2009, Vol 7, No 2
Prevention of uterine cervix adenocarcinoma: a review
GIN ONKOL 2009, 7 (2), p. 83-87
ABSTRACT

Cervix adenocarcinoma accounts for 7-8% of all uterine cervix cancers. Most often it affects women under 50. As has been demonstrated, its development is associated with persistent infection by types 16, 18, 45 and 31 of human papilloma virus. Precursor (precancerous) lesion develops in the transitional area in the form of adenocarcinoma in situ (AIS), then infiltrates the cervical canal and after 5-12 years progresses to invasive cancer. Cytological study is much less sensitive in the detection of adenocarcinoma and colposcopic examination – less useful. Inferior sensitivity of cytological studies is caused by incorrect technique of harvesting exfoliated cells (e.g. from vaginal portion only, omitting the cervical canal), or by use of a cotton-swab instead of a special plastic brush (Cervex-Brush). Prognosis in cervical adenocarcinoma is worse than in planoepithelial cancer (even if detected at the same clinical stage), particularly if associated with persistent infection by HPV type 18. Vaccinations against this type of cancer (Cervarix and Silgard) play a significant role in the prevention of this condition, which is notoriously difficult to detect.

Keywords: adenocarcinoma of uterine cervix, anti-HPV vaccinations, CIN, TBS system, HPV type 16, 18, 45, 31
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Radiochemotherapy in advanced vulvar cancer. Own experience and review of the literature
GIN ONKOL 2009, 7 (2), p. 88-96
ABSTRACT

Background: In cases of advanced vulvar cancer with non-resectable lesions, permanent cure is extremely rare. In the past, chance for improved outcomes was sought in extensive exenterative procedures, resulting in significant disability and compromising the patients functioning. An alternative therapeutic option of far-advanced vulvar cancer is radiotherapy, either used as a stand-alone modality or as neoadjuvant modality, prior to surgery. At present, chemosensibility of vulvar cancer is relatively well documented. Implementation of synchronous chemotherapy with a 15-20% reduction of total dose of radiotherapy provides a favourable therapeutic index. The aim of this paper is to evaluate tumour response to radiochemotherapy in patients with advanced vulvar cancer, based on own experience to-date. Material and method: Since January 1st, 2005 thru December 31st, 2008, at the Department of Female Genital Tumours of the Centre of Oncology in Warsaw, we have treated 17 patients with planoepithelial vulvar cancer in clinical stages T3 and T4, N0-N2M0, aged 56-81 years (mean: 68 years). The patients were irradiated with photons X (6-15 MeV) over vulvar area, inguinal lymph nodes and pelvis. Total doses delivered to vulvar area ranged from 50 to
65 Gy (depending on extent of tumour infiltration) and to pelvic and inguinal lymph nodes – 45-65 Gy. Chemotherapy consisted of 5-FU at the dose of 750-1000 mg/m2, administered in a 96-hours’ infusion on days 1st-4th and cisplatin at a dose of 50 mg/m2 on day 1st, administered on the 1st and 5th week of radiotherapy. Results: Complete regression of tumour (complete response, CR) was achieved in 7 (41%) patients, partial response (PR) – in 9 (53%) patients, and progression of disease in spite of the therapy was observed in 1 (6%) patient. In 3 (33%) patients who obtained partial response, at surgery only radiation-induced damage was seen, with no viable tumour remnants. Conclusions: Radiochemotherapy should be considered the treatment of choice in far-advanced vulvar cancer. Treatment plan should be elaborated by qualified gynaecologists-oncologists, in close cooperation with radiotherapists. Surgery should be reserved for patients with recurrent disease or those with incomplete regression after radiotherapy.

Keywords: advanced vulvar cancer, radiochemotherapy, tumour regression, reaction to radiation, treatment outcome
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Current opinions on possible preservation of fertility in patients undergoing antineoplastic therapy
GIN ONKOL 2009, 7 (2), p. 97-106
ABSTRACT

Implementation of increasingly aggressive protocols in oncology results in increasing permanent cure rates. This is particularly noticeable in the youngest age group, including women of reproductive age. In this population of patients, permanent cure rates may reach 75% according to some authors. Unfortunately, implemented treatment frequently results in a compromised function of gonads and associated therewith secondary infertility, thus significantly influencing the patients’ quality of life. Aggressive and multidrug systemic therapy, used in most frequent paediatric malignancies, e.g. in Hodgkin disease or haematological neoplasms, is associated with high risk of ovarian damage. Particularly gonadotoxic effects have been documented after radiotherapy and alkylating agents-based chemotherapy. At present, there are several methods aiming at preservation of reproductive capacity of patients undergoing such treatment. Currently used transposition of ovaries out of irradiated area and freezing of embryos, in spite of considerable effectiveness, are burdened by several limitations and do not solve the problem of infertility in a satisfactory way, particularly in the youngest oncologic patients. Recently, research is focused on attempts of using GnRH agonists and antagonists, as well as on freezing immature oocytes. Among novel techniques, considerable hopes are associated with freezing and transplantation of ovarian tissue. These procedures do not delay implementation of antineoplastic treatment and do not compromise its effectiveness, but as novel still raise much controversy and debate.

