Gynecological cancers: broad overview

There are 3 main types of cancers under this heading ie cancers of female reproductive system viz 

1. Cervical cancer
2. Uterine or endometrial cancer
3. Ovarian cancer

There are few other cancers too like vulvar cancers and vaginal cancers. Let’s discuss the common 3 gynecological cancers and their Rx plan with special reference to surgery and preparedness for the same.

Gynecological cancers are managed with multimodality therapies like surgery, chemotherapy and radiotherapy. The sequence and/or combination of these are used as per the stage and patient related factors, which is known as personalized or precision medicine in cancer care. Surgery remains the mainstay of therapy in gynecological cancers. Chemotherapy and radiation are used as adjunct treatments in many of the cancers.

Symptoms of common gynecological cancers:

Symptoms of cancers of the female genital tract vary according to the organ of origin of cancer. Most of them remain asymptomatic for a significant period unless regular health check ups are done. Following is the list of symptoms in various cancers of the female genital tract.

Diagnosis:

Diagnosis: 

Ovarian cancer:

• Ca 125
• CECT abdomen and pelvis or whole body PET CT
• Ascitic fluid cytology or biopsy from ovarian mass or deposits

Uterine or endometrial cancer:

• Endometrial biopsy or dilatation and curettage
• MRI pelvis and CT abdomen or whole body PET CT Scan

Cervical cancer:

• PAP smear or Punch biopsy from cervical lesion
• MRI pelvis with CT abdomen or whole body PET CT Scan

Lets understand terminologies

1. Definitive Therapy: usuallySurgery/ Radiation therapy: mainstay of treatment producing maximum benefit for curative intent.
2. Neoadjuvant therapy: usually chemotherapy, given to decrease extent and size of disease bulk
3. Adjuvant therapy: additional treatment for additional benefit to prevent local or systemic recurrences and improve disease free survival
4. Metastatic: disease stage in which cancer has spread to distant sites that make it beyond scope of curability
5. Palliative therapy: treatment to the disease that has grown beyond the level of cure.
6. Symptomatic treatment: treatment to alleviate symptoms alone and not aiming to treat disease [that has grown beyond treatable limits], not involving chemotherapy, radiation or surgery, usually tender loving care at end of life.
7. Prognosis: the probability of survival. It’s the gross measure of outcome after treatment of cancer.

It’s important in gynec cancers that multimodality treatments involving surgery, chemotherapy and radiation are offered in the most appropriate sequence and time to get the best results. Your surgeon, medical oncologist and radiation oncologist should so discuss and make a consensus decision.

Cancer	Stage	Neoadjuvant Rx	Definitive Rx	Adjuvant Rx
Cervical	Early		Surgery	Radiation or chemoradiation
	Locally advanced	+/-Chemotherapy	Chemoradiation
Ovarian	Early		Surgery	+/-Chemotherapy
	Locally advanced	Chemotherapy	Surgery	Chemotherapy
Endometrial	Early		Surgery	Radiation +/- chemotherapy
	Locally advanced	Chemotherapy	Surgery	Radiation +/- chemotherapy

Understanding the Surgery for gynecological cancer:

Incision or concern of scar:

Generally for ovarian cancer  the incision of choice is vertical midline and for cervical or endometrial cancers either can be used however the vertical is preferred, especially when removal of abdominal nodes is anticipated.

Extent of surgery for ovarian cancer:

The ovarian cancer surgery encompasses diagnostic laparoscopy i.e. pre operative visualisation of disease for staging via a small cut and a camera. Upon ascertaiong complete operability i.e. having near zero possibility of residual disease left behind, major surgical resection is attempted. The conventional surgery includes removal of ovarian mass with ovaries, tubes, uterus, omentum [fat laden curtain like organ in abdomen that may have cancer cells], lymph nodes in pelvis &/or abdomen, appropriate peritonectomy and excision of all gross disease noted during surgery.

Surgery for endometrial cancer:

The surgery for endometrial cancer involves resection of the uterus with clear margins around and vagina, tubes, both ovaries, lymph nodes in pelvis and sometimes nodes in abdomen too.

Surgery for cervical cancer: Wertheim’s Radical Hysterectomy

Cervical cancer surgery begins with examination under anesthesia, proctoscopy, cystoscopy to rule out invasion into rectum, urinary bladder or sides of the cervix, better known as parametria.

Upon ascertaining resectability, surgery includes removal of the uterus with a wide cuff of vagina and parametrium, tubes, ovaries and bilateral pelvic lymph nodes.

What is lymph node dissection?

The lymph nodes are the filtering stations that harbours first immune power against any harmful agents like bacteria, virus, cancer cells etc. the nodes have immune cells that trap them and prevent them from spreading ahead. In cases of cancer, though the nodes trap cancer cells, they have to be removed for two purposes, one being treatment of cancer spread and second for accurate staging. The figure below shows the propensity or common lymph nodes that can be involved in cancers of the female genital tract. In certain cases of ovarian/ endometrial and cervical cancers, lymph nodes in either sides of pelvis and abdomen [retroperitoneum] are ought to be removed.

Role of laparoscopic or robotic surgery in gynecologic cancers:

The laparoscopy is a great invention that makes patients return early to work and get surgery with much less discomfort. The utility of laparoscopy is debatable in gynecological cancers, hence this modality needs further studies for the approval in gynec cancer surgeries. Until then open surgeries remain the standard of care.