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Basic principles in gynecologic radiotherapy

Key points 1. Radiation therapy is used for the treatment of primary and metastatic gynecologic malignancies. 2. Radiation therapy depends on the differential susceptibility of tumors to irradiation compared with normal tissues, and research attempts to maximize the therapeutic ratio are ongoing. 3. Photons, a nonparticulate form of radiation, are the primary modality of therapeutic irradiation used in gynecologic carcinomas. 4. Particulate irradiation with electrons and…

Epidemiology of commonly used statistical terms, and analysis of clinical studies

Key points 1. Epidemiology is the study of distribution of disease and factors that determine disease occurrence in populations. 2. As much as possible, medical decisions should be based on quality evidence. The best evidence is a properly designed randomized controlled trial. Evidence from nonrandomized but well-designed control trials is of lesser quality. Next in reliability is well-designed cohort or case-control studies, which have been repeated…

Role of minimally invasive surgery in gynecologic malignancies

Key points 1. Minimally invasive surgery (MIS) is practiced by more than 90% of gynecologic oncologists. 2. Knowledge of anatomy, the disease process, and surgical technique is key during these complicated surgical procedures. 3. Several studies have shown that 10 to 20 cases are needed to gain proficiency with a certain procedure. 4. MIS reduces blood loss, transfusions, length of hospital stay, and wound complications without…

Palliative care and quality of life

Key points 1. Palliative care is interdisciplinary care that seeks to prevent, relieve, or reduce the symptoms of a disease without affecting a cure. 2. Certain treatments may not result in improved survival but may result in decreased symptoms. Clinical trials have therefore begun measuring quality of life (QoL). 3. Other QoL measures include survivorship. That is the process of helping the patient have the highest…

Genes and cancer: Genetic counselling and clinical management

Key points 1. Cancer is not always inherited, but it is always genetic. 2. The inherited aspect of cancer always needs to be considered and appropriate counseling and testing arranged. 3. Genetic counseling and testing need to be an integral part of all cancer management. 4. Genetic counselors are necessary for management and treatment of inherited disease. 5. Options for prevention of cancer for individuals with…

Immunotherapy in gynecologic malignancies

In 1893, William Bradley Coley reported the case of a German immigrant with a neck sarcoma that was deemed inoperable and yet disappeared after an erysipelas infection ). Coley hypothesized that the immune response provoked by the bacterial infection led to remission of the sarcoma. Therefore, he went on to develop Coley’s toxins, a mixture of initially live and later dead bacteria that included Streptococcus pyogenes…

Molecular hallmarks of cancer

Key points 1. Malignant cells develop from molecular abnormalities in growth control. 2. The molecular abnormalities are in one or more of 10 key pathways. 3. These altered pathways provide important targets for new therapeutic agents. 4. Angiogenesis, PARP, immunologic cascades and cellular signaling pathways are examples of important targets. 5. Antibody drug conjugates are new therapeutic agents which rely of cell surface targets. 6. Many…

Targeted therapy and molecular genetics

Key points 1. The development of new and effective therapies should be rooted in a clear understanding of tumor biology. 2. Bevacizumab, a humanized monoclonal antibody to human vascular endothelial growth factor, was the first US Food and Drug Administration–approved drug targeting angiogenesis 3. There are three poly (ADP-ribose) polymerase (PARP) inhibitors approved for the treatment of ovarian cancer. 4. As knowledge regarding tumor biology and…

Basic principles of chemotherapy and other systemic therapies

Key points 1. In malignant tumors, unregulated growth appears to result from a combination of loss of normal cell cycle controls and a failure of normal apoptotic mechanisms. Despite uncontrolled growth, malignant cell division does not appear to be more rapid than normal cell division. 2. In general, as tumors grow, they display gompertzian growth characteristics: As the tumor mass increases in size, the time necessary…

Complications of disease and therapy

Key points 1. Women with gynecologic cancers can have significant complications from their cancer and/or treatments. 2. Vaginal bleeding is usually controlled with packing although arterial embolization may be needed to control severe hemorrhage. 3. Ureteral obstruction can be treated by diversion, either with ureteral stent placement, percutaneous nephrostomy, or surgery. 4. Nearly all small bowel complications are initially treated with conservative management, but surgery may…

