Gynaecology Marrow Pg 239-248 (Gynaecological Oncology)
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Questions and Answers

What is a primary indication for performing a diagnostic procedure in gynecologic oncology?

  • Suspecting adenocarcinoma (correct)
  • For routine screening purposes
  • To treat stage II cervical cancer
  • To assess for benign Tumors

    • P-16 protein results are not used to differentiate between HSIL and LSIL.

    False

    What type of cancer is indicated by stage IA?

    Microinvasive cancer

    The discrepancy between the pap smear and colposcopy reports can indicate a possible _______.

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

    Match the following terms with their descriptions:

    <p>HSIL = High-grade squamous intraepithelial lesion LSIL = Low-grade squamous intraepithelial lesion P-16 Protein = Used to differentiate between HSIL and LSIL Stage IA = Microinvasive cervical cancer</p> Signup and view all the answers

    What is the recommended follow-up period for CIN 1?

    <p>2 years</p> Signup and view all the answers

    Cryoablation obtains tissue specimens for further analysis.

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

    What are the two methods of choice for managing CIN 2/3?

    <p>LLETZ and LEEP</p> Signup and view all the answers

    Cryoablation involves freezing and thawing with CO₂ or N₂O for treating areas of __________.

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

    Match the following CIN management criteria with their relevance:

    <p>Entire T2 visible = A prerequisite for CIN 1 Lesion not HIV +ve = A prerequisite for CIN 1 Lesion &lt; 2 quadrants = A prerequisite for CIN 1 Persistent water discharge = Side effect of cryoablation</p> Signup and view all the answers

    Which of the following indicates a high-risk level after surgery?

    <p>Margin positive (+ve)</p> Signup and view all the answers

    Lymphvascular involvement is considered a low-risk factor after surgery.

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

    What treatment is usually indicated for high-risk patients after surgery?

    <p>Post-op chemo radiation or Post-op radiotherapy</p> Signup and view all the answers

    A patient with no post-operative metastasis is classified as being at ______ risk.

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

    Match the following risk levels to their corresponding factors:

    <p>High Risk = Margin positive (+ve) Intermediate Risk = Deep stromal invasion Low Risk = No post-operative metastasis</p> Signup and view all the answers

    What is the most common type of cervical cancer?

    <p>Squamous cell cervix</p> Signup and view all the answers

    HPV 18 is the most common association with squamous cell cervical cancer.

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

    What symptom is considered the most specific for cervical cancer?

    <p>Post coital bleeding</p> Signup and view all the answers

    The most common site for cervical cancer is the __________ zone.

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

    Match the type of cervical cancer with its corresponding feature:

    <p>Squamous cell cervix = Most common type Adenocarcinoma = Most common in young females Small cell = Poor prognosis Large cell keratinising = Type of squamous cell cervix</p> Signup and view all the answers

    Which lymph nodes are involved in the management of cervical cancer?

    <p>Para-aortic lymph nodes</p> Signup and view all the answers

    The cervix drains into superficial lymph nodes.

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

    What examination findings are characteristic of a friable cervix?

    <p>Bleeds on touch</p> Signup and view all the answers

    The collection of pus in the uterus is known as _______.

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

    Match the following presentations with their descriptions:

    <p>Post coital bleeding = Ca cervix, polyp, endometrium Thin built = Cachexic appearance Hard cervix = Indurated cervix with nodularity Ulcerative mass = Fungating growth on cervix</p> Signup and view all the answers

    What is the primary indication for a radical trachelectomy?

    <p>Young females who desire future childbearing</p> Signup and view all the answers

    What is the significance of lymph nodes in cervical cancer staging?

    <p>They indicate the prognosis.</p> Signup and view all the answers

    Chemoradiation is indicated for stage IIA cervical cancer.

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

    What is the isotope used in brachytherapy?

    <p>Iridium 192</p> Signup and view all the answers

    Stage IA of cervical cancer is defined as macroinvasive cancer greater than 5 mm deep.

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

    The source of radiation in teletherapy is _______.

    <p>outside the body</p> Signup and view all the answers

    What diagnostic procedure is performed for microinvasive cancer of the cervix?

    <p>Cone biopsy</p> Signup and view all the answers

    The FIGO staging system uses a __________ scan to evaluate the involvement of ovaries.

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

    Match the following radiation therapy types with their characteristics:

    <p>Brachytherapy = Intracavitary therapy using Iridium 192 Teletherapy = External beam radiotherapy using Cesium Chemoradiation = Combination of chemotherapy and radiation therapy Radical Trachelectomy = Uterus stitched to vagina after cervix removal</p> Signup and view all the answers

    Match the stages of cervical cancer with their respective features:

    <p>IA = Microscopic/microinvasive cancer ≤5 mm deep IB = Macroinvasive cancer &gt;5 mm deep IIA = Involvement of upper 2/3rd of vagina</p> Signup and view all the answers

    What is a significant advantage of the LLETZ/LEEP procedure?

