Field Of Gynecologic Oncology Research Articles

Approaches for end-of-life care in the field of gynecologic oncology: an exploratory study

We sought to explore the Society of Gynecologic Oncologists (SGO) members' opinions and decisions about end-of-life issues and incurable conditions. A survey was mailed to members of the SGO. Their responses were recorded on a Likert scale and entered into a database. The survey explored opinions, experiences, and decisions in managing terminally ill gynecologic oncology patients. Of 900 surveys, 327 were returned (response rate, 36%). Seventy-three percent were men, 89% were white, and 72% were of Christian denomination. Respondents believed that 97% of patients who are dying realize that they are dying but stated only 40% of these patients initiate conversations about end-of-life issues. In contrast, 92% of respondents stated that they initiate end-of-life discussions with patients. Ninety-two percent of respondents thought that the patients should be allowed to make end-of-life choices independently after the facts are given to them. However, 44% thought that it is important to influence the way information is presented, and 54% believe that the gynecologic oncologist (GO) controls the outcome of end-of-life discussions. Although the physicians' sex, race, religion, and age did not correlate with their treatment decisions, religion did correlate with less fear of death (P= 0.011) and less discomfort when talking with patients about death (P= 0.005). Fifty-four percent of respondents believed that the GO controls the outcome of end-of-life discussions, and 40% believe that their actions prolong the process of dying. Expanding our understanding of what motivates GOs to recommend continued treatment over palliation is important for preserving informed patient-motivated end-of-life decisions.

Laparoscopy and oncology: where do we stand today?

The clinical application of laparoscopic surgery has grown rapidly over the last few years. Since the first documentations of laparoscopic lymphadenectomy, many reports highlight the use of modern laparoscopy in the field of gynecologic oncology. Laparoscopic treatment of early-stage cervical and endometrial cancer, and laparoscopic evaluation and staging of cervical, ovarian, and endometrial carcinomas, are feasible procedures. The place of minimal-access surgery in the arsenal of gynecologic oncological surgery has been established, especially after the recent developments and practical application of video laparoscopy, novel instrumentation, and advanced surgical techniques. Although operative laparoscopy in gynecologic oncology is still in its infancy the potentiality of the procedure is underscored. Many patients may benefit from the treatment or staging of gynecologic malignancies with laparoscopic means. Literature reports highlight that laparoscopy may be an effective procedure with lower morbidity and complication rates than traditional abdominal surgery. The short hospital stay and recovery time have a positive impact in a cancer patient's quality of life, as they return to normal activities rapidly. Many risks, though, may arise from the application of minimal-access surgery in cancer patients, and many questions regarding safety and efficacy need answers, based on prospective clinical trials. We must emphasize that such studies with large patient numbers and long-term follow-up are lacking. Until results from these trials are available, laparoscopic oncologic procedures should be performed only in an investigational setting by expert teams.

Laparoscopic surgery for gynaecological oncology.

The use of laparoscopic staging and/or surgery in the field of gynaecological oncology was pioneered in the early 1990s. The issue has been very controversial from the beginning, with some justification in view of the possible consequences of faulty cancer surgery. After more than 10 years, long-term follow-up and comparative studies, both of which are required in clinical oncological research, are now available. A number of papers have confirmed the absence of significant adverse effects on survival after laparoscopic diagnosis or surgery in gynaecological cancers. New developments cover virtually all the basic techniques in cancer surgery, excluding major exenterative surgery. The use of an extraperitoneal technique for aortic dissections is emerging. New indications, such as radical vaginal trachelectomy, pelvic sentinel node identification, interval debulking surgery of adnexal malignancies, or the liberal use of surgical staging of uterine cancers, have been developed as a direct result of the availability of laparoscopic techniques. Continuing worldwide interest clearly demonstrates that laparoscopic techniques are now part of the armamentarium of the gynaecological oncologist. Postoperative morbidity and recurrence risk do not seem to be affected. Cost-efficiency of laparoscopic procedures is based on the reduction of hospital stay. Combined training in gynaecological oncology and in laparoscopic surgery is, more than ever, mandatory as a means of avoiding the risk of inadequate staging or the mismanagement of pelvic malignancies. The diversity of techniques, including laparotomy, laparoscopy, and vaginal surgery, allows the individualization of surgical approaches, whereby tumour size and local or general conditions can be taken into account.

