Formative Menti Cancer week

Question 1

What are the two main types of Tx for Ovarian Cancer?

Answer 1

Surgery (salpingo-oophorectomy)
- Optimal Debulking.

or

Chemotherapy (Platinum therapy)

Question 2

What are the main types of Tx for Uterine Cancers?

Answer 2

Surgical (Histerectomy, BSO, PLND)

Question 3

What are the main types of treatment for cervical Cancers?

Answer 3

Surgical:
- Large Loop Excision of the Transformational Zone (LLETZ), Simple or Radical Hysterectomy, Trachelectomy (removal of cervix)
or
Radiotherapy (Radical or Adjuvant)
or
Chemotherapy

Question 4

When would you give radical and when Adjuvant Radiotherapy in cervical cancer?

Answer 4

Radical As curative in Stage 2,3 and 4 cervical cancers. - Stage 1 if unfit for surgery.

Adjuvant if there is a large tumour diameter, positive margins on resection or +ve Lymphnodes.

Question 5

What types of Tx are used in Endometrial cancer?

Answer 5

Surgery first line (Hysterectomy with BSO)

Progestrogens (oral progesterone as the cancers are usually Oestrogen dependant) - For older ladies not undergoing Sx

Rarely Radical Radiotherapy.

Question 6

What type of drugs are given in Cervical cancer Chemotherapy?

Answer 6

Cisplatin,
Carboplatin,
Paclitaxel

Question 7

What treatment is used in Tx of Vulval cancers?

Answer 7

Wide Local Excision to remove the cancer.

Sentinel Node Biopsy to check for Lymph node spread.
If Pos - Pelvic Lymph node dissection.

Question 8

What is required for Chemotherapy to be effective.

Answer 8

High cell replication / Turnover.

Question 9

Which cancers will chemo not work so well in?

Answer 9

Low grade serous tumours and Borderline Ovarian tumours as they are slow growing (low cell Replication)

Question 10

What Tumour Markers are requested in a young patient with a complex ovarian mass?

Answer 10

LDH, AFP, CA125, HCG

Question 11

What are some non-cancerous reasons for a raised CA125?

Answer 11

• Endometriosis,
• Fibroids,
• Adenomyosis,
• Pelvic infection,
• Liver disease,
• Pregnancy.

Question 12

When is p53 checked in gynae cancers.

Answer 12

Checked in the tissue sample rather than as Tumour Marker.
p53 mutations are indicative of a more aggressive tumour (usually)

Question 13

What is the first step in management of a 75-yr old women is Post-menopausal bleeding?

Answer 13

Transvaginal Ultrasound (checking thickness of endometrium)

Question 14

What is the cut off for biopsy of endometrium on TVUS?

Answer 14

If >4mm take a biopsy for this patient. (normal <4mm in post menopausal patients)

Endometrium is thickest at ovulation and can be at 16mm.

Question 15

What are the differentials for Post menopausal bleeding?

Answer 15

Endometrial cancer (10%).
Endometrial Hyperplasia.
Sporadic Ovulation (most common cause).
Atrophic Vaginosis.

Question 16

A 28-yr old patient has abdominal discomfort. USS shows ovarian mass with fat content and calcification within the cyst. What is the likely diagnosis?

Answer 16

Dermoid cyst (mature benign teratoma)
- Most common ovarian germ cell tumour.

Question 17

A 39-yr old women has heavy menstrual bleeding and a 14 week sized pelvic mass (aka. 14 cm sized). What is the most appropriate investigation for her?

Answer 17

TVUS first-line and then MRI if more info is needed.
Most likely to be a Fibroid (Intramural)

Question 18

What are the different types of Fibroids? (leiomyomas)

Answer 18

Subserosal.
Submucosal.
Intramural.

Question 19

What are typical clinical signs of each fibroid type?

Answer 19

Submucosal fibroids - Present with Intermenstrual bleeding.

Subserosal fibroids - tend to cause pressure relate symptoms.

Intramural Fibroids - Heavy menstrual bleeding.

Question 20

A 65-yr old women has ascitis and CA125 of 40. USS shows bilateral Ovarian Masses with free fluid. What is her RMI?

Answer 20

360

Question 21

How is Relative Malignancy Index (RMI) calculated?

Answer 21

Combination of Serum CA125 (CA125), Menopausal status (M) and Ultrasound score (U):

RMI = M x U x CA125

Question 22

What determines ultrasound score in RMI?

Answer 22

Ultrasound result is scored 1 point for characteristics: “BAMMS”
- Bilateral lesions
- Ascites
- Multiocular cysts
- Metastases
- Solid areas

U = 0 (none are present)
U = 1 (For ultrasound score of 1)
U = 3 (For Ultrasound score 2 to 5)

Question 23

How is Menopausal Status scored in RMI?