Keywords: chemotherapy, infertility, freezing of ovarian tissue, paediatric malignancies, premature ovarian failure
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Role of peritonectomy in cytoreductive surgery of ovarian cancer
GIN ONKOL 2009, 7 (2), p. 107-113
ABSTRACT

Background: Global statistics indicate continuously increasing incidence of ovarian cancer. As the outcome of surgery- and chemotherapy-based therapies of this condition are highly unsatisfactory, the search is underway for novel surgical techniques, more effective drugs and new treatment protocols. Peritonectomy is a technique enabling a more complete cytoreduction and better survival indices. The aim of this paper is to review current literature related to peritonectomy – a novel technique in cytoreductive surgery of ovarian cancer. Material and method: Internet-based search of medical libraries (Cochrane, PubMed and Medline) using such key words as: “ovarian”, “cancer”, “chemotherapy”, “peritonectomy”, “chemohyperthermia”, and various combinations thereof. The review encompassed papers published after 1990. Results: Literature data enable an insight into several techniques of peritonectomy, as well as its combination with intraperitoneal hyperthermic chemotherapy. Results of surgical treatment including peritonectomy and complications on the part of other organs as sequels of this procedure are reviewed. Conclusions: Peritonectomy is a novel surgical technique, which may contribute to improvement of outcome of ovarian cancer treatment. Although this type of procedure is associated with an increased risk of complications due to its greater invasiveness, in most authors’ opinion complication and mortality rates are acceptable. Based on available literature we may conclude that prospective studies are necessary in order to determine the role of this technique in the aspects of survival and postoperative complication rates.

Keywords: ovarian cancer, cytoreductive surgery, peritonectomy, hyperthermic chemotherapy, debulking
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Significance of D-dimers in first-line chemotherapy of ovarian cancer
GIN ONKOL 2009, 7 (2), p. 114-122
ABSTRACT

Background: Ovarian cancer is usually diagnosed late and is one of leading causes of genital malignancies-related mortality in women. Thromboembolic events are a frequent complication of neoplastic disease, occurring four-fold more often in patients with this disease and six-fold more often in persons undergoing chemotherapy. The aim of paper was to answer the following questions: What is the impact of first-line chemotherapy on D-dimer level during treatment? Is there any correlation between D-dimer level and FIGO stage of ovarian cancer? Is there a correlation between D-dimer level during chemotherapy and completeness of tumour resection? Is there a correlation between D-dimer level and incidence of thromboembolic complications during chemotherapy of ovarian cancer? Material and method: Study population initially consisted of 20 women with ovarian cancer treated at the Department of Oncologic Gynaecology of the K. Marcinkowski Medical University in Poznaƒ. Each patient underwent cytoreductive surgery with subsequent paclitaxel-plati-num chemotherapy. Peripheral blood has been obtained four times from each patient in order to assess D-dimer level, CA 125 tumour marker and blood count. Results: In persons with ovarian cancer, preoperative D-dimer level several-fold exceeded normal range. Application of chemotherapy significantly (p<0.05) reduced D-dimer level in women with ovarian cancer. Conclusions: Assessment of risk of thromboembolic complications in women with ovarian cancer during chemotherapy based on D-dimer level is not possible.

