2010, Vol 8, no 4
Cutaneous vulvar metastases of cervical cancer 9 years after radical surgical excision followed by radiochemotherapy – case report
CURR. GYNECOL. ONCOL. 2010, 8 (4), p. 244-250
ABSTRACT

Cutaneous metastases of cervical cancer are extremely rare, even in late stage disease. They usually appear up to 10 years after first diagnosis in about 0.1-2.0% of all cases. They most frequently appear in the abdomen, vulva and anterior chest, usually as an isolated lesion; multifocal lesions are rare. We present a case of an isolated cutaneous vulvar metastasis of an adenosquamous cervical cancer, developing 9 years after radical surgical treatment followed by radiotherapy (tele- and brachytherapy), 8 years later undergoing surgical excision of recurrent tumor with subsequent chemotherapy. Histological study of both primary cervical and secondary cutaneous lesions excluded vulva as place of origin, confirming metastatic character of adenosquamous tumor. Upon surgical excision of the metastasis, the patient received adjuvant chemotherapy. Unfortunately, rapid progression followed in spite of treatment instituted, as confirmed by imaging studies (multiple round focal lesions in the lungs and liver, bilaterally enlarged inguinal lymph nodes consistent with secondary tumor seeding seen on magnetic resonance imaging and a local intrapelvic lesion visualized by computed tomography). Cutaneous metastases of cervical cancer are considered a ominous prognostic factor, associated with faradvanced terminal phase of the disease or local recurrence with multiple distant metastases, as confirmed by the present case. In this setting, treatment is palliative only, consisting in chemotherapy, radiotherapy and surgical excision of the lesion, used either in combination or alone. Mean survival since diagnosis is only 3-4 months and only about 20% of the patients survive over 1 year.

Keywords: cervical cancer, cutaneous metastases, diagnosis, treatment, disease progression
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Clinical significance of sentinel node in the treatment of vulvar cancer
CURR. GYNECOL. ONCOL. 2010, 8 (4), p. 251-255
ABSTRACT

Surgical treatment still remains the cornerstone of treatment of vulvar cancer. Several large-scale studies indicate that prognosis in vulvar cancer patients depends on depth of infiltration and invasion of regional inguinal-femoral lymph nodes. Due to considerable radicality of surgical procedures in vulvar cancer, women undergoing such procedures experience early and delayed complications, resulting in prolonged hospital stay and psychosexual alterations, stemming from the sense of mutilation. For the past few years, we are witnessing attempts at limiting the extent of surgical resection. Introduction of the concept of sentinel node in the treatment of vulvar cancer to oncologic gynecology will hopefully contribute to reduction of extent of surgical procedures in the future, i.e. refrain from inguinal-femoral lymphadenectomy, as metastatic lesions are not universally present in this part of the lymphatic system. The paper presents techniques enabling identification of a sentinel node. Based on quoted papers reporting on two multicenter studies encompassing patients with vulvar cancer, in a selected group of patients with negative sentinel node, departure from inguinal-femoral lymphadenectomy is justified. Contrariwise, detection of tumor cells in sentinel nodes warrants radical excision of regional inguinal-femoral lymphatic system, independent of the size of metastatic lesions (micro- or macroscopic). To date, departure from inguinal-femoral lymphadenectomy in vulvar cancer is permissible only if stromal invasion does not exceed 1 mm and tumor diameter is less than 2 cm (FIGO IA1, T1AN0M0).

Keywords: vulvar cancer, sentinel node, surgical treatment, inguinal-femoral nodes, lymphadenectomy
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Sex cord stromal tumors of the ovary: principles of management
CURR. GYNECOL. ONCOL. 2010, 8 (4), p. 265-272
ABSTRACT

