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PROLOG
Gynecologic Oncology and Critical Care
seventh edition

Online
Assessment
https://prolog.acog.org
Gynecologic Oncology and Critical Care
seventh edition

Critique Book

Online
Assessment
https://prolog.acog.org
ISBN 978-1-948258-11-1

Copyright 2016 by the American College of Obstetricians and Gynecologists. All rights
reserved. No part of this publication may be reproduced, stored in a retrieval system, posted
on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photo-
copying, recording, or otherwise, without prior written permission from the publisher.

2345/0

The American College of Obstetricians and Gynecologists

409 12th Street, SW
PO Box 96920
Washington, DC 20090-6920
Contributors

PROLOG Editorial and Advisory Committee

CHAIR MEMBERS
Ronald T. Burkman Jr, MD Louis Weinstein, MD
Professor of Obstetrics and Past Paul A. and Eloise B. Bowers
Gynecology Professor and Chair
Department of Obstetrics and Department of Obstetrics and
Gynecology Gynecology
Tufts University School of Medicine Thomas Jefferson University
Baystate Medical Center Philadelphia, Pennsylvania
Springfield, Massachusetts

PROLOG Task Force for Gynecologic Oncology and Critical Care, Seventh Edition

COCHAIRS MEMBERS
Linda Van Le, MD Leslie R. DeMars, MD
Leonard Palumbo Distinguished Associate Professor
Professor Director, Division of Gynecologic
Division of Gynecologic Oncology Oncology
University of North Carolina School of Dartmouth-Hitchcock Medical Center
Medicine Geisel School of Medicine at Dartmouth
Chapel Hill, North Carolina Lebanon, New Hampshire
Jason D. Wright, MD Marcela G. del Carmen, MD, MPH
Sol Goldman Associate Professor Associate Professor
Chief, Division of Gynecologic Oncology Division of Gynecologic Oncology
Columbia University College of Massachusetts General Hospital
Physicians and Surgeons Harvard Medical School
New York, New York Boston, Massachusetts
Linda R. Duska, MD
Professor
Department of Obstetrics and
Gynecology
Division of Gynecologic Oncology
University of Virginia
Charlottesville, Virginia
Kenneth H. Kim, MD
Assistant Residency Director
Division of Gynecologic Oncology
Department of Obstetrics and
Gynecology
The University of North Carolina School
of Medicine
Chapel Hill, North Carolina

Continued on next page

iii
iv
iv PROLOG

PROLOG Task Force for Gynecologic Oncology and Critical Care, Seventh Edition
(continued)
David M. Kushner, MD Cyril Spann, MD, SM
Director, Gynecologic Oncology Professor Emeritus, Emory University
Professor of Obstetrics and Gynecology School of Medicine
University of Wisconsin School of Dekalb Medical Center
Medicine and Public Health Decatur, Georgia
Madison, Wisconsin Deanna Teoh, MD
Michael McHale, MD Department of Obstetrics, Gynecology
Clinical Professor, Reproductive and Women’s Health
Medicine Division of Gynecologic Oncology
Fellowship Director University of Minnesota Masonic Cancer
Division of Gynecologic Oncology Center
Moores Cancer Center Minneapolis, Minnesota
University of California, San Diego
San Diego, California COLLEGE STAFF
Tashanna Myers, MD Sandra A. Carson, MD
Assistant Professor of Obstetrics and Vice President for Education
Gynecology Erica Bukevicz, MBA, MS
Tufts University School of Medicine Senior Director, Educational
Division of Gynecologic Oncology Development and Testing
Department of Obstetrics and Division of Education
Gynecology Christopher T. George, MLA
Baystate Medical Center Editor, PROLOG
Springfield, Massachusetts
Ritu Salani, MD, MBA
Associate Professor
Division of Gynecologic Oncology
The Ohio State Wexner Medical Center
Columbus, Ohio
PROLOG v

