Gynaecology Marrow Pg 219-228 (Gynaecological Oncology)
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Questions and Answers

Which gene mutation is commonly associated with Cowden syndrome?

  • BRCA1
  • MSH
  • PTEN (correct)
  • MLH

    • Universal screening for endometrial cancer is routinely conducted.

    False

    What is the most common histopathological type of endometrial cancer?

    Adenocarcinoma

    An annual endometrial biopsy is recommended starting at age _____ for individuals with hereditary cancer risk.

    <p>35</p> Signup and view all the answers

    Match the following cancer types to their characteristics:

    <p>Adenocarcinoma = Most common type of endometrial cancer Clear cell = Most malignant type Serous = Type of endometrial carcinoma Mucinous = Another variant of endometrial cancer</p> Signup and view all the answers

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

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

    Tamoxifen is associated with an increased risk of endometrial cancer.

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

    Name one protective factor against endometrial cancer.

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

    Lynch II syndrome is also known as _____ syndrome.

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

    Match the following conditions with their associated factors relating to endometrial cancer:

    <p>Obesity = Most common risk factor Nulliparity = Risk factor Multiparity = Protective factor Tamoxifen = Increases cancer risk</p> Signup and view all the answers

    Which layer of the cervix is lined by columnar epithelium?

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

    The exocervix is lined by columnar epithelium.

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

    What is the area where the columnar epithelium meets the squamous epithelium called?

    <p>Transformation Zone</p> Signup and view all the answers

    At puberty, Doderlein bacilli act on glycogen to produce ________ acid, changing the pH of the vagina.

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

    Match the following components of the cervix with their descriptions:

    <p>Endocervix = Lined by columnar epithelium Exocervix = Lined by stratified squamous epithelium Transformation Zone = Area of epithelial junction External os = Opening of the cervix</p> Signup and view all the answers

    Which type of endometrial carcinoma is characterized by adenocarcinoma grade 3 and has a bad prognosis?

    <p>Type II</p> Signup and view all the answers

    Type I endometrial carcinoma is primarily related to decreased estrogen levels.

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

    What is the most common complaint presented by patients with endometrial cancer?

    <p>Irregular vaginal bleeding</p> Signup and view all the answers

    The first investigation in the diagnostic algorithm for endometrial cancer is ___ .

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

    Match the following characteristics with their corresponding types of endometrial carcinoma:

    <p>Adenocarcinoma grade 1, 2 = Type I Clear cell = Type II Obese = Type I Thin = Type II</p> Signup and view all the answers

    What is the primary cause of endometrial hyperplasia (EH)?

    <p>Increased estrogen</p> Signup and view all the answers

    Endometrial sampling requires general anesthesia.

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

    What is the gold standard investigation for diagnosing endometrial hyperplasia?

    <p>Fractional curettage and hysteroscopy</p> Signup and view all the answers

    In endometrial hyperplasia, excessive bleeding is often reported by __________ females.

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

    Match the endometrial sampling instruments with their descriptions:

    <p>Karma's cannula = Unique instrument used in India for endometrial biopsy Pipelle = Commonly used instrument for endometrial aspiration Vabra aspirator = Instrument used to gently suction endometrial tissue</p> Signup and view all the answers

    Which of the following cancer stages is considered high risk for post-operative management?

    <p>Stage III/IV</p> Signup and view all the answers

    Radiotherapy is the only treatment option recommended for all patients with endometrial cancer.

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

    What is the most common cause of post-menopausal bleeding in India?

    <p>Cancer cervix</p> Signup and view all the answers

    If the endometrial thickness is greater than ___ mm, an endometrial biopsy is recommended.

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

    Match the following post-operative management options with their respective indications:

    <p>No management = Low-risk adenocarcinoma grade 1/2 Stage IA Chemotherapy + Radiotherapy = High-risk stages or aggressive cancer types Radiotherapy = Intermediate risk or other specific cases</p> Signup and view all the answers

    What is the recommended next step for endometrial hyperplasia without atypia?

    <p>Progesterone - Mirena</p> Signup and view all the answers

    The risk of malignancy in endometrial hyperplasia with atypia can be as high as 30%.

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

    What should be done if there is continued bleeding after initial management of endometrial hyperplasia with atypia?

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

    The risk of malignancy in endometrial hyperplasia without atypia is _____%.

