2013, Vol 11, No 1
Recommendations of Polish Gynecological Oncology Society concerning epithelial tumors of the ovary: ovarian cancer and borderline tumors
CURR. GYNECOL. ONCOL. 2013, 11 (1), p. 9–23
DOI: 10.15557/CGO.2013.0001
Sarcoma of the uterus: diagnostic and therapeutic recommendations
CURR. GYNECOL. ONCOL. 2013, 11 (1), p. 24–32
DOI: 10.15557/CGO.2013.0002

Uterine sarcoma is a rare malignancy, accounting for 3–8% of all malignant tumors of the uterus. As a rule, patients are treated in reference centers by multispecialty diagnostic-therapeutic teams. Sarcoma of the uterus originate basically from two tissues – uterine muscle and endometrial stroma and constitute a heterogenous group of tumors. A standard of local treatment of all these tumors is transabdominal hysterectomy. High recurrence rate supports the rationale for adjuvant treatment, although to date no effect of adjuvant radiotherapy on overall survival and local recurrence rate has been proven. Some reports concerning stromal uterine sarcomas suggest an improved survival in patients undergoing postoperative hormonal therapy. The role of chemotherapy in adjuvant treatment of leiomyosarcomas remains to be defined. In the treatment of advanced stromal uterine sarcomas, there is a place for hormonal therapy (progesterone analogs, aromatase inhibitors and GnRH analogs). Treatment of far-advanced/ metastatic leiomyosarcoma cases and non-differentiated sarcomas is similar to systemic treatment of other soft-tissue sarcomas. The topic of this paper are current recommendations concerning diagnostic and therapeutic management of uterine sarcoma patients. Based on own experience confronted with literature data, we present current classifications, epidemiology, risk factors and generally accepted therapeutic protocols used to treat these malignancies.

Keywords: uterine sarcoma, prognostic factors, primary treatment, treatment of recurrences, follow-up
Hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of patients with disseminated intraperitoneal malignancy: preliminary report
CURR. GYNECOL. ONCOL. 2013, 11 (1), p. 33–41
DOI: 10.15557/CGO.2013.0003

HIPEC (hyperthermic intraperitoneal chemotherapy) is a novel therapeutic modality implemented in selected cases of genital malignancies in the females, mainly in patients with intraperitoneal cancer dissemination. The procedure is an integral part of surgical treatment, because it is done during radical tumor excision or cytoreductive surgery. A prerequisite for HIPEC is excision of all visible tumor foci of over 5 mm. This facilitates penetration of cytostatics to the peritoneum and destruction of persisting viable cancer cells. We present preliminary assessment of effectiveness of cytoreductive surgery combined with intraperitoneal perfusion chemotherapy under hyperthermia in 18 patients with late-stage ovarian cancer, peritoneal mesothelioma and disseminated uterine sarcoma. In our material, in 2 cases only surgery preceding HIPEC consisted in freeing of adhesions and excision of isolated intraperitoneal implants of less than 1 cm. All other patients underwent extensive cytoreduction. In all cases, the HIPEC procedure was performed by closed technique after completion of cytoreductive surgery. Cytostatics used included cisplatin (75 mg/m2) and adriamycin (30 mg/m2), which, depending on diagnosis, were administered alone or combined. After surgery, the predominating complication experienced by over 83% of the patients were nausea and vomiting of varying severity. To date, HIPEC procedure has not won a secure position in the treatment of ovarian cancer, both due to required proper equipment and disposable sets of drains, but mainly because of lack of unequivocally defined and optimal for a particular patient timing of execution. It has not been settled, whether such an optimal moment is completion of first-line adjuvant or neoadjuvant chemotherapy or recurrence of disease after another line of treatment. An indispensable prerequisite for implementation of intraperitoneal chemotherapy is maximal cytoreduction of tumor mass. Based on initial experiences we may state that the HIPEC procedure is a valuable adjunct for other established therapeutic modalities in oncology on the condition of proper, multidisciplinary qualification for the procedure.

Keywords: hyperthermic intraperitoneal chemotherapy (HIPEC), ovarian cancer, peritoneal cancer, intraperitoneal tumor spread
Sense of coherence and coping styles in women after hysterectomy
CURR. GYNECOL. ONCOL. 2013, 11 (1), p. 42–54
DOI: 10.15557/CGO.2013.0004

Introduction: Stress associated with inevitable hysterectomy affects an ever increasing number of women. A person’s ability to cope depends on individual predisposition which is closely related to sense of coherence (SOC) and individual coping style. Aim of paper: To define possible associations between SOC level and type of coping style in women after hysterectomy as a determinant of recovery and successful functioning in society and family. Material and methods: Analysis encompassed data of 97 women after hysterectomy, treated at the Department of Gynecology, Obstetrics and Pathology of Gestation at Dr Emil Warmiński Memorial Hospital, Bydgoszcz. SOC was assessed by Antonovsky SOC-29 questionnaire and effectiveness of coping was measured by Endler and Parker CISS questionnaire, in its Polish version developed by Szczepaniak, Strelau and Wrześniewski. Results: SOC score was within average limits (134.46 pts). High scores were noticed in the area of resourcefulness. Most patients presented “task-oriented” and “emotional” styles of coping with health problems. Patients with higher global SOC level usually resorted to task-oriented coping style while those with lower SOC level mostly resorted to emotional style. Conclusions: our results may be used to develop psychoeducational programs and to plan care of women at different stages of their treatment.

