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Thankyouforjoining thisweek’s sessionoftheObs& Gynaeinthespotlightseries.We’rethrilled thatyou’reherewithus &hopethatyoufind thesessionuseful. Beforeyouuse ourresources,kindly takenoteofthefollowing: •Contentinthispresentationhasbeendesigned byourcommitteemembers,whoaremedical studentslike yourselves!Therefore,thequestionsmaynotberepresentativeofwhatcomesout inyourexamsandtheremaybeerrorsinthequestions. •DoNOTrelysolelyupontheseresourcesforyourmedicalpractice andexamrevision.Please refertoyourlocalguidelines and/orsupervising clinician ifyouneedanyclarification. •Wewouldbe gratefulifyoucouldtake thetimeatthesendofthesessiontofill outfeedback form.Thankyou.Session outline • Cervical cancer • Endometrial cancer • Ovarian cancer • Vulvalcancer • Through case studies Case study1 • 35yowoman presentstoher GPwithpostcoital bleeding. • Sheisworriedas it’sgettingworse. • What couldbe causingit?What questionswould you askher?Gynaehistorytaking • Histroryofpresentingcomplaint(SQITARS/SOCRATES) • Vaginalbleeding(IMB/PCB/PMB) • Vaginaldischarge/vulval itching/akinchanges • MenstrualHistory • Dyparenunia • Infertility • PMH- cervicalscreens/STIs/Pregnancies/ • Drughistory-allergies • FH • SH • SystemsWhichcauseisthemostlikely? • Cancer • Ectropion • Cervicitis • Cervical polyps • Dryness• She tells youshe’s never attended anyof her cervical screens nor had she received anyvaccinations asa child. She has a 10 packyear smoking history and she has had many sexual partners. • At whatage should she have received a vaccine that would decrease her chances atcervical cancer?Gardasil9 • It protects against nine types of HPV - HPV 6, 11, 16, 18, 31, 33, 45, 52 and 58. • At 12-13 yoSymptoms • Whenshouldshehave attendedCervical screenings?Howoftenare womencalled forroutinecervical screening? Every3yearsbetweentheagesof25and49, Every5yearsbetweentheagesof50and64Investigations • Cervical screen – identify dyskaryosis • Colposcopy- direct visualizationof the cervix • Cervical biopsy- large loop excision of the transformation zone (LLETZ)/ cone biopsy • CT chest+abdo+pelvis FIGO staging • STI checksManagementEndometrial cancerWhatare the riskfactors for endometrial cancer? •Protectivefactors •Multiparity •Continuous combined HRT •COCPRiskfactors • Nulliparity • Obesity • Earlymenarche • Latemenopause • PCOS • Oestrogen-onlyHRT • Tamoxifen • Diabetes • Lynch syndromeHowwould theypresent?Presentation • Abnormal bleeding • Postmenopausal • Intermenstrual • Watery/bloody discharge • Dyspareunia • Pelvicpain • Abdominal distensionand discomfort • Weight loss • Anaemia • Enlargeduterusonbimanual pelvic examinationpelvic pain,weightlossand abdo discomfort. Howdoyou investigate?Investigations Transvaginalultrasound •7.3%riskofcancer ifendometriumis >5mmwith PMB •< 0.07%riskofcancer ifendometriumis≤ 5mmwithPMB Endometrialbiopsy •Pipelle(mostcommonly) •Dilatation& curettage Hysteroscopy •Directvisualisationofthe endometrium CTchest/abdo/pelvis •FIGO stagingEndometrial hyperplasia Pre-malignant condition Can be with or without atypia Atypical cells may progress to carcinoma Endometrial carcinoma Type 1 (80%): Histology Adenocarcinoma Type 2 (20%): Serous Clear cell CarcinosarcomaFIGO staging Management • Stage1 –totalhysterectomy+ bilateralsalpingo-oophorectomy • Peritoneal washings taken • Stage2 –radicalhysterectomy+ bilateralsalpingo-oophorectomy • May be offeredadjuvant external beam radiotherapy orbrachytherapy • Stage3/4–de-bulkingsurgery • Additional chemotherapy and radiotherapy • Palliative approach may bepreferred – progestogensotherapy orhigh dose oralOvarian cancerWhataretheprotectivefactors? • Risk Factors: • Obesity • Smoking • Nulliparous • Early menarche • Late menopause • Oestrogen-onlyHRT • BRCA 1/2 • LynchsyndromeProtectivefactors • Multiparity • Breastfeeding • Earlymenopause • COCP • SterilisationHowwould theypresent?Presentation • Abdominal distension and discomfort • Early satiety • Urinary frequency • Inlaterstages: • Change inbowelhabits • Dyspareunia • Pelvic,backandabdominalpain • Ascites • PalpableabdominalorpelvicmassHowwould theyinvestigate?Investigations RiskofMalignancyIndex(RMI) •Menopausalstatus •Pelvicandabdominalultrasound •CA-125 AFP&β-hCG •Germcellcancers •Womenunder40 CTchest/abdo/pelvis •FIGOstaging Laparotomy •SurgicalstagingEpithelial (85-90%) Serous (50%) Mucinous (10-15%) Endometroid (10-15%) Clear cell (5%) Germ cell Teratoma Dysgerminoma Yolk sac Histology Choriocarcinoma Sex cordstromal Granulosa cell Theca cell Sertoli-Leydig Miscellaneous Lymphoma Krukenberg tumourManagement • Surgery • Staging laparotomy • TAHBSO • Debulking • Oophorectomymaybe consideredinwomenofreproductiveagewherethetumour isconfinedto oneovary • Adjuvantchemotherapy • diseasendedfor allapartfromthose with who havehadoptimal surgicalstagingandhavelow-riskstage1 • Platinum-basedcompounds i.e. carboplatin • Followup • Clinicalexamandmonitoring ofCA-125levelfor5 yearswithintervalsbetweenvisitsbecoming further apart • Recurrentdisease • PalliativechemotherapyVulvalcancerBackground • Very rare • 90% squamous call carcinoma • 10% : primary vulval melanoma, basal cell carcinoma, Bartholin’s gland carcinoma, adenocarcinoma, and rarely, sarcoma. st • Risk factors: HPV,multiplesexual partners, early age at1 sexual intercourse, cigarette smoking, lowsocio-economic statusPresentation • Purities • Soreness • Bleeding • Pain • Lump • Most squamous callcancers occur on the labiamajoraInvestigation,Staging,Management • Investigation: Keye’s punch biopsy • Management: surgerySBA1 • A 62-year-old female presents to • Diagnostic laparoscopy the clinic with postmenopausal • Endometrial biopsy vaginal bleeding. Transvaginal • HRT ultrasound shows endometrial thickness of 10 mm with no • Repeat USS in 6months other significant findings. • Observation without • Which of the following is the intervention most appropriate next step in management?SBA2 • A 59-year-womanpresentsto her • Ann- Arborstaging month historyof vaginal bleeding.- • Dukes’staging She saysthis occurs almost daily • TNMstaging and has progressed from a brown • FIGOstaging has alsolost approximately 3kgin • Gleason scoring weight in the past sixmonths, with no major changes toher diet. • An endometrial biopsy confirms endometrial cancer, andshe is referredfor furtherinvestigations. • stageendometrial cancer?s used toSBA3 • to her GP with symptoms ofts • CA-125levels bloating, early satiety and • Faecal calprotectin weight loss. She has no changes • Transvaginal ultrasound to bowel movement or blood in • Urgent colonoscopy the stool. She believes she may have IBS and would like advice • 2 week waitreferral to gynae on foods to avoid. She has no family history of note and has not had any children. • What is the most important initial investigation?SBA4 • A 27-year-old woman attends the GP with • Epithelial cell tumour last 6 weeks. She isnot currently sexually • Fibroids active. She has a 32-day regular • Germ cell tumour menstrual cycle. Stool culture is negative. A trial of a gluten-free diet and dairy-free • IBS examination, a suprapubic mass iss. On • Follicular cyst palpated. Serum tissue transglutaminase (tTTG) and immunoglobulin A (IgA) are negative. Alpha-fetoprotein (AFP) and hCG) are found to be raised. Anhin (b- abdominal ultrasound is performed, which identifies a pelvic mass, and she is investigation. Which isthe most likely diagnosis?SBA5 • A 68-year-oldwomanattendsthe • Metastaticbreastcancer bowel habit. Her sisterdied ofd • Epithelial celltumours breastcancerin her 40s.She is • Ductalcellcarcinomainsitu known to be positivefor • Stromalcell tumours mammogram8 weeks ago showed • Germcelltumour no signs of breast cancer.Her Ca125is found to be raised. An performed, which shows a suspicious largeovarian mass.She is referred togynaecology for further management.Which is the most likely histologicaldiagnosis?SBA6 • to gynaecology as she iseferred •assessmenttoneal lymphnode suspected of having ovarian cancer. She has a high Ca-125. • Start palliativecare The pelvic ultrasound is • Radiotherapy abnormal and so a chest- • Surgery aiming to remove all abdomen-pelvis CT is requested. macroscopic disease The CT shows that the cancer • Fullbody MRI has seeded in the peritoneum and the liver. • What of the following is the most appropriate next step?SBA7 • your clinic after receiving the • Cervical screening in 3years results of her cervical screening • Cervical screening in 1year test, which show borderline • Cervical screening ASAP changes in squamous cells and is • Cervical screening in 6months negative for high-risk HPV. She is anxious and asks when she • Cervical screening in 5years should have her next cervical screening test according to the NHS Cervical Screening appropriate advice?the mostSBA8 • A 27 year old woman attends for • Untreated natural history of the her cervical smear appointment disease mustbe known at the practice. She asks what a • Must bee an acceptable screening test is. Which of the surgical treatment following is a criteria a screenin• Condition must be eventually test must fulfil? terminal • Screening mustbe one off • Must be recognisable late symptomaticstageSBA9 • A 26 year old woman is newly • HPV 16&18 diagnosed with cervical cancer. • HSV 2 • Which of the following viruses i• HPV 6&11 most associated with cervical cancer? • EBV • HSV1SBA10 • Which of the following • Ferric subsulphate substances used in a colposcopy • Acetic acid procedure are taken up by • Silver nitrate abnormal cervical cells to enhance their appearance? • Iodine solution • LidocaineSBA11 • the gynaecology clinic to receive • year’s timed repeat scree in 3 the results of her most recent smear test. The results are • Refer for total hysterectomy positive for HPV with normal • Refer to colposcopy clinic cytology. She has had normal • Reassure arepeat screen in smears previously. The patient 3month’s time asks what the next steps would • Reassure and repeat screen at be for her ongoing management. 12 month’s time • What is the most appropriate next step in the management of thisSBA12 • A 75-year-old woman presents to her • Syphilis month history of a vulval burningsix- • Vulvovaginal candiasis sensation. She also reports pruritis, • Lichen sclerosus soreness and occasional bleeding. She reports no urinary symptoms, no • Barthelin’s cyst appetite and weight are stable. She is • Vulval carcinoma taking Ramipril 5 mg once daily for essential hypertension. On examination, there is an ulcerated lesion on her left previous bleeding. On bimanuale of examination, her uterus is non-tender, and no masses are palpable. • What is the most likely diagnosis?SBA13 • A 55-year-old woman presentstoher • Soft tissuesarcoma GP with a non-healing ulcer on her • Squamous cell carcinoma left labia majora. She statesthat this notimproving. She denies any weight • Transitionalcellcarcinoma loss and other than the ulcer feels • Basal cellcarcinoma well in herself. Her only historyof • Malignantmelanoma noteis her last 2 smears, bothof butno dysplasticcells. The GPHPV suspectsvulvar cancerand refers the patienton a 2-week-waitpathway for biopsy. • What is the mostcommontype of vulval cancers?Whatdidwecover • Cervical cancer • Endometrial cancer • Ovarian cancer • Vulvalcancer Any questions? Pleasefill outthe feedbackformtogainaccessto theslidesand recording!