Essay 363

1)  A history is important to assess if this is the first episode of vaginal discharge/bleed since menopause and to identify any risk factors of endometrial cancer like early menarche, late menopause, hormone replacement therapy and especially unopposed oestrogen, nulliparity and a family history of endometrial cancer, cervical cancer, colon cancer that would indicate Familial Non-Polyposis Colon cancer. Moreover, the patient should be asked if she is secually active as this blood-stained discharge could be provoked due to vaginal atrophy. Any urinary symptoms such as pain on urination, frequency, urgency, haematuria should be asked for as these could indicated bladder origin of the bleeding. It is important to elicit if the patient used to have smear tests in the past and if these were normal. A past medical history of endometrial polyps could imply recurrence.

An abdominal examination is important to identify any masses. A speculum should be performed to assess the vaginal mucosa and the cervix. A bimanual examination should follow, to assess the size and mobility of the uterus and the presence of any adnexal mass. A pipelle biopsy should be attempted at the time of the examination. A urine sample should be obtained to exclude haematuria or urinary tract infection. An ultrasound scan of the pelvis should be organised to assess the endometrial thickness and exclude any endometrial polyps although this is not a very sensitive tool. A hysteroscopy and targeted endometrial biopsies should be the gold standard investigation.

2) The treatment options will depend on patient's wellbeing and comorbidities as well as the staging of the endometrial cancer. If she is fit for a major operation and the cancer is not too advanced, that is stage I-II, she should be offered a total abdominal hysterectomy, bilateral salpingoophorectomy and peritoneal washings. Lymph node dissection has not been shown to imporve survival therefore it would not be recommended. Depending on the stage (especially stage II and above) and grading of the adenocarcinoma and after a discussion with the multidisciplinary team, adjuvant radiotherapy could be offered in terms of external beam and vaginal brachytherapy to reduce the risk of recurrence and treat any pelvic disease. For a stage III disease, total abdominal hysterectomy and bilateral salpingoophorectomy could still be offered along with radiotherapy. If the patient is not fit for surgery or if the tumour is very big to be operated, then neoadjuvant radiotherapy could be offered as a treatment or to achieve a reduction of the size of th tumour before an operation is planned. For stage IV disease palliative radiotherapy to control the symptoms could be offered. In addition, medical management in the form of high dose progesterones could be used as a paliative measure to control the symptom of bleeding. There is also a role for chemotherapy in advanced disease but this should be discussed with the multidisciplinary team. The patient should be provided with appropriate information both verbal and written regarding her diagnosis and treatment options and she should also be provided with appropriate help and support to cope with her diagnosis.

A) I will take a history to establish if this is her first episode of postmenopausal bleeding (PMB) and if she has had any investigations or treatments in the past. I will find out her age of menopause as late menopause is a risk for endometrial cancer.  I will ask her if she has previously used or currently using hormone replacement therapy as this increases her risk of endometrial cancer. The most likely cause is atrophic vaginitis so will ask her if she has any dyspareunia. I will ask her if she has any itching, soreness in her vulva or if she has noticed any unsual lumps suggesting vulval cancer. I will ask her about her smear history and if she had previous treatment to her smear increasing the possibility of cervical carcinoma. I will ask her is she has symptoms of abdominal pain, loss of appetite, early satiety, altered bowel habit or urinary symptoms suggesting an ovarian malignacy such as a granulosa tumour which is associated with PMB. I will ask her about symptoms of a prolapse since an ulcerated procidentia can present with PMB. I will enquire about her current medications since warfarin can be the cause of her PMB if her INR is high. I will ask her if she has history of breast cancer and treatment with tamoxifen which increases her risk of endoemtrial cancer. I will enquire about medical comorbidities which may interfer with my management. I will enquire about a family history of cancer which will increase her risk of either ovarian or endometrial cancers. I will enquire about her social circumstances and if she is indepenedent with her daily activities as this will influence management. I will measure her BMI and BP. I will perform an abdominal examination to assess for pelvic masses and previous abdominal scars. I will inspect the vulva for any lesions. I will perform a speculum examination to look for lesions on the cervic and for vaginal atrophy. I will perform a bimanual examination to assess the size of the uterus and palapate for adnexal masses. I will perform a rectal examination if infiltrative cancer is suspected trom the history or from my pelvic examination.

B) Her treatment options will depend on the stage and grade of the disease determined by biopsy and further imaging and her fitness state assessed from the history and examination. The aim of treatment is cure or palliative for an advanced stage of endometrial cancer. Stage I can be treated with surgery which includes a total abdominal hysterectomy and bilateral salpingo-ophorectomy (TAH+BSO) with lymphadenectomy if suspicious nodes palpated. She may require additional radiotherapy. Surgery offers accurate staging and option of cure.  Where there is local expertise she can be offered laparoscopic total hysterectomy and BSO or a laparoscopic vaginal hysterectomy. If she is not fit for surgery she may be offered internal and external beam radiotherapy alone or she may be eligible for a clinical trial offering additional chemotherapy. if she has Stage II disease she can be offered radical hysterectomy +BSO  with lymphadenectomy if palpable nodes with radiotherapy.  Stage III disease she can be offered radical hysterectomy +BSO with lymphadenectomy and internal and external beam radiotherapy if she is medically fit. She can be offered radiotherapy alone. Another option is progesterone treatment either in the form of oral medroxyprogesterone continuously or by the Mirenal coil. This will improve her symptoms any may prolong survival. She may be eligible for clinical trials offering additional chemotherapy. If she has stage IV disease then her treatment options are palliative and should be directed in improving her symptoms. External and internal beam radiotherapy can be offered to prolong survival but prognosis is poor. She can also be offered progesterone treament for symptom control.

Qn: A 77 year old woman has been referred to the gynaecology clinic because of a 3 months history of blood-stained vaginal discharge. (a) Discuss your clinical assessment [9 marks].  (b) She is found to have endometrial adenocarcinoma. Discuss her treatment options [11].

a) I will ask her about her age at menopause, age at menarche. Late menopause and early menarche is associated with endometrial cancer. I will enquire about the amount and severity of bleeding and ask her if she has symptoms of anaemia e.g. breathlessness and giddiness. I will ask her if she has other associated symptoms of malignancy such as abdominal bloating, loss of weight and appetite; bowel and urinary symptoms - including urethral or rectal bleeding. I will ask further about the nature of discharge - if it is foul smelling, associated with vaginal itch and dryness, which may suggest infection and/ or atrophy. I will ask her if she is sexually active - if so, is there any post-coital bleeding? I will ask about when the last cervical smear was done and if the result was normal. I will enquire about drug history - whether she is on hormonal replacement therapy, tamoxifen or anticoagulation. I will ask if she has any significant medical history such as bleeding tendencies. I will ask if she has a personal/ family history of breast or colorectal cancer. I will also enquire about her past obstetrics history and parity.

On examination I will check her BMI and measure her blood pressure and pulse rate. I will assess her for conjunctival pallor, examine for lymphadenopathy. I will auscultate her lungs - metastatic lung disease may be present if there is malignancy. I will perform an abdominal examination to look for palpable masses, tenderness; speculum examination to look for vaginal atrophy, nature of vaginal discharge, as well as cervical lesions, polyps, tumours. Bimanual examination should be done to assess adnexal masses, uterine size, presence of any hard nodularities. Per rectal examination may be indicated if she has bowel symptoms/rectal bleeding.

b) Explain the diagnosis to her in a sensitive manner, anticipating that she may be emotionally distressed. Refer her to a specialised gynaecological cancer centre with multidisciplinary care team of gynaecology-oncologist, Macmillan nurse, psychosocial counsellor, radiologist. Explain the need for referral and operation by specialised gynaecology-oncologist to optimise prognosis. I will explain that the prognosis for early stage endometrial adenocarcinoma is good, about 85% for stage I disease after surgery. I will discuss with her that she will need a staging laparotomy, total hysterectomy and bilateral salpingo-oophorectomy (THBSO) as minimum. She will need pre-operative imaging assessment - with CT or MRI scan to aid planning of the operation. If it is likely early Stage I disease, THBSO may be sufficient. If later stages, paraaortic and pelvic lymphadenectomy and debulking surgery with postoperative radiotherapy will be arranged after discussion at the multidisciplinary team meeting. Depending on surgical expertise and facilities, laparoscopic THBSO may be offered as an alternative to abdominal THBSO for early stage disease. For late stage disease, debulking surgery, palliative radiotherapy and high dose progestogen therapy may be used. Provide written information and contact numbers of support groups, e.g. Macmillan cancer support groups.

(a)

I would ask about the time of menopause and if she had any previous episode of postmenopausal bleeding.

I would ask for the frequency and quantity of blood stained vaginal discharge which she had for the past 3 months and if it was precipitated by any factors such as post coital.

I would ask for any associated symptoms such as abdominal pain, abdominal mass, or change in urinary and bowel habits.

I would check for symptoms associated with malignancy such as loss of weight, loss of appetite, lung symptom such as breathlessness which suggests distant spread.

I would ask for any symptoms suggesting atrophy such as vaginal dryness or dyspareunia.

I would check for symptoms of anaemia such as decrease in effort tolerance, lethargy, giddiness, chest tightness.

I would check for risk factors for endometrial cancer such as history of HRT or tamoxifen use, medical condition of hypertension or diabetes.

I would ask for history of previous gynaecological surgeries such as LETZ for cervical pathology.

I would check if her previous cervical smears were normal.

On examination, I would perform a general examination, including her BP and BMI to check for fitness for surgery as well as signs suggestive of distant spread such as jaundice or pleural effusion.

I would look out for any enlarged lymph nodes especially over the supraclavicular and inguinal areas.

I would perform an abdominal examination for any abdominal mass or ascities.

