Epithelial ovarian cancers (EOCs) are the most common cause of death from gynaecological malignancy in the developed world. EOCs comprise a heterogeneous group of neoplasms including serous (68 %), clear cell (13 %), endometrioid (9 %) and mucinous (3 %) pathological subtypes.

https://​www.​rcog.​org.​uk/​globalassets/​documents/​guidelines/​scientific-impact-papers/​sip44hgscs.​pdf

The risk of endometrial cancer in a low-risk woman in the UK is 2.7 %. However, it may be increased in certain high-risk groups. The hereditary non-polyposis colon cancer syndrome (HNPCC—Lynch syndrome) is a predominantly colorectal cancer syndrome with an increased risk for cancer of the endometrium, ovary, stomach, urothelium and pancreas. Two genes account for the majority of the families with HNPCC − MLH1 and MSH2. Germline MSH6 mutations, which are rare in HNPCC, have been reported in several families with multiple members affected with endometrial carcinoma. These genes show highly penetrant autosomal dominant inheritance. In males the lifetime risk of colorectal cancer by 70 is 70 %. In females it is 50 % by 70, with an equally high risk for endometrial cancer and a lifetime risk for ovarian cancer of 12 %.

HNPCC families are usually identified clinically by their family history of colorectal cancer rather than endometrial or ovarian cancer. Families most likely to have HNPCC fulfil all the Amsterdam criteria:

The appropriate surveillance method for endometrial cancer is still disputed, and some would argue that, given the relatively early presentation with symptoms and the relatively good prognosis, active surveillance is not warranted. Surveillance methods have included transvaginal ultrasound scans, pipelle aspiration and hysteroscopy. The detection rates for endometrial cancer using the pipelle were 97 % and 91 % in post- and premenopausal women, respectively.

Gardiner C. Family history of gynaecological cancers. Obstet Gynaecol Reprod Med. 17(12):356–61.

Use of the combined oral contraceptive pill has been shown to decrease the risk of endometrial cancer. This effect is likely to be due to the suppression of endometrial proliferation by the progestagen component of the oral contraceptive pill. Duration of use is important as patients with 12–23 months of use have a 40 % reduction in risk, and women with 10 years use have a 60 % reduction. There is an ongoing research study to identify whether intrauterine progestagens, delivered using the MIRENA intrauterine contraceptive device, can reduce the risk of endometrial cancer in women with HNPCC mutations.

Gardiner C. Family history of gynaecological cancers. Obstet Gynaecol Reprod Med. 17(12):356–61.

It is not uncommon to find foci of malignant tumours in the ovaries of women who have undergone prophylactic oophorectomy for a high risk of ovarian cancer. A recent study found 12 % of women who underwent an oophorectomy because of a BRCA1 or BRCA2 mutation had occult ovarian tumours, which had not been identified by surveillance. A small number of women who undergo prophylactic oophorectomy subsequently go on to develop intra-abdominal carcinomatosis that is indistinguishable from ovarian cancer. These tumours are thought to be papillary serous carcinomas of the peritoneum, which shares a common embryological origin with the ovarian epithelium.

Gardiner C. Family history of gynaecological cancers. Obstet Gynaecol Reprod Med. 17(12):349–55. Subject – Gynaecology.

Increasing use of laparoscopy in oncology has led to a change in the surgical approach for borderline tumours, but there are concerns regarding the possibilities of cyst rupture, development of port-site metastases and understaging of disease; higher risk of recurrence and worsened survival have been documented. In the absence of clear evidence to the contrary, staging and treatment of borderline ovarian tumours should ideally be performed by midline laparotomy.

The risk of recurrence varies between 0 and 58 %, depending upon the histological type of borderline ovarian tumour and extent of primary surgery. Published evidence suggests that the incidence of invasive disease at recurrence varies from 8 to 73 %. For women treated with conservative surgery, clinical examination and vaginal ultrasound have been shown to benefit the detection of recurrent disease. Currently, we follow up every 3 months for the first 2 years, every 6 months for the next 2 years and annually thereafter.

Bagade P, Edmondson R, Nayar A. Management of borderline ovarian tumours. Obstet Gynaecol. 2012;14:115–20.

Borderline tumours represent a disease that is distinct from invasive ovarian cancer. It is now clear from molecular studies that there are at least two distinct forms of ovarian cancer.

High-grade serous cancers, which are associated with very high rates of p53 mutation, are the most common form of invasive neoplasm. Low-grade tumours, which include borderline ovarian tumours, are characterised by mutations of the BRAF/KRAS pathway. It is thus clear that there is no progression from one type to the other and that, although borderline ovarian tumours can progress to invasive disease, this tends to be the low-grade invasive phenotype rather than the high grade. There is no evidence that women with mutations of the BRCA genes, which clearly predispose to invasive cancers, are at increased risk for the development of borderline ovarian tumours.

Bagade P, Edmondson R, Nayar A. Management of borderline ovarian tumours. Obstet Gynaecol. 2012;14:115–20.