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

    Match the management option with its appropriate indication:

    <p>Total abdominal hysterectomy = Patients with atypia Progesterone (megestrol) = Patient refuses TAH Repeat biopsy = 3-6 months after diagnosis FC + hysteroscopy = Atypia present</p> Signup and view all the answers

    Which stage of endometrial cancer indicates involvement of pelvic and para-aortic lymph nodes?

    <p>Stage 3C</p> Signup and view all the answers

    Which of the following mutations is associated with a good prognosis in gynecologic oncology?

    <p>POLE mutation</p> Signup and view all the answers

    Stage 4B of endometrial cancer is characterized by regional metastasis to the bladder or bowel.

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

    What is the best investigation method for assessing myometrial and parametrium involvement in endometrial cancer?

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

    Microsatellite instability indicates a bad prognosis in gynecologic oncology.

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

    Endometrial cancer stage that involves the cervix is Stage _____

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

    What is the surgical procedure recommended for Stage 1 gynecologic tumors?

    <p>TAH + BSO</p> Signup and view all the answers

    Match the following endometrial cancer stages with their respective features:

    <p>Stage IA = Limited to uterus, 50% myometrium involvement Stage 3B = Beyond cervix; vagina/parametrium involvement Stage 4A = Regional metastasis to bladder/bowel Stage 3C = Lymph node involvement; pelvic nodes</p> Signup and view all the answers

    A patient with a p53 abnormality is expected to have a __________ prognosis.

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

    Match the following stages with their surgical approach:

    <p>Stage 1 = TAH + BSO (Type 1 Hysterectomy) Stages 2 &amp; 3 = Wertheim's Hysterectomy (Type 2 Hysterectomy) Stage 4 = Debulking Surgery</p> Signup and view all the answers

    What is a primary advantage of fractional curettage (FC)?

    <p>Diagnosis of generalized endometrial pathology</p> Signup and view all the answers

    Hysteroscopy is primarily used for generalized endometrial conditions.

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

    What medication is commonly used for managing metropathia hemorrhagica?

    <p>Tranexamic acid</p> Signup and view all the answers

    The risk of malignancy associated with cystic glandular hyperplasia is _______.

    <p>1%</p> Signup and view all the answers

    Match the following management strategies with their corresponding conditions:

    <p>Normal = First-line medications for AUB Metropathia hemorrhagica = Tranexamic acid and FC/Hysteroscopy Endometrial hyperplasia ± Atypia = Progesterone or Mirena</p> Signup and view all the answers

    Study Notes

    Endometrial Cancer

    • Most common type: Adenocarcinoma
    • Most malignant type: Clear cell
    • Grading based on percentage of undifferentiated solid component
    • Risk Factors: Family history, hypertension, obesity (most common), late menopause, early menarche, diabetes, atypical endometrial hyperplasia, unopposed estrogen, PCOS, estrogen-only HRT, estrogen-secreting tumors (Granulosa cell tumors), nulliparity, Tamoxifen (most common), corpus cancer syndrome
    • Protective Factors: Multiparity, pregnancy, OCPs (progesterone downregulates estrogen receptors on endometrium), physical exercise and green tea
    • Familial syndromes: Lynch II syndrome (AKA HNPCC syndrome), Cowden syndrome
    • Lynch II syndrome cancers: colon cancer (most common), endometrial cancer
    • Increased risk of endometrial cancer in Lynch II syndromes.
    • Best prevention method in familial syndromes: TAH + BSO (TAH prevents endometrial cancer, BSO prevents ovarian cancer)
    • Indication for TAH + BSO: Completed family by 40 years of age
    • Staging based on FIGO 2009 classification
    • Superficial lymph node involvement: Stage 4B
    • Spread to cervix: Stage I → II
    • Spread to uterus: Stage does not change
    • Staging investigation: MRI (myometrial & parametrium involvement), CT (omental & lymph node involvement), PET-CT (lymph node status), surgical staging + histopathological examination + molecular classification (used in 2023 staging)
    • Treatment of choice: Radiotherapy
    • Molecular classification: Good (POLE mutation), Intermediate (MMRD, msi), Bad (p53 abnormality)
    • Surgical staging based on stage: Stage 1: TAH + BSO, Stages 2 & 3: Wertheim's Hysterectomy, Stage 4: Debulking surgery
    • In papillary serous tumors/Carcinoid sarcoma: Intracolic omentectomy (due to increased chances of micrometastasis of omentum)
    • In mucinous tumors: TAH + BSO + Appendectomy (due to association with appendix cancer)
    • Lymph node dissection: Stage IA – Size of tumor, All other stages – All lymph nodes