I would perform a bimanual pelvic examination to check for pelvic mass.

I would inspect her vulval for any atrophy or skin lesions. I would perform a speculum examination to check for any vaginal atrophy or lesions, any cervical polyps or mass and a cervical smear.

Lastly, I would perform a per rectal examination to check for blood in stools or any rectal mass.

(b)

Treatment options depend on the stage and grade of endometrial cancer, as well as her fitness for surgery. Treatment plans should be discussed at the multidisciplinary team meeting at a cancer center, consisting of gynae-oncologists, medical oncologists, radio-oncologists, Macmillian nurses, cyto-pathologists, radiologists, medical social workers, physiotherapists.

For stage 1A endometrial cancer in which there is less than 50% myometrial involvement, total hysterectomy and bilateral salpingo-oophorectomy (THBSO) is the choice treatment. But it involves surgery complications such as bleeding, infection, bladder or bowel injury, blood vessel injury and need for blood transfusion, VTE and death.

For stage 1B endometrial cancer in which there is more than 50% myometrial involvement but confined to the uterus, THBSO with selective pelvic and para-aortic lymph node sampling is recommended. Post operative radiotherapy (RT) may be considered to decrease recurrence but does not improve overall survival. Complications of RT include vaginal dryness and narrowing, diarrhoea, haematuria.

Stage 2 endometrial cancer involves spread to cervical stroma. Treatment options include THBSO then post operative vault RT; or neadjuvant brachytherapy with external beam then THBSO for bulky tumours; or radical THBSO with pelvic and para-aortic lymph node dissection.

Stage 3 endometrial cancer involves pelvic spread and lymph nodes involvement. Treatment options include THBSO then adjuvant RT; or RT (intracavity and external beam) alone if she is not fit for surgery. If she is not fit for surgery or RT, chemotherapy with doxorubicin, cisplatin and palitaxal can be considered. Side effects include cardiac complications, neuropathy, nephropathy, alopecia, nausea and vomiting. If she is not fit for any of the above mentioned treatments, high dose progestogen such as megestrol can be considered. However, it is not a definitive treatment and may be associated with high recurrence rates.

Stage 4 endometrial cancer involves spread to bladder or bowel mucosa and distant metastasis. Palliative RT or chemotherapy can be given for symptom control, especially with bulky tumours. Option of progestogen can be considered if she cannot tolerate RT or chemotherapy. Palliative team should be involved to help with control of pain and symptoms according to patient’s wishes.

Written information and names of support groups should be given to the patient and her carers for more information of the stage, prognosis, treatment options, side effects and recurrence rates of the cancer.

A 77 year old woman has been referred to the gynaecology clinic because of a 3 months history of blood-stained vaginal discharge.

(a) Discuss your clinical assessment [9 marks]. 

current history of nature of vaginal discharge and its frequency, foul smell, whether there is passage of any clots or fresh bleeding for which she has to take precaution with pads.

whether there is presence of itching suggesting added infection.

Symptoms of frequency urgency dysuria, dypareniua due to atrophy of urovagina.

History of lump coming out and whether she is pessary or tampons.

Questioning on quality of life and its impact on daily activity.

History of any medication tried for symptom control.

present or past history of intake of hormone replacement therapy for menopausal symptoms, preparation used and its duration of use since estrogen only preparation or sequential estrogen progesterone preparation.

Past obstetric history of nulliparity, early age of onset of menarche and  delayed menopause more than 55 which are risk factors for bleeding.

History of cough, chest pain , hemoptysis, abdominal swelling, anorexia weight loss suggesting advanced stge of cancer if detected.

Past cervical smear history and whether she is still following up even after 65 years exit age of screening.

History of Diabetes, hypertension  presence since how long and whether controlled on treatment.

Past hsitory of any breast lump or personel history of breast cancer and taking chemoprophylaxis  tamoxifene for its prevention.

Family history of bowel cancer, cancer of ovary and uterus, diagnosed case of bowel cancer less than 50 yrs of age.

 whether she has any allergies to medication and has addiction to smoking alcohol or recreational drugs. 

I would do following things in order, general examination includes checking weight and height and measuring BMI, high BMI > 30 kg/sq metre associated more with bleeding and  blood pressure with appropriate cuff size to rule out hyprtension.

Abdominal examination to note for any mass, swelling, abdominal pain arising out of pelvis may be uterine or ovarian swelling

Local examinaton of vulva and perinuem for any ulcer,selling soreness, redness, urethra for any swelling.

Speculum examination to look at origin of dischareg whether coming of bleeding and dischrge is from uterus, vagina cervix, also to detect local causes like ersosion, atrophy and polyp. Cervical smear taken if it is due and if still following up since previous smears were not normal or did not follow up from 50 to 65 years of age.

 Bimanual examination to note for uterine sixe, mobilty, irregularity, adnexal mass.

Rectal examination to look fo any irregularity of mucosa or mass.

(b) She is found to have endometrial adenocarcinoma. Discuss her treatment options [11].

I would manage patient in cancer unit or centre with Multidisciplinary team involvin oncologist chenotherapist radiotherapist histocytopathologist and cancer nurse specialist.

Preoperative or pre treatment fitness done with FBC, chest Xray, LFT, RFT, blood group, urine dipstick and anestheitic check  is done up due to old age.

 I would like to do MRI pelivs for noting cervical involment, lymph node status, myometrial invasion,  CT scan pelivs abdomen and chest if there is any symptoms.

Treatment will depend upon surgical staging, stage, myometrial invasion, lymph node status,grade of tumor at histology after biopsy with surgery being main stay of treatment.

Stage 1 a with myometrail invasion less than half thickness requires TAH with BSO and no lymph node sampling  or adjuvant radiotherapy as it does not improve survival or outcome , with survival rate being 85 %. 

Stage 1 b  and above and grade 3 tumor requires TAH with BSO plus pelvic lymph node sampling followed by adjuvant radiotheray though lymph node sampling does not improve survival. Chemotheray can also be given with radiotherapy with doxorubicin, cisplatin and paclitaxel.

Neoadjuvant radiotherapy followed by surgery for bulkier tumor cancer also be done for advanced stage lesion stage 2 and above.

Primary radiotherapy with intracavitatory and external beam readiation for pelvis and pelvic and para aortic lymph nodes for advanced stage lesion.

Laparscopic TAH and BSO is safe if done by experineced surgeon, and is associated with less pain, less blood loss, less post operative morbdity and analgesics requirement with early recovery and it has same survival rates as compared wiht open approach.

Post operative follow up is done  quaterly for 2 years, half a year for 2 years and than annually.

Overall survival rate is 80% with 85%, 75%, 45% 25 % 5 year  individually for stage 1 2 3 4 respectively.

(a) Discuss your clinical assessment [9 marks]. 

The assessment starts by thorough history. Menstrual history should cover age of menarche, menopause (LNMP), any previous similar episodes of bleeding and if she ever used any type of HRT.

We should focus on any associated complains as well like weight loss, bloatedness and altered bowel movements as they may indicate malignancy.

Local symptoms in form of vaginal dryness, dyspareunia or dysuria may indicate hypoestrigenemic cause or, if associated with discharge, infection.

Medical history is essential, especially if she is on any thrombolytic treatment.

Past obstetric and gynaecologic history, including that of cervical smears and family history of any malignancies is also important.

On examination I will try to notice for any pallor, breathless or signs of emaciation on the patient.

Abdominally I will feel for any masses or ascites, and check for palpable lymphnodes. By inspecting the vulva and vagina I will for any signs of dryness or ulcers. Bimanual examination will outline any uterine enlargement and pelvic masses. By speculum examination I will visualise the cervix, to check for any polyps or other pathology, and I will obtain an endometrial biopsy (Pipelle or Vibra). If there is a discharge I will obtain a high vaginal swab.

Then I’ll arrange an urgent pelvic ultrasound, within two weeks, and hysteroscopy (outpatient or inpatient depending on the easiness of obtaining the biopsy) so that we obtain a descent biopsy.

(b) She is found to have endometrial adenocarcinoma. Discuss her treatment options [11].

The treatment depends on the stage and grade of the cancer.

I will make the patient aware that further investigations, CT or MRI, are required to check the spread of the condition.

The treatment should be discussed in multidisciplinary meetings so that the best and most appropriate management is offered. Additionally, we should assess if the patient is fit to undergo surgery.

Very early stages (Ia) require only surgical treatment in the form of total abdominal hysterectomy (TAH) and bilateral salpingoophorectomy (BSO) with no need for lymphadenectomy. In Ib she will require TAH and BSO with pelvic and para-aortic lymphadenectomy, followed by radiotherapy.

In stage II she may have radical gysterectomy and radiotherapy (external or brachytherapy).

For stage III the management depends on the spread of the disease (i.e. if it is operable) and the patient’s general condition. Surgical procedure will be as above, followed by radiotherapy and/or chemotherapy.

In further advanced cases the surgical management is only for the benefit of debulking the mani management is on radiotherapy or chemotherapy, and palliative care.

Whichever the method of treatment, the patient should be aware of the surgical, anaesthetic and postoperative complications. She should also be aware of the complications of radiotherapy like skin burns, vomiting and diarrhoea, pneumonitis and bone marrow reaction. Moreover, she should know the side effects of chemotherapy e.g. vomiting, alopecia, hepato- renal toxicity etc.

