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Sentinel Lymph Node Mapping for Endometrial Cancer

The majority of patients with endometrial cancer have early-stage uterine-confined disease at presentation. However, many patients will still undergo a complete pelvic and sometimes paraaortic lymphadenectomy for staging purposes despite having disease confined to the uterus, resulting in prolonged operating time, additional cost, and potential long-term side effects such as lymphocyst formation and lower extremity lymphedema. Sentinel lymph node (SLN) mapping in endometrial cancer is an…

Hysterectomy With Pelvic and Paraaortic Lymphadenectomy

The mainstay of treatment in patients affected by endometrial cancer is surgery, including simple hysterectomy and bilateral salpingo-oophorectomy with or without lymphadenectomy. Regardless of the stage of disease, removal of the uterus is recommended in every patient unless there are medical or surgical contraindications or fertility is to be preserved. Effective surgical treatment for early-stage endometrial cancer can be achieved through several approaches, all with comparable…

Surgical Staging for Treatment Planning

Along with ovarian cancer debulking and radical hysterectomy, pelvic and paraaortic lymph node dissections are procedures that define gynecologic oncology. Complete pelvic and paraaortic lymphadenectomies (open and transperitoneal) for staging in early-stage cervical cancer are similar in approach to procedures for uterine cancer (see Chapter 9 for details). Lymphatic mapping and sentinel lymph node biopsy for early-stage cervical cancer are also described elsewhere in this book…

Abdominal Radical Hysterectomy

According to National Comprehensive Cancer Network (NCCN) guidelines, radical hysterectomy is the preferred treatment for patients with histologically confirmed stage IB1 to IIA1 cervical cancer who are not interested in future fertility. Radical hysterectomy requires comprehensive knowledge of pelvic anatomy and the relationship among vital structures such as the rectum, ureters, bladder, and pelvic vasculature and the vast pelvic neural network. The aim of this chapter…

The Application of Sentinel Lymph Node Biopsy in Cervical Cancer

∗ The authors also wish to thank the following individuals for their contributions to this chapter: Charlotte Ngo, Myriam Deloménie, Chérazade Bensaid, Caroline Cornou, Léa Rossi, and Marie Gosset. In early cervical cancer (ECC)—that is, International Federation of Gynecology and Obstetrics (FIGO) stage IA to IIA1 disease, when the tumor is still limited to the cervix or the adjacent vagina—the most popular treatment is radical hysterectomy…

Conservative Surgery in Early-Stage Cervical Cancer

The standard treatment for women with early-stage cervical cancer (stages IA2–IB1) remains radical hysterectomy with pelvic lymphadenectomy. In select patients interested in future fertility, radical trachelectomy with pelvic lymphadenectomy is also considered a viable option. Data from retrospective studies have confirmed that oncologic outcomes of radical hysterectomy and radical trachelectomy are equivalent. Radical Trachelectomy According to the National Cancer Institute, 40.1% of cervical cancers are diagnosed…

Vulvar Surgery and Sentinel Node Mapping for Vulvar Cancer

In the past 100 years, the surgical approach to vulvar cancer has evolved from one of gynecologic oncology’s most morbid procedures to one of its least. The original approach included the radical en bloc resection of the vulva, groins, and iliac lymph nodes ( Fig. 4.1A ). Although this procedure greatly improved survival compared with earlier procedures, postoperative morbidity was exceedingly high as patients often experienced…

Enhanced Recovery After Surgery in Gynecologic Oncology Surgery

Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway to improve functional rehabilitation after a surgical procedure, reducing the patient’s stress response in reaction to the operation and postoperative catabolism. The concept was first introduced by Kehlet, who suggested that a focus on early postoperative rehabilitation and nutrition, use of regional analgesia, and avoidance of recovery-limiting procedures (e.g., liberal use of intravenous [IV] fluids,…

Abdominal and Pelvic Anatomy

Anatomy is to physiology as geography is to history; it describes the theater of events. Jean FranÇois Fernel All gynecologic oncology surgeons should be familiar with the anatomy of the abdomen and pelvis to perform all complex and radical procedures required in the surgical management of women with gynecologic tumors. There has been an increasing emphasis on the role of upper abdominal surgery, particularly in the…

Obstructive sleep apnea and polycystic ovary syndrome: Clinical interactions and underlying pathophysiology

Introduction In 1935, Dr. Stein and Dr. Leventhal first described the polycystic ovary syndrome (PCOS; Stein-Leventhal syndrome) as the etiology for irregular ovulation in young female patients presenting with hirsutism, amenorrhea, and enlarged ovaries with multiple cysts . PCOS is now a well-established syndrome in women of reproductive age, which currently represents the most frequent chronic endocrine disorder in this population, with reported prevalence rates that…