Keywords: ovarian cancer, neoplasm, thromboembolic complications, D-dimers, first-line chemotherapy
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Palliative care in advanced breast cancer
GIN ONKOL 2009, 7 (2), p. 123-130
ABSTRACT

Breast cancer is currently one of the most frequent malignant neoplasms in Polish women. Since the ‘80s of past century, breast cancer is the leading cause of mortality in women aged 40-59. Patients are usually admitted to the stationary palliative care facilities in a far advanced stage of neoplastic disease originating primarily in the breast and are mostly in a poor general condition. Their overall condition is a resultant of development and severity of the tumour itself with possible distant metastases, coexisting diseases, as well as late complications of cause-oriented or palliative treatment implemented. In the setting of palliative treatment, the primary goal is relief of pain, according to the recommendations of the so-called “analgetic ladder”, conforming with general principles of analgetic management. This consists in determination of cause of pain, evaluation of its type and severity, regular pace of administration of analgetic drugs, careful titration of dose of strong analgetics, oral administration of drugs, as this is the most physiologic and recommended route of administration, if only the patient can tolerate it. An important issue is also to relieve other bothersome ailments, both somatic, mental, spiritual and social. According to the WHO definition, palliative care ensures the patients a comprehensive and active care, improves their quality of life and, when justified, includes all oncologic therapeutic modalities. In the setting of palliative care, oncologic treatment aims at arresting or slowing-down of development of primary tumour and metastatic foci, thus improving the patient’s comfort and quality of life, obviously taking into account current state of the patient and toxicity of drugs.

Keywords: palliative care, advanced breast cancer, quality of life, oncologic treatment
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Giant breast tumours. Experience of a regional Palliative Care Unit
GIN ONKOL 2009, 7 (2), p. 132-137
ABSTRACT

Breast cancer is the most common malignant tumour developing in Polish women. Each year, over 11,000 new cases are registered in our country. Breast cancer is the leading cause of mortality due to malignant neoplasms in the females. The aim of paper, apart of presenting extremely advanced clinical cases of breast cancer and management strategies implemented, is to highlight the complexity of this problem, due overlapping of several medical and social factors. Inoperable, locally advanced breast cancer usually presents clinically as a giant primary tumour, frequently with extensive metastases in the axillary fossa. Giant breast tumour, with a diameter exceeding 5 cm, frequently extensively invading skin and deeper tissues, is usually accompanied by lymphatic oedema. Occurrence of such clinically advanced and morphologically gigantic forms of breast cancer in the material of Palliative Care Unit is most often due to one of the following: dynamic progression or recurrence of the disease, refusal of cause-oriented treatment or its interruption and extreme neglect. The main treatment option in this group of patients is aggressive induction chemotherapy. If surgery is contraindicated, patients undergo radical radiotherapy. Principal goal of therapy at a palliative care unit is relief of symptoms and improvement of quality of life, realized by medical and non-medical means. Psychological and spiritual support aims at creating a positive attitude of the patient towards his or her condition. The key factor is partner-like relations with patients, preservation of their autonomy and respect for their decisions concerning continuation of further treatment.

Keywords: breast cancer, giant tumour, palliative care, lymphatic oedema, ulcer
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Development of palliative care with special emphasis on Polish achievements in this field
GIN ONKOL 2009, 7 (2), p. 138-142
ABSTRACT

Since the dawn of time, care for terminally ill people was considered a challenge, a duty or an obligation. The Latin word hospes meant initially a hospitable person providing shelter and food for those in need. Places where most severely ill people were cared for were called hospitale, hospitium or infirmarium. In ancient Greece and Rome, chronically ill people were placed in special rooms, usually adjacent to temples. Throughout the entire Western Empire, the poor and the ill were cared for by religious congregations. Monasteries ran “hospitable rooms” providing shelter not only for pilgrims, but also for ill people, who could also benefit from simple medical procedures. Numerous pilgrimages, epidemics, wars and crusades, resulted in rapid increase of number of hospitals and shelters in Medieval Europe. Homes of care designed exclusively for the terminally ill appeared in the XIX century. The essence of their mission was compassion for suffering and pain experienced by other people, expressed by will to help, resulting also from religious motives. In the XX century, Cecily Saunders M.D. organized the first St. Christopher Stationary Hospice in London, thereby giving rise to modern hospice organizations. Later, the Hospice expanded its activity on home-based patient care and support of families after loss of the loved ones. In the ‘70s of the XX century, the term “palliative care” has been introduced in the USA and Canada. The Latin word pallium, meaning a large woollen coat, has been adopted to denote protection of patients and their relatives from physical and mental suffering. Nevertheless, definition of palliative care has been developed as late as 1990 and has been published in a WHO document. It specifies the basic mission of this medical specialty: comprehensive and active care for terminally ill people, whose disease does not respond to cause-oriented treatment. Palliative treatment encompasses relief of pain and other ailments, as well as overall support in mental, spiritual and social areas. The essence of palliative care is team work of persons representing various specialties – doctors, nurses, priests, psychologists, physiotherapists, non-medical volunteers, aiming at improving the patients’ quality of life.

Keywords: palliative care, hospice, history, hospitality, WHO
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