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Answers on p 353.
A 36 year old women (para 0 + 1) was referred to the colposcopy clinic in August 1995 after a routine cervical smear had shown severe dyskaryosis. Her previous smears had been unremarkable and she had no risk factors for developing cervical abnormalities. She suffered from ulcerative colitis and two paternal uncles had developed colorectal cancer.
The colposcopic directed punch biopsy was reported as showing cervical intraepithelial neoplasia (CIN) III with an area of squamous carcinoma.
After subsequent examination under anaesthesia she was staged as having an 1B cervical carcinoma. Histologically the tumour had invaded to a depth of 1 mm and had spread laterally to 10 mm. Because of her desire to preserve fertility, she decided after extensive counselling to be treated as conservatively as possible and a cone biopsy was performed. As the tumour was close to the excision margins a repeat cone biopsy was performed to obtain more extensive tumour-free margins. Subsequent histology was negative and follow up colposcopy was arranged.
In September 1996 she presented with abdominal discomfort. A pelvic ultrasound scan demonstrated an 8 cm left simple ovarian cyst. The serum CA 125 (a tumour marker for epithelial ovarian cancer) was normal. At surgery the cyst appeared to be benign and only a left oophorectomy was performed.
However histological examination diagnosed a clear cell variant of endometrioid carcinoma with an intact capsule. She was therefore referred to the gynaecological oncological unit for further management. A staging laparotomy was performed which included peritoneal washings, examination of all peritoneal surfaces and biopsy of right ovary, an infracolic omentectomy, and pelvic lymphadenectomy. All specimens were reported as negative and the ovarian carcinoma was staged as an 1A.
Thereafter she was followed up in the gynaecological oncology clinic at three monthly intervals. In early 1998, at a review appointment, she reported a new symptom of menorrhagia. As clinical examination was unremarkable and as her symptoms were tolerable, reassurance was given. However, the menorrhagia persisted and in September 1998 at the age of 38 years, an endometrial biopsy with a Pipelle de Cornier was attempted. This was unsuccessful, secondary to narrowing of the cervical canal from her previous cone biopsies. Definitive endometrial assessment in the form of hysteroscopy and dilatation and curettage was therefore performed in October 1998. At this procedure, thick suspicious currettings were obtained from a normal sized uterine cavity.
These were reported as grade 2 endometrioid adenocarcinoma. She was therefore counselled that treatment would entail a hysterectomy and right oophorectomy with loss of childbearing potential. Two weeks later she underwent surgery and the endometrial carcinoma was staged as a 1B. This was considered by the pathologist to be a new primary after her ovarian pathology had been reviewed.
Postoperatively she made an uneventful recovery.
- What is the management of a 1B squamous cervical carcinoma in a patient who wishes to preserve fertility?
- What are the guidelines in the investigation of menorrhagia in a women under 40 years?
- What further course of management should be recommended for this patient?