Cancer in pregnancy

Key points 1. Data from the Surveillance, Epidemiology, and End Results database indicate that cancers during the reproductive ages, in order of decreasing frequency are breast, melanoma, thyroid, cervix, and lymphoma. 2. The most critical period for cancer treatment during pregnancy extends from the 3rd to 8th weeks of development (5th through 10th weeks of gestational age), when susceptibility to teratogenic agents is maximal. In the…

Breast diseases

Key points 1. Women who present with a breast mass require triple assessment , which comprises physical examination, breast imaging with mammography and ultrasound, and pathologic or cytologic evaluation. Discordant results require further investigation and careful follow-up. 2. Breast cancer screening recommendations beyond established guidelines are informed by individual risk assessment . 3. Breast-conserving therapy , which includes lumpectomy and adjuvant radiation therapy, and mastectomy share…

Germ cell, stromal, and other ovarian tumors

Key points 1. Germ cell tumors are arise from primordial germ cells of embryonic gonad and sex-stromal derivatives. 2. Most germ cell tumors are found in the second and third decades of life. 3. Surgery is the preferred initial approach in the treatment of germ cell and sex cord stromal cancers. 4. Bleomycin, etoposide, and cisplatin chemotherapy remains the standard of care for adjuvant treatment of…

Epithelial ovarian cancer

Key points 1. Ovarian cancer is the most lethal of all gynecologic cancers. Elderly women are more likely to develop ovarian cancer than are young women. 2. Oral contraceptives decrease the incidence of ovarian cancer substantially. 3. Ovarian cancer may be inherited, with increased risk being caused by a mutation in BRCA1 or BRCA2 , mismatch repair defect, or any number of other less common genes…

Adnexal masses

Key points 1. Adnexal masses are common, and careful evaluation is required before a therapeutic intervention is planned. 2. Masses are classified based on the workup for risk of malignant potential. Of all the variables, age is probably the most predictive of cancer. 3. There are many markers that help in determining how likely the mass represents a cancer, and these should be considered preoperatively. 4.…

Gestational trophoblastic disease

Gestational trophoblastic disease (GTD) comprises a spectrum of neoplastic conditions derived from the placenta. Hydatidiform moles, gestational choriocarcinoma, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor (ETT) are histologic diagnoses, whereas postmolar gestational trophoblastic neoplasia (GTN) is defined by clinical and laboratory criteria. The disease entities included in GTD have a wide variation in behavior, whereas GTN specifically refers to those with the potential for…

Invasive cancer of the vulva

Key points 1. Invasive vulvar cancer is a relatively rare tumor, accounting for 4% of all female genital malignant neoplasms. 2. Squamous cell carcinoma of the vulva develops by human papillomavirus- (HPV-) dependent and HPV-independent pathways. 3. Sentinel lymph node biopsy represents the largest innovation in the care of vulvar cancer patients in the past decade. 4. The standard of care is pelvic lymph node irradiation…

Adenocarcinoma of the uterine corpus and sarcomas of the uterus

Key points 1. Adenocarcinoma of the endometrium is the most common gynecologic malignancy, with both rising incidence and mortality. 2. Classically, endometrial cancer is divided into two histologic types: type I is endometrioid, and type II consists of uterine serous carcinoma, clear cell (CC), and other more aggressive histologic types, although the molecular classification is emerging as an important paradigm. 3. The mainstay of treatment is…

Endometrial hyperplasia, estrogen therapy, and the prevention of endometrial cancer

Introduction The endometrium is a dynamic tissue in reproductive age women. It is continuously cycling in response to hormonal, stromal, and vascular influences, with the ultimate goal of implanting an embryo and supporting the nutritional needs of the developing pregnancy. While estrogen stimulation is associated with the growth of proliferative endometrium ( Fig. 4.1 ), progesterone produced by the corpus luteum after ovulation inhibits proliferation and…