Ultrapotent steroids are important in the management of women diagnosed with lichen sclerosus. Corticosteroids have anti-inflammatory and immunosuppressive properties by altering lymphocyte differentiation and function and inhibiting cytokine production. Clobetasol propionate is the most potent topical corticosteroid available. Response rates reported from large-case series of women diagnosed with lichen sclerosus are high, with either complete or partial resolution of symptoms in 54–96 % of women. Approximately 4–10 % of women with anogenital lichen sclerosus will have symptoms that do not improve with topical ultrapotent steroids (steroid-resistant disease). The recommended second-line treatment is topical tacrolimus under the supervision of a specialist clinic.

Tacrolimus and pimecrolimus belong to the class of immunosuppressant drugs known as calcineurin inhibitors. Their mode of action differs from that of corticosteroids, mainly reducing inflammation by suppressing T-lymphocyte responses. Tacrolimus and pimecrolimus have both been shown to be effective at controlling a number of vulval dermatoses including lichen sclerosus and lichen planus.

RCOG Green-Top guideline No. 58 – The management of vulval skin disorders.

Anogenital lichen sclerosus can present at any age but is more commonly seen in postmenopausal women. It causes severe pruritus, which may be worse at night. The whole vulval perianal area may be affected in a figure-of-eight distribution. Uncontrollable scratching may cause trauma with bleeding and skin splitting and symptoms of discomfort, pain and dyspareunia. Lichen sclerosus is not linked to female hormone changes, contraceptives, hormone replacement therapy or the menopause. Evidence suggests that it is an autoimmune condition, with around 40 % of women with lichen sclerosus having or going on to develop another autoimmune condition.

RCOG Green-Top guideline No. 58 – The management of vulval skin disorders.

Lichen planus is a common skin disease which may affect the skin anywhere on the body. It usually affects mucosal surfaces and is more commonly seen in the oral mucosa. Lichen planus presents with polygonal flat-topped violaceous purpuric plaques and papules with a fine white reticular pattern (Wickham striae). However, in the mouth and genital region, it can be erosive and is more commonly associated with pain than with pruritus. Erosive lichen planus appears as a well-demarcated, glazed erythema around the introitus. The aetiology is unknown, but it may be an autoimmune condition. It can affect all ages and is not linked to hormonal status.

RCOG Green-Top guideline No. 58 – The management of vulval skin disorders.

Long-term follow-up of randomised clinical trials have reported similar survival rates for women treated by mastectomy or breast conservation surgery. However. all of these studies had selection criteria and indeed the vast majority of patients in these studies presented with tumours < 2.5 cm. Accurate preoperative assessment of the size and extent of the tumour is essential for deciding whether breast conservation surgery is an alternative option to mastectomy. Routine methods for assessing the extent of disease in the breast are clinical examination, mammography and ultrasound. In a significant number of cases, the true extent of disease is underestimated, particularly with invasive lobular cancer.

While many women may be suitable for breast conservation surgery, various factors (e.g. biological, patient choice) may lead to some women being advised or choosing to have a mastectomy for their disease.

Surgical guidelines for the management of breast cancer, association of breast surgery at BASO 2009. Eur J Surg Oncol. 2009. doi:10.​1016/​j.​ejso.​2009.​01.​008

Some patients with invasive breast cancer may be diagnosed with axillary disease prior to definitive surgery. The use of preoperative axillary assessment with ultrasound and appropriate fine-needle aspiration (or core biopsy if feasible) can yield a diagnosis of involved nodes in some cases. If a positive diagnosis of axillary nodal metastasis is made in a patient with early breast cancer, that patient should normally proceed to an axillary clearance. If an axillary clearance is carried out, all axillary lymph nodes should be removed unless there are specific reasons or unit policies not to do this. In the latter cases the anatomical level of dissection should be specified in the operation note. The number of nodes retrieved from axillary node clearance histology specimens will be both surgeon and pathologist dependent. However, for a full axillary clearance, at least 10 nodes should be retrieved in >90 % of cases.

Surgical guidelines for the management of breast cancer, Association of Breast Surgery at BASO 2009. Eur J Surg Oncol. 2009. doi:10.​1016/​j.​ejso.​2009.​01.​008

The NHS Breast Screening Programme provides free breast screening every three years for all women aged between 50 and 70 years. Once women reach the upper age limit for routine invitations for breast screening, they are encouraged to make their own appointment.

Women under 50 are not currently offered routine screening. Research has shown that routine screening in the 40–50 age group is less effective. As a woman goes through menopause, the glandular tissue in her breast ‘involutes’, that is to say, the proportion of fat in her breast increases. This makes the mammogram easier to interpret.

However, the DMIST study has shown that digital mammography is better for screening younger women and women with denser breasts and is equally effective as film mammography in older women. So the programme is now being gradually extended to women aged 47–49, as well as to those aged 71–73.

http://​www.​cancerscreening.​nhs.​uk/​breastscreen

A lump in the breast is a cause of great concern. High-frequency, high-resolution USG helps in its evaluation. This is exemplified in women with dense breast tissue where USG is useful in detecting small breast cancers that are not seen on mammography.

Several studies have described the sonographic characteristics commonly seen in benign lesions of the breast:

The following are the common benign causes of breast lump and their ultrasound characteristics:

Breast cysts—the commonest cause of breast lumps in women between 35 and 50 years of age. A cyst occurs when fluid accumulates due to obstruction of the extralobular terminal ducts, either due to fibrosis or because of intraductal epithelial proliferation. A cyst is seen on USG as a well-defined, round or oval, anechoic structure with a thin wall.