Sex cord stromal tumors of the ovary are rare neoplasms that account for only 7% of all ovarian malignancies. They are derived from the sex cords and the ovarian stroma or mesenchyme. Most common in this group is granulosa cell tumor that accounts for approximately 70% of malignant sex cord stromal tumors and divides into adult and juvenile type. Surgery remains the mainstay of initial management and is necessary to establish a definitive tissue diagnosis. In patients wishing to preserve their fertility unilateral salphingo-oophorectomy seems to be reasonable. In patients with advanced disease and in postmenopausal women total abdominal hysterectomy with bilateral salphingo-oophorectomy and complete surgical staging should be performed. Most of these tumors are classified as stage I at the time of diagnosis. Patients with stage I disease have a very good prognosis (5-years survival 84-95%) and do not require adjuvant treatment. Only long-term, careful follow-up is recommended. In advanced stages adjuvant chemotherapy with BEP is usually considered standard first line. Serum tumor markers are very useful in follow-up, especially inhibins and estradiol. Other sex cord stromal tumors include tumors from thecoma-fibroma group, Sertoli-Leydig cell tumors and very rare gynandroblastoma and sex cord tumors with annular tubules.

Keywords: sex cord stromal tumors, granulosa cell tumor, thecoma-fibroma group, Sertoli-Leydig cell tumors, gynandroblastoma, sex cord tumors with annular tubules, management
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Preservation of fertility in oncologic patients
CURR. GYNECOL. ONCOL. 2010, 8 (4), p. 273-284
ABSTRACT

Significant progress in oncology over the past years resulted in a noticeable improvement of mean survival rates of patients treated for malignant tumors. Particularly rewarding is the treatment of tumors in the pediatric and juvenile age group. A sizeable proportion of patients subjected to oncologic treatment, i.e. chemotherapy, radiotherapy and surgery, experience a limited procreative potential as a sequel of administered therapy. Among chemotherapeutics, some of the most toxic compounds are alkylating agents, e.g. cyclophosphamide, chlorambucil, melphalan and procarbazine. Severity of negative effects of cytostatics on the patients’ fertility depends largely on administered dose and patient’s age at the time of treatment. In the case of radiotherapy, severity of limitation of procreative potential correlates with total absorbed dose of radiation, irradiated body area and, as in the case of chemotherapy, on the patient’s age. Induced iatrogenic infertility is a tremendous problem for survivors, adversely affecting their quality of life. Apart of inherited genetic syndromes, no evidence is available suggesting that oncologic treatment instituted in the past in the parents might increase the risk of cancer or congenital malformations in their offspring. Thanks to the development of novel procreation-enhancing techniques, several options are currently available enabling preservation of procreative potential of oncologic patients. Prior to institution of antitumor therapy, persons who wish to preserve fertility should be offered cryopreservation of embryos, oocytes, sperm or of a sample of gonadal tissue, transposition of ovaries or hormonal suppression of oogenesis and spermatogenesis. Implementation of these techniques should provide young people with a chance to raise their own children.

Keywords: cancer treatment, fertility preservation, infertility, fertility after oncologic treatment, fertility enhancement
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Quality of nurses’ work as assessed patients with ovarian cancer undergoing chemotherapy
CURR. GYNECOL. ONCOL. 2010, 8 (4), p. 234-243
ABSTRACT

Ovarian cancer is the second most common cause of mortality due to female genital malignancies in Poland and thus a considerable problem in gynecologic oncology. In spite of introduction of novel therapies and new diagnostic modalities, treatment outcome is far from satisfactory. Therapeutic failures are associated first and foremost with detection of the disease at a late clinical stage in most patients. Treatment of ovarian cancer, characterized by a high recurrence rate, is prolonged and cumbersome for the female organism, due mainly to multiple side effects associated with administration of cytostatics. The purpose of this study was to evaluate the work of nurses and midwives, caring for patients undergoing chemotherapy at the Department of Gynecologic Oncology. In 2009 and 2010, 100 hospitalized patients filled-in a custom-designed questionnaire. The questionnaire included a general part, devoted to sociodemographic and clinical data, and a detailed part, consisting of 6 sections, assessing particular aspects of nursing care stemming from nurses’ and midwives’ professional functions. Results obtained have led us to conclude that patients’ level of satisfaction concerning the quality of nursing care is in fact very high. Not a single negative mark appeared in the study, evidencing good quality of services provided. Only a few aspects of care assessed by the patients require institution of reparative action. These include patients’ education and sense of intimacy during examination and nursing procedures. Comparative analysis included results of studies performed at Center of Oncology in Warsaw, at two oncologic departments in Lublin and at the Regional Center of Oncology in Kielce. Results obtained demonstrate that the highest level of satisfaction with quality of nurses’ work was obtained at the Department of Gynecologic Oncology in Poznań.

