Of all gynecologic cancers, ovarian cancer is the most lethal. The lack of effective primary prophylaxis and initially noncharacteristic symptoms make ovarian cancer most often diagnosed in high stages. Most patients either have or are at high risk for intraperitoneal dissemination and are therefore not ideal candidates for locoregional treatment, such as irradiation. The 5-year survival rate does not exceed 50%. In the years preceding the introduction of platinum-based chemotherapy, and later taxane-based chemotherapy, radiotherapy was used as an adjuvant treatment. The techniques of irradiation of the entire abdominal cavity used at that time were burdened with significant toxicity. The results of studies comparing tolerance and survival after whole abdominal radiotherapy and chemotherapy did not show the superiority the former. The introduction of new cytostatics ultimately contributed to the fact that chemotherapy became the basic treatment after surgery and in recurrent ovarian cancer. The emergence of new radiotherapy techniques: intensity modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT), stereotactic body radiation therapy (SBRT), enabling precise modulation of dose distribution within the tumor or volume of high risk tissues, with simultaneous sparing of critical organs, have contributed to the re-growth of interest in radiotherapy in patients with ovarian cancer. Recent reports indicate usefulness of radiotherapy in patients with localized relapses, especially nodal ones, and as palliative care.
The effectiveness of the treatment of advanced ovarian cancer depends on its proper qualification based on clinical assessment, imaging and biochemical studies. However, due to the dissemination of the disease, the methods given above often turn out to be insufficient. Intraoperative, quantitative assessment of the stage of the cancer, conducted with the use of the peritoneal carcinomatosis index developed by Sugarbaker, consisting in awarding points dependent on the location and the size of cancerous lesions in the peritoneal cavity, allows for precise estimation of the possibility of debulking surgery. It has to be kept in mind that in cases of advanced ovarian cancer surgical treatment is a multiorgan procedure, requiring the participation of a team of highly skilled gynecologists and oncological surgeons. Numerous studies have demonstrated the superiority of surgical treatment performed by competent and experienced teams – the result of their work is the optimal reduction in the size of the tumor, which is reflected by the length of time before the recurrence of the disease and the time of patient survival. Suboptimal treatments, on the other hand, caused, among others, by inadequate pre- and intraoperative assessment of the progress of the disease, significantly worsen the results. Determining the feasibility and the degree of the resection of the tumor allows to make a decision about the adequate treatment, that is, the primary or secondary surgery. It is well known, after all, that lack of possibility to achieve at least the optimal cytoreduction is an indication for neoadjuvant chemotherapy. An objective assessment of the extent of the disease by calculating the peritoneal carcinomatosis index can therefore be crucial in the treatment of advanced ovarian cancer.
Ovarian carcinoma remains a serious clinical challenge. Five-year survival rates in patients with ovarian carcinoma reach merely 46%, while the rate of patients diagnosed with advanced ovarian carcinoma (stage III and IV according to the International Federation of Gynecology and Obstetrics) amounts to 70%. It is very important to establish the correct diagnosis, confirm it histopathologically, and plan treatment in patients suspected of having a malignant ovarian tumor. In the diagnostic process, one should assess whether complete cytoreduction is possible, as this is the only optimal therapy for patients. After surgery, patients usually receive chemotherapy, typically paclitaxel and carboplatin in 6 courses every 3 weeks. In certain cases, intravenous chemotherapy can be combined with intraperitoneal therapy. The latest studies have also shown benefits of adding antiangiogenic agents, such as bevacizumab, to chemotherapy. This modification is associated with prolonged recurrence-free survival by approximately 4 months. The most common complications of antiangiogenic therapy are proteinuria and hypertension. When it is not possible to perform primary cytoreductive surgery in advanced ovarian cancer patients, neoadjuvant chemotherapy, usually including paclitaxel and carboplatin, can be applied. Treatment outcomes are similar to those obtained in patients with suboptimal primary resection, whilst perioperative mortality is significantly lower. Debulking surgery can be reconsidered after 3 courses of chemotherapy. In patients using antiangiogenic agents, such as bevacizumab, it is important to maintain a 6-week drug-free interval before and after surgery, as this drug affects operative wound healing.
Cancer stem cells (CSCs) are one of the causes of failure in the treatment of patients with malignant tumors. Although these cells account for only about 2% of the tumor mass, they possess unique properties, such as self-renewal, unlimited proliferation, asymmetric cell division and the ability to form dormant cells. Cancer stem cells are responsible for treatment failure as they are resistant to standard anticancer treatment (chemo- and radiotherapy), leading to cancer progression, metastases and relapse. They carry specific biomarkers which enable their identification and isolation. The most common markers identified in breast, ovarian, and endometrial cancer as well as in other localizations include: CD44+, C117 (c-Kit), CD133+ (promin), ALDH1 (aldehyde dehydrogenase 1), Oct-4 (POU5F1), nestin and BMI1. Cancer stem cells take advantage of numerous signaling pathways (Wnt, SHH – sonic hedgehog homologue, PI3K/AKT/mTOR). Studies have demonstrated that clinical advantage can be gained using salinomycin (an antibiotic isolated from Streptomyces albus), or metformin, an antidiabetic drug. Research is continued on targeted therapy aimed at cancer stem cells: both cancer stem cell biomarkers or signaling pathways (their components) used by cancer stem cells may be targeted. Studies on microRNA, which coordinates the expression of multiple genes, and on metabolic strategies targeting cellular mitochondria are underway.