CONFLICT OF INTEREST DISCLOSURE

This PROLOG unit was developed under the direction of the PROLOG Advisory Committee
and the Task Force for Gynecologic Oncology and Critical Care, Seventh Edition. PROLOG
is planned and produced in accordance with the Standards for Enduring Materials of the
Accreditation Council for Continuing Medical Education. Any discussion of unapproved use
of products is clearly cited in the appropriate critique.
Current guidelines state that continuing medical education (CME) providers must ensure
that CME activities are free from the control of any commercial interest. The task force and
advisory committee members declare that neither they nor any business associate nor any
member of their immediate families has material interest, financial interest, or other relation-
ships with any company manufacturing commercial products relative to the topics included
in this publication or with any provider of commercial services discussed in the unit except
for Linda R. Duska, MD, who is a principal investigator for clinical trials funded by GSK,
Millenium, and BMS, and a contractor with Parexel working as an independent reviewer of
clinical trials, and a member of a DMSC for Inovio; Michael McHale, MD, who is on the
speakers bureau for Ethicon Biosurgery; and Jason D. Wright, MD, who is a consultant with
TheVax Genetics. All potential conflicts have been resolved through the American College
of Obstetricians and Gynecologists’ mechanism for resolving potential and real conflicts of
interest.
Preface
Purpose
PROLOG (Personal Review of Learning in Obstetrics and Gynecology) is a voluntary,
strictly confidential, self-evaluation program. PROLOG was developed specifically as a
personal study resource for the practicing obstetrician–gynecologist. It is presented as a self-
assessment mechanism that, with its accompanying performance information, should assist
the physician in designing a personal, self-directed lifelong learning program. It may be used
as a valuable study tool, a reference guide, and a means of attaining up-to-date information
in the specialty. The content is carefully selected and presented in multiple-choice questions
that are clinically oriented. The questions are designed to stimulate and challenge physicians
in areas of medical care that they confront in their practices or when they work as consultant
obstetrician–gynecologists.
PROLOG also provides the American College of Obstetricians and Gynecologists (the
College) with one mechanism to identify the educational needs of the Fellows. Individual
scores are reported only to the participant; however, cumulative performance data and evalu-
ation comments obtained for each PROLOG unit help determine the direction for future edu-
cational programs offered by the College.

Process
The PROLOG series offers the most current information available in five areas of the spe-
cialty: obstetrics, gynecology and surgery, reproductive endocrinology and infertility, gyne-
cologic oncology and critical care, and patient management in the office. A new PROLOG
unit is produced annually, addressing one of those subject areas. Gynecologic Oncology and
Critical Care, Seventh Edition, is the fourth unit in the seventh 5-year PROLOG series.
Each unit of PROLOG represents the efforts of a special task force of subject experts
under the supervision of an advisory committee. PROLOG sets forth current information as
viewed by recognized authorities in the field of women’s health. This educational resource
does not define a standard of care, nor is it intended to dictate an exclusive course of manage-
ment. It presents recognized methods and techniques of clinical practice for consideration by
obstetrician–gynecologists to incorporate in their practices. Variations of practice that take
into account the needs of the individual patient, resources, and the limitations that are special
to the institution or type of practice may be appropriate.
Each unit of PROLOG is presented as a two-part set, with performance information and
cognate credit available to those who choose to submit their answer sheets for confidential
scoring. The first part of the PROLOG set is the Assessment Book, which contains educa-
tional objectives for the unit and multiple-choice questions, and an answer sheet with a return
mailing envelope. Participants can work through the book at their own pace, choosing to use
PROLOG as a closed- or open-book assessment. Return of the answer sheet for scoring is
encouraged but voluntary.
The second part of PROLOG is the Critique Book, which reviews the educational objec-
tives and questions set forth in the Assessment Book and contains a discussion, or critique, of
each question. The critique provides the rationale for correct and incorrect options. Current,
accessible references are listed for each item.

Continuing Medical Education Credit

ACCME Accreditation
The American College of Obstetricians and Gynecologists is accredited by the Accreditation
Council for Continuing Medical Education (ACCME) to provide continuing medical educa-
tion for physicians.
AMA PRA Category 1 Credit(s)™
The American College of Obstetricians and Gynecologists designates this enduring material
for a maximum of 25 AMA PRA Category 1 Credits™. Physicians should claim only the
credit commensurate with the extent of their participation in the activity.

vii
viii PROLOG

College Cognate Credit(s)

The American College of Obstetricians and Gynecologists designates this enduring mate-
rial for a maximum of 25 Category 1 College Cognate Credits. The College has a reciproc-
ity agreement with the American Medical Association that allows AMA PRA Category 1
Credits™ to be equivalent to College Cognate Credits.
Fellows who submit their answer sheets for scoring will be credited with 25 hours.
Participants who return their answer sheets for CME credit will receive a Performance Report
that provides a comparison of their scores with the scores of a sample group of physicians
who have taken the unit as an examination. An individual may request credit only once for
each unit. Please allow 4–6 weeks to process answer sheets.
Credit for PROLOG Gynecologic Oncology and Critical Care, Seventh Edition, is ini-
tially available through December 2018. During that year, the unit will be reevaluated. If the
content remains current, credit is extended for an additional 3 years, with credit for the unit
automatically withdrawn after December 2021.

