Ken LimConsultant Gynaecological Oncology
SurgeonWelsh Regional Centre for Gynaecological Oncology
Llandough Hospital
• Mrs REM is a 67 year old retired solicitor on HRT presented with heavy PV bleeding to the GP.
• She is overweight and a non insulin dependent diabetic.
• Rapid access referral to local gynaecologist, who then performed pipellebiopsy of the endometrium and a transvaginal scan. This demonstrated –
1. Complex atypical hyperplasia on histology
2. 20mm endometrial thickness
A Hysteroscopy is therefore warranted
TAH and BSO +/- LN
Difficulties with large patient and comorbity
Risk of complications
Role of lymphadenectomy still unsure –ASTEC trial
(Total Abdominal Hysterectomy and bilateral
salpingoopherectomy and possibly lymph node dissection)
Histology of TAH
• More than 50%
invasion of
myometrium (Stage
1C) with Negative
Lymph Nodes
• Will require adjuvant
treatment
• Mrs JW is 70 and was visiting her son in Canada
• She developed abdominal distension and bloating was diagnosed with irritable bowel syndrome. A week after her return to the UK she developed a swollen left leg and was diagnosed with a DVT.
• On further vaginal examination she was found to have a mass in the pelvis
• An abdominal ultrasound scan demonstrated –– “12cm x 14cm multiloculated mass in the right iliac fossaand extending into the Pouch of Douglas, there is also a moderate amount of ascites”
– Ca 125 came back as 970iu/l.
• The consultant gynaecological oncologist came to see her the next day to brief her on the management plan.
• Main aim to debulk to 0cm disease
• Attempt to remove ovaries and uterus and
omentum
• Also to clinically stage disease
Laparotomy results
• Moderately
differentiated serous
papillary
adenocarcinoma
• Surgically staged 3A
• Will require adjuvant
chemotherapy
Colposcopy
• Mrs RW is 28, nulliparous and a young professional
• She had a smear when she was 21 and since then has persistently defaulted from her smear
• She had persistent post coital bleeding for 4 months before presenting to her GP
• At examination the cervix appeared abnormal and she was then referred on to the local colposcopy unit
• An EUA, cystoscopy and biopsy confirms a 3.5cm mass confined to the cervix. An MRI demonstrated no further extent of the tumour
• Clinically and radiologically stage 1b1
• She arrives at the gynaeoncology clinic to discuss her treatment plans and options.
Suitable for
surgery
Radical Hysterectomy and Node
dissection• Histology confirms a
stage 1b1 squamous
cell cancer with
negative nodes
• The patient does not
require any further
adjuvant treatment
Treatment of cervical cancerFIGO Stage
Definition Management 5 yearsurvival
1 Confined to cervix
1A1 Microinvasive disease <3 mm Cone biopsy <95%
1A2 Microinvasive 3-5 mm Simple Hysterectomy
1B Visible tumour 80%
1B1 < 4 cms Radical Hysterectomy and ND*
1B2 > 4 cms Chemoradiotherapy
2A Extension to upper two thirds of vagina
Radical Hysterectomy 60-70%
2B Parametrium Chemoradiotherpay 50%
3 Extension to
Case dependent
3A Lower third ofvagina
37%
3B Pelvic Wall 25%
4A Extension tobladder or rectum
>10%
4B Distant metastases eg lung 0%
*Fertility sparing surgery (if <2cm) – radical trachelectomy and laparoscopic LN
Recurrent Cervical/endometrial
cancer• If had full radical dose
of radiotherapy and
ONLY central disease
then….
• Exenterative
procedure (Removal
of bladder +/- rectum)
• Mrs GT is a catering manager who has been suffering with quite severe pruritis vulvae for the 2 years
– No help with various creams
– A 3 cm nodule was discovered on the left labia which bled easily
– A lump was found on the right groin
• Referred to the gynaecological oncology centre
• EUA and Wide Local Excision scheduled for the following week– “a moderately differentiated
Squamous Cell Carcinoma extending to the cut margins”.
• A CT scan – 1 abnormal looking lymph
nodes in the right groin measuring 2 cm and was thought to be suspicious of a metastasis
• She was brought back to the clinic the following week for the results.
• Definitive surgery is Radical excision (hemivulvectomy/vulvectomy/WLE) and Bilateral groin node dissection
• Choice of whether unilateral or bilateral groin nodes performed is dependent on the distance from midline
• Complications include
– 50% risk of wound breakdown
– High risk of lymphoedema
Follow Up
• Very variable
• No evidence that it is useful in detecting early recurrence
• Other useful reasons to follow up– Complications
– Patient and Physician morale
– Research data
• Currently – 3 months (1st year)
– 6 months (2nd year)
– Yearly till 5 years