Answer 23

Pre-menopausal = Menopausal status of 1

Post-menopausal = status of 3

Post-menopausal is defined as a women who has had no period for > 1 yr.

Question 24

What RMI score Constitutes as Low, Intermediate or High?

Answer 24

< 30 is Low (3% risk of Ovarian Cancer)

30 - 200 is Intermediate. (20% risk of Ovarian Cancer)

> 200 is high. (75% risk of Ovarian cancer)

Question 25

16-yr old girl has a 20cm large complex ovarian mass with no other disease seen on CT. What is the most likely diagnosis?

Answer 25

Malignant Ovarian Mass. (in a young patient you could think of a benign ovarian cyst. But in a patient so young, who'll likely only just have started ovulating. A mass thats managed to get this big would likely indicated malignancy).

Question 26

62-yr old women with 16cm complex right ovarian mass has pleural effusion and ascites seen on CT scan, what is the most likely pathology?

Answer 26

Malignant ovarian mass.

Question 27

What is Meig's syndrome?

Answer 27

Meig's syndrome is an uncommon presentation where a benign ovarian tumour presents alongside ascites and pleural effusion. Triad: - Benign ovarian tumour. - Ascites - Pleural effusion typically in older patients.

Question 28

23-yr old with severe right sided abdominal pain which settles on analgesics has a 4cm right ovarian cyst on scan. What is the likely diagnosis?

Answer 28

Haemorrhagic ovarian Cyst. Haemorrhage will (unlike Torsion of the ovary) Settle with analgesics.

Question 29

When does torsion of the Ovary occur?

Answer 29

Usually due to an ovarian mass >5cm. Such as a Cyst or Tumour, it is more likely to occur with benign tumours. Also more likely to occur during pregnancy.

Question 30

How does an Ovarian torsion present?

Answer 30

Sudden onsent severe unilateral pelvic pain. Pain gets worse over time. Nausea and Vomiting. Pain doesn't settle with analgesics. O/E - Localised Tenderness and Palpable mass.

Question 31

What is the Ix and Tx of Ovarian Torsion?

Answer 31

Ix: - Pelvic Ultrasound is initial Investigation of choice. TVUS slightly better than Trans Abdominal. "whirlpool sign" and "Free Fluid in pelvis". Oedema of Ovary. Tx: - Laparoscopic surgery. Either un-twist or Removal of effected ovary. Complications: - necrosis > infection > Abscess > Sepsis. or - Rupture > Peritonitis and Adhesions.

Question 32

23-yr old with severe abdominal pain and 6 cm ovarian cyst on scan. Pain not settling with analgesics. How would you manage?

Answer 32

laparoscopy

Question 33

A 72-yr old women has new onset bloating and early satiety. What investigation would you organise for her?

Answer 33

CA125 and Ultrasound. Nice guidelines suggest doing CA125 and TVUS for any new onset bloating/ abdominal distension especially women > 50 yrs. Worried about Ovarian Cancer

Question 34

When are patients invited for there first cervical smear?

Answer 34

25 years old (until they hit 65 years)

Question 35

If an individual has a negative hr HPV (high-risk) on routine screening, when is there next smear test due?

Answer 35

5 years.

Question 36

If an individual has a positve HPV test on routine screening but is their cells look normal on cytology, when is there next smear test due?

Answer 36

1 year - Most individuals will be negative at this point . (back to 5 yearly screening) If pos again - 1 more year and re-test. If positive for 3rd time in 2 years - refer to Colposcopy.

Question 37

Following the treatment of high grade Cervical Intraepithelial Neoplasia, when is the test for cure done?

Answer 37

6 months with one smear. If negative then there is no need for further follow-up. Back to 5 yearly review.

Question 38

What interventions can effectively reduce the chance of cervical cancer?

Answer 38

Cervical Screening. HPV vaccination. Smoking cessation.

Question 39

Gardasil 9 vaccine offers protection from what Lr and Hr HPVs?

Answer 39

Low-risk: 6 and 11 High risk: 16, 18, 31, 33 and 3 others.

Question 40

What is the most effective treatment in Endometrial cancer?

Answer 40

Hysterectomy

Question 41

What is PID?

Answer 41

An ascending infection of the pelvis. Complication of STIs e.g. Gonorrhoea or Chlamydia.

Question 42

How is PID treated?

Answer 42

Treatment is typically with Abx depending on the causative organism. Individual can be treated as out-patient as long as temp <38. >38 may require laparoscopic drainage of pus to make Abx more effective.