Keywords: hysterectomy, sense of coherence, coping styles, stress, acceptance of disease
Prophylactic ovariectomy in patients with colorectal cancer: is it justified?
CURR. GYNECOL. ONCOL. 2013, 11 (1), p. 55–61
DOI: 10.15557/CGO.2013.0005

The article is a review of available literature concerning the incidence of synchronous and metachronous metastases of colorectal cancer to the ovaries. A separate analysis included data from autopsy and clinical studies (incidence in historic series: 5–10% in the former and 3–14% in the latter). Recent studies estimate the incidence of metastases of large bowel cancer to the ovaries at 0.9–2.9%. At the time of diagnosis, metastasis to the ovary usually takes the form of solid or solid-cystic tumor of over 4 cm in diameter, often bilateral (5–70%). Recent studies did not confirm higher incidence of metastases to the ovaries of tumors located in the rectum versus those located in the colon. Furthermore, we discuss prognostic value of metastases to the ovaries considering current TNM classification, highlighting newly created categories M1a (isolated metastasis, e.g. to the ovary) and M1b (multiple distant metastases). The authors suggest simplified clinical recommendations, advocating against prophylactic ovariectomy of grossly normal ovaries. On the other hand, excision of tumor-invaded ovary in premenopausal women or of both ovaries (diseased and normal contralateral) in postmenopausal women, appears justified. However, before undertaking such a procedure, one must be sure about absence of other tumor foci or – if they are present – about feasibility of complete excision of all other extraovarian metastases.

Keywords: colorectal cancer, ovarian metastasis, incidence, prognosis, prophylactic ovariectomy
Hormone replacement therapy in gynecologic oncology
CURR. GYNECOL. ONCOL. 2013, 11 (1), p. 62–73
DOI: 10.15557/CGO.2013.0006

Age-related increase of risk of developing a genital malignancy in the females, increasing level of health awareness in general population, improved oncologic prevention, better diagnostic techniques and therapies, all of them contribute to increased number of patients at menopausal age completing oncological treatment. The problem concerns also young women, who require radical surgical consisting in oophorectomy, radiotherapy and chemotherapy. An increasingly frequent problem in the gynecologic practice is the use of hormonal replacement therapy in patients with a history of malignancy. Oophorectomy before menopause results in development of atrophic lesions in estrogen-dependent tissues, osteoporosis, cardiovascular and urogenital diseases, sexual dysfunction, vasomotor disorders and compromised quality of life, resulting in disorders of lipid metabolism and affects mental condition. An absolute contraindication for hormonal replacement therapy during menopause is active estrogen-dependent malignancy. Other clinical situations and controversies associated therewith concerning safety, particularly in view of hormone-dependent tumors, result in several attempts at development of uniform and generally accepted guidelines concerning the use of hormonal replacement therapy in menopausal women. This paper discusses hormonal replacement therapy in the context of its role in the carcinogenesis process and its use in patients with current or past history of a malignancy. The aim of this paper is to present current state-of-the-art in the aspect of safety of hormonal replacement therapy in patients with a malignancy: endometrial cancer, breast cancer, ovarian cancer, cervical cancer, vulvar cancer and also benign tumors, e.g. uterine myoma and endometrial cyst.

Keywords: hormone replacement therapy, gynecologic oncology, breast cancer, endometrial cancer, ovarian cancer, cervical cancer, vulvar cancer, benign tumors
Angioleiomyoma – a rare variant of genital myomas: report of two cases
CURR. GYNECOL. ONCOL. 2013, 11 (1), p. 74–81
DOI: 10.15557/CGO.2013.0007

Background: Angioleiomyoma (leiomyoma angiogenes) is a benign tumor of mesenchymal origin. Its location in the uterine body is extremely rare and in the broad ligemant is considered exceptional (to date, only isolated cases have been described). The aim of this paper is to present two histologically verified cases of angioleiomyoma – of the uterine body and of the broad ligament. Incidence of this subtype of leiomyoma among patients operated on for genital myomata is discussed. Material and methods: Patients were qualified for surgery based on gynecologic examination, sonographic study and histological assessment of uterine scrapings. Final diagnosis was made in Department of Pathology of the Doctor Tytus Chałubiński Specialized Hospital in Radom based on microscopic study