PCOS in adolescence: Pathophysiology, diagnostic challenges, and therapeutic controversies

Introduction Polycystic ovary syndrome (PCOS) is a highly prevalent (5%–10%) endocrine-metabolic dysfunction in adult women, characterized by chronic oligo-anovulation, hyperandrogenism, and polycystic ovarian morphology (PCOM). Most women with PCOS also show neuroendocrine dysfunction, reflected by increased luteinizing hormone (LH) levels and insulin resistance, which plays a key role in the pathogenesis of this condition and in its long-term health consequences, including type 2 diabetes and cardiovascular…

The challenging role of antiandrogens in the management of polycystic ovary syndrome

Introduction (why to use antiandrogens) Excessive androgen secretion, manifested as hirsutism, acne, and/or alopecia, constitutes one of the cardinal features in women and adolescents with polycystic ovary syndrome (PCOS) . Regardless of its severity, clinical hyperandrogenism may harm psychosocial well-being and reduce the quality of life, since it has been associated with both anxiety and depression . Therefore, lowering androgen concentrations or controlling their effect at…

Vitamin D metabolism in polycystic ovary syndrome (PCOS)

Vitamin D metabolism Vitamin D is a steroid hormone, synthesized mainly by the skin on exposure to natural sunlight, with < 10%–20% deriving from the diet . Vitamin D is hydroxylated to 25-hydroxyvitamin D (25(OH)D) or calcifediol by the liver; then, calcifediol is converted by renal 1α-hydroxylase to the active form 1,25-dihydroxyvitamin D3 [1,25-(OH) 2 D 3 ] or calcitriol. The enzyme 1α-hydroxylase is expressed in…

Long-term health in women of age more than 40years with polycystic ovary syndrome

Introduction Polycystic ovary syndrome (PCOS) is the most common endocrinopathy, affecting women in reproductive age. The manifestations of this condition consist of ovulatory, metabolic, aesthetic, psychological, and possibly an elevated risk of cancer as well. Authorities have published guidelines on the management and consequences of PCOS in younger women . A growing body of evidence focused on identifying the prevalence and describing the manifestations of PCOS…

Endocrine-disrupting chemicals and PCOS: A novel contributor in the etiology of the syndrome

Introduction Polycystic ovary syndrome (PCOS), despite being one of the most common endocrine disorders among reproductive-aged women (5%–10%) and one of the most leading causes of female infertility, is still characterized by notable uncertainties and limitations about its etiology, diagnosis, and clinical management. This is partially originating from its intrinsically heterogenous nature, regarding both its pathophysiology and clinical expression . Specifically, the cardinal features of PCOS,…

Cardiometabolic risk in women with PCOS

Introduction It is well known that in young women with PCOS, the cardiovascular (CV) risk is increased . In fact, in these patients, all CV risk factors including atherogenic dyslipidemia, LDL (low-density lipoproteins) levels, C-reactive protein, hypertension, and metabolic syndrome are elevated . In addition, several markers of clinical and subclinical atherosclerosis, including carotid intima-media thickness and coronary artery calcium may be altered . The concept…

Polycystic ovary syndrome and nonalcoholic fatty liver disease

Overview of metabolic risk profile and complications of NAFLD Excessive hepatic fat accumulation defines the primary event in the continuum of nonalcoholic fatty liver disease (NAFLD) that has become the commonest liver disease in Western populations, affecting 17%–46% of adults . A strong linear correlation is confirmed between the presence of metabolic syndrome (MetS) or its components and the general prevalence of NAFLD . The latter…

Inositols and other supplements in the management of PCOS

Introduction Polycystic ovary syndrome (PCOS) is associated with neuroendocrine dysfunctions, insulin resistance (IR), impaired ovarian steroidogenesis and hyperandrogenism . Although the etiology of PCOS is still poorly known, androgens and insulin are thought to be two key factors in its pathogenesis. Thus, PCOS treatment needs to cure both hyperandrogenism as well as hyperinsulinemia. Given the central role of insulin resistance in the onset of PCOS, insulin-sensitizing…

Targeting infertility in PCOS: Unfolding “Ariadne’s thread”

Introduction The myth of Ariadne's thread is a fitting analogy for providing a practical and logical algorithm for the management of anovulatory PCOS. The legend tells of King Minos who, after conquering Athens, demanded the annual sacrifice of seven maidens and seven young men to the Minotaur, that inhabited the infamous labyrinth in Crete. Theseus, the son of King Aegeus of Athens, volunteered to take the…