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Gynaecological Oncology for the MRCOG and Beyond
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Book description

A multidisciplinary approach to the care of women with gynaecological cancer - with treatment delivered in linked local or specialist centres - has been established in the UK. The second edition of this book therefore includes chapters which focus on the multidisciplinary approach. Chapters on pathology, radiology, chemotherapy and radiotherapy will increase understanding of these disciplines that are central to the care of women with gynaecological cancers. Chapters on laparoscopic surgery, basic surgical principles, palliative care, emergencies and treatment-related complications provide additional information. All content has been updated to reflect current practice and present the latest evidence on investigation, staging and management. The book is primarily designed to provide a comprehensive summary for candidates preparing for the Part 2 MRCOG examination, and as such covers the RCOG curriculum for gynaecological oncology. It is also a valuable guide for all healthcare professionals working in the field, including trainees, consultants and midwives.

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Contents

Contents
  • 1 - Basic epidemiology
    pp 1-14
  • View abstract

    Summary

    Information from epidemiological studies helps us to clarify the aetiology of gynaecological cancers. The mortality associated with cervical cancer has fallen over the second half of the last century in the UK. The link between human papillomavirus (HPV) and cervical cancer has been conclusively established. Most women with endometrial cancers develop abnormal vaginal bleeding as an early symptom and their tumours are diagnosed while confined to the uterus. Epidemiological studies have shown that pregnancy, breastfeeding and oral contraceptive use appear to be protective against the development of ovarian cancer. Apart from its rarity, squamous vulval cancer is a condition that largely affects the elderly: 80% of women with this condition are over 55 years of age. It is not surprising, therefore, that medical comorbidity is high in the vulval cancer population, and the link between HPV, cervical intraepithelial neoplasia (CIN) and cervical cancer is well known.
  • 2 - Basic pathology of gynaecological cancer
    pp 15-34
  • View abstract

    Summary

    This chapter describes the salient features that would enable the gynaecologist to aid and understand the pathologist in examination of specimens removed for diagnosis and definitive surgery for gynaecological cancers. Cervical intraepithelial neoplasia (CIN) is the term used to describe proliferative intraepithelial squamous lesions that display abnormal maturation and cytonuclear atypia. The diagnosis of endometrial hyperplasia has been shown to be an area of gynaecological pathology with low diagnostic reproducibility. Mixed tumours of the uterus contain a mixture of glands and mesenchymal tissue: müllerian adenomyomas, including adenomyoma of endocervical type, typical adenomyomas of endometrioid type, atypical polypoid adenomyoma. There are three main groups of primary ovarian tumours: epithelial tumours that are derived from müllerian epithelium; sex-cord or stromal tumours, derived from the ovarian stroma, sex-cord derivatives or both; and germ cell tumours, which originate from the ovarian germ cells.
  • 3 - Preinvasive disease of the lower genital tract
    pp 35-52
  • View abstract

    Summary

    This chapter discusses premalignancy of the cervix, as this is the most common of the preinvasive conditions and the only one that is screened for on a population basis. Several large randomised studies have now been completed and published and they have shown that quadravalent and bivalent types of vaccine effectively increase specific immunoglobulin G, reduce or eliminate infection with type specific virus and effectively eliminate preinvasive disease related to the vaccinated subtypes. Genital human papillomaviruses (HPVs) are divided into higher-risk types and lower risk types depending on their association with malignancy. If a woman has VIN, the rest of the lower genital tract should be carefully examined, as there is an increased risk of intraepithelial neoplasia at other sites. Local treatment for cervical intraepithelial neoplasia (CIN) is highly effective. Vaginal and vulval intraepithelial neoplasias are much less common and appear to have less invasive potential than CIN.
  • 4 - Radiological assessment
    pp 53-66
  • View abstract

    Summary

    Radiological assessment forms an integral part of the multidisciplinary management of gynaecological cancers. This chapter describes the role of imaging modalities in gynaecological cancer. Peritoneal spread from other tumours can mimic ovarian cancer. Ultrasound or computed tomography (CT)-guided biopsies of peritoneal deposits can be performed, and the transvaginal ultrasound approach can be used for isolated pelvic disease. Imaging has a vital role to play in determining correct management of cervical cancer, at initial staging, recurrent disease and looking for complications. The role of cross-sectional imaging in the management of endometrial cancer has changed as a result of the (A Study in the Treatment of Endometrial Cancer (ASTEC)) trial. CT is performed in stage IV disease, and plays a role in radiotherapy planning in more advanced stages of disease. CT and magnetic resonance imaging (MRI) are performed in cases which are chemoresistant or have a high FIGO score.
  • 5 - Surgical principles
    pp 67-82
  • View abstract