Keywords: ovarian cancer, quality of care, nurses, midwives, patients’ satisfaction level
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Treatment outcome in uterine cancer in the material of Gynecologic Oncology Clinic of Wroclaw Medical University
CURR. GYNECOL. ONCOL. 2010, 8 (4), p. 225-233
ABSTRACT

Cancer of the uterine corpus is the most frequent gynecologic malignancy in Poland and the fourth most common malignancy in the females. Periodic assessment of effectiveness of treatment outcomes in the context of 5-year survival rate is crucial for objective evaluation of efficacy of therapeutic protocols used at a particular center. The aim of this study was a retrospective analysis of outcomes in women treated at our center for cancer of the uterine corpus observing a 5-years’ follow-up and comparison of these data with international literature. Analysis encompassed only patients undergoing surgical treatment only (n=37) and those offered complementary radiotherapy (n=207), treated for endometrioid type of uterine corpus cancer since 2003 thru 2005. Every case underwent clinical staging (acc. to FIGO classification) and tumor grading. Results of this analysis, in the form of 5-year overall survival data, were compared with those published in the 2006 Annual Report. The study confirmed a similar overall survival rate in the whole group, i.e. in surgery-only patients: 84% vs. 80% (Annual Report) and combined-treatment patients: 75% and 83%. Results of our study were favorable in FIGO stage I and in G1 tumors at higher stages. In other settings, they differed somewhat from Annual Report data. Concluding, a more individualized approach to particular cases and adherence to recommendations of recognized opinion-making bodies in this area should contribute to improved treatment outcomes in even late-stage uterine corpus cancer.

Keywords: uterine corpus cancer, treatment outcome, 5-year survival, surgery, radiotherapy
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Radiation-induced rectovaginal fistulas
CURR. GYNECOL. ONCOL. 2010, 8 (4), p. 256-264, 284
ABSTRACT

Background: Rectovaginal fistula (RVF) is a pathological channel lined with epithelium, located between rectum and vagina. RVFs account for about 5% of anorectal fistulas. Due to differences in etiology, location and diameter, no single algorithm of management of such conditions has been developed. Therefore, an individual approach in the diagnostic-therapeutic work-up is mandatory. A particular variant of RVF are fistulas developing as a sequel of radiotherapy of intrapelvic tumors, mainly of cervical, vaginal, rectal and anal origin. They usually appear within 2 years after termination of treatment, although there are documented cases developing even 20 years after termination of radiotherapy. In the Polish literature, the incidence of radiation-induced RVF is estimated at 0.2-2.0%, while in international publications this rate varies from 0.3 to 6%. It appears, however, that the true incidence of RVF may be considerably higher. Several techniques for the management of RVF have been described, using various approaches and of varying extent and complexity. Local techniques are used mostly in small and low fistulas, rarely in the case of medium-sized fistulas. High fistulas are treated using the transabdominal route. In the case of radiation-induced fistulas, the technique of choice is the one described by Parks. Aim of paper: Our purpose is to provide a systematic review of current concepts concerning causes, diagnosis and treatment of RVF, with particular emphasis of fistulas following radiotherapy for intrapelvic tumors. Conclusions: RVF constitutes an important clinical problem, significantly influencing the patient’s everyday life and compromising her quality of life. This is a very complex condition and only a multidisciplinary approach, including surgeon, gynecologist, oncologist and radiotherapist as well as representatives of other medical specialties, provides hopes for developing an effective therapeutic algorithm. Correct diagnosis of type of fistula, selection of most appropriate therapeutic method and careful surgical technique may contribute to a favorable outcome in about 80% of the cases.

Keywords: rectovaginal fistula, radiation-induced fistula, cervical cancer, radiation-induced compli
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