Transcript Mr Ketankumar Gajjar Consultant Gynaecological Oncologist NUH

Gynaecological
cancers
Mr Vivek Nama MD MRCOG
Consultant Gynaecological Oncologist
Gynaecological cancers
Why do we need 2 week wait ?

Early/timely diagnosis of cancer

Possibly less invasive treatment and better QoL

Avoid emergency admissions

Planned delivery of care

Higher standards and job worthwhile

Fewer dissatisfactions, complaints and risk of litigation

16 % of claims at MPS are delayed diagnosis

Assessment and examination of patient
Challenges

Shift from being always right to being safe

Low diagnostic yield rates – increase referral – inability of
services to cope with it

Multiple providers resulting in a complex
diagnostic/therapeutic pathway
CUH USC performance

20 per week.

(Nov 16 to Feb 2017)

62 day treatment – 3 breeches (One each month)

Reasons for delays –

medical reasons for diagnostic delays,

patient choice, other
Ovarian Cancer:
Ovarian cancer

7029 case in 2012 in the UK and Life time risk 1: 51

Relative 5 year survival rates – 34 %, lower than European
average, But stage 1, survival rates of 90 % achieved

Not a silent killer, symptoms present

No effective screening test – UKCTOCS trial, PLCO trial,
ROcKets ongoing

Screening history- ovarian cancer – BRCA – Genetic tree
Ovarian cancer detection in
Primary care
Women presenting with symptoms to GP

Examination shows ascites and/or mass (exc. Fibroids)


refer urgently. Perform CA 125 and USS.
any woman of 50 or over who has experienced symptoms
within the last 12 months that suggest irritable bowel
syndrome (IBS) OR if symptoms are concerning for ovarian
cancer but no physical features – Based on Symptom Index


Perform serum CA 125
Unexplained weight loss, Fatigue, Change in bowel habits

Perform CA125
Raised CA125 & Normal Examination
USC
Arrange USS
USS Abnormal
Refer
USS Normal
Repeat CA125
in few weeks
Refer?
RMI
Repeat CA125
> 200 Discuss at RMH
< 200 Operate at CUH
Decreasing
Increasing
CT Scan
Discharge
Abnormal
Normal
Lap and Biopsy
Risk of Malignancy index

CA 125 levels in U/ml × menopausal score ×
ultrasound score

Ultrasound features:

Multi-loccular cyst

Evidence of solid areas

Evidence of metastasis

Presence of ascites

Bilateral lesions

0 – none, 1 – one abnormal feature, 3 – 2 or more abn.

Menopausal score – pre – 1 , post -3

Sensitivity – 78 %, specificity 87 %
Problem with tests - CA 125
and USS

CA 125 also elevated in
 fibroids
 medical
 liver
problems such as heart failure
disease and other cancers
 Endometriosis
Ovarian masses in pre-menopausal
group

IOTA – International Ovarian Tumour Analysis Group

M-features and B-features

Reported sensitivity 95 % and specificity 91 %
M-rules
•Irregular solid mass with irregular
B-rules
component 80 % of the tumour
•Unilocular cysts
•Presence of ascites
•Solid components <7 mm
•At least 4 papillary structures with
•Presence of acoustic shadowing
a height >= 3mm
•Smooth multilocular tumour with a •Irregular multi-locular solid tumour
•largest diameter <100mm
with a max diameter > 10cm
•No blood flow
•Strong vascularity
Case

Scenario


Clinical assessment


70 y old with persistent bloating and abdominal pain
Abdominal and pelvic examination – no masses/ascites
Normal CA125
USS
Normal CA125 with Symptoms
Difficult to convince patients
Return if
Symptoms
Persist
Consider Evaluation for Bowel Cancer
OVA1 and HE4
Ovarian Cysts with normal
CA125
Post-menopausal ovarian masses

Cysts 2-5 cms, unilateral, unilocular and echo-free with no
solid parts or papillary formations

Risk of malignancy is less than 1%.

In addition, more than 50% of these cysts will resolve
spontaneously within three months.

Thus, it is reasonable to manage cysts of 2–5 cm
conservatively.

4 monthly scan and CA 125 x one year, no change
discharge.

Other options Lap SO
Pre-menopausal cyst

The following cysts should be treated as simple cysts:

Ovarian/para-ovarian cyst, cysts containing daughter cysts

Cysts with one thin septation (<3mm, with no vascularity)

Cysts with small calcification in wall. If there is an obvious area of
calcification; consider whether this may be a dermoid cyst.

Cyst criteria apply even if cysts are multiple (cysts completely
separate from each other) or bilateral.
Pre-menopausal cyst - management

Less than 5cm

No follow up required unless there is clinical concern.

Findings are likely to be physiological in nature and almost
always resolve within 3 menstrual cycles.
Pre-menopausal cyst - management

5 - 7cm - Suggest rescanning in four months.

If smaller or resolved no further follow up required.

If larger or persisting suggest further gynaecological review.

Ovarian cysts that persist or increase in size are unlikely to be
functional and may warrant surgical management.


If symptomatic, for benign gynaecological review.
> 7 cm – suggest benign gynaecological team review with a
view to surgical removal.
Summary
Ovarian cancer management is multi-modal


CA 125 and TV US scan

Move to increase surgical efforts Vs quality of life
Cervical cancer – fertility preservation

HPV vaccination
2 WW Referral criteria - PMB

2 WW referral – criteria changed in 2015


2 ww referral


age (55) as a factor, Other non-PMB symptoms and tests
if aged 55 and over with PMB
Consider

2 WW in under 55 with PMB [new 2015]
Suspected cancer: Recognition and referral
NICE Guideline June 2015
2 WW Referral criteria - PMB

Consider direct access USS
 if
> = 55 with unexplained vaginal discharge
 for
first time or with thrombocytosis or report haematuria
 visible
 low
haematuria with
haemoglobin levels or thrombocytosis or high blood
glucose levels. [new 2015]
Suspected cancer: Recognition and referral
NICE Guideline June 2015
PMB
1 Clinic/USS/OPH
1 Clinic/USS
2
Outpatient
Hysteroscopy
Pathology
Failed Hysteroscopy
Surgery
Pathology
Discharge
Surgery
Discharge
3 GA Hysteroscopy
Surgery
Discharge
Discharge
Scan results and outcomes

5mm or thicker endometrium


Irregular endometrium
Unable to comment on all of the
endometrium
Negative scan
40% ( negative
exam)
 Endometrial cancer 5-10%
 Hyperplasia
5%
 Benign pathology
~15%
 Atrophic or benign
30%

Secondary Care 
Laparoscopic Hysterectomy and BSO

Enhanced Recovery

24-36 hour discharge

CNS phone call after 7-10 days and discuss results
Case.

42 y old

4 weeks of IMB

Stopped the POP one year ago

Normal vaginal examination
Would you refer on 2WW?

NO – IMB has been taken out of 2WW referral
criteria
Questions ?
Croydon University Hospitals
Email – [email protected] or
0779525157