Investigations for gynecological cancers: checklist

A] For diagnosis:

• Cervical cancer: PAP smear, Cervical biopsy or endocervical curettage.
• Endometrial cancer: dilatation and curettage
• Ovarian cancer: ascitic fluid cytology or FNAC or Tru cut biopsy of ovarian mass or deposit.

B] Metastatic work up:

Whole body PET CT. or, CECT abdomen and pelvis, Ct chest

C] Local extent or resectability:

•      MRI pelvis with CECTAbdomen/ whole body PET CT: in case of cervical or endometrial cancer
•      CECT abdomen and pelvis or whole body PET CT: for ovarian cancer.

D] for assessment of fitness for surgery:

❏  CBC/ hemogram,

❏  LFT [liver function tests],

❏  RFT [renal / kidney function tests],   

❏  PT,PTT,INR  [coagulation profile],

❏  BG: blood group

❏  Random blood sugar, Urine routine examination,

❏  Viral markers: HIV, HCV, HBsAg

❏  Cardiac assessment: Chest X Ray, ECG, 2D ECHO

❏  Other tests as per individual risk factors

❏  Fitness evaluation from Physician and anesthesiologist

Declare:

 ❏  Previous surgeries– be it any,

❏  Allergies: drug allergy, sticking allergy or any substance allergy.

❏  Comorbidities like hypertension or high BP, diabetes, previous heart attack, arrhythmias, previous cardiac stenting or bypass surgery, asthma etc

❏  If you are taking blood thinner [commonly used being aspirin or clopidogrel], it needs to be stopped at least 5 days prior with your cardiologist’s advice.

❏  Policy for blood reservation: usually blood transfusions are not needed in this surgery unless the patient has anemia in pre op assessments. However on the safer side blood is reserved so it can be given in untoward emergencies.

Pre surgical checklist:Dos & Don’ts 

Pre-Operative

❏Blood thinners: Stop clopidogrel, aspirin or similar medications prior to the surgery with the physician’s advice.

❏Nil by mouth & Bowel preparation: In anticipated major or supra major surgeries and those involving surgery on rectum or colon or small intestines, emptying of intestines by medications &/or enemas are given. 

The Peglec powder is to be mixed in water with strong lemon juice to make it acceptable and mask its taste. Such 1 lt solution is to be consumed sip by sip over one hour an evening prior to surgery. Patient  would thereafter pass stools and the intestines would be cleansed medically thereby. She can consume clear liquids till midnight or 6-8 hrs scheduled time of surgery. Patients need to maintain 8 hours of fasting prior to surgery, conventionally. The newer ERAS protocols allow the patient to take clear energy drinks containing glucose, salts etc upto 4-6 hrs prior to surgery. The RMO or Nurses would communicate the plan for you

❏Shower: 

Shower the night before and the day of surgery.

 • Use approximately one ounce of antiseptic soap (CHLORHEXIDINE OR SAVLON      soap :  30 ml), washing below the neck only. You may use your regular soap / shower gel or shampoo for face and hair.

 • Rinse well.

 • Repeat above steps.

 • Use a freshly laundered towel to dry off after each shower.

 • Put on freshly laundered garments (night clothes, underwear, etc.).

 WARNINGS – This soap is for external use only. DO NOT USE ON FACE. Keep soap out of your eyes, ears, and mouth. Misuse around eyes could cause serious and permanent eye injury. If soap should contact the eyes or ears, rinse out thoroughly and promptly with water. NOT for use as a shampoo or douche.

❏Arrange for a family member, friend or near keen to bring you to the hospital, sign consent as a responsible and near relative.  

❏The secretary from the Suyog Cancer clinic or RMO doctor will get in touch with you in the evening before surgery to confirm time and location for check in for your surgery. If you have not received a call by 4 p.m., you may call on 9819073781 . 

❏Please discuss any medications you usually take in the morning with the on duty RMO at hospital.

 Day of Surgery   

❏  Leave jewellery and valuables at home.  NO METAL CONTAINING THING ON PATIENT’S BODY DURING SURGERY like chain, ear ring or rings in toes, bracelet etc

❏  Wear your glasses instead of contacts if you have them. Hand it over to relatives before entering the operating room.

❏  Please do not use deodorant or lotions on your skin and nail paints too.

❏      Avoid using hair spray or gel.

❏      Wear comfortable clothing and hospital clothings only.

Post surgery: 

•  Food after surgery: depending on extensive surgery, Dr and nurses will inform about food intake. Usually, patients are kept nil by mouth for 8-12 hours. Thereafter clear liquids are started as per patient’s tolerance. If no intestines are operated during the surgery, semisolid foods are given on day 1 or 2 and slowly escalated towards solids and normal diet.

•  Position after surgery: Better to remain 30- 45 degree head and back inclined up till full recovery.

•  Post op treatment: Nurses will give the IV fluids as per instruction and sugars will be timely checked as ordered. Antibiotics,anti acidity  and pain medications will be given for 1-3 days and oral medications thereafter.
• Epidural catheter: there could be a tiny bore tube inserted before surgery into the spine by an anesthesiologist, called an epidural catheter. It is used to deliver medicines to alleviate pain post surgery. It is usually kept in place for 3 days after surgery.

• Patient’s previous medicines for comorbidities like blood pressure or diabetes etc can be resumed after the physician’s advice.

• Dressings & Suture removal: Dressing will be changed before discharge. It is advisable to actively learn and follow the dressing technique so relatives can do it at home as required. My patients are advocated to take bath with soap and water over the surgical clips, keep it clean and observe it thereby, if need be , click a photo and send across for any concern. Clips are usually removed after 14 days post surgery.

Post anesthesia recovery symptomes: 

You may feel drowsy and have minor side effects after your procedure or surgery with anesthesia. These side effects include:

• Sore throat        • Headache        • Muscle aches • Dizziness off and on

• Nausea               • Vomiting (rarely) 

Some of these symptoms may be from the pain medicine you are taking. The side effects from anesthesia usually go away quickly in the hours after your procedure. Still, it may take several days for your body to recover from the stress of surgery and anesthesia.Urination: there would be a urinary catheter for 3-5 days post surgery. So patients need not get out of bed for micturition.

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.