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Gynaecological Malignancies

Whether following a career in gynaecology, or becoming a general practitioner as the vast majority of us will do, knowledge of gynaecological malignancies is essential. Knowledge of screening processes, understanding results and recognising symptoms are all vital skills not only for passing exams but for future practice. This revision article will briefly cover all of these topics.

 

If you can only start by drilling two simple points into your memory then they should be these:

Important 'red flags' for gynaecological malignancies

Endometrial carcinoma

Post-menopausal bleeding

Causes around 1750 deaths per year in the UK

 

Risk Factors

  • Anything increasing oestrogen exposure: nulliparity, unopposed oestrogen                       therapy, obesity, functioning ovarian tumours, late menopause
  • Family History: breast, ovary, colon caner
  • Polycystic ovaries
  • Tamoxifen treatment
  • Diabetes

     

    Diagnosis

    Uterine Sampling

    Using a pipelle (specialised catheter) to take a sample of the endometrium. The pipelle is inserted through the cervical os and advanced until the tip touches the fundus. The inner piston is then withdrawn to create suction/a vacuum. The endometrial sample is obtained by moving the pipelle up and down within the uterine cavity. As the cannula is rotated during removal, a strip of endometrium is peeled off and sucked into the syringe. This is usually repeated four times.

     

    Diagram of uterine sampling- taken from https://www.beaumonthospitals.com/files/health-library/image

    Hysteroscopy

    Visualisation of abnormal endometrium and improved uterine sampling

     

    Uterine Ultrasound

    Not diagnostic, but thickened endometrium is suggestive/supportive.  Endometiral thickness suggestive of cancer:      

    • >5mm in post-menopausal women not on exogenous hormone therapy
    • >20mm in pre-monpausal women or those on hormone replacement

     

    Staging

    Stage 1) Body of uterus only

    Stage 2) Stage 1 plus Cervical involvement

    Stage 3) Further spread within pelvis

    Stage 4) Spread outside pelvis (commonly bladder and/or bowel)

     

    Treatment

    • Stages 1+2 = Total Hysterectomy +/- radiotherapy
    • Stages 3+4 = Any combination of: surgical resection, radiotherapy, chemotherapy and cytotoxics.  

     

    Cervical carcinoma

    Intermenstrual bleeding

    Causes around 1000 deaths a year in the UK

     

    Risk Factors

    • HPV
    • Prolonged COCP use
    • High parity

     

    Staging

    Stage 1) Cervix only  (Stage 1a: microscopic, limited to the stroma, maximum depth of 5mm and width of 7mm.  Stage 1b: Visible cervical lesions or large microscopic lesions)

    Stage 2) Extended to vagina

    Stage 3) Spread to (a)lower vagina or (b)pelvic wall

    Stage 4) Spread to bladder or rectum (4b-distant organs)

     

    Treatment

    • Stage 1a = Cervical conisation or Hysterectomy.
    • Stage 1b = Radical hysterectomy plus Lymphadenectomy or Radiotherapy
    • Stages 2 to 4 = Chemotherapy

     

    Smear Screening, taken from http://medicalimages.allrefer.com/large/the-pap-smear.jpg

    Screening

    • Ages 25 - 49    Every 3 years
    • Ages 50 - 64   Every 5 years

     

    Pre-malignant disease: Cervical intraepithelial neoplasia (CIN)

    Cervical intra-epithelial disease (CIN) =  The transformation and dysplasia of squamous cells on the surface of the cervix. Most cases of CIN do not progress, or are resolved by the action of the individual’s immune system. However a small proportion develop into cervical cancer if not treated before.

     

    A more detailed description of Cervical Screening can be found here.  

    Ovarian Carcinoma

    Causes around 4500 deaths a year in the UK (more than endometrial and cervical malignancies combined as it usually presents late once the disease has metastasised).

     

    Risk factors

    • Two first-degree relatives affected - 40% lifetime risk
    • BRCA1 mutation - 40% lifetime risk
    • BRCA2 mutation - 25% lifetime risk
    • Unopposed oestrogen exposure; nulliparity, early menarche etc.
    • The contracteptive pill is protective

     

    Presentation

    Symptoms are often vague such as abdominal discomfort or distention. Other possible symptoms include ascites and urinary frequency.

     

    Staging

    Stage 1) Only in ovaries

    Stage 2) Beyond ovaries but only in pelvis

    Stage 3) Involving retroperitoneal nodes/inguinal nodes/peritoneal implants outside pelvis

    Stage 4) Distant metstases

     

    Treatment

    Surgical de-bulking of the tumour followed by 6 months chemotherapy.  

     

    The 5-year survival is:

    • 42% for stage 3
    • 14% for stage 4

     

    The rarer gynaecological malignancies

     

    Vulval carcinoma

    • Rare
    • Occur in the elderly
    • Indurated ulcer with everted edge
    • Often un-noticed and presents late
    • Can present with pain or bleeding
    • Some association with HPV

     

      Can be preceeded by vulval intra-epithelial neoplasia which may present as vulval pruritus.  This can be excised or treated with laser ablation.  

       

      Stage 1) If tumour<2cm and no nodal involvement treat with ‘triple incision' surgery

      Stage 2) Treat by radical vulvectomy (=wide removal of vulva and inguinal nodes)

       

       

      Vaginal malignancy

      • Mainly adenocarcinoma
      • Presents as bleeding (IMB, PCB or PMB)
      • Treatment by radiotherapy
      • Spread increases cervical cancer risk
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