    Types of Endometrial Carcinoma

    • Type I: Most common, Adenocarcinoma grade 1, 2, good prognosis, increased estrogen, endometrial hyperplasia, 50-60 years old, obese, PTEN, KRAS
    • Type II: Adenocarcinoma grade 3, clear cell, papillary serous, poor prognosis, decreased estrogen, endometrial atrophy, 60-70 years old, thin, p53 gene
    • Age group: Most common: 50-70 years, Median: 60 years

    Presentation

    • Irregular vaginal bleeding/AUB (most common)
    • Postmenopausal bleeding (PMB): most specific
    • Most common causes of PMB: Polyp (37%), Endometrial atrophy (30%), Dirty vaginal discharge, Pelvic pressure/pain
    • 10% of PMB cases are endometrial cancer

    Spread

    • Most common route: Direct

    Management

    • First investigation: TVS
    • Endometrial thickness ≥ 24 mm -> Endometrial biopsy (10C)
    • Malignancy positive -> Fractional curettage + Hysteroscopy (Gold standard)
    • Gatekeeper gene: PTEN

    Endometrial Hyperplasia

    • Histopathology diagnosis
    • Cause: Increased estrogen (Hyperestrogenic state)
    • Presentation: Perimenopausal female with excessive bleeding
    • Classification: Abnormal uterine bleeding (AUB) - most common
    • Investigations: TVS with increased endometrial thickness (suspect EH), Endometrial biopsy (10C)
    • Gold standard for diagnosis: Fractional curettage + Hysteroscopy

    Endometrial Sampling

    • AKA: Endometrial biopsy/endometrial aspiration cytology
    • Done in: OPD
    • Anesthesia: Not required
    • Instruments used: Karma's cannula (India), Pipelle, Vabra aspirator
    • Indications: Reproductive age (suspect EH, amenorrhea), Postmenopausal

    Fractional Curettage (FC)

    • Procedure: Done in OT, General anesthesia, Endocervical curettage followed by endometrial curettage
    • Advantages: Diagnosis of generalized endometrial pathology
    • Disadvantages: Not suitable for localized pathology

    Hysteroscopy

    • Diagnostic tool for localized pathology

    EB Report Interpretation & Management

    • Outcomes: Normal, Metropathia hemorrhagica, Endometrial hyperplasia ± Atypia
    • Management of Normal: Use first-line medications for abnormal uterine bleeding (AUB)
    • Management of Metropathia Hemorrhagica: Tranexamic acid (medication), FC + Hysteroscopy (procedure).
    • Patient Profile: Perimenopausal female with anovulatory cycles and heavy menstrual bleeding (HMB) for 2-3 months. Pathology report mentions possible amenorrhea
    • Histopathological Examination (HPE): Findings: Swiss cheese pattern, proliferative endometrium, Equivalent: Cystic glandular hyperplasia, Risk of malignancy: 1%
    • Treatment options: Oral, Progesterone, Mirena
    • Single best investigation for diagnosis: Fractional curettage

    Post-op Management

    • Low risk: Adenocarcinoma grade 1/2 + Stage IA
    • High risk: Stage 3/4 or Papillary serous/Clear cell tumor
    • Intermediate risk: All others
    • Treatment: No treatment, Chemotherapy + Radiotherapy (Carboplatin + Paclitaxel), Radiotherapy

    Postmenopausal Bleeding

    • TVS for endometrial thickness: ≤4 mm (normal), >4 mm -> Endometrial biopsy
    • Causes: Tranexemic acid, Bleeding, Suspect type 2 endometrial cancer -> Fractional curettage + Hysteroscopy, Polyp (most common), Endometrial atrophy (most common), HRT, Endometrial cancer (10%)
    • Most common cause of PMB in India: Cancer cervix

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    Description

    Dive into the critical aspects of endometrial cancer, focusing on its most common type, adenocarcinoma, and the various risk and protective factors involved. Understand the familial syndromes associated with increased risk, particularly Lynch II syndrome, and explore prevention strategies such as TAH + BSO. This quiz will enhance your knowledge about the complexities of this malignancy.

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