Further follow ups will be required and depending on the improvement and recovery she makes.

i will ask her about relation of this blood stained discharge and sexual intercourse,any itching or burning sensation in the vulva,if it associated with dificulty in defecation,iwill ask about medical diseases such as hypertension which if not well controlled may cause this symptoms,also liver disease which may cause decrease in coagulation factors and cause bleeding tendency,also i will ask about any bleeding from other orifices such as bleeding gum, bloody urine.iwill ask her about risk factors of endometrial carcinoma such as DM,early menarche,late menpouse,Also, asking if she  is taking combined HRT, phytoestrogen,which are a common cause of this complain,if she is taking warfarin.history of breast cancer for her or taking Tamoxifen therapy before,asking about family history of breast ,ovarian or colorectal carcinoma should be taken as this increase her risk of malignancy.i would ask also about symptoms of cachexia as raoid weight loss ,decrease apetite,cough ,bloody sputum as a signs of metastasis,any pressure syptoms any changes in the bowel function.after that i will make general examination to detect pallor cachexia BMI as obesity increase rishk of malignancy and anasthestic complications,abdominal examination will check any abdominal or abdminalopelvic mass,check and Hepatosplinomegally,any[petecheal haemorahge in the skin,and pelvic examination to see any vulval suspected lesions,whitish patches ,atrophy,any cervical lesions such as polyp,erosions,masses and to check uterine size if enlarged and adynxial lesions.Then i will do investigations to diagnose such as transvaginal u/s to detect endometrial thichness if >4mm will make endometrial biopsy as outpatient procedure by Pipelle or Vabra ,hystroscopey and biopsy also is the gold standard for dignosis as outpatient butmay need anasthesia.investigation should also asess fitness fo operation as FBC,Liver function U&E,coagulation profile,and also to assess if 

if there is metastasis as chest xary MRI to detect lymph node.

B-

counsilling the patient by simple and symapathetic way and written information is giving to her explaning finding , treatment options ,complications of  open or laproscopic surgery or radiotherapy procedures ,prognosis for her stage and consequences of no treatment.psycological support should be ofered.

the patient should be treated by MDT consist of consultant obstetrcian,oncologist,midwife,anasthetics counsltation to know her fittness for anasthesia and surgery should be done.

traetment will depend on her stage if stage 1 a less than 50% on mymotrial invasion TAH&BSO will be curative and could be done by consultant obstetrician ,if she is stage 1b (more than 50 % of myometrium)  so treatment should be by oncologist in cancer center and TAH&BSO with lymphadenectomy,radiotherpy decrease risk of recurrence.

if she in stage II (extend to cervix) could by TAH&BSO and aortic lymph node sampling with radiotherapy intracavitary,external beam 

adjuvant radiotherapy can be used first then TAH&BSO and lymphadenectomy

if the patient in the stage III  or IV or she is not fit for operation or her tumour inoperable, so intracavitry and external beam radition used with chemotherapy by  doxorubicine and cisplatin ,paclitaxil may be added .debulking operation can be done .

TAH&BSO can be done by laproscope with advantage of short hospital stay less pain but carry risk of recurrence in the port orificies and need  high expireince .

if the patient complain of pain she should have analgesic according to her degree of pain assessed by pain scale,if she is inoprerable so, pallitive Care should be focus on increase quality of live ,decrease other associated symptoms such as nausea,vomiting bowel obstruction ,infection should be treated.

                                                                       CLINICAL ASSESSMENT

The main aim of clinical assessment is to rule out genital tract malignancy particularly endometrial carcinoma. I will ask her age of menarche and menopause.Any aggravating factors like post coital bleeding will be enquired. Enquiry will be made if her previous cervical smears were normal.Haematuria or rectal bleeding will be asked.Symptoms of malignancy like weight loss, loss of appetite, abdominal distension and chest symptoms like breathlessness and haemoptysis will be asked.Risk factors for endometrial malignancy like diabetes, hypertension,HRT,or tamoxifen will be enquired. Obstetric history of number of pregnancies and breas feeding will be taken as multiparity and breast feeding are protective factors for endometrial carcinoma. Prior use of oral contraceptive pills will be enquired. Family history of genital tract malignancy or gastro intestinal malignancy will be taken.I will ask about smoking because increases risk of cervical cancer. Previous history of multiple sexual partners will be taken. Symptoms of genital tract atrophy like itching vulva, vagina and dyspareunia will be enquired.

Examination is done to assess her general state if she is ill looking or cachectic. B.P and body mass index is assessed. I will look for lymphadenopathy. Chest examination is done for evidence of metastasis like pleural effusion in advanced malignancy. Abdominal examination will look for any organomegaly, ascites or abdomino-pelvic mass. vulval inspection is done to look for any atrophy , mass or ulcer. Speculum examination will detect atrophic vaginitis, cervical ectopy, polyp or lesion suggestive of malignancy and the nature of discharge. Bimanual vaginal examination will assess the size, mobility and tenderness of uterus, any adnexal mass or adnexal tenderness.

                                                                      TREATMENT OPTIONS

The management of the patient should be multidisciplinary involving an gynacological oncologist, anaesthetist, specialist nurses and social services and haematologist. Treatment should take place in a cancer centre. Prior to treatment counselling to the woman and her family should be provided by a Mac milan nurse.The diagnosis will be associated with anxiety and sensitive counselling should take place. 

The management will depend upon the stage, grade of the disease, fitness for surgery and the woman's wishes. There is no place for conservative treatment in endometrial malignancy as there is associated ovarian malignancy in 10-30% cases .

The standard treatment in stage 1 is total hysterectomy plus bilateral salpingo-oophorectomy. Hysterectomy can be done by laparotomy,laparoscopy or laparoscopic assisted vaginal hyterectomy. Pelvic lymphadenectomy is not needed in stage 1. Selective pelvic and para-aortic node sampling is enough. Post-operative radiotherapy reduces the risk of local recurrence.

Stage 2 disease can be managed as above with adjuvant radiotherapy. Pre-operative radiation( intra-cavitary +external beam radiation) followed by TAH+BSo is another option.In selected cases radical hysterectomy + bilateral pelvic lymphadenectomy may be done if the woman choses not to have radiotherapy.

In stage 3 disease the treatment is TAH+BSO+radiotherapy. However if the disease is inoperable and extends to pelvic side wall only radiotherapy will be given both intracavitary and external beam. If radiotherapy is declined , chemotherapy with combination of Doxorubicin+Cisplatin or paclitaxel is an alternative. Granulocyte colony stimulating factor is given to overcome the bone marrow supression. If the woman is unsuitable for both radiotherapy as well as chemotherapy then she may be treated with progestogens like medroxyprogesterone acetate or high dose megestrol.

In stage 4 where there is bladder,bowel involvement  radiotherapy will be given. Distant metastasis wil be managed with progesterone therapy.

Information and details of support groups should be provided. Written information about management and possible complications and their management should be provided .

a)History should be taken from this lady include her parity and mode of delivery,the onset and duration of menopause,any associated dysparunia if she is still sexually active,previous use of HRT,review of results of the last cervical smear.History of smoking(duration and number of cigarrette) and alcohol consumptiom

  Her general condition  ,her fitness and suitability for surgery should also be evaluated ;any chronic medical disease she is suffering from like hypertension,diabeties mellites,bronchial asthma,,,ect ,any operative surgery done in the past e.g cesraean section,any allergy to any medication ,any medication she is been on like hormonal replacent therapy(onset) and it's duration of use personal or family history of endometrial,ovarin and  breast cancer 

Any recent weight loss,haemoptysis,abdominal pain or abd distension,any altered bowl symptoms like constipation or urinary symptoms (e.i urinary incontinence).

Examination per abdomen may reveal any pelvi abdominal mass,Inspection of the vulva and vagina may reveal atrophy.Speculum exam may shows polyps,HVS should be taken for culture/sensitivity. bimanual examination may reveal bulky uterus or ? adenexeal swelling or mass.

In this particular age,blood stained vag discharge should raise suspecion of malignancy(endometrail carcinoma) untill proved otherwise,differential diagnosis is polyp,vaginal atrophy,infection,uretheral caruncle,

b)In empathetic way I should disclose the finding to the woman.patient should be offered  to have her partner or family member with her if she wish to .Support should be given to her as she maybe shocked or confused.

A case of endometrial carcinoma should ideally be dealt with in cancer unit by a gyne oncologist  rather than gerneral gynaecologist and this will improve life survival of the patient and well as decrease pt morbidity and mortality.

Clinical staging of the disease is important in determining the best treatment  for the patient,Chest X ray looking for metastasis and CT scan  should be done as minimum,the best modality of treatment for this patient is surgical ,Total abdominal hyterectomy and bilateral salpingo oophrectomy +/-selective pelvic and para aortic lymph node sampling should be done.Specimen should be sent for hisotopathology for examination.Muiti disciplinary meeting may be of value in discussing best option for the patient .

If the case is stage I   disease confined to the uterus ,TAH+BSO is sufficient  treatment for her ,However if stage II identified where tube and ovarian stroma is involved without breaching the serosa then TAH+BSO+pelvic and para aortic lymphadenectomy followed by adjuvant chemotherapy.Same will apply to stageIII.For Stage IV of distant metastasis surgical +adjuvant chemo/radiotherapy or palliative chemo/radio therapy could be used.

Good comunication bewtween gyne oncologist and medical oncologist is vital in post operative period,patient GP should be informed about the progress and the update of the case.Follow up of this patient every 6 months to look for recurrence or symptoms of metastasis is crucial.

 AAaaaa

1.she should be asked about associated  symptom with blood stain vaginal discharge ,amount ,odour and pelvic and abdominal pain and heaviness in abdomen . She should be enquired about loss of apetite, weigth loss ,alteration of bowel habbit like diarhoea and constipation along with nausea and vomiting. She should be asked about urinary symptom like haematuria and frequency . she should be asked about any respiratory symptom.

She should be asked about her duration of the menopause and any episodes of postmenopausal bleeding and investigation and treatment for that. Her smear history should be asked  whether she follow regular screening programme and any abnormality detected during screening. Her obstetric history and mode of delivery should be asked .  she should be asked about oral contraceptive use in the past.