    <p>Can be performed in an outpatient setting</p> Signup and view all the answers

    The cone biopsy procedure is performed in an outpatient setting under local anesthesia.

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

    What is the primary purpose of performing a LLETZ/LEEP procedure?

    <p>To remove dysplastic tissue from the cervix.</p> Signup and view all the answers

    In cases of positive endocervical curettage, a cone biopsy may be followed by a diagnosis of __________.

    <p>adenocarcinoma in situ</p> Signup and view all the answers

    Match the following procedures with their descriptions:

    <p>LLETZ/LEEP = Outpatient procedure for removing dysplastic cervical tissue Cone Biopsy = Excision of a cone-shaped area of the cervix Endocervical curettage = Diagnostic procedure that can indicate adenocarcinoma in situ Colposcopy = Visual examination of the cervix followed by possible biopsy</p> Signup and view all the answers

    What is a significant feature of stage IIIC in gynaecologic oncology?

    <p>Pelvic lymph nodes involvement</p> Signup and view all the answers

    Stage IVA indicates distant metastasis or superficial inguinal lymph node involvement.

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

    What type of surgical procedure is preferred for complete family preservation in gynaecologic oncology?

    <p>Type 1 procedure</p> Signup and view all the answers

    In gynaecologic oncology, tumours less than ______ cm are usually indicated for surgical management up to stage IIa.

    <p>4</p> Signup and view all the answers

    Match the stage of gynaecologic oncology with its corresponding feature:

    <p>Stage IIA = Involvement of lower 1/3rd of vagina Stage IIB = Pelvic side wall involved: Hydroureter/Hydronephrosis Stage IIIC = Lymph nodes involvement Stage IV = Regional metastasis: Bladder/Bowel</p> Signup and view all the answers

    What procedure should be performed for LSIL in patients aged 25 years or older?

    <p>Colposcopy + Endocervical curettage</p> Signup and view all the answers

    Colposcopy allows visualization of the endocervix.

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

    What is the focal length of a colposcope?

    <p>30</p> Signup and view all the answers

    A biopsy is taken from acetowhite areas after applying ______% acetic acid on the cervix.

    <p>3-5</p> Signup and view all the answers

    Match the following colposcopy indications with their procedures:

    <p>HSIL, ASC-H = Any age colposcopy ASCUS &lt; 25yrs = Repeat pap in 12 months ASCUS &gt; 25yrs = HPV DNA testing AGCUS = Colposcopic biopsy + Endocervical and Endometrial biopsy</p> Signup and view all the answers

    Study Notes

    P-16 Protein

    • P-16 protein is used to distinguish between high-grade squamous intraepithelial lesions (HSIL) and low-grade squamous intraepithelial lesions (LSIL) on Pap smear when the results are indeterminate.
    • Increased P-16 protein levels are associated with HSIL.
    • Normal P-16 protein levels are associated with LSIL.

    Post-Surgery Risk Assessment

    • Patients are categorized into three risk levels based on the presence or absence of post-operative metastasis.
    • High risk patients have margin-positive, parametrium-positive, or lymph node metastasis.
    • Intermediate risk patients have large tumor size, lymphovascular involvement, or deep stromal invasion.
    • Low risk patients have no post-operative metastasis.

    Management of CIN

    • The management of cervical intraepithelial neoplasia (CIN) depends on the grade of CIN and the patient's characteristics.
    • CIN 1 is managed with a follow-up in 2 years.
    • CIN 2/3 is managed with LLETZ or LEEP.
    • Cryoablation is an alternative treatment for CIN 1 when specific criteria are met.

    Cryoablation: A Treatment Option for CIN

    • Cryoablation uses CO₂ or N₂O at a very low temperature to destroy dysplastic areas in the cervix.
    • The principle involves freezing and thawing the tissue multiple times to destroy up to 3-5 mm of epithelium.
    • A persistent watery discharge is a potential side effect.
    • A disadvantage of Cryoablation is the lack of tissue specimen for further evaluation.

    Cancer Cervix

    • Squamous cell carcinoma is the most common type of cervical cancer
    • The most common subtype of squamous cell carcinoma is large cell non-keratinizing type.
    • HPV 16 is most commonly associated with squamous cell carcinoma.
    • Adenocarcinoma is most common in young females.
    • HPV 18 is most commonly associated with adenocarcinoma.
    • The most common site of cervical cancer is the endocervix.

    Cervical Cancer: Symptoms

    • Irregular bleeding is the most common symptom
    • Post coital bleeding is the most specific symptom.
    • Dirty vaginal discharge can be a symptom.
    • Pyometra (collection of pus in the uterus) is the most common cervical cancer causing pyometra.
    • Lung metastasis can cause dyspnea, cough, hemoptysis, and chest pain.
    • Pelvic side wall involvement can manifest as sciatica, hematuria, and lymphedema.
    • Renal failure is the leading cause of death in patients with cervical cancer.

