Gynaecological cancer

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Gynaecological cancer

• Laura Bealey

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Case - Presentation

• 70 year old female
• Presented with several hours of vaginal bleeding
  on 9th July 2012.
• PMH LVH, HTN, Breast cancer, type 2 diabetes,
  DVT.
• Taking warfarin and tamoxifen
• Nulliparous
• Examination atrophic inflammed vulva, speculum
  examination NAD.
• Referred to gynae on 2ww

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Case - Investigations

• Saw gynae on 24th July.
• Had hysteroscopy endocervical canal normal,
  unable to enter the uterine cavity as tight
  internal os.
• Speculum showed cervical polyp.
• Pipelle biopsy taken.
• Endometrial sample highly suspicious of
  endometrial neoplasm.
• Ultrasound scan showed a 5cm irregular mass.

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Case - Treatment

• 23rd August.
• Patient had a hysterectomy with bilateral
  salpingo-oophrectomy.
• Originally planned laproscipic operation but had
  to be converted to open due to the size of
  fibroids that were removed.
• 10th September diagnosed as uterine sarcoma,
  stage 3B.
• Radiotherapy carried out after operation,
  completed 19th November.

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Case - Recurrence

• 4th February 2013
• Worsening lower abdo pain over the last month
• On examination tender lower abdomen ?mass.
• Admitted to WPH for assessment.
• Discharged on 22nd February widespread abdominal
  mets, acute renal failure and DIC.
• Died at home 23/02/13.

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Uterine sarcoma

• Arise in the uterine muscle
• Rarely can occur due to transformation of a
  previously benign fibromyoma
• Occur in adults and present with uterine bleeding
• They grow rapidly giving increasing pain
• The prognosis is poor
• Stage 3 64 28 5 year survival.

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NICE guidelines gynaecological cancer.

• Gynaecological cancers may present as
• - Intermenstrual bleeding
• - Post-coital bleeding
• - Postmenopausal bleeding
• - Vaginal discharge
• When a patient presents with any of these
  symptoms a full pelvic examination including
  speculum should be done.
• If on examination the cervix has features that
  make you suspicious of cancer a 2ww referral
  should be done and no smear should be taken.

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NICE guidelines Ovarian cancer

• Difficult to diagnose due to vague symptoms
• - Bloating
• - Abdominal pain
• - Back pain
• - Constipation
• Urinary symptoms
• In a women presenting with unexplained symptoms a
  pelvic examination should be carried out.

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NICE guidelines

• Any patient presenting with an abdominal mass
  should have an urgent ultrasound scan.
• If the scan is suggestive of cancer or an urgent
  USS can not be arranged an urgent referral should
  be sent to gynaecology.

10
Postmenopausal bleeding

• If a women presents with postmenopausal bleeding
  she should be referred on a 2ww.
• Unless she is on HRT. In this case a referral
  should be made if the bleeding persists for more
  than 6 weeks after the HRT has been stopped.
• If a lady is taking tamoxifen then they should be
  referred immediately if they are on HRT or not.
• An urgent referral should be considered in a
  patient with persistent inter-menstrual bleeding
  and a negative pelvic examination.

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Vulval cancer

• Urgent referral should be made for
• - Unexplained vulval lump
• - Vulval bleeding or ulceration
• For pruritus or pain it is reasonable to treat,
  watch and wait.
• If symptoms persist you can refer urgently or
  non-urgently depending on your suspicion of
  cancer.