chemoradiation Signup and view all the answers

Match the management steps with their corresponding requirements:

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 Signup and view all the answers

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

Extra mammary Paget's disease Signup and view all the answers

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

True Signup and view all the answers

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

Biopsy Signup and view all the answers

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

1/3rd Signup and view all the answers

Match the following types of VIN with their characteristics:

Differentiated VIN = Unifocal Undifferentiated VIN = Multifocal Signup and view all the answers

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

Clitoris Signup and view all the answers

The introitus is responsible for the outflow of menstrual blood.

True Signup and view all the answers

Name one type of cyst found in the vulva.

Bartholin's cyst Signup and view all the answers

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

hymen Signup and view all the answers

Match the following types of hymen with their descriptions:

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

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

VIN 3 shows dysplastic changes but no invasion. Signup and view all the answers

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

False Signup and view all the answers

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

Lichen sclerosis Signup and view all the answers

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

Sentinel Signup and view all the answers

Match the VIN category to its description:

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

Which ultrasound technique requires a full bladder?

Trans-abdominal sonography (TAS) Signup and view all the answers

Hysteroscopy is a non-invasive procedure.

False Signup and view all the answers

What is the primary use of hysterosalpingography (HSG)?

To assess the patency of the fallopian tubes. Signup and view all the answers

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

trans-vaginal sonography (TVS) Signup and view all the answers

Match the following imaging techniques with their features:

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

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

Uterus Signup and view all the answers

The labia minora contains hair and sweat glands.

False Signup and view all the answers

What is the length range of the clitoris?

1.5 to 2 cm Signup and view all the answers

The area between the labia minora is called the __________.

vestibule Signup and view all the answers

Match the following conditions with their associated descriptions:

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 Signup and view all the answers

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

Supracervical Hysterectomy Signup and view all the answers

Robotic hysterectomy provides 2-D views for surgeons.

False Signup and view all the answers

Name one disadvantage of laparoscopic hysterectomy.

Difficult to know the extent of thermal burns Signup and view all the answers

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

shorter Signup and view all the answers

Match the following types of hysterectomy with their characteristics:

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

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

Small incision Signup and view all the answers

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

True Signup and view all the answers

What is one indication for performing a supracervical hysterectomy?

Postpartum hemorrhage Signup and view all the answers

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

To identify the first lymph node affected by cancer. Signup and view all the answers

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

False Signup and view all the answers

What symptom is considered the most common in vulval cancer?

Pruritus (vulval itching) Signup and view all the answers

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

bilateral inguinofemoral Signup and view all the answers

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

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 Signup and view all the answers

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

25% Signup and view all the answers

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

False 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.

CA clitoris or CA fourchette or CA perineum or CA anterior part of labia minora 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

Urethra. 2, 3. Paraurethral/Skene glands.
Introitus.
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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Test your knowledge on Bartholin gland conditions, focusing on symptoms, management, and indications for biopsy. This quiz covers essential aspects of Bartholin gland cancer and related procedures. Perfect for medical students and professionals looking to refresh their understanding.