Her personel history should be asked life style smoking and alchohal. She should be asked about medical comorbidity diabetes ,hypertension ,vte as it will affect her treatment plan. She should be asked about past history of PCOS ,endometrial hyperplasia or menstrual abnormality and treatment taken for that. she should be asked about any gynaecological surgery done in the past ,and reason for that should be explored.

She should be asked about history of breast cancer or treatment with tamoxifen for the recurrence. She should be asked about the HRT ,whether its estrogen ,estrogen and progesterone ,sequential or combine including over the counter drugs , and phytoestrogens.

Her family history should be asked about malignancy for the breast ,ovarian, endometrial cancer . and any hereditary familial cancer running in the  family like HNPC.

Her general condition should be assessed cachetic look , pallor and jaundice .Blood pressure and BMI should be recorded. On per abdominal examination for any mass palpable ,tendeness  ,ascitis  ,hepatomegaly and lymph node palpable. Per speculum examination condition of the vagina ,atrophic change ,prolapsed or decubitus ulcer ,condition of the cervix and appearance of vaginal discharge. Per vaginal examination for the uterine size , adenexa ,mass palpable ,mobility and tenderness.

2.she should be treated in the multidisciplinary team in cancer center which will include gynaecological onchologist, radiologist, specialist nurse, and  radiotherapist.,to optimize her out come.

Her treatment option will depend on the stage of disease, grade of tumour ,her fitness for the surgery and her wish. She should be given full evidence base information about her stage of the disease ,prognosis and different treatment option so that she can decide her mode of the treatment.

Her psychological ,psychosocial and psychosexual need should be taken into account. She should be given full support and detail of the support group . her family member also need information and counseling and support.

Staging done according to FIGO staging system.  In stage 1 –disease is confined to the uterus ,which can be devided into  1a –myometrium less than 50% involved ,stage 1b- myometrum > 50 % involved . in this case chance of involvement of the lymph node is very less ,so treatment option for her is total hysterectomy with bilateral salphingo-ophorectomy. It can be done open or through laproscopy out come is same. At this stage 5 year survival rate is around 80%. In this case post operative radiotherapy is not needed. Routine lymph adenectomy is not needed as it will not improve survival.

In stage 2-lesion involved to endocervical stroma , lymphnode involvement is there so need for the radical hysterectomy along with bilateral salphingo oophorectomy . need for the lymphadenectomy should be assessed. adjuvant post operative radiotherapy may be needed .5 yr survival is around 60%.

In stage 3 – where there is loco-regional spread ,role of surgery is for only cyto reduction ,here primary radiotherapy is opted .at this stage 5 yr survival rate is around 40%. In stage 4 there is involvement is local pelvic organ and distant metastasis , here treatment option for her is radiotherapy  and chemotherapy needed for the distant metastasis in form of doxorubicin and cisplatin. Survival rate is around 18-20% in 5 years.

There is no role of progesterone in early disease how ever it may be used in recurrent disease.

She should be informed about the palliative care in advanced disease for the pain ,GI symptom and urinary symptom. She should be given written information leaflets.

a)

History 

I would ascertain further information regarding her vaginal discharge/bleeding.  This would include the frequency it has been occurring since initial presentation 3mths ago any any additional symptoms such as vaginal/vulva sorneness or itch.  I would ask about any previous episodes of a similar discharge/ vaginal bleeding and results of investigations  if undertaken.    I would enquire about systemic symptoms, specifically bloating/abdominal distension, abdominal pain, nausea, appetite disturbance, weight loss, bowel or bladder disturbance.  I would ask if she is sexually active and if there is any post-coital bleeding.

I would ask about her past medical history, in particular focusing or risk factors or protective factors for endometrial cancer.  I would enquire about her age at menopause, approximate age of menarch (if she remembers) her parity and whether she has taken HRT.  In addition I would enquire about potential surgical comorbidities i.e. cardio-respiratory disease.  I would note any drug history in addition to that of HRT,  In particular the use of antiplatelet agents or anticoagulants which may contribute to unscheduled vaginal bleeding or necessitate surgical planning.  I would ask about any personal history of cancer, particularly breast cancer and the use of tamoxifen, ovarian cancer and colon cancer.  I would enquire about any family history of cancer, noting the type of cancer and the age at diagnosis (possibility of HNPCC)

I would ask about her pap smear  history and whether she ever had any cervical abnormalities or treatment.

I would ask about past surgical history, in particular abdominal surgery.

Examination and investigations

Height and weight would be recorded with calculation of BMI.  Following this an abdominal examination would be performed noting any distention, tenderness or palpable masses.

A pelvic USS (TVS unless VI) would be performed or arranged if not already done so.   This would specifically look at the endometrium/uterine cavity noting its contour/regularity, the presence of fluid within the endometrial cavity and a measurement of the endometrial thickness (ET), specifically whether it is ≥ 5mm, the thickness at which histopathological endometrial assessment is required.   I would then perform a vaginal examination (speculum + VE) looking for any evidence of vaginal lesions, cervical lesions, followed by assessment of uterine size, mobility, tenderness and presence of any possible adnexal pathology.   If the lady has an ET ≥ 5mm without the suggestion of focal endometrial pathology on scan I would offer simple outpatient endometrial sampling i.e. pipelle or Vabra.  If  endometrial sampling indicated but not possible (or focal pathology suggested which may be missed on pipelle) I would arrange for a hysteroscopy and endometrial sample to be performed.

Finally I would also examine for inguinal and supraclavicular lympadenopathy which may suggest the possibility of metastatic  spread. 

b)

The treatment options for endometrial adenocarcinoma depend on the tumour grade (as determined from endometrial sampling), the stage of the disease which can be ascertained from imaging (and confirmed at surgery), along with the overall health of the woman and her fitness for surgery.  MRI can help stage the disease by predicting the degree of myometrial invasion +/- evidence of metastatic lymph node disease and CXR/pulmonary CT can help assess for pulmonary metastatic disease.  The lady’s medical history +/- investigations will help determine her fitness for surgery.  Of course, the lady’s wishes should be taken into account in any treatment plan and any plan should at a minimum involve liaison with a gynae oncology team+ /- oncology support team.

Should the lady be a surgical candidate, surgery would be the treatment of choice in early stage disease.  This would involve a hysterectomy & BSO via a route which allows assessment of the peritoneal  cavity and collection of peritoneal washings intra-operatively(TAH, LAVH/TLH).  Should there be evidence or suggestion of cervical stroma or extra-uterine disease (stage II, stage  Ic with serosal disease, stage III/IV respectively) or high grade disease (as identified on histopathology) then radiotherapy should be offered (external bean or vaginal brachytherapy).  This may be stand alone treatment or adjuvant treatment either pre-or post surgical.  If the woman is medically unfit for surgery with locally advanced disease then her treatment plan should consider palliative radiotherapy for local symptom control.  Chemotherapy should be considered as a treatment option if the disease is found to be stage IV and may be considered in stage III disease also (evidence from phase 2 and 3 trials).

Progesterone therapy should not be offered since evidence has revealed no survival benefit.

Ongoing follow up will depend on outcome after initial treatment.  If treatment successful, follow up may involve 4 monthly review for 1 yr, 6 monthly review for the following 2 years and then yearly follow up until yr 5.

(a) I would ask her to quantify her bleeding, if it is heavy associated with clots or only lightly staining. I would ask if it is affecting her quality of life. I would ask for associated symptoms of anaemia like lethargy and breathlessness. I would ask if it is associated with post coital bleeding as it would suggest a cervical pathology. I would ask for other red flags symptoms like loss of weight and appetite, abdominal pain and distension, urinary or bowel symptoms or any offensive vaginal discharge. I would ask for her age of menopause and menarche as late menopause and early menarche is associated with endometrial cancer. I would ask if her previous menstrual cycle was irregular, as it would suggest anovulation. I would ask for her parity. I would ask if she has any medical conditions like diabetes mellitus or any other conditions which would affect the treatment options. I would ask for previous abdominal surgeries as it would affect the mode of surgery that can be used if needed. I would ask if she took hormone replacement therapy and the duration. I would ask if she had personal history of breast cancer and if she took tamoxifen. I would ask for family history of breast, ovarian and endometrial cancer. I would ask for the result of her last cervical smear.

I would measure her BMI and her blood pressure as baseline. I would look for conjunctival pallor for signs of anaemia. I would do an abdominal examination to feel for masses, distension or ascites. I would do a speculum examination looking at the cervix and vulva for suspicious masses and polyps and would do a biopsy if necessary. I would do a bimanual examination to feel for bulky uterus and adnexal masses.

I would do a transvaginal ultrasound of the pelvis to look for adnexal masses as estrogen-secreting tumours can cause post-menopausal bleeding. I would look at the endometrial thickness to look for signs of hyperplasia and malignancy. I would arrange for a hysteroscopy with endometrial sampling to look at the endometrium for suspicious lesions and obtain histological diagnosis. I would do a full blood count to look for anaemia.

(b) Treatment options of endometrial carcinoma are dependent on the stage of the disease and the fitness of the patient for surgery. The standard treatment is a complete surgical staging with total hysterectomy, bilateral salpingo-oopherectomy and pelvic lymph node sampling. The surgery can be done either abdominally, laparoscopically or laparoscopic assisted vaginally. Laparoscopic and vaginal surgery have the advantage of less blood loss, decreased need for analgesia post operatively, faster return to normal function, and a shorter hospital stay. But it has the risks of bowel and vessel injury and the need to convert to laparotomy.

