A 60yo lady (LMP 8yrs ago) presents to the PMB clinic with a 2/52 history of spotting.
What is your differential diagnosis for PMB?
- vaginal atrophy
- endometrial/cervical polyps
- endometrial hyperplasia
- HRT
- endometrial carcinoma - until proven otherwise
- cervical or ovarian carcinoma
A 60yo lady (LMP 8yrs ago) presents to the PMB clinic with a 2/52 history of spotting.
How will you investigate her?
- TVUS to look at endometrial thickness
- if >5 mm: hysteroscopy + endometrial biopsy for diagnosis + histology
- FBC
- CT chest/abdo/pelvis +/- MRI pelvis: for staging
What is the most common type of endometrial carcinoma?
80% adenocarcinomas (oestrogen-dependent)
Suggest possible risk factors for endometrial carcinomas
Prolonged periods of unopposed oestrogen:
- early menarche, late menopause, nulliparity, 1st child >30yo
- obesity + DM
- PCOS
- tamoxifen
- previous breast/ovarian cancer
- BRCA1/2 and HNPCC
- endometrial polyps/hyperplasia
- Parkinson’s disease
Which staging system is used for endometrial cancer?
FIGO staging:
I. limited to myometrium
II. cervical spread
III. uterine serosa, ovaries/tubes or vagina, pelvis/para-aortic LNs
IV. bladder/bowel involvement or distant mets e.g. lung, liver, bone
What are the management options for endometrial cancer?
- hysterectomy + bilateral salpingo-oophorectomy: 1st line for most pts
- +/- adjuvant RT: if high recurrence risk or stage III-IV
- non-surgical alternatives:
- progestogens e.g. for stage IA without myometrial invasion in women who wish to preserve fertility
- primary RT
- chemo
- palliative care
What is endometrial hyperplasia? What are the 2 types?
Abnormal proliferation of endometrium:
- hyperplasia without atypia: <5% risk of progression to carcinoma within 20yrs
- atypical hyperplasia (cytological change present): pre-malignant condition with 28% risk of progression
What treatment would you offer a woman with endometrial hyperplasia (without atypia + atypical)?
Without atypia:
- reassurance (most return to normal) + watchful waiting
- progestogen Tx e.g. levonorgestrel IUD
- 6-monthly biopsies until 2 consecutive ones are negative (annual biopsy thereafter for high-risk women e.g. BMI >35)
- hysterectomy: may be required if no regression after 1yr of Tx or woman’s preference
Atypical:
- total hysterectomy + bilateral salpingo-oophorectomy for post-menopausal women
- progestogen Tx as above for women wishing to preserve fertility with 3 monthly biopsies + hysterectomy as soon as potential fertility no longer required
A 27yo woman is referred to gynae OP due to an abnormal cervical smear result.
How should she be investigated?
- colposcopy + biopsy
What are the main types of cervical cancer?
- squamous cell cancer (80%)
2. adenocarcinoma (20%)
What are the main risk factors for cervical cancer?
- HPV 16, 18 and 33 infection
- early 1st intercourse, many sexual partners
- smoking
- low SES
- HIV
- high parity
- COCP
How does HPV cause cervical cancer?
HPV 16 produces E6: inhibits p53 tumour suppressor gene
HPV 18 produces E7: inhibits Rb suppressor gene
What are the management options for cervical cancer according to stage?
Stage IA (confined to cervix, <7mm wide)
- hysterectomy +/- LN clearance OR
- cone biopsy with -ve margins + close f/u
Stage IB (confined to cervix, >7mm wide)
- RT + CISPLATIN chemo OR
- radical hysterectomy + pelvic LN dissection (if >4cm)
Stage II and III
- RT + chemo
- +/- nephrostomy if hydronephrosis
Stage IV
- RT and/or chemo
- palliative chemo if stage IV B
How often should women be screened for cervical cancer?
- age 25-49: every 3yrs
- age 50-64: every 5yrs
in pregnancy, usually delayed 3/12 post-partum unless missed screening or previous abnormal smears
A 55yo woman presents to the GP with a 3/12 history of abdo. discomfort + bloating, as well as fatigue + 6kg weight loss. No PMH of note. O/E: NAD.
How should she be investigated/managed by the GP?
- measure CA-125
- if raised (35 IU/mL): urgent abdo/pelvis USS
- if abnormal: urgent 2ww gynae referral
Suggest possible causes for a raised CA 125.
- ovarian cancer
- endometriosis
- PID
- pregnancy
- ovarian cyst torsion, rupture or haemorrhage
- other cancer e.g. peritoneal, lung, pancreatic
- other peritoneal pathology (trauma, irritation)
- HF
A 55yo woman presents to the GP with a 3/12 history of abdo. discomfort + bloating, as well as fatigue + 6kg weight loss. She has a raised CA-125 and abnormal pelvic USS.
How should she be assessed in secondary care?
- measure Risk Malignancy Index 1 score
2. CT abdo/pelvis +/- chest: to confirm Dx + extent
How is RMI 1 calculated?
USS score x menopausal score x CA 125 (IU/ml)
USS score: multilocular cyst, solid areas, bilateral lesions, ascites, intra-abdominal mets (1 = 1 abnormality, 3 = 2+ abnormalities)
Menopausal score: 1 = premenopausal, 3 = postmenopausal
What are the main types of ovarian cancer? Which subtype is most common?
- epithelial ovarian cancers (90%): most common subtype = serous cystadenoma (characterised by Psamomma bodies)
- germ cell tumours (5-10%)
- sex-cord stromal tumours (<5%)
Which blood tests should be performed in a woman <40yrs with ovarian cancer?
- AFP: to exclude endodermal sinus tumours
- B-hCG: to exclude dysgerminomas, embryonal carcinomas or choriocarcinomas
- LDH
What are the main risk factors for development of ovarian cancer?
- smoking
2, obesity + DM - asbestos or RT exposure
- FHx
- BRCA1/2 genes
- previous ovarian, breast or bowel cancer
- endometriosis
- infertility + use of fertility drugs e.g. clomifene
- nulliparity, early menarche, late menopause
- HRT use >5yrs
What are the treatment options for a woman with ovarian cancer?
- total abdominal hysterectomy
OR unilateral salpingo-oophorectomy (if early ovarian cancer in young woman who desires fertility)
Further Mx depends on stage + histology of tumour:
- adjuvant chemo: if stage II-!V
- interval debulking
- palliative care