Conclusion
PROLOG was developed specifically as a personal study resource for the practicing
obstetrician–gynecologist. It is presented as a self-assessment mechanism that, with its
accompanying performance information, should assist the physician in designing a personal,
self-directed learning program. The many quality resources developed by the College,
as detailed each year in the College’s Publications and Educational Materials Catalog,
are available to help fulfill the educational interests and needs that have been identified.
PROLOG is not intended as a substitute for the certification or recertification programs of
the American Board of Obstetrics and Gynecology.

PROLOG CME SCHEDULE

Gynecologic Oncology and Critical Care, Credit through 2016
Sixth Edition
Patient Management in the Office, Reevaluated in 2014–
Sixth Edition Credit through 2017
Obstetrics, Seventh Edition Reevaluated in 2015–
Credit through 2018
Gynecology and Surgery, Seventh Edition Reevaluated in 2016–
Credit through 2019
Reproductive Endocrinology and Infertility, Reevaluated in 2017–
Seventh Edition Credit through 2020
Gynecologic Oncology and Critical Care, Reevaluated in 2018–
Seventh Edition Credit through 2021
PROLOG Objectives

PROLOG is a voluntary, strictly confidential, personal continuing education resource that

is designed to be stimulating and enjoyable. By participating in PROLOG, obstetrician–
gynecologists will be able to do the following:
• Review and update clinical knowledge.
• Recognize areas of knowledge and practice in which they excel, be stimulated to explore
other areas of the specialty, and identify areas requiring further study.
 Plan continuing education activities in light of identified strengths and deficiencies.
 Compare and relate present knowledge and skills with those of other participants.
 Obtain continuing medical education credit, if desired.
 Have complete personal control of the setting and of the pace of the experience.

The obstetrician–gynecologist who completes Gynecologic Oncology and Critical Care,

Seventh Edition, will be able to
 identify epidemiologic factors that contribute to the risks of various malignancies and
determine appropriate screening tests.
 analyze the pathophysiology and evaluate the histopathology of various malignancies.
 associate symptoms with early onset of specific malignancies, determine appropriate diag-
nostic tests, and select diagnosis.
 identify physical and surgical findings related to specific stages of malignant disease.
 determine appropriate surgical and nonsurgical management for various types of cancer
and identify common complications of therapy.
 determine approaches for preoperative assessment, select surgical techniques for gyneco-
logic disorders, and identify common complications of surgery.
 apply knowledge of anatomy, wound management, and appropriate surgical techniques in
the surgical therapy of gynecologic disease.
 determine the appropriate management of the critical care patient.

Gynecologic Oncology and Critical Care, Seventh Edition, includes the following topics
(item numbers appear in parentheses):

SCREENING AND DIAGNOSIS

Atypical glandular cells test result (23)
Breast cancer (121)
Breast cancer risk factors (36, 55)
Breast surveillance in patients who are BRCA positive (13)
Cervical cancer staging (93)
Cervical cytology screening (67, 102)
Colon cancer (53)
Complete mole (144–147)
Endometrial cancer (78)
Endometrial cancer recurrence (85)
Evaluation of palpable breast mass (10)
Follow-up of patient with endometrial cancer (35)
High-risk gestational trophoblastic disease (4)
Human papillomavirus primary screening (86)
Human papillomavirus vaccination (15)
Immunohistochemistry staining for pathologic evaluation (29)
Indications for BRCA testing (2)
Lung compliance complications (105)
Lymph node involvement in cervical cancer (101)
Lynch syndrome (1, 91)

ix
x PROLOG

Malignant ascites (103)

Ovarian cancer (113)
Ovarian cancer recurrence (65)
Paraneoplastic syndrome (3)
Posttreatment surveillance in cervical cancer (72)
Preoperative cardiac risk assessment (20)
Preoperative diagnosis of pelvic mass (41)
Pseudomyxoma peritonei (27)
Pulmonary embolism (5)
Radiation cystitis (114)
Systemic inflammatory response syndrome and sepsis (151–153)
Tumor markers (143)
Vulvar cancer (118)