Early stage disease has a good prognosis and stage 1 disease has a 85% 5 year survival, thus only surgical treatment is needed. If the prognosis is poor, for example it has a higher grade, cell-type with a poorer prognosis, further spread of the disease, adjuvant therapy with radiation or chemotherapy with radiation might be needed. If the cancer has spread and not deemed operable or the patient has other co-morbidities which are not suitable for surgery, treatment will be palliative only. Radiation can be used to control bleeding. High dose progestogen can be used and also to treat distant metastases. The option of no treatment needs to be discussed but the patient needs to understand that cancer will progress and can cause debilitating symptoms like pain, bleeding and fistula formation. It can also cause death.

Her treatment needs to be discussed in a multidisciplinary meeting with gynaeoncologists, medical oncologist, radiation oncologist, pathologist, radiologist, specialist nurses and social workers. The patient has the choice of the type of treatment option to choose as we need to respect her autonomy. Written information about the condition should be provided and contacts to local support group given.

I will ask her in detail about the discharge, whether it is associated with itching, colour of discharge.I will also inquire if this the first time she had blood stained discharge or it is recurrent. Any associated symptoms like pressure or pain,change in bowel habit, bladder complaints like haematuria.

Menstrual history-to know about the age of menarche, cycles regular or irregular and when she had menopause.

If the patient was having regular cervical smear .

Obstetric history to know about parity.Smoking history.

I will also ask if she is on any medications like HRT,any comorbid conditions like diabetes,Hypertension and history of polycystic ovaries.

Family history of breast,ovarian,endometrial and colon cancer.

Examination- Assess the patient general condition, BP and BMI.

Per abdomen examination-feel for any masses, ascites, abdominal distension.

Per speculum examination-examine the vulva , vagina and cervix for masses, any atrophic changes and discharge

Per vaginal examination to assess the size of the uterus, mobility, adnexal mass .

Investigation-Full blood count,liver function test, renal function test, trans vaginal ultrasound and endometrial sampling and vaginal swabs.hysteroscopy with endometrial sampling.

Treatment of the patient will depend on the stage of the tumour,grade of the tumour ,fitness of the patient and her wishes.treatment should be carried out in the cancer centre and urgent referral should be sent to the cancer centre within 2 weeks.

patient should be informed about her disease,

Stage 1a- less than 50%myometrial invasion and stage 1b-more than 50% myometrial invasion. treatment is total hysterectomy and BSO with pelvic and paraaortic lymph node sampling.Survival rate around 86%

Stage 2-cervical stromal involvement and treatment is total hysterectomy with Bilateral salpingo-oophorectomy and pelvic lymph node sampling and radiotherapy. Survival rate around 60%

Stage 3a-tumour involves the serosa and adnexa

Stage 3b-tumour involves the vagina and parametrium. 

Stage 3c-paraaortic and pelvic lymph node involvement.

treatment includes Total abdominalhysterectomy with BSO, lymphadenectomy and radiotherapy. survival rate around 40%

Stage 4a-tumour invades the bowel ,bladder mucosa

Stage 4b-distant metastasis.

Treatment includes radiotherapy.progestogens can also be advised.survival rate around 16%.

Patient should be given evidence based information about the treatment options, benefits and side effect of treatment, prognosis and we should also address her psychosocial and psychosexual issues.self help strategies to optimise independence. Written information should be given and leaflets and names of the support groups given. A 24 hour contact number . Support to the family and carers should also be given.

A) I will ask about menarche and menopause as there is increase risk of endometrial cancer in women with early menarche and late menopause.

I will ask about symptoms of bowel involvement like fecal incontinence, urinary involvement like urine incontinence, frequencyand sensation of incomlete emeptying of the bladder.

I will ask about history of polycystic ovary syndrome and any hx of osterogen or tamoxfen as these associated with increase risk of endometrial cancer.

I will also ask about any family history of cervical or colon cancer as there is associated genetic predisposition of these with endometrial cancer

Then iwill examine vital signs T,BP,PR,RR.

I will caculate BMI as there increase risk of endometrial cancer with obesity

I will also examine chest for any signs of lung metastesis 

I will examine abdomen for any palpable mass or organomegaly.

Iwill perform examination for lymph nodes like inguinal, paraaortic and cervical looking for lymphadenopathay.

I will do bimanual examination of the uterus to assess uterine size and presence of any adnexal mass

Iwill also perform speculum ex to assess amount of bleeding and any cerical mass or abnormalities .

B) Treatment of endometrial cancer depend on cancer staging

Stage i cancer is treated by TAH+BSO and laproscopy is better than laprotomy in reducing complications.

Stage ii cancer is treated by TAH+BSO followed by radiotherapy or radical hystrectomy follwed by BSO and lymphadenectomy

stage iii and iv cancer can be treated with adjuvent surgery plus radio therapy or chemotherapy

Chemotherapy can be either single or combined agent and combined agents have better effect than single one

women should be observe for any signs or symptoms of radiotherapy complication lik bowel injury ,anal fistula or bladder injury.

If women can not tolerate radio or chemotherapy progesteron therapy can be given

Majority of women with post menopausal bleeding /spotting have benign pathology. However genital tract malignancies like endometrial,cervical,vulval and vaginal cancers also present with these complaints.

These women must be assessed as soon as possible and within 2 weeks of referral .

h/o age at  menarche and menopause would be asked for as early menarche and late menopause  are risk factors for endometrial cancer.

Obstetric history  would be taken as nulliparity and subfertility are associated with endometrial cancer.

Post coital bleeding or abnormal smears would suggest a cervical pathology.

Any associated symptoms like vaginal discharge ,dryness of vagina,  and dyspareunia are enquired into to see if atrophic changes of the genital tract are a cause of her problem.

h/o itching, soreness and lump in the vulva will be asked for to exclude vulval cancer.

h/o gastrointestinal symptoms like rectal bleeding and haematuria would suggest the invasion of GI tract and bladder.

Drug history  regarding usage of tamoxifen or HRT in the form of unopposed estrogen  would alert to endometrial cancer .

A family history of endometrial, ovarian or colonic cancer may suggest the Lynch syndrome and an increased risk of endometrial cancer.

Personal h/o diabetes mellitus and hypertension would increase the risk of endometrial cancer hence would be enquired into.

Cachexia or weightloss would also increase the suspicion of malignancy.

 Weight will be checked and BMI noted as obesity increases the risk of endometrial cancer.

A general examination to look for pallor and a cardio- respiratory assessment will aid to estimate her fitness for surgery.

Abdominal examination for abdomino-pelvic masses would be carried out.  it could be an estrogen secreting ovarian tumour responsible for the bleeding.

Any ascites and lymphadenopathy will be noted.

inspection of vulva to check for suspicious lesions like ulcers and presence of a lump with itching will be carried out.

Speculum examination to check for atrophy of the genital tract, cervical polyps or  malignancy would help in the diagnosis.

A bimanual examination would be performed as an enlarged or fixed uterus will suggest invasive malignancy.

Adnexal masses and tenderness to be checked for adnexal involvement.

A per rectal examination will help to know if the tumour is extending to the pelvic side wall.

b)

Endometrial carcinoma is a surgically staged disease. The minimal procedure should include the acquisition of peritoneal fluid or washings, a thorough exploration of the abdominal cavity and pelvic and para-aortic nodal areas

 A total hysterectomy with bilateral salpingo-oophorectomy is the primary operative procedure for carcinoma of endometrium.

The subsequent management and post operative therapy depends on the stage and histo-pathological grading .

In stage 1a where the tumour is confined to the body of the uterus the  treatment option is TAH + BSO.   

ASTEC trial showed that  pelvic lymphadenectomy is not beneficial.

In stage   Ib – where 50% or more of myometrium is invaded ,  TAH + BSO and selective pelvic and peri-aortic node sampling is performed.

Radio therapy without lymph node dissection would be a better option in early stage disease as post-operative radiotherapy has been shown to reduce the risk of regional recurrence with no improvement in overall survival.

 Radiotherapy is associated with morbidity. The risk of bowel complications is increased if radiotherapy is administered after pelvic lymphadenectomy.

in  stage II where tumour invades the cervical stroma but does not  extend beyond the uterus treatment options  include  TAH + BSO + node sampling followed by postoperative radiation therapy.

Preoperative intracavitary and external beam radiotherapy followed by TAH +BSO + biopsy of para-aortic nodes can be considered.

 Radical hysterectomy and pelvic lymphadenectomy can be performed  in selected cases.

 In stage III where tumour has local and / or regional spread and involoves pelvic and para aortic lymph nodes the treatment options include  the standard option of TAH + BSO + radiotherapy.

Patients with inoperable disease caused by the tumour extending to the pelvic side wall can be treated by  radiotherapy, with intra-cavitary and external-beam radiotherapy.

Chemotherapy with a combination of doxorubicin and cisplatin +/- paclitaxel and granulocyte colony-stimulating factor is an alternative to radiotherapy.

Patients who are not candidates for surgery or radiotherapy may be treated with progestogens

Stage IV where Tumour invades bladder and / or bowel mucosa and / or distant metastases  standard treatment options are dependent on site of metastatic disease and symptoms..

Intracavitary and external beam radiotherapy would be  for bulky pelvic disease .

 Distant metastases are treated using hydroxyprogesterone, medroxyprogesterone or  megestrol .

Overall 5 year survival for endometrial cancer is  78%.

 laparoscopic hysterectomy (including laparoscopic total hysterectomy and laparoscopically assisted vaginal hysterectomy) for endometrial cancer have proven efficacy and safety and can be performed if expertise is available.

Overall survival rates and disease-free survival rates are not significantly different in women treated laparoscopically compared to those treated by laparotomy.

follow-up is as follows

Most recurrences will occur within the first 3 years after treatment, and 3- to 4-montly evaluations with history, physical and gynecological examination are usually recommended.

Follow-up intervals of 6 months are recommended during the fourth and fifth years, and annually thereafter.