    Summary

    Surgery has various applications in the management of cancer. This chapter discusses the roles performed by surgery such as: diagnosis, staging, treatment, reconstruction, and palliation. It reviews the intraoperative complications of laparotomy. A number of studies have proposed chemotherapy before definitive surgery in patients with advanced ovarian carcinoma. A significant number of women with recurrent disease will develop bowel obstruction, and surgery is often the palliation method of choice. Stage IB disease can be treated by surgery or radiotherapy, and the surgical options are radical vaginal hysterectomy and laparoscopic or extraperitoneal lymph node dissection, and radical trachelectomy with laparoscopic or extraperitoneal lymph node dissection. The standard surgical management for endometrial cancer in the UK has been total abdominal hysterectomy and bilateral salpingo-oophorectomy. Biopsy of a vulval lesion is essential for diagnosis before definitive surgery. Conservative surgery should be considered for young patients with early cervical cancer.
  • 6 - Role of laparoscopic surgery
    pp 83-94
  • View abstract

    Summary

    Laparoscopic surgery is associated with reduced levels of postoperative pain, early discharge from hospital and quick return to normal activity. Chemoradiotherapy is considered as the main treatment for advanced cervical cancers such as FIGO stage II and above. The majority of women with endometrial cancer will be cured by a total hysterectomy and bilateral salpingo-oophorectomy. Meta-analysis has reported lower complication rates and similar recurrence and survival after laparoscopic surgery. The role of laparoscopy in advanced stage ovarian cancer is controversial. Several retrospective studies have reported that laparoscopic surgery is safe and offers outcomes equivalent to open surgery. The main indication for a pelvic lymph node dissection is in the management of cervical cancer often combined with radical surgery. New developments such as robotic laparoscopic surgery and the use of small single-site incisions are likely to further expand the number of women suitable for laparoscopic management and reduce morbidity.
  • 7 - Radiotherapy: principles and applications
    pp 95-102
  • View abstract

    Summary

    The aim of radiotherapy is to destroy the cancer if possible without damaging the surrounding normal tissues. Two modalities of external beam radiotherapy and brachytherapy can be combined or used individually. Four parameters form the basis of radiobiology: repair, reoxygenation, repopulation and redistribution. The doses of radiotherapy employed in treating carcinoma of the cervix depend particularly on the intracavitary technique and equipment used. The design of radiotherapy for carcinoma of the cervix depends on the extent of the cancer. The radiation tolerance of normal tissues is related to the acute or chronic radiation reactions that occur in them. Primary radiotherapy may be used for patients who are unfit for surgery. Radiotherapy was formerly used in the treatment of ovarian cancer. There is a survival advantage for chemoradiation over radiotherapy alone in cervical cancer. Radiotherapy is widely used in vulval cancer as adjuvant treatment.
  • 8 - Chemotherapy: principles and applications
    pp 103-114
  • View abstract

    Summary

    This chapter lists the uses of chemotherapy in gynaecological oncology. In endometrial cancer, chemotherapy is used to treat advanced or relapsed cases where surgery and or radiotherapy are considered inappropriate, although hormone treatment is also used in these situations. In some situations, the intent of treatment may be curative, an example being trophoblastic tumours, while in others the intent is palliative, for example in recurrent epithelial ovarian cancer. In all situations, conventional chemotherapy used to kill tumour cells will also kill normal, healthy cells. This gives rise to treatment-related toxicity such as myelosuppression, emesis, alopecia and peripheral neuropathy. In general terms, until recently, the first-line therapy for cervical cancer was a choice between surgery and radiotherapy for early-stage disease with radiotherapy for advanced disease. The malignant non-epithelial tumours comprise mainly sex-cord stromal and germ-cell tumours. Of the sex-cord stromal tumours, granulosa cell tumours may require chemotherapy.
  • 9 - Ovarian cancer standards of care
    pp 115-144
  • View abstract

    Summary

    Ovarian cancer is the fourth most common cause of cancer deaths in women and the leading cause of gynaecological cancer death in Europe with a lifetime prevalence in the developed world of 1-2%. Primary ovarian tumours are a heterogeneous group, which includes epithelial tumours, sex-cord stromal and germ-cell tumours. There are a number of indications for surgery for ovarian carcinoma: establishment of diagnosis, accurate staging, primary cytoreduction, interval and secondary cytoreduction, and palliative and salvage surgery. Modest improvement in progression-free survival in the lymphadenectomy arm was offset by increased morbidity. Although surgery is usually the primary treatment, ovarian cancer is a chemosensitive disease and chemotherapy has been shown to improve prognosis in advanced disease. Treatment for relapsed disease is usually regarded as a palliative measure in women with symptomatic recurrent tumours. Radiotherapy is mainly used as palliative treatment to reduce pain and, occasionally, to control bleeding.
  • 10 - Endometrial cancer standards of care
    pp 145-154
  • View abstract

    Summary

    Endometrial hyperplasia can be termed as a premalignant condition of the endometrium. Women presenting with postmenopausal bleeding are at the risk of having endometrial cancer and investigations to confirm or exclude such a possibility should be performed. The standard surgical procedure for the management of endometrial cancer is hysterectomy and bilateral salpingo-oophorectomy by the method for evaluation of the peritoneal cavity. Patients with clear-cell or papillary serous tumours may receive pelvic radiotherapy and adjuvant chemotherapy to try to impact on the possibility of extrapelvic relapse. The optimum management of endometrial cancers requires close coordination between the primary healthcare team, the treatment teams at the cancer unit and cancer centre, the palliative care team and patients and their families. For endometrial cancer, the cancer unit should provide a rapid and appropriate assessment service at the local level for women with postmenopausal bleeding.
  • 11 - Cervical cancer standards of care
    pp 155-168
  • View abstract