MEDICAL MANAGEMENT
Acupuncture for cancer patients (124)
Acute kidney injury (139)
Acute respiratory distress syndrome (77)
Adenocarcinoma in situ of the cervix (89)
Adverse effects of aromatase inhibitors (52)
Antibiotic prophylaxis (154–157)
Basal cell carcinoma of the vulva (100)
Breast cancer (98)
Breast ductal carcinoma in situ (119)
Cancer in older women (129)
Cell salvage (60)
Cervical cancer (135)
Cervical cancer in pregnancy (9)
Cervical dysplasia in younger women (82)
Chemoradiotherapy and cervical cancer (97)
Chemotherapy-associated emesis (34)
Chemotherapy for recurrent ovarian cancer (75)
Chemotherapy for serous endometrial cancer (94)
Chemotherapy-induced anemia (28)
Clostridium difficile infection (69)
Complementary and alternative medicine (45)
Complex adnexal mass in a postmenopausal woman (42)
Complex hyperplasia with atypia (43)
Complications of chemotherapy (26)
Deep vein thrombosis (14)
Early-stage cervical cancer (38)
Endometrial cancer (39, 83)
Febrile neutropenia (48)
Fertility-sparing therapy for gynecologic malignancies (108, 138)
Hemodynamic monitoring (148–150)
Heparin-induced thrombocytopenia (73)
Hereditary breast and ovarian cancer (88)
Hormone therapy in BRCA patients (133)
Human chorionic gonadotropin (19, 49)
Hyperkalemia (32)
Initial chemotherapy for ovarian cancer (54)
Large-bowel abnormalities (12)
Low-grade serous ovarian cancer (74)
Low-risk gestational trophoblastic disease (136)
PROLOG xi

Malignant ovarian germ cell tumor (31)

Malignant pleural effusion (44)
Mechanical ventilation (117, 128)
Microinvasive cervical cancer (70, 142)
Necrotizing fasciitis (16)
Needlestick injury and human immunodeficiency virus infection (109)
Nosocomial aspiration pneumonia (95)
Nutrition in a postsurgical patient (63)
Ovarian cancer (68, 130)
Paget disease of the vulva (92)
Pain medication after surgery (123)
Palliative care (30, 111)
Perioperative venous thromboprophylaxis (7)
Placental-site trophoblastic tumor (64)
Postmolar gestational trophoblastic disease (110)
Postoperative feeding (46)
Postoperative ileus (131)
Radiation enteritis (132)
Sepsis (87)
Sex cord–stromal tumors of the ovary (47)
Small cell cervical cancer (106)
Squamous dysplasia in pregnancy (125)
Tamoxifen citrate therapy (8, 141)
Thromboprophylaxis (127)
Uterine carcinosarcoma (25)
Uterine smooth muscle tumor of uncertain malignant potential (33)
Vulvar intraepithelial neoplasia (62)

PHYSIOLOGY
Sexual function after vulvectomy (99)
Ureteral injury (76, 90)

SURGICAL MANAGEMENT
Bladder injury during abdominal surgery (71)
Blood product selection after massive hemorrhage (18)
Breast cancer (96)
Cervical cancer (59)
Cystoscopy (50)
Cytoreductive surgery (22)
Follow-up of patient with endometrial cancer (35)
Incisional hernia repair (112)
Intraoperative hemorrhage (58)
Intraoperative rupture of a malignant ovarian cyst (122)
Intraperitoneal chemotherapy (115)
Laparoscopic complications (11)
Laparoscopic port-site metastases (126)
Leiomyosarcoma (21)
Low-malignant-potential tumor of ovary (66)
Lymphadenectomy complications (140)
Lymphedema (134)
Malignant ovarian germ cell tumor (61)
Patient with ovarian mass (107)
Pelvic exenteration (84)
Postoperative hemorrhage (40)
xii
xii PROLOG

Preoperative care of an obese patient (120)

Preoperative mechanical bowel preparation (57)
Ureteral injury (76, 90)
Use of sealants in gynecologic cancer surgery (158–160)
Wound infection in an obese patient (137)

