Gynaecological cancers. Mr Vivek Nama MD MRCOG Consultant Gynaecological Oncologist

Transcription

1 Gynaecological cancers Mr Vivek Nama MD MRCOG Consultant Gynaecological Oncologist

2 Gynaecological cancers

3 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

4 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

5 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

6 Ovarian Cancer:

7 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

8 Ovarian cancer detection in Primary care

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10 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

11 Raised CA125 & Normal Examination USC Arrange USS USS Abnormal USS Normal Refer Repeat CA125 in few weeks Refer? RMI Repeat CA125 > 200 Discuss at RMH < 200 Operate at CUH Decreasing Increasing Discharge Abnormal CT Scan Normal Lap and Biopsy

12 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 %

13 Problem with tests - CA 125 and USS CA 125 also elevated in fibroids medical problems such as heart failure liver disease and other cancers Endometriosis

14 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 B-rules Unilocular cysts Solid components <7 mm Presence of acoustic shadowing Smooth multilocular tumour with a largest diameter <100mm No blood flow Irregular solid mass with irregular component 80 % of the tumour Presence of ascites At least 4 papillary structures with a height >= 3mm Irregular multi-locular solid tumour with a max diameter > 10cm Strong vascularity

15 Case Scenario 70 y old with persistent bloating and abdominal pain Clinical assessment Abdominal and pelvic examination no masses/ascites Normal CA125

16 USS Difficult to convince patients Normal CA125 with Symptoms Return if Symptoms Persist Consider Evaluation for Bowel Cancer OVA1 and HE4

17 Ovarian Cysts with normal CA125

18 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

19 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.

20 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.

21 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.

22 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

23 2 WW Referral criteria - PMB 2 WW referral criteria changed in 2015 age (55) as a factor, Other non-pmb symptoms and tests 2 ww referral 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

24 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 haematuria with low haemoglobin levels or thrombocytosis or high blood glucose levels. [new 2015] Suspected cancer: Recognition and referral NICE Guideline June 2015

25 PMB 1 Clinic/USS 1 Clinic/USS/OPH 2 Outpatient Hysteroscopy Pathology Failed Hysteroscopy Surgery Discharge Pathology Discharge Surgery Discharge 3 GA Hysteroscopy Surgery Discharge

26 Scan results and outcomes 5mm or thicker endometrium Irregular endometrium Unable to comment on all of the endometrium Negative scan exam) 40% ( negative Endometrial cancer 5-10% Hyperplasia 5% Benign pathology ~15% Atrophic or benign 30%

27 Secondary Care - Laparoscopic Hysterectomy and BSO Enhanced Recovery hour discharge CNS phone call after 7-10 days and discuss results

28 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

29 Questions? Croydon University Hospitals or