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Hysterectomy and Malignancies Blessy George Y3 UBMSThanks to our partners!Hysterectomy Learning Objectives: ● Discuss how hysterectomies can be classified ● Discuss the various approaches to a hysterectomy (abdominal vs vaginal vs laparoscopic) ● Discuss the possible indications for a hysterectomy (eg heavy menstrual bleeding, uterine prolapse, malignancy etc) ● Recognise possible complications following a hysterectomy (eg damage to bladder/ bowel, major haemorrhage etc) TYPES OF HYSTERECTOMY ▪ Hysterectomy is an operation to remove the uterus. ▪ It is the second most common female surgery after Caesarian section. ▪ Hysterectomy for cases other than cancer is often done as a last resort when all other non-invasive treatments did not work. There are 3 types of hysterectomies, depending on whether the cervix and/or ovaries are removed. • Subtotal or Supracervical- Removes only the upper part of the uterus and keeps the cervix in place. • Total- Removes the whole of the uterus and cervix. • Radical- Removes the whole of the uterus plus tissues on the sides of the uterus, the cervix and the top part of the vagina. Generally done when cancer is present. ▪ A total hysterectomy with ovaries and fallopian tubes removed is called total hysterectomy with bilateral salpingectomy-oophorectomy.ROBOTIC ASSISTED LAPAROSCOPIC ABDOMINAL HYSTERECTOMYABDOMINAL HYSTERECTOMY REASONS FOR HYSTERECTOMY •Abnormal bleeding •Adenomyosis •Dysmenorrhea (painful menses) •Endometriosis •Gynaecologic cancer, including cancer of the uterus, cervix, ovary or the endometrium •Heavy or prolonged menstrual bleeding (menorrhagia) •Fibroids •Uterine prolapse, which may be combined with bladder repair •Gender affirmation for males who are transgender and people who are nonbinaryHYSTERECTOMY SIDE EFFECTS AND RISKSCervical Cancer & Endometrial Cancer Learning Objectives: ● Discuss the aetiology and pathophysiology of endometrial and cervical cancer ● Discuss the main risk factors for endometrial and cervical cancer ● Discuss the clinical features of endometrial and cervical cancer and other differentials to consider ● Discuss the appropriate investigations for suspected cancer ● Discuss how available surgical options depend on the stage of cancerAETIOLOGY AND PATHOPHYSIOLOGY OF ENDOMETRIAL CANCER ▪ There are of 2 main types- Type 1 is oestrogen driven and type 2 is non oestrogen driven. ▪ Type 1 has low grade cells and are more common and have more favourable prognosis. ▪ Type 2 has high grade cells and are less common and have less favourable prognosis. ▪ Type 1s are usually grade 1 or grade 2 endometrial adenocarcinomas. ▪ Type 2s are usually grade 3 endometrial adenocarcinomas, serous clear cells, undifferentiated and carcinosarcoma. ▪ Incidence- In 2020, 417,336 women were diagnosed with EC worldwide. It is the 6 most commonly occurring female related cancers. Most cases are between 65-75 years of age. Highest burden of the disease was found in North America and Western Europe. When detected early, 81% have 5-year Overall Survival (OS), but when detected late (Stage 4A or 4B) the OS reduces to less than 20%. Obesity was associated in more than 50% of the cases. ▪ EC varies greatly by race. In the US, black women are found to have worse outcomes at every stage, grade and histological type of EC. This may suggest additional factors, such as molecular phenotypic differences, may contribute to differences in these outcomes. ▪ Tumour genomic differences are also important factors. TP53 and PIK3R1 mutations in type II EC in Black women, along with higher HER2 expression, may be associated with a more unfavourable prognosis.CERVICAL CANCERAETIOLOGY AND PATHOPHYSIOLOGY OF CERVICAL CANCER th ▪ 4 most common female related cancer worldwide. ▪ Cervical cancer intervention involves primary and secondary prevention with primary prevention and screening being the best methods to decrease the burden of cervical cancer. ▪ In the US and UK, most screening and diagnostic efforts include HPV testing and pap smear. ▪ Women between the ages of 25 and 64 are invited for regular cervical screening under the NHS Cervical Screening Programme to detect abnormalities within the cervix that could, if undetected and untreated, develop into cervical cancer. ▪ HPV is found in most sexually active people at some point during their lifetime. ▪ There are more than 130 types of known HPV, with 20 HPV types identified as cancer-related. ▪ HPV types 16 and 18 are the most common HPV types identified in invasive cervical cancer. ▪ Population-based HPV prevalence studies show the greatest prevalence of high-risk HPV occurs in adults younger than 25 years and is largely self-limiting, and cervical cancer deaths peak in middle-aged women between 40 and 50 years.CANCER IN THE CERVIX NORMAL CERVIXDIFFERENTIAL DIAGNOSIS (FOR BOTH ENDOMETRIAL AND CERVICAL CANCERS) ▪ Endometrial hyperplasia ▪ Fibroids ▪ Endometrial polyps ▪ Cervical cancer ▪ Cervical polyps ▪ Certain STDs like chlamydia and gonorrhea. ▪ Pelvic Inflammatory disease. ▪ Endometriosis ▪ Von Willebrand Disease ▪ Urinary Tract InfectionINVESTIGATIONS FOR CERVICAL CANCER INVESTIGATIONS FOR ENDOMETRIAL CANCER▪ Surgical options include hysterectomy (complete removal of the uterus) which may or may not include removal of other associated organs such as fallopian tubes and ovaries depending on the stage of endometrial cancer. ▪ If fallopian tubes and ovaries are involved, a salpingo-oophorectomy is involved along with hysterectomy.Surgical options for treating cervical cancer are 1. Large Loop Excision of transformation zone (LLETZ)- Suitable for early stages 2. Cone Biopsy- Suitable for early stages. 3. Hysterectomy 4. Trachelectomy-Complete removal of the cervix +/- upper part of the vagina and nearby tissues. REFERENCES • https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/hysterectomy • https://www.webmd.com/women/hysterectomy • https://link.springer.com/chapter/10.1007/978-981-13-8098-3_2 • https://howardisms.com/obgyn/simplified-vaginal-hysterectomy/ • https://www.aerzteblatt.de/int/archive/article/75240 • https://moushuspilates.com/hysterectomy-rehab-pilates/ • https://www.rcog.org.uk/media/tubmuqqp/abdominal-hysterectomy-for-print.pdf • https://www.cancer.org/cancer/types/cervical-cancer/causes-risks-prevention/risk-factors.html • https://www.mayoclinic.org/diseases-conditions/endometrial-cancer/diagnosis-treatment/drc-20352466 • https://www.macmillan.org.uk/cancer-information-and-support/treatments-and-drugs/cervical-cancer-surgery • https://www.ncbi.nlm.nih.gov/books/NBK431093/ • https://www.cancer.org/cancer/types/endometrial-cancer/causes-risks-prevention/risk-factors.html • https://paulandperkins.com/endometrial-cancer/ • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9421940/ • https://www.youtube.com/watch?v=O-NRDz-JyIo (How a colposcopy is done) • https://www.youtube.com/watch?v=DLxBTVgyrrE (How a cone biopsy is done) • https://www.youtube.com/watch?v=e8C_Qq5s8CM (How a LLETZ procedure is done)@supta_uk @SUPTAUK www.supta.uk