EPIDEMIOLOGY AND BIOSTATISTICS

Breast cancer risk factors (36, 55)
Clear cell ovarian cancer (80)
Colon cancer (79)
Endometriosis-associated ovarian cancer (104)
Fibrocystic changes and risk of breast cancer (17)
In vitro fertilization and ovarian cancer (56)
Lung compliance complications (105)
Lymphedema (134)
Performance characteristics of a test (24)
Risk of infection from blood transfusion (81)
Serous endometrial cancer (51)
Sexual function after vulvectomy (99)
Tamoxifen citrate therapy (8, 141)

COUNSELING
Acupuncture for cancer patients (124)
Cancer survivorship (116)
Complementary and alternative medicine (45)
Human papillomavirus (37)
Sexual function after vulvectomy (99)
Tamoxifen citrate therapy (141)

ETHICAL AND LEGAL ISSUES

Advance directives (6)

A complete subject matter index appears at the end of the Critique Book.
1^
Lynch syndrome

A 45-year-old woman is diagnosed with grade 2 endometrioid adenocarcinoma of the endome-

trium, and she undergoes hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy.
She has a family history that includes cancer of the breast, lung, and colon in first-degree relatives.
The test that will best inform her of her risk of future cancer is immunohistochemical staining of
tumor tissue for

* (A) MLH1, MSH2 overexpression

(B) BRCA1 mutation
(C) progesterone receptor
(D) TP53 mutation
(E) PTEN mutation

Lynch II syndrome, also known as hereditary nonpoly- more of the nucleotide markers are unstable, the sensitiv-
posis colorectal cancer (HNPCC) syndrome, is an auto- ity of detecting HNPCC is 94%. For endometrial cancer,
somal dominant disorder characterized by germline results from immunohistochemistry for mismatch repair
mutations in the mismatch repair genes MLH1, MSH2, proteins MLH1, MSH2, MSH6, and PMS2 can be used
MSH6, PMS2, or EPCAM. Affected individuals have for rapid triage of patients at risk of HNPCC by family or
increased risks of cancer of the endometrium, ovary, gas- personal history or by age at diagnosis. Some institutions
tric tract, and small bowel. Lynch syndrome-associated recommend universal screening for endometrial cancer
endometrial cancer accounts for up to 6% of all endome- with immunohistochemistry profiling of mismatch repair
trial cancer. Therefore, identification of women who may proteins. Women with positive screening test results are
have Lynch syndrome is important to inform the patient referred for genetic counseling. In one series using uni-
and her family of additional cancer risks. Based on the versal screening, approximately 25% of women referred
described patient’s family history and her personal his- for genetic testing were found to have Lynch syndrome.
tory of endometrial cancer, she and her family are more Germline mutations in BRCA1 and BRCA2 are associ-
likely to have Lynch syndrome than another inherited ated with breast and ovarian cancer but not with endo-
familial cancer syndrome, as suggested clinically by the metrial cancer. Although TP53 mutations can be seen
modified Amsterdam and Bethesda criteria (Appendix in high-grade endometrial cancer, germline TP53 muta-
B). The modified Amsterdam criteria have only 40% tions are associated with Li–Fraumeni syndrome, which
sensitivity to identify individuals with an HNPCC muta- is associated with a high risk of soft tissue sarcomas;
tion. Alternatively, when HNPCC is present, character- leukemia; and adrenocortical cancer, breast cancer, and
istic abnormalities are seen in tumor tissue more than brain cancer. In women, the lifetime risk of an associated
90% of the time with immunohistochemistry testing for cancer reaches 100%, often with the first cancer occur-
mismatch repair protein overexpression or with microsat- ring in the fourth decade of life. Presence of progester-
ellite instability (MSI) testing. Individuals whose tumors one receptors suggests a type I endometrial cancer with
are identified as having markers for HNPCC then can good prognosis but does not suggest risk of other types
elect to proceed with genetic counseling and possible of cancer. Overexpression of PTEN is associated with
germline mutation testing. Cowden disease, which is an autosomal dominant dis-
The Bethesda guidelines for testing colorectal tumors order characterized by predisposition for breast cancer,
for MSI were established in 1997 and revised in 2002. thyroid cancer, and endometrial cancer as well as benign
The guidelines recommend that MSI testing of the mucocutaneous lesions.
tumor should be performed in any patient with colon
cancer who is younger than 50 years or in a patient with Heald B, Plesec T, Liu X, Pai R, Patil D, Moline J, et al. Implementation
synchronous or metachronous colon cancer or other of universal microsatellite instability and immunohistochemistry
screening for diagnosing Lynch syndrome in a large academic medical
HNPCC-candidate cancer, colon cancer with MSI histol- center. J Clin Oncol 2013;31:1336–40.
ogy, or colon cancer when the Amsterdam criteria are Lachiewicz MP, Kravochuck SE, O’Malley MM, Heald B, Church
fulfilled. When MSI testing is completed and two or JM, Kalady MF, et al. Prevalence of occult gynecologic malignancy at