    Cervical Cancer: Route of Spread

    • Cancer spreads through direct, lymphatic, and hematogenous routes.
    • The lungs are the most common site of hematogenous metastasis.

    Management of Cervical Cancer:

    • External Beam Radiotherapy (EBRT) is indicated for pelvic lymph node involvement.
    • Extended EBRT is used when Paraaortic lymph nodes are involved.

    Post Coital Bleeding: Algorithm

    • Possible causes of post coital bleeding include Cervical Cancer, polyp, and endometrium.
    • If a visible cervical growth is observed, Pap smears and colposcopy with punch biopsies are recommended.

    Colposcopy

    • Colposcopy is a procedure that uses a magnifying instrument to examine the cervix and vagina.
    • Colposcopy is recommended for patients with HSIL, ASC-H, or LSIL (age ≥ 25).
    • It is recommended to repeat pap smears in 12 months for patients with ASCUS (age < 25) or LSIL (age < 25).
    • Colposcopic biopsy, endocervical curettage, and endometrial biopsy are necessary for patients with AGCUS.

    Colposcopy Instrument & Procedures

    • Colposcopy uses a magnifying instrument that magnifies up to 30 times.
    • It visualizes the exocervix, transformation zone, and external os.
    • Colposcopy does not allow visualization of the endocervix.
    • A urine pregnancy test (UPT) is recommended before colposcopy if needed.
    • Colposcopy is an out-patient procedure.
    • Biopsies are taken from rough or pale areas.
    • Acetic acid (3-5%) is applied to the cervix to highlight abnormal areas.
    • Green filters are used to identify abnormal blood vessels.

    LLETZ/LEEP Procedure

    • LLETZ/LEEP is the preferred treatment method for CIN 2/3 in all age groups and parities.
    • It is an outpatient procedure that takes 10-15 minutes.
    • Tissue samples are extracted for histopathologic examination.
    • A cone biopsy is performed if endocervical curettage is positive.

    Cone Biopsy/Conisation

    • A cone-shaped area is excised from the cervix, which includes the ectocervix, transformation zone, and endocervix.
    • The procedure requires general anesthesia in an operating room.

    Cancer Cervix: FIGO Staging

    • FIGO staging is used to classify cervical cancer based on the extent of disease.
    • Stage IA is microscopic or microinvasive cervical cancer ≤5 mm deep.
    • Stage IB is macroinvasive cancer > 5 mm deep.
    • Stage IIA: The cancer involves the upper two-thirds of the vagina but not the parametrium.
    • Stage IIB: The cancer involves the pelvic side wall.
    • Stage IIIC: The cancer spreads to lymph nodes.
    • Stage IV: The cancer metastasizes to regional sites (bladder or bowel) or distantly.

    Management of Cervical Cancer: Surgery

    • Surgery is an option for cervical cancer up to Stage IIA, when the tumor size is less than 4 cm.
    • Complete family preservation procedures include Type 1, Type 2, and Type 3 hysterectomies with or without lymph node dissection.
    • Incomplete family preservation surgeries include conization, radical trachelectomy, and Type 3 hysterectomy with pelvic lymphadenectomy.

    Management: Radiotherapy

    • Radiotherapy is used in all stages of cervical cancer.
    • It is used when surgery is contraindicated.
    • Cisplatin and SFU are radiosensitizers used to enhance the sensitivity of cancer to radiotherapy.

    Radical Trachelectomy

    • Radical trachelectomy involves the removal of the cervix with uterus stitching to the vagina.
    • It is followed by abdominal cerclage.
    • It is indicated for young females desiring future childbearing with a tumor size less than 2 cm.
    • Cesarean section is recommended for delivery after radical trachelectomy.

    Chemoradiation

    • Chemoradiation involves the administration of chemotherapy drugs (Cisplatin and SFU) before radiotherapy for Stage IIB, IIA, and Stages III to IV.
    • It can lead to vaginal fibrosis and ovarian failure due to the high sensitivity of the ovaries to radiotherapy.

    Brachytherapy

    • Brachytherapy involves the internal placement of radioactive sources (Iridium 192) inside the body.
    • It's used after teletherapy to target the parametrium (Point A) and obturator nodes (Point B)
    • Point A is located 2 cm above and lateral to the external os, while Point B is 3 cm away from Point A.

    Teletherapy

    • It involves delivering radiation from outside the body using external beam radiotherapy (EBRT).
    • Cesium is the isotope typically used in teletherapy.
    • Teletherapy is used initially to shrink the size of the tumor.

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    Description

    Test your knowledge on the role of P-16 protein in distinguishing HSIL from LSIL on Pap smears, as well as post-surgery risk assessment for cervical cancer patients. Explore the management strategies for cervical intraepithelial neoplasia (CIN) based on its grades. This quiz covers essential aspects of cervical cancer diagnosis and management.

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