I would enquire about any other associated factors such as itching or fowl smell discharge in view of local causes for blood stained vaginal discharge or Foreign body.  It is highly unlikely to be sexually transmitted disease, but still we need ask about post coital bleed, possibility of cervical pathology. 

I would ask the history of early menarche, late menopause, any pregnancies, diabetes, and hypertension to assess the risk factors for endometrial carcinoma.  Also I would ask whether she is taking any hormone replacement therapy and family history of ovarian, breast, endometrial and colon cancer to assess the risk.  I would like to know any history of breast cancer and treatment with tamoxifen are important to assess the risk.

I would like to know whether all her smears until the age of 64years were normal.  I would like to enquire smoking history or long term immunosuppressant which may be relevant in terms of assessing cervical, vulval or vaginal carcinoma. 

Any history of lichen sclerosis and follow-up so far, may be useful to assess the risks of vulval changes.

History of loss of appetite and loss of weight, Thrombosis history or leg swelling will help towards the possibility of carcinoma.

On examination, I would like to check her BMI, as high BMI is a risk factor for endometrial carcinoma.  On abdominal examination, rule out any obvious abdominal mass or pelvic masses.  On local examination, I would like to rule out any obvious ulcer or lump or skin changes in the vulva and vaginal area.  Then, by speculum examination, check the cervix to rule out any macroscopic changes or obvious ulcer or polyp or mass.  Also, if possible take endometrial biopsy by pipelle.  This helps to assess the uterine length size and have a tissue biopsy.  On vaginal examination, check the mobility of uterus, cervix, and adnexal masses and tenderness to help to point any suspicious pathology.

Investigation:  She needs to have transvaginal scan to check the endometrial thickness and to rule out adnexal masses.

We need to stage the level, before we plan for surgical management.

We should discuss the findings with the patient and to find out her wishes in terms of further treatment options to be discussed.

We need to arrange for her to have MRI with contrast to help with staging.

She needs blood tests: FBC, Blood group and save, U&E, LFT, Chest X-ray, ECG to assess the general condition, severity of the co-morbid conditions and assess if any involvement of other organs due to secondaries.  She may need CT scan chest abdomen and pelvis for assessment.

With all the above in place, the case should be discussed at the gynae-oncology MDM meeting and plan for a treatment should be made.  It would include whether she would have surgery either at cancer unit or cancer centre based on staging.  The outcome from the MDM should be clearly documented in the notes and GP should be notified.  The patient should be again seen by her primary gynaecologist and should be told about the full information and if she agrees to be referred, refer her to the cancer unit or centre as per MDM. 

At the earliest opportunity, before the surgery, the gynae-oncology consultant should see the patient and explain when she would be operated, mode of operation such as laparoscopic assisted procedure or laparotomy through transverse or midline incision.  She should be told about total hysterectomy with bilateral salphingo-oophorectomy,  and possible pelvic nodes removal if noted in the MRI scan.  She should be told that how long she would likely to stay hospital, her recovery time following the surgery and any further treatment would be necessary based on the operative findings and histological diagnosis.  It would be either chemo or and radiotherapy.

Any personal and family support should be offered.  Cancer nurse should be present during the consultation.  All the above should be documented in the notes.  Patient should be given the contact details of relevant team, leaflet.

A)

Details are obtained regarding nature of the vaginal discharge and its impact on her quality of life.

Her menstrual history is taken which includes age of menarche, regularity , cycle length and flow including last menstrual period.

Enquiry is made about her parity as nulliparity is predisposing factor for endometrial carcinoma.

Any precipitating factors are asked such as intercourse as post coital bleeding suggests cervical pathology. Previous cervical smear history is taken.

History is taken about vaginal dryness and other menopausal symptoms. If she is taking HRT she should be asked about compliance. Details of HRT are noted as unopposed and sequential form of HRT is associated with risk of endometrial carcinoma. Enquiry is made if she is using exogenous estrogens such as phytooestrogens.

History is taken regarding loss of weight, loss of appetite as they suggest malignancy. She should be asked about chest symptoms such as cough and haemoptysis suggesting lung involvement.

Rectal bleeding and haematuria should be excluded as women may misinterpret the origin of bleeding.

She should be asked if she is diabetic or hypertensive as both are risk factors for the development of endometrial carcinoma.

She should be asked about family history of endometrial carcinoma .

Examination includes assessment of BMI as obesity is a risk factor.

Pallor and cachexia suggest malignancy. BP is recorded .

Examination is performed to note enlarged supraclavicular node.

Abdominal examination is conducted to detect hepato splenomegaly, and to exclude abdominal or pelvic masses.

External examination of vulva and vagina is done to assess genital tract atrophy, vulval and vaginal ulcerations.

Speculum examination is done to assess any obvious cervical lesion such as carcinoma or polyp requiring biopsy.

Bimanual pelvic examination is done to identify adnexal mass.

B)

Treatment options of endometrial carcinoma depends upon the stage of the disease and mainly surgical.

If she belongs to stage 1a with no or less than 50% endometrial invasion, TAH and BSO are sufficient and pelvic lymphadenectomy is not beneficial according to ASTEC trial.

If she belongs to stage Ib - 50% or more myometrial invasion: TAH + BSO and selective pelvic and peri-aortic node sampling should be performed. Use of radiotherapy in the post operative period has been shown to reduce the risk of regional recurrence with no improvement in overall survival with added risk morbidity like bowel complications .

Current evidence supports the use of laparoscopic total hysterectomy or laparoscopic assisted vaginal hysterectomy for the treatment of endometrial cancer with no significant different disease free survival rates.

Stage II is tumour invading stroma of cervix and gladular extension is considered to be stage I. The treatment options for this stage include TAH

+ BSO + node sampling followed by radiotherapy in the post operative period.

The radiotherapy can be given in the preoperative period followed by TAH + BSO with biopsy of para- aortic nodes.

In few selected cases radical hysterectomy and pelvic lymphadenectomy can be performed.

For stage III the standard treatment options include TAH+BSO+ radiotherapy.

If the tumour is inoperable i.e if extends to the pelvic wall, radiotherapy with intra-cavitary and external beam radiotherapy.

An alternative to radiotherapy is chemotherapy with a combination of doxorubicin and cisplatin with or without paclitaxel and granulocyte colony stimulating factor.

If she is not fit for either surgery or radiotherapy may be treated with progestogens.

In case of stage IV i.e if the tumour invades bladder or bowel mucosa ( Iva) or distant metastases intraabdominal or inguinal nodes (IV b), the treatment options depend upon site of metastatic disease or symptoms.

For bulky pelvic disease, intracavitary and external beam radiotherapy is recommended. Other option for distant metastases is progestogen therapy using hydroxyprogesterone, medroxyprogesterone or megestrol.

History in regards of timing of bleeding is taken and whether it occurs after sexual intercourse which might suggest cervical pathology. Patient is asked if the bleeding starts while scratching the vulval because of intense pruritus. Enquires about other associated symptoms like weight loss, early satiety which might  malignancy.  She is asked about increased urine frequency and abdominal girth as a result of presence of mass.Hx of smear test is asked for. Risks factors for endometrial cancer are asked for such as early menarche, nulliparity, late menopause and if she is diabetic or hypertensive. Drugs hx. Is taken especially warfarin, tamoxifen or use of prednisolone which can cause PVB. Patient is asked about family hx of  colorectal, pancreatic and prostate cancer as the might show hereditary component of cancer as well as personal hx of breast cancer.On examination BMI is assessed as well as fitness for surgery by  auscultating the chest and checking the BP, P, T. Abdomen is palpated for presence of masses and previous suregeries. Speculum examination to assess vulvav and vagina for atrophy or presence of lumps or lesions as potentiual causes of PVB. Cervix is assessed for any macroscopical abnormalities. Bimanual examination to assess size of uterus and presence of adnexal masses

B)Treatment options will depend on stage of endometrial cancer, fitness for surgery and patient’s wishes. Treatment plan is discussed in MDT including Oncologist Gynaecologist lead, specialist nurse, Pathologist and medical Oncologist

In stage Ia and I b TAH and BSO is recommended as 10-20% will have occult ovarian metastasis at time of diagnosis. It can be performed laparoscopically if expertise available. Lymphadenectomy in early disease is not recommended as ASTEC trial did not show any benefits. In stage II radical hysterectomy is recommended for the cervical component as well as BSO. Lymph nodes sampling can be done but it adds on risk of surgery. Radiotherapy is recommended as an adjuvant therapy after all  high risk stages as it decreases the vaginal vault recurrence. In her case as 77 years old radiotherapy can add on morbidity and should be MDT.In stage  III  and IV she can be offered high doses of Megestrol as well as palliative therapy. Radiotherapy can be used for arresting the bleeding 

More information is required into the presenting compliant, such as is this the first episode, was it associated with pain are there any other associated symptoms suggestive of an underlying malignancy such as weight loss or reduced appetite. The history should be cover risk factors for endometrial cancer. Within the gynaecological history this will include an early menarche and late menopause, nulliparity and the use of any HRT, in particular unapposed estrogen. A smear history should be taken as cervical cancer can also present with post menopausal bleeding. 

A general medical history could also highlight risk factors for endometrial cancer such as diabetes and hypertension, these and other co-morbidities should be established as they will impact on possible treatment planning. A drug history should be taken, anticoagulants could predispose her to bleeding if INR levels are not stable and tamoxifen use increases her risk of endometrial cancer. A family history is important asking about other family members with colon, prostate or endometrial cancer as she may have inherited Lynch 2. 

This woman should have her blood pressure checked. Her BMI should be calculated. An abdominal examination should be performed she may have a large pelvic mass. If tolerated a bimanual examination and speculum examination should be performed. This may reveal atrophic vaginitis, a cervical abnormality or a bulky uterus. 