THREE-DIMENSIONAL ULTRASOUND IN GYNECOLOGIC ONCOLOGY

Background. Although three-dimensional ultrasound (3D US) imaging has been used for a decade, debate continues about its potential clinical aplications in gynecology. The same is true for the field of gynecologic oncology. Also, reports regarding usfulness of 3D US in gynecologic oncology are limited. A few potentially useful clinical applications have been described and some of these are now gaining general acceptance. In this paper, the usfulness of 3D US in the main areas of its application is demonstrated: diagnostics of cervical, endometrial, ovarian and breast cancer. Conclusions. An important advantage of 3D US over conventional two-dimensional imaging is the ability to reconstruct and display any arbitrarily chosen section within the volume dataset as well as ability to measure the volume of pelvic organs regardless of their shape. 3D US also allows the realtime analysis of the acquired image data to be conducted at a later time when the patient is off the examination table.

Three-dimensional ultrasound and three-dimensional power Doppler in the assessment of adnexal masses

ABSTRACTThree-dimensional ultrasound is a new, emerging technology that provides additional information for the evaluation of ovarian tumors. Multiplanar and volume-rendering display methods combined with the ability to rotate volume data into standard orientations are essential components of the current and future success of three-dimensional ultrasound.Increasing knowledge about three-dimensional ultrasound, as well as improved handling allow application of this method to the field of gynecological oncology. The recent development of real-time three-dimensional ultrasound imaging will further advance the clinical applications, particularly in the assessment of pelvic tumors. The introduction of the three-dimensional power Doppler systems may improve the information available on ovarian tumor vascularity and speed up the entire patient management process.

Cytoreductive surgery for advanced stages of ovarian cancer.

During the past two decades, maximum cytoreductive surgery (also called debulking surgery) has been the recommended surgical approach for advanced stages of ovarian carcinoma. The residual tumor volume after surgery is one of the strongest prognostic factors, and only patients who undergo complete or optimal surgery are likely to be long-term survivors (i.e., 50% after five years). A well-trained surgeon in the field of gynecologic oncology can achieve an optimal tumor reduction in up to 75% of patients with advanced stage ovarian cancer. During the procedure, bowel resection, especially rectosigmoid, must be undertaken in 30% to 40% of cases, and para-aortic and pelvic lymphadenectomy should be performed after adequate tumor reduction in the abdominal cavity. The experienced surgeon can perform these surgeries with an acceptable morbidity, allowing chemotherapy to be undertaken within the month following surgery. However, very advanced cancer with massive peritoneal carcinomatosis and/or Stage IV disease requires a very aggressive surgical procedure but yields a poor prognosis and a higher risk of unacceptable complications. For these worst cases, the concept of cytoreductive surgery is moving toward the alternative strategy of chemosurgical cytoreduction, in which interval cytoreductive surgery is undertaken after three cycles of front-line chemotherapy. The goal of this experimental strategy is to achieve a complete tumor response after front-line chemosurgical therapy, and a better quality of life.

32 Minimal access surgery in oncology

The gynaecologists were the first to use minimal access surgery. This kind of surgery was, during years, limited to benign conditions. We were the first, in December 86, to use it in the management of cancer while performing a laparoscopic assessment of the pelvic lymph nodes for a woman affected by an infiltrative cervical cancer. We have now an experience of more than 400 cases. Pretherapeutic assessment of the retroperitoneal lymph nodes remains the best of the good indications of laparoscopy in the field of gynecologic oncology. Laparoscopy enables us to assess either the pelvic or the aortic retroperitoneal lymph nodes, using either the direct retroperitoneal approach or the transumbilical transperitoneal one. Many data clearly established that such an assessment is as reliable as the classical surgical assessment, while avoiding all the drawbacks of the open surgery. Knowledge of the lymphnodal status enables us to take at the good time (before radical surgery or radiotherapy) the good decision: in the good cases (no risk factor, no lymphnodal involvement) the treatment can be exclusively surgical and the surgery can be performed using the vaginal route: in the bad cases (risk factors and/or lymphnodal involvement) the treatment has to be multimodal using combinations (chemotherapy, radiotherapy, surgery) whose choice depends on the extend of the disease as it has been denned by the laparoscopy. The chosen example is representative regarding the role of minimal access surgery in oncology. The laparoscopie debulking surgery has been advocated by some surgeons in thoracic, abdominal and pelvic surgery. This practice appears as hazardous except, maybe, in the frame of neoadjuvant chemotherapy protocols during which a laparoscopie debulking of the residual masses can be undertaken. However the actual place of laparoscopie surgery is not here. Laparoscopy's first role is selecting the cases for an appropriate treatment. Minimal access surgery is a cost effective tool to use in order to improve the cost effectiveness of the treatment of pelvic, abdominal and thoracic cancer. The gynaecologists were the first to use minimal access surgery. This kind of surgery was, during years, limited to benign conditions. We were the first, in December 86, to use it in the management of cancer while performing a laparoscopic assessment of the pelvic lymph nodes for a woman affected by an infiltrative cervical cancer. We have now an experience of more than 400 cases. Pretherapeutic assessment of the retroperitoneal lymph nodes remains the best of the good indications of laparoscopy in the field of gynecologic oncology. Laparoscopy enables us to assess either the pelvic or the aortic retroperitoneal lymph nodes, using either the direct retroperitoneal approach or the transumbilical transperitoneal one. Many data clearly established that such an assessment is as reliable as the classical surgical assessment, while avoiding all the drawbacks of the open surgery. Knowledge of the lymphnodal status enables us to take at the good time (before radical surgery or radiotherapy) the good decision: in the good cases (no risk factor, no lymphnodal involvement) the treatment can be exclusively surgical and the surgery can be performed using the vaginal route: in the bad cases (risk factors and/or lymphnodal involvement) the treatment has to be multimodal using combinations (chemotherapy, radiotherapy, surgery) whose choice depends on the extend of the disease as it has been denned by the laparoscopy. The chosen example is representative regarding the role of minimal access surgery in oncology. The laparoscopie debulking surgery has been advocated by some surgeons in thoracic, abdominal and pelvic surgery. This practice appears as hazardous except, maybe, in the frame of neoadjuvant chemotherapy protocols during which a laparoscopie debulking of the residual masses can be undertaken. However the actual place of laparoscopie surgery is not here. Laparoscopy's first role is selecting the cases for an appropriate treatment. Minimal access surgery is a cost effective tool to use in order to improve the cost effectiveness of the treatment of pelvic, abdominal and thoracic cancer.

