Gynaecological oncology and breast disease
Introduction
The exam tests the Czech screening programmes and, for each tumour site, the staging system and the first correct management step - plus triple assessment of breast disease.
Cervical cancer
- Screening: cervical cytology from 15 years within the annual preventive gynaecological examination; HPV testing is used for triage and follow-up.
- HPV 16 and 18 are the dominant oncotypes; vaccination before sexual debut is primary prevention.
- FIGO 2018: IA1 invasion ≤3 mm, IA2 3–5 mm, IB1 ≤2 cm, IB2 2–4 cm, IB3 ≥4 cm. Stages IA1 to IB1 permit fertility-sparing conisation or radical trachelectomy.
- Postcoital or contact bleeding demands colposcopy with targeted punch biopsy.
Endometrial cancer
- Postmenopausal bleeding is malignancy until excluded: transvaginal thickness ≤4 mm is reassuring; above that take Pipelle or hysteroscopic biopsy.
- Type I endometrioid carcinoma is oestrogen-driven and associated with obesity, diabetes and hypertension; Lynch syndrome accounts for a minority, so mismatch repair testing is performed in all cases.
- Stage I treatment: total hysterectomy with bilateral salpingo-oophorectomy and sentinel node staging.
Ovarian cancer
- High-grade serous carcinoma predominates; CA125 is not a screening test. The risk of malignancy index combines CA125, menopausal status and ultrasound score; RMI above 200–250 means referral to a gynaecological oncology centre.
- Early disease needs staging with hysterectomy, bilateral salpingo-oophorectomy, omentectomy and peritoneal biopsies; advanced disease is treated by maximal cytoreduction plus platinum–taxane chemotherapy.
Breast
- Triple assessment: clinical examination, imaging (mammography plus ultrasound in dense breasts or under 40) and core biopsy.
- Czech mammography screening: women aged 45–69, every 2 years.
- BI-RADS 2 benign, 4 suspicious, 5 highly suggestive of malignancy.
Worked example
A 61-year-old with postmenopausal bleeding has a 9-mm endometrium. Hysteroscopy and biopsy show grade 1 endometrioid adenocarcinoma; MRI suggests myometrial invasion under 50% with no nodal disease, so stage IA. She undergoes laparoscopic total hysterectomy, bilateral salpingo-oophorectomy and sentinel node biopsy, and needs no adjuvant radiotherapy because she is low risk. Mismatch repair testing is requested.
Traps
- Using a normal CA125 to reassure about an adnexal mass.
- Assuming a normal smear excludes endometrial cancer.
- Omitting Lynch syndrome testing.
- Failing to refer a woman with an RMI above the threshold to a cancer centre.