* Indicates correct answer. 1

Note: See Appendix A for a table of normal values for laboratory tests.
2 PROLOG

the time of risk reducing and nonprophylactic surgery in patients with trial cancers at a large academic medical center. Gynecol Oncol
Lynch syndrome. Gynecol Oncol 2014;132:434–7. 2013;130:121–6.
Leenen CH, van Lier MG, van Doorn HC, van Leerdam ME, Kooi Resnick KE, Hampel H, Fishel R, Cohn DE. Current and emerging
SG, de Waard J, et al. Prospective evaluation of molecular screening trends in Lynch syndrome identification in women with endometrial
for Lynch syndrome in patients with endometrial cancer </= 70 years. cancer. Gynecol Oncol 2009;114:128–34.
Gynecol Oncol 2012;125:414–20.
Moline J, Mahdi H, Yang B, Biscotti C, Roma AA, Heald B, et al.
Implementation of tumor testing for Lynch syndrome in endome-

2^
Indications for BRCA testing

A 42-year-old woman, gravida 2, para 2, in whom breast cancer was diagnosed at age 38 years,
comes to your office for her annual well-woman visit. Her family history is significant for a mother
who was diagnosed with ovarian cancer at age 68 years and a maternal aunt who developed a low-
malignant-potential tumor of the ovary in her 20s. Her risk of having an inherited predisposition
for ovarian cancer or breast cancer is

(A) less than 1%

(B) 1–10%
(C) 11–20%
* (D) greater than 20%

The lifetime risk of breast cancer for a woman who carries ages at diagnosis of cancer, and Ashkenazi Jewish ances-
a BRCA1 or BRCA2 mutation is approximately 65–74%. try (ie, individuals who are descended from Jews who
The lifetime risk of ovarian cancer is 39–46% for a came from Eastern Europe). Family history can accurately
woman with a BRCA1 mutation and 12–20% for a woman place a patient in a high- or low-risk group for an inherit-
with a BRCA2 mutation. BRCA mutations occur in 3–5% able mutation. Efforts should be made to confirm family
of all cases of breast cancer. Approximately 10–15% of history through pathology reports that confirm invasive
cases of ovarian cancer are associated with a genetic pre- disease. For the described patient, her personal history of
disposition. Ovarian cancer is the most lethal of the gyne- breast cancer at age 38 years and her first-degree relative
cologic malignancies. It is important to identify women with ovarian cancer make her risk of a genetic mutation
with a personal or family history suggestive of a genetic greater than 20% (Box 2-1).
component to allow for timely referral for genetic testing, The spectrum of BRCA mutation-associated gyneco-
increased accuracy of risk assessment, and implementa- logic cancer includes ovarian cancer of predominantly
tion of risk-reducing strategies. serous and endometrioid histologies, tumors of the fal-
Women with BRCA1 mutations have earlier onset of lopian tube, and primary peritoneal cancer. Tumors of
breast cancer and ovarian cancer and a 40% higher risk low malignant potential and mucinous histology are
of second primary breast cancer compared with BRCA2 associated with other mutations and are not included in
mutation carriers. This risk of secondary cancer can be the spectrum of BRCA-associated cancer. Therefore, the
reduced with the use of adjuvant tamoxifen citrate, chemo- low-malignant-potential ovarian tumor in the patient’s
therapy, and salpingo-oophorectomy. Male BRCA2 muta- maternal aunt does not increase the patient’s risk of hav-
tion carriers have a higher risk of breast cancer and early ing an inheritable genetic mutation.
prostate cancer. Both genders have a higher incidence of Several risk-reducing strategies have been demon-
pancreatic cancer and melanoma. strated to decrease the incidence of breast cancer and
To identify women with a genetic predisposition, the ovarian cancer in patients with BRCA mutations. Risk-
family history should include a woman’s personal his- reducing salpingo-oophorectomy has been shown to
tory of cancer, first-degree relatives (parents, siblings, decrease the risk of breast cancer by approximately 50%
and children) with cancer, second-degree relatives (aunts, and to decrease the risk of ovarian cancer by 80–95%.
uncles, grandparents, nieces, and nephews) with cancer, Although breast cancer screening has been effective,
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cataracts, but on one of the lower stretches of the river; and so his
pleasant family party was broken up.”—The Times.
“He recalls very pleasantly the various incidents of that daily Nile
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exceptional experience, indeed, he met with. His dahabieh was
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old. He has written, in truth, a volume by no means deficient in the
quality which should be understood in the full sense of the term
—‘information;’ and his command of easy, graceful, and natural
language shows the literary faculty that might be expected in him.”—
Daily Telegraph.
“The charm of this diary consists in its faithful account of the life
and experiences of an English party travelling in Egypt. A very
exciting and alarming adventure befel them almost at the
commencement, the vessel in which they were travelling being
wrecked. The story of the disaster, and the narrow escape of the two
ladies and two gentlemen, is vividly told.”—Daily Chronicle.
“Messrs. Tinsley have seldom brought out a more attractive work
than this voyage upon the Nile.... The series of pictures furnished by
Mr. Arnold’s graphic description of the various scenes he visited
remain fixed on the mind’s eye of the reader long after the book is
closed.”—Court Journal.
“‘The book,’ says Mr. Arnold in his preface, ‘does not aspire to take
the place of any learned treatise or methodical guide, but simply to
catch the joyous spirit of the rich sunlight of the river, and to
reproduce its scenes and sights by easy and passing touches.’ This
aim it attains with very considerable success.... Really a delightful
book.”—Spectator.
“We cannot but congratulate Mr. Arnold on his success as a clever
and effective narrator. Seldom have we read a more enjoyable book
of travels than ‘Palms and Temples.’”—Literary World.
“Mr. Arnold’s book is distinctly new, novel, and interesting.”—Land
and Water.