The treatment options will depend on the patients performance status, the stage of the cancer and any other poor prognostic markers such as clear cell or grade 3 cancer. The case will be discussed at the MDT and the appropriate treatment decided. The patients wishes should also be respected and the intention of any treatment should be made clear. The woman will be treated at the hospital with the appropriate facilities, if she has stage 1b or above she will be treated in a cancer centre.

If she is fit generally surgery is the preferred approach. This involves TAH and BSO with peritoneal washings and lymph node sampling. Further advances in surgery now mean that the procedure can be performed laparoscopically with vaginal assistance.  The Astec trial showed no survival advantage of routine lymphadenectomy and increased morbidity with lymphadenectomy and radiotherapy compared with radiotherapy alone. Occasionally if the woman is fit and has stage 2 disease she can be offered a radical hysterectomy and lymphadenectomy.

If the woman has undergone a simple hysterectomy and BSO and the sampled lymph nodes are positive or there are poor prognostic markers the woman will also be offered radiotherapy. The Portec study showed the Bracytherapy is as effective as external beam radiotherapy.

Women who are not fit for surgery can be offered radiotherapy as their initial treatment with curative intent. However in advanced disease and those not fit for surgery chemotherapy can be offered for palliation ie Progesterone.

Trials are now looking into adjuvant chemotherapy and the woman could be recruited for this.

my subscription expires on 29th.

Can i have to opportunity to use for additional 5 days prior to exams.

1.Clinical asseessment of the patient includes a detailed history,examination and investigations which all may help to reach a diagnosis.

in the history it is important to note the duration of symptoms,whether she is sexually active,any associated post coital bleeding,use of HRT,previous smear history,whether she was update with the smears,her mental capacity and forgetfullness to rule out the chances of foreign bodies and forgotten IUCDs.

Detailed examination of the patient to assess the general health status,cancer cachexia,pallor,BMI,lymphadenopathy and blood pressure.

Abdominal examination done to rule out any palpable abdominal massess,ascites and lymphadenopathy.

Local and speculum examination to notice the atrophic changes in the genitalia any evidence of trauma and cervix to notice any lesion or polyp.If the intritus is narrowed owing to the postmenopausal status examination under sedation may be needed

Investigations include blood investigations including FBC,urae and electrolytes,liver function tests and imaging studies.

Trans vaginal ultrasound is the initial investigation of choice in the patient specifically to notice the endometrial thickness.If the endometrial thickness is more trhan 3mm in non HRT users and more than 5mm in HRT users ,it needs further evaluation with endometrial studies ,this is undertaken by outpatient hysteroscoy and biopsy.

2.The management options for the patient with endometrial adenocarcinoma depends on the stage of the tumour and the patients clinical fitness to the various modalities like surgery,radiotherapy and chemotherapy.chest xray and MRI will aid in the accurate staging,at the ouitset she should be counselled regarding the dignosis in a sensitive manner to take into account the traumatic situation.Further management should be done in a cancer centre with multidisciplinary input.

Early stage low grade tumours can be managed with total abdominal hysterectomy with bilateral salpingo oophorectomy without pelvic node dissection.laparoscopic approach can be done in early stage disease and well selected cases.

stage 2 disease is managed with radical  hysterctomy ,bilateral salpingo oophorectomy with node dissection,alteratively node dissection can be omitted in view of the high morbidity and post operative irradiation can be arranged to manage the nodes

advanced stage disease not amenable to surgery needs palliative chemotherapy and radiotherapy.

Patient should be offered psychological support and contact with support groups.

A) Clinical assessment include thorough history regarding any previous episode of blood stained vaginal discharge since menopause, anorexia, weight loss. Ask if early menarche and late menopause, PCOS (unopposed estrogen exposure)were present or not which are risk factors for endometrial cancer and also of diabetes, hypertension, obesity, nulliparity, family history of endometrial, breast cancer.

Drug history is of paramount importance;if on HRT( unopposed estrogen) due to menopausal symptoms, tamoxifen for breast cancer which may lead to endometrial hyperplasia and anticoagulants( lead to increased APTT). Ask if this is post-coital bleeding,(cervicitis/Ca Cx) or associated with itching in vagina, dyspareunia (atrophic vaginitis). h/o purulent discharge( senile endometritis), coagulopathy has to be asked.

Associated features of bladder pain, hematuria, dysuria has to be asked to rule out pathology of bladder and constipation , rectal bleeding should be enquired to rule out piles,rectal carcinoma. H/o of previous smears and their report has to be asked. Past treatment history has to be asked of cervical cauterisation,LLETZ,LEEP, cervical/endometrial polypectomy, hysterectomy( granulation tissue at vault leads to bleeding) as there may be recurrence of those lesions.

Examination include general examination ; BMI, BP measurement, pallor(estimation of blood loss), icterus(any metastasis to liver), supraclavicular and inguinal lymphadenopathy( advanced stage of endometrial cancer) Abdominopelvic examination has to be done, to look for any palpable abdominal mass, its consistency (hard s/o malignant and cystic s/o benign pathology),mobility, margins, tenderness.(fixed,irregular margins, s/o malignancy) and associated ascites .

Local genitalia examination – look for urethral caruncle ,piles ( Bladder and bowel origin of bleeding needs to be ruled out).Sterile per speculum examination has to be done to look for the atrophic changes in vagina, cervicitis, erosion,cervical polyp. Take endometrial sample with Vibra aspirator during clinical assessment. Bimanual pelvic examination has to be done to assess the size of uterus, consistency, adnexal mass and its mobility.

B) On diagnosis of endometrial adenocarcinoma,if surgical fitness is there; definitive treatment is Staging laparotomy followed by TAH + BSO, pelvic and paraortic lymphnode sampling, peritoneal washing and peritoneal biopsy.

On frozen section if cervical stromal(stage II) involvement is present, do paraortic and pelvic lymphadenectomy. Post-op adjuvant radiotherapy is given in form of intracavitary and external radiotherapy to decrese regional recurrence . For Stage Ia i.e, no or < 50% myometrial involvement, no post-op radiotherapy is required. Patient has to be kept in close follow-up regarding recurrence of any metastasis.

For stage III- inoperable cases due to extension of tumour to pelvic wall, intracavitary and external radiotherapy is given. Chemotherapy with doxorubicin+ cisplatin or granulocyte colony stimulating factor can also be used if not fit for radiotherapy. If the patient is not fit for surgery and stage IVB(distant metastasis) start her on high dose progestogen- 100-200mg medroxyprogesterone in divided doses. For stage IVA palliative treatment by radiotherapy is given.

Social support by local authorities and written information leaflets should be provided to the patient.

A) History would include further questioning of her vaginal bleeding such as whether it was associated factors such as intercourse which could indicate atrophic vaginitis. An offensive discharge may indicate an infection. If she uses HRT the bleeding maybe due to missed pills.

Risk factors for endometrial cancer should be asked as 8% of women that present with PMB have endometrial cancer. Early menarche, late menopause and nulliparity as well as the use of sequential HRT, unopposed HRT or tamoxifen should raise suspicion. A previous history of PCOS and family history of endometrial or colorectal cancer should be asked as there is an association with HNPCC.

Ovarian cancer can also present with PMB so a history of weight loss, altered bowel habit and abdo pain should be asked.

Her smear history should be elicited as well as previous history of any treatment for abnormal results.

A past medical history should elicit other health problems and how fit she is if surgery was needed.

Examination would include assessment of BMI as if this is high it increases her risk of endometrial cancer. BMI is also important in terms of planning treatment options such as surgery. Her BP should also be recorded. An abdo and VE examination would be warranted to assess for any pelvic masses. The vulva should be inspected to see if any lesions or atrophy that could be causing the bleeding. A speculum to assess the cervix should be carried out.

A transvaginal U/S should be arranged as soon as possible. If she is not on HRT and the endometrial thickness is >3mm, sampling of the cavity is required. This can be done in clinic with a pipelle biopsy or as an in or out patient hysteroscopy. She should be bought back to clinic to discuss these results if abnormal as soon as possible so subsequent management can be arranged.

B) Endometrial cancer is surgically staged so she would be advised that a TAH/BSO would be necessary if she was medically fit. Current recommendations advise that washings and lymph nodes do not need to be taken at the time of surgery. Her case would be discussed in an MDT setting where histology, US, MRI and other imaging would be discussed. If it is suspected from the MRI that she has stage 3 disease she would be transferred to a specialist cancer centre for her treatment.

The patient would be counselling regarding the procedure, that her womb and ovaries would be removed. The operation can be done as an open procedure, vaginally or laparoscopically. This would depend on patient factors (ie if she has a large bulky uterus vaginal hysterectomy would not be appropriate) and local expertise and protocol. The procedure would be under a general anaesthetic and she would be in hospital for several days recovering.

Following surgery she would be seen in the rapid access clinic, the endometrial cancer would be staged. If she has stage 2 disease and above or clear cell cancer she will require radiotherapy.Bracytherapy has been shown to be as effective treatment as external beam radiotherapy.If she has stage 3 or grade 3 she should also receive chemotherapy.

If she is unfit for surgery or has advanced disease radiotherapy or high dose progesterone can be offered as a treatment option. She should be advised that there is a high risk of recurrence with progesterone therapy.

A 77 year old woman has been referred to the gynaecology clinic because of a 3 months history of blood-stained vaginal discharge. (a) Discuss your clinical assessment [9 marks].  (b) She is found to have endometrial adenocarcinoma. Discuss her treatment options [11].

Features of the history would involve exploring the presenting complaint further. I would ask regarding any associated weightloss, loss of appetite, or involvement of urinary or bowel symptoms. Past medical history should explore any history of breast cancer or other malignancy, or with previous tamoxifen use, or previous HRT use. Previous Gynaecology history including history of cervical smears and abnormalities, Parity and other risk factors for gynaecological cancers, including age of menopause and if she had any associated treatment (e.g. radiation menopause) or PCOS. Social history would include history regarding tobacco use and also any associated family history of cancers, as this can predispose her to gynaecological cancers.

