“Subspecialisation has been good for patient care. It is possible that all the advances in oncology, diagnosis and therapy, advanced reproductive technology and perinatal medicine would have taken place without subspecialty development – possible but unlikely…”
I consider it a great honor and privilege, that as President of Polish Society of Oncologic Gynecology (PTGO) I have an opportunity to present on the pages of the first issue of the new journal “Ginekologia Onkologiczna” some aspects of this subspecialty stemming from obstetrics-gynecology, which has been recognized many years ago in several countries and approved in Poland only in April 2003.
American Society of Obstetrics and Gynecology was the first to recognize oncologic gynecology as a subspecialty in 1970, one year after the foundation of the Society and appearance of the first issue of the journal “Gynecological Oncology”.
The aim of this subspecialty and journal was to improve the care of women with a diagnosis of cancer of reproductive organs and to improve treatment outcomes by better education of specialists in this field.
Precise diagnosis and staging of carcinoma of the cervix is crucial for optimal treatment of patients with this malignancy.
All the diagnostic steps described below are needed for confirming the diagnosis and establishing a clinical stage of the disease.
A direct biopsy of the cervical tumor with microscopic examination of the specimen plays a principal role in establishing the diagnosis of cervical cancer.
For proper staging of the disease the following diagnostic steps have to be completed:
1. Vaginal and rectal bimanual examination
2. Chest X-ray
3. US or CT of the whole abdomen (liver, kidneys, retroperitoneal space)
4. Basic blood test (TBC, BUN)
5. Cystoscopy for locally advanced cases with anterior vaginal wall involvement or suspected bladder infiltration on US or CT
Biopsy of the suspected lesion is mandatory.
6. Rectoscopy for cases with posterior vaginal wall infiltration
with biopsy of the suspected area
7. For patients with the symtoms of distant metastases additional diagnostic procedures should be performed
- bone scan
- fine needle biopsy of the suspected lesions ( for example paraaortic nodes)
8. For differential diagnosis between adenocarcinoma and poorly differenciated carcinoma of the cervix and endometrium the following procedures should be performed:
- dilatation & curettage with microscopic examination of the specimen
- histeroscopy for selected cases
9. For praeinvasive lesions additional procedures are recommended:
- curettage of the cervical canal
- cytology of the vaginal fornices smear
10. For microinvsive lesion cone biopsy should be performed to establish the stage of the disease
DIAGNOSIS OF ENDOMETRIAL CANCER
The determination of the extend of the tumor has a basic importance for optimal treatment strategy choice for every patient. Histologic verification of endometrial tissue is required to make diagnosis of endometrial carcinoma. Additive diagnostic studies to make the diagnosis of endometrial cancer are as follows:
a) bimanual gynecologic vaginal and anal examination
b) histeroscopy, if endometrial biopsy is inconclusive and the suspicion for cancer is high
c) chest radiography
d) ultrasound of renal, liver and peripleural space
e) transvaginal ultrasonography (TV USG)
f) complete blood count, urianalysis, renal and liver function studies
g) in III and IV A stage sometimes cystoscopy, proctosigmoidoscopy or barium enema needs to be performed
h) in case of vaginal metastases suspicion, histological verification of suspected material is necessary
In Poland, 1957 deaths due to ovarian cancer were registered in 1999. Ovarian cancer is the most frequent cause of death among the female genital tract cancer. In Poland it accounts for the third place among all deaths cause in women. The mortality structure for ovarian cancer was 5.66% in 1999, and the standardized mortality factor was 6.7/100 000 women. It has been estimated that in about 5-10% of ovarian cancer is familial hereditary one. The most important risk factor of ovarian cancer is developing of this disease in firs-degree relatives ( mother, daughter, sister ). The risk significantly increases with strong family history meaning two first-degree relatives with ovarian cancer. Familial hereditary ovarian cancer falls into three categories: site-specific familial ovarian cancer, breast-ovarian cancer syndrome, and Lynch syndrome type II. The true, familial ovarian cancer and/or breast cancer develops mainly due to mutation of BRCA1 which is located on the long arm of chromosome 17q21. The mutation of BRCA2 gene ( location on chromosome 13q21 ) is also responsible for ovarian and breast cancer syndrome. It has been recommended that women with two or more first-degree relatives with ovarian carcinoma may be offered prophylactic oophorectomy after completion of childbearing or age 35 years. But one should emphasize that there is still insufficient evidence for or against this procedure to reduce ovarian cancer risk. It has been suggested that development of primary peritoneal cancer is not prevented by prophylactic oophorectomy. The ovarian cancer disseminates intraperitoneally in most cases. The frequency of pelvic lymph nodes metastases found during primary surgery depend mainly on staging. The disturbances of lymph circulation caused by neoplastic cells infiltrating the peritoneum effect in ascites. The transudation of cancer cells or free fluid into pleural cavity is also observed.
The beneficial prognostic factors are as following:
· young age
· good general condition
· histological type other than mucinous and clear cell
· low stage
· well differentiated tumors
· small initial tumor volume
· lack of ascites
· post surgical residual volume Ł 1 cm
· disease-free time interval
Surgery and chemotherapy are the major contributors to the management of patients with advanced epithelial ovarian cancer. Most clinicians accept that when optimal debulking seems likely cytoreductive surgery should be performed first (1). However, when doubt exists about successful debulking the use of chemotherapy before such surgery (neoadjuvant chemotherapy) could be a reasonable alternative (2). Several nonrandomized studies in the past have suggested that a) survival might not be different with upfront chemotherapy followed by interval debulking surgery when compared to the standard approach, b) optimal surgical cytoreduction is more likely to be achieved after administration of chemotherapy, and c) this alternative approach might induce less morbidity (3-6). In order to verify the conceptual advantages of chemical versus surgical upfront debulking a prospective randomized phase III trial (protocol 55971) has been initiated within the EORTC Gynecologic Cancer Group, which is presently ongoing in cooperation with several European and non-European cooperative groups (Intergroup trial). The study is expected to close in 2005 with a target accrual of 704 patients.