Tinsley Brothers, 8, Catherine Street, Strand.

 New Books for the Season.
Tales and Traditions of Switzerland.
By William Westall, Author of “Larry Lohengrin,” “The Old
Factory,” etc. 1 vol. crown 8vo.

On the Grampian Hills:

Grouse and Ptarmigan Shooting, Deer-Stalking, Salmon and
Trout Fishing, etc. By Fred. Field Whitehurst (“A Veteran”),
Author of “Tallyho,” “Harkaway.” 1 vol. 9s.

Road Scrapings:
Coaches and Coaching. By Martin E. Haworth, late Captain
60th Rifles, Queen’s Foreign Service Messenger, M.F.H., etc.,
Author of “The Silver Greyhound.” 1 vol. 8vo, with 12
Coloured Illustrations, 10s. 6d.

Men we Meet in the Field:

Or the Bullshire Hounds. By A. G. Bagot (“Bagatelle”),
Author of “Sporting Sketches in Three Continents,” etc. 1 vol.
7s. 6d.
 NEW WORKS OF TRAVEL.
With a Show through Southern Africa,
and Personal Reminiscences of the Transvaal War. By
Charles du Val, late of the Carbineers, Attaché to the Staff of
Garrison Commandant, and Editor of the News of the Camp
during the investment of Pretoria. 1 vol. demy 8vo, with
numerous Illustrations.

Palms and Temples:

Incidents of a Four Months’ Voyage on the Nile. With Notes
upon the Antiquities, Scenery, People, and Sport of Egypt. By
Julian B. Arnold. Prefatory Notice by Edwin Arnold, Author of
“The Light of Asia,” etc. 1 vol. demy 8vo, with Frontispiece
and Vignette, 12s.

Among the Sons of Han:

Notes of a Six Years’ Residence in China and Formosa. By
Mrs. T. F. Hughes. 1 vol. demy 8vo, with Map, 12s.

Keane’s Journeys to Meccah and Medinah.

Each in 1 vol. demy 8vo, 10s. 6d.

Tinsley Brothers, 8, Catherine Street, Strand.

 Transcriber’s Notes
Punctuation errors have been corrected.
Page 155: ‘case unprecendented’ changed to ‘case unprecedented’
Page 200: ‘ith what’ changed to ‘With what’
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