Examination would entail a general examination (BP, pulse) including calculation of BMI. Chest examination would be performed check for any chest signs for spread of metastasis. Abdominal examination would be performed to check for any palpable masses, enlarged uterus. Pelvic examination would look at external genetalia to check for alternative sites of bleeding. Vulva, vagina and cervix would be inspected as other possible sites of PMB, eg, atrophic vaginitis. Speculum examination to visualise cervix and perform Pipelle biopsy to send for histology. Ideally this patient should have had an abdominal/pelvis transabdominal/transvaginal scan of pelvis and seen in rapid access clinic prior to review, to visualise pelvic organs including ovaries and assessment of endometrial thickness. The pipelle can be sent for histology and follow up dependent on histology. If a pipelle biopsy can not be tolerated/performed, a hysteroscopy +/- endometrial biopsy should be performed urgently with review of results after.

B)

Treatment options for this lady would depend on staging of endometrial cancer, cell type, patient morbidity and wishes of the patient. 

Her diagnosis should be be discussed in the regional MDT meeting and she should have appropriate imaging to check for spread prior to any surgical managment, by a CT Chest, Abdomen and Pelvis. The spread of any possible metstasis and stage should determine where she has surgery, e.g. secondary cancer centre or to send to regional gynaecological cancer unit. 

If likely stage I, she should be offered a TAH + BSO at the local unit. Stage II options include surgery with TAH & BSO & Chemotherapy. Stage III, surgical with TAH & BSO & pelvic, aortic lymphadenectomy combined with chemotherapy (paclitaxel) and in combination with radiotherapy. Alternatively she can be offered progestogens if not suitable for surgery. Stage IV would involve pallliation treatment. 

The treatment should be multidisciplinary involving the care of a gynaeco-oncologist, oncologist, pathologist and radiologist with interest in gynae cancer, a specialist nurse.

When informing the patient of disase diagnosis this should be done with a specialist nurse available and family/friend support. Support groups should be informed to the patient and how to contact them, together with information leaflets.

a) i will obtain history of cancer in family and age at meopause and use of contraception.also need to know having medical problem like diabetes and hypertension and obesity as association with endometrial cancer.i obtain history of cervical smear and any similar history or biposy taken. examination will involve general fit foe surgery and lpresence of lymph nodes and abdominal for masses 

pelvic for size of uterus and will take biopsy like sampling in clinic and arrange to have hysterrscopy and ultrasound for endometrial thickness. cervical cause should ideally be excluded . watery discghaege may denote tubal cancer...

i will arrange to have ct and mri to exclude extension metastasis and lymph node assessment..

b) treatment option will depend on stage of disease and prognosis and whether she benifit from surgery or not fitt so radiotherapy may be the only available option

hormonal treatment in form of progesterone either long action as depot provera or mirena or the surgicall managment would be total abdominal hysterctomy and bilateral salpingooopherectomy omental biopsy and aspiration..

multidiciplinry tem as oncologist and MDT meeting and informing family with a macmilln nurse is the main stps to manage endometrial cancer

A

I would  ask about the nature of the bleeding

Post coital bleeding  is a marker of cervical pathology or atrophic change.

History of early menarche and late menopause increases the risk of endometrial cancer.

I would  ask about the nature of the bleeding 

Post coital bleeding point to presence of cervical pathology  and atrophic changes

History of early menarche and late menopause increase the likelyhood of endometrial pathology

History of breast cancer and tamoxifen therapy also increase the posibility of  endometrial cancer

History of hypertention and diabetes is associated with increase risk of endometrial cancer  .

Would inquiry about the last  cervical smear and what was the result.

History  of sequential combined hormonal replacement therapy  as well as non opposed oestrogen increase the risk of endometrial cancer.

I would examine her abdomen for pelvi abdominal mass.

Speculum examination  looking for local causes  , atrophic changes and cervical pathology is important step in the diagnosis .

Bimanual examination for both fossae  to exclude   any oestrogen secreting tumour.

B/

Options depend on the stage of the cancer , fittness of the patient to surgery as well as to anathesia in addition to her acceptance to specific modality of treatment after counselling

Patient should refer to  gynae oncolog centre

Radiological staging  using MRI of the abdomen and pelvis  helps in determining extent of the cancer

Ultrasound of the pelvis and abdomen can detect presence of ascites ,enlarged lymph nodes, hydronephrosis as well as liver metastasis

Chest X ray helps in diagnosis of distant metastasis.

Surgical staging then of paramount importance .

Total abdominal hysterectomy plus bilateral salpingo overectomy (TAH+BSO)is the gold standard step in the staging as well as in treatment  of stage 1a a cancer

In stage 1 b cancer  in addition to TAH+BSO, selective lymph node sampling  should be performed.post operative radio therapy shows decrease risk of regional recurrence with increase complications related to radiotherapy but with no increase in the over all survival rate.

For stage2 cancer TAH+BSO + lymph node sampling followed by radi therapy is the suitable choice.

For stage 3 cancer  , if operable TAH+BSO+selective lymphedenectomy  +intacavitory and external beam radiotherapy is the option.

       Chemo therapy   is an alternative to radio therapy.

       progesteron is an option  for non operable cases.

For stage 4 cancer , radio therapy  including external beam radiation + intracavitory for ,pelvic disease.

          progesterons is the option for distant metastasis. 

Surgery (Total abdominal hysterectomy plus bilateral salpingo overectomy plus pelvic and abdominal lymph node sampling ,)

plus radiotherapy for  operable   stage 2b and stage 3 cancer

Stage 1 and stage 2b  could be manged 

Chest X ray helps in dignos

Dear Paul,

Was my clinical examination for my answer for part a entirely wrong that's why it was left unmarked?I mentioned BMI, abdominal, speculum and bimanual examination etc. Also, I would like to check are we expected to know the specific management in detail for all stages of gynaecology cancers for the MRCOG part 2 examination?

Thanks.

Dear Paul,

Since staging of endometrial cancer is surgical-pathological staging.Then how to diagnose&differntiate stage Ia/b,II.and to proceed further with lymphadenectomy.Is it by frozen section?

 A)

Post menopausal bleeding is associated with a 10% risk of endometrial carcinoma therefore I will tailor the history toward risk assessment. Symptoms of weight loss and anorexia are seen in malignancies. A history of diabetes mellitus and hypertension are associated with endometrial carcinoma. Nulliparity, early menarche, late menopause and a prior history of polycystic ovarian syndrome are associated with endometrial carcinoma.  A family or personal history of breast, ovarian or colonic cancer is associated with the Lynch 2 syndrome (familial cancer). Use of tamoxifen, unopposed estrogen or sequential hormone replacement therapy or phytoestrogens predispose to endometrial hyperplasia and carcinoma. A history of her cervical smears would assess her risk of cervical cancer. Post coital bleeding suggests a cervical cause. Vaginal dryness suggests atrophic vaginitis. Vulval itching and soreness suggests a vulval cause. Surgical, anaesthetic and VTE risk assessment should also be done.

On examination measure her blood pressure and calculate her BMI. Palpate for supraclavicular and inguinal lymphadenopathy. Perform an abdominal examination for abdominal masses and ascites. Inspect vulva for ulcers. Perform a speculum vaginal examination. Cervical abnormalities or contact bleeding warrants colposcopy. Note vaginal epithelial atrophy. Perform a bimanual palpation for pelvic masses. Bleeding from the urethra or rectum may be mistaken for vaginal bleeding. Examine the urethra for local causes like a urethrocele. Perform a rectal examination to palpate possible pelvic metastases and diagnose rectal causes of bleeding like a rectal tumor.

B)

Treatment will follow a multi-disciplinary team approach consisting of a gynaecological oncologist, anaesthesist, radiologist, pathologist, oncology nurses, psychiatrist and her general practitioner. Treatment depends on the stage of disease. Stage 1a requires a Total Abdominal Hysterectomy and Bi-Salpingo Oophrectomy (TAH/BSO). Stage 1b requires a TAH/BSO with pelvic and para-aortic node sampling followed by adjuvant brachytherapy . Brachytherapy reduces the incidence of pelvic recurrence. Stage 2 disease requires a TAH/BSO with pelvic and para-aortic lymph node sampling and adjuvant radiotherapy. Bulky tumors may require neo-adjuvant radiotherapy prior to TAH/BSO and pelvic-para aortic lymph node sampling. Selected cases will benefit from a radical hysterectomy and pelvic lymphadenectomy. Stage 3 disease requires TAH/BSO and adjuvant radiotherapy. Disease spread to the pelvic side walls precludes primary surgery and is treated with intra-cavitary and external beam radiotherapy. Chemotherapy using doxorubicin and cis-platin with paclitaxel and granulocyte colony stimulating factor offers some benefit. Patients not suitable for surgery or radiotherapy may be offered progestogens (hydrodxyprogesterone, medroxyprogesterone or megestrol). Stage 4 disease requires intracavitary and external beam therapy for pelvic disease and progetogens for distant metastases. Discuss morbidity associated with radiotherapy. These include acute effects like vomiting, diarrhea and haematuria which may cause discontinuation of therapy. Late effects include rectal bleeding and fistulation. Morbidity of radiotherapy is increased with lymph node dissection. Ensure adequate analgesia adopting the WHO 3 step ladder. Offer psychiatric consult and discuss end of life care if appropriate.

Good day Dr. Paul, was my essay (363) corected?. I can't find your corrected version. Thank you.

Dr. Paul..sorry to ask...but could you correct my essay...it was submitted  on the 25th...again...my apologies for asking...and thank you.