The growing incidence of cancer poses a diagnostic and therapeutic challenge for modern medicine. Surgical treatment remains the standard of care in gynecology, particularly in cancer patients. Proper selection of surgical technique is of key importance for optimal therapeutic outcomes with the lowest risk of postoperative complications. Thorough knowledge of these complications will enable not only proper treatment, but also providing patients with complete, reliable information on possible complications, pain or distant consequences of the chosen procedure. Age and comorbidities are well-known primary factors modifying the postoperative risk. The paper discusses prevention and interdisciplinary treatment of the most important and most common complications after major gynecologic surgeries. Due to the common location of the gastrointestinal, urinary and genital tracts in the abdominal cavity, the treatment of complications after extensive gynecologic surgeries often requires cooperation with a surgeon and an urologist. Proper pre-anesthetic assessment, hydration of the patient, assessment of preoperative nutritional status and an early onset of postoperative nutrition may reduce complications resulting from the clinical condition of the patient. It should be also noted that the proportions of different procedures have changed in recent years, with a gradual replacement of conventional laparotomies and transvaginal surgeries with increasingly popular endoscopic techniques. The paper discusses the most important postoperative complications, their symptoms and treatment strategies based on a literature review.
Uniform medical nomenclature enables proper communication both in scientific and clinical settings. The aim of this analysis is to present the latest nomenclature of vulvar, vaginal and cervical precancerous conditions compared with the previous terminology. In 2012, the College of American Pathologists and American Society for Colposcopy and Cervical Pathology replaced the three-grade classification of precancerous lesions of the vulva, vagina and cervix, i.e. IN (intraepithelial neoplasia), with a two-grade system, i.e. SIL (squamous intraepithelial lesion): LSIL and HSIL. This terminology concerns HPV-induced non-neoplastic lesions of all the mentioned areas. The mandatory diagnostic workup now also includes p16 immunostaining. At present, precancerous vulvar lesions are divided into: 1) LSIL, including condyloma and HPV effect, 2) HSIL, previously called uVIN, occurring in younger women and associated with HPV infection, and 3) dVIN, developing in older patients with lichen sclerosus. Precancerous vaginal lesions are divided into: 1) LSIL, previously classed as VaIN 1, and 2) HSIL, prior VaIN 2/3. The analogous division refers to cervical pathologies: 1) LSIL, i.e. all CIN 1 and p16-negative CIN 2 lesions, and 2) HSIL, i.e. CIN 3 and p16-positive CIN 2 lesions. The new nomenclature enables better understanding of the etiology and natural history of the diseases, and helps select appropriate management. The introduction of changes to the common terminology requires education of the medical staff.
The paper presents selected views on pain as an experience and as a phenomenon as well as an analysis of factors reducing the efficacy of pain management in women with gynecologic cancer. Pain is an inseparable, natural and necessary element of life, which is primarily involved in responding to threat, but also accompanies effort, overcoming of which brings a number of psychosocial benefits. The subjective experience of pain depends on several factors, such as stimulant intensity, individual susceptibility and resistance to pain, or individual mental predispositions. In addition to appropriate pharmacotherapy, the efficacy of pain management in patients with gynecologic malignancies is further affected by mental disorders (cognitive, anxiety and depressive disorders), fixed, subjective ideas about the disease and its treatment (coined as nocebo by Walter Kennedy), multiple comorbidities, memory of pain, contact with the doctor, respecting patient’s rights by medical staff, age, and the quality of support received by the patient. The paper takes a critical look at replacing proven analgesic treatment strategies based on scientific and clinical evidence with unconventional methods, such as yoga, reiki or bioenergy therapy, which have not been verified or documented.
Cancer in pregnancy is defined as the diagnosis of a malignant tumor in the period between becoming pregnant and 12 months after delivery. Diagnostic and therapeutic procedures must take into account the preservation of proper development and maximum protection of the fetus as well as effective therapy and maintenance of reproductive capacity in the mother. For these reasons, anticancer treatment in pregnant women should be conducted by experienced, multidisciplinary teams of specialists. Recently, a significant increase in the frequency of detection of tumors in pregnancy has been observed. Due to the non-specific nature of cancer symptoms, the diagnosis is made relatively late, even though diagnostic biopsies are not contraindicated during pregnancy. The most preferred treatment is surgery performed in the second or third trimester of pregnancy. Chemo- and radiotherapy are associated with a large number of contraindications and complications. The article presents the most frequently occurring non-gynecologic cancers in pregnancy such as melanoma, renal cell carcinoma, lung cancer, leukemia and others. The article ends with case reports of pregnant patients diagnosed with cancer hospitalized at the Department of Obstetrics and Pathology of Pregnancy and the Department of Hematooncology of the Medical University of Lublin, Poland.