    Summary

    All women with cervical cancer should be referred to a gynaecological oncology multidisciplinary team. Any woman with smear suggestive of invasion or of glandular neoplasia should be referred urgently for colposcopy within 2 weeks; those with high-grade cytological abnormality should be referred and seen at a colposcopy clinic within 4 weeks. Diagnosis is made based on biopsy. If the lesion is large and clinically highly suspicious, then the directed biopsy will often suffice. Following histological confirmation, investigations focus on staging and treatment planning. Stage IA2 disease can be managed by local excision, but consideration of pelvic lymphadenectomy should be carried out on an individual case basis. Radical trachelectomy with lymphadenectomy allows scope for fertility sparing in some women having small (stage IB1) tumours when ovarian function is lost, as a result of either surgery or radiotherapy for cervical cancer, hormone replacement therapy should be considered.
  • 12 - Vulval cancer standards of care
    pp 169-188
  • View abstract

    Summary

    The rarity of vulval cancer has meant that few, if any, robust randomised trials have been performed. Women with predisposing conditions should be counselled with regard to risk. This rarity, combined with the modesty that women might feel owing to the intimate location of the problem means that cancer might be easily overlooked, misdiagnosed or ignored. Diagnosis of vulval cancer is made based on biopsy. The major factors that influence treatment planning are the need to assess nodal status, the extent of the disease and the woman's suitability for treatment. Pelvic node involvement tends to follow inguinofemoral spread of disease. Preoperative radiotherapy should be considered if primary surgery is likely to compromise sphincter function. The requirement for reconstruction should be considered in all patients undergoing surgery for vulval cancer. Sentinel node sampling is a recent innovation, which provides diagnostic information to direct further care while minimising morbidity.
  • 13 - Uncommon gynaecological cancers
    pp 189-208
  • View abstract

    Summary

    The investigation and management of uncommon gynaecological cancers is made based mainly on cohort studies, case series and expert opinion. Risk factors for gestational trophoblastic disease (GTD) include: maternal age, race, reproductive history, parental blood groups, and genetic predisposition. Staging for fallopian tube carcinoma is analysed by the surgical pathological system. Surgery has a limited role in the management of women with vaginal cancer. Uterine sarcomas are mesodermal tumours and account for 3-5% of all uterine cancers. FIGO has only recently introduced a staging system for these tumours to separate them from the corpus uteri staging. Uterine sarcomas are more common in black women and women who have undergone previous pelvic irradiation. Gynaecological malignancy is uncommon in childhood and adolescence. The most common malignant ovarian tumours in childhood are germ-cell carcinomas: dysgerminoma, endodermal sinus tumour, malignant teratoma and, more rarely, embryonal carcinoma, primary ovarian choriocarcinoma and mixed germ-cell tumour.
  • 14 - Palliative care
    pp 209-228
    • By Jo Sykes, South Devon Healthcare NHS Foundation Trust
  • View abstract

    Summary

    The principles of palliative care form an important part of disease management and are encouraged as part of good practice for all health professionals caring for the women. Knowledge and application of the principles of palliative care should be part of the practice of health care professionals. This chapter discusses the management of the common symptoms associated with gynaecological malignancies. Hypercalcaemia of malignancy is common in cervical carcinoma and is a poor prognostic indicator. Clinical features include anorexia, nausea, vomiting, constipation, drowsiness and confusion but it should be looked for in patients who are deteriorating with no clear reason. Although syringe drivers are used at the end of life, they can be appropriate at other stages of illness. The chapter tabulates the drugs which can be mixed with morphine or diamorphine in a syringe driver. Provision of palliative care to women with gynaecological cancer requires excellent communication and team working.
  • 15 - Emergencies and treatment-related complications in gynaecological oncology
    pp 229-244
  • View abstract

    Summary

    Emergencies in gynaecological oncology are influenced by the site of cancer, stage of disease, presence of associated comorbidities and the treatment received. Women with advanced cervical cancer may develop distressing symptoms and may present with acute admissions. Vaginal bleeding caused by endometrial cancer can be usually managed conservatively. If there is an associated pyometra, operative treatment for endometrial cancer should be preceded by intravenous antibiotic treatment to avoid septicaemia and other septic postoperative complications. In severe cases, respiratory compromise may require omission of laparoscopy or conversion to laparotomy and postoperative ventilatory support. Catastrophic haemorrhage after gynaecological cancer surgery is uncommon, owing to the extensive use of electronic haemostatic devices; however, persistent oozing from large dissected surfaces may lead to haematomas. The most common complications, which require admission during chemotherapy, are febrile neutropenia and vomiting. Complications of radiotherapy depend on radiation-related factors and patient-related characteristics.

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