Ethical Difficulties with Randomized Clinical Trials Involving Cancer Patients: Examples from the Field of Gynecologic Oncology

Ethical Difficulties with Randomized Clinical Trials Involving Cancer Patients: Examples from the Field of Gynecologic Oncology

Changing Perspectives in Gynecologic Oncology and Treatment

DOI: http://dx.doi.org/10.5915/23-1-15227 Gynecologic oncology has a unique status in the field of oncology. Due to easy accessibility, early detection by cytology and first successful radiotherapy were achieved in cancer of the cervix. In addition, the first successful radical surgery and the first successful chemotherapy were in the field of gynecologic oncology. Gynecologic oncology is always in evolution and our aim in this article is to review the new approaches to diagnosis, staging, and treatment.

Arterial embolization in the management of abdominal and retroperitoneal hemorrhage

In the field of gynecologic oncology, surgical intervention has been the traditional management of postoperative abdominal hemorrhage. Recently, arterial embolization has been reported to effectively control vaginal hemorrhage associated with gynecologic malignancy, obstetrical trauma, and hysterectomy. This study reports the use of arteriographic embolization in the management of six cases of postoperative abdominal and retroperitoneal arterial hemorrhage. Analysis of these cases provides valuable information which enhances the safety and efficacy of this procedure. Results suggest that arterial embolization, by an experienced arteriographer, should be considered early in the post-operative management of abdominal hemorrhage in gynecology and gynecologic oncology.

Clinical applications of monoclonal antibodies against ovarian cancer-associated antigens

Monoclonal antibodies (McAbs), reactive with tumour-associated antigens (TAAs) present on tumour cells, appear to offer new possibilities in the diagnosis and treatment of cancer (Table I). In addition to these prospects for clinical application, monoclonal antibodies also serve as useful instruments in basic cancer research. The hybridoma technology initiated by Köhler and Milstein in 1975, underwent a very rapid development and has now shown its potential in the field of oncology. This technique made it possible to produce very large quantities of homogeneous antibodies of a stable quality. These McAbs often recognize only one antigenic determinant, or epitope, of cell surface and other molecules. This high specificity is essential for in vivo applications, especially in therapeutic immunotargeting. A central question is whether the antibodies can reach and identify those antigens on ovarian tumour cells that are not shared with normal tissues. Various antibodies have been described in the field of gynaecological oncology, which are assumed to be capable of recognizing such ovarian tumour-related antigens. These McAbs, single or in combination, are capable of showing, unambiguously, the presence of various tumour-associated antigens on ovarian carcinoma cells either in tissue or, when antigen shedding occurs, in blood. However, these McAbs may also react with tumour-associated antigens present on endometrial, cervical, colorectal, breast or other carcinoma cells. The original immunogens used to generate these McAbs differ as to their origin: ovarian cancer cells, breast cancer cells, human milk-fat preparations, trophoblastic cells, endometrial cancer cells have been used as well as osteogenic sarcoma cells, epidermoid carcinoma cells and small-cell lung cancer, colorectal, pancreatic and laryngeal carcinoma cells. The histological distribution patterns of the antigens recognized by these McAbs vary widely: cross-reactions with normal tissue and with carcinomas different from those used as immunogen are frequently seen.

12 Vesicovaginal fistulae

In the past few decades, amidst the revolutionary new advances in the surgical, chemotherapeutic, and radiotherapeutic treatments for cancer, the role of the gynecologic oncologist has diverged from that of the obstetrician–gynecologist and the general surgeon. In the past, the general surgeon was responsible for treating any disease process that was surgically approachable. As new methods of treatment have arisen in the fight against cancer, the field of gynecologic oncology has developed its own identity and exists now as a separate subspecialty. Nevertheless, many of the surgical modalities used by the gynecologic oncologist require understanding of experiences shared by general surgeons, surgical oncologists, urologists, colorectal surgeons, and even vascular surgeons.Intraoperative injuries encountered during gynecologic oncology surgery occur because of the complexity of the involved anatomy and the intimate relationships of these various structures. Most pelvic tumors have the ability to invade and compromise surrounding tissues. With the close proximity of the pelvic organs to those of the abdomen, many pelvic tumors tend to involve a number of adjacent organ systems, including the gastrointestinal tract, the urinary tract, nerves, and blood vessels. The distortion caused by tumor invasion and growth can render normal anatomy difficult to recognize.Gynecologic oncologists normally perform a wide array of procedures, such as staging laparotomy, lymphadenectomy, radical hysterectomy, radical vulvectomy, debulking for ovarian cancer, second-look laparotomy, pelvic exenteration with reconstruction for recurrent cancer, and operations for surgical and radiotherapeutic complications. Unfortunately, even the most expert surgeon in the field encounters situations in which iatrogenic injury cannot be avoided. The pelvic surgeon must be familiar with the most common injuries and be able to solve the problem without hesitating to call for intraoperative consultation when indicated. Often, gynecologic oncologists who work in close contact with gynecologists and obstetricians are the first physicians to be consulted intraoperatively to perform corrective surgery for iatrogenic complications during benign procedures. The management of these various iatrogenic complications should be familiar to the gynecologic oncologist and any pelvic surgeon acting as a consultant. The choice of the reparative technique should be based on the type of injury; the disease and extension; the general condition of the patient; and, just as importantly, the surgeon's personal experience.This article discusses the management of the most common intraoperative injuries encountered during gynecologic cancer surgery. The management of any of these complications can be applied to surgery for benign gynecologic, obstetric, or any surgical procedure in which a pelvic surgeon may be asked to consult intraoperatively. Discussion is dedicated to injuries of the genitourinary tract, gastrointestinal tract, and commonly encountered nerves. The reader is referred to the article by Montz in this issue for a discussion of the management of vascular injuries.

Accident Flying Squad

Background and Aims: Cost increases in the healthcare system are leading to a need to distribute financial resources in accordance with the value of each service performed. Health-economic decision-making models can support these decisions. Due to the previous unavailability of health utilities in Germany (scored states of health as a basis for calculating quality-adjusted life-years, QALYs) for women undergoing treatment, international data are often used for such models. However, these may widely deviate from the values for a woman actually living in Germany. It is, therefore, necessary to collect and analyze health utilities in Germany. Materials and Methods: In a questionnaire survey, health utilities were collected, along with data for a healthy control group, for 580 female patients receiving treatment in the fields of mastology and gynecological oncology using a German version of the EuroQol questionnaire (EQ-5D) and a visual analogue scale (VAS). Data were also collected for the patients9 medical history, tumor disease, and treatment. Results: Significant differences with regard to quality of life were measured in relation to the individual tumor entities and in comparison to the controls. Apart from the healthy control group, patients with breast or cervical carcinoma had the best quality of life. In patients with recurrent and metastatic disease, those with breast carcinoma experienced the greatest impairment of their quality of life. According to current treatment, the most important impairment of life quality occurred in patients under radiotherapy and after surgical treatment. There are significant differences from the health utilities recorded for other countries – for example, the state of health declines much more markedly in patients with metastatic disease among American women with breast carcinoma than among German women, in whom recurrent disease and a first diagnosis of metastasis were comparable. Overall, the VAS was able to distinguish more adequately than the EQ-5D questionnaire between the different situations and impairments resulting from diagnosis and therapy. Conclusion: Health utilities are now, for the first time, available for further health-economics analyses in the field of gynecological oncology and mastology for women living in Germany. Important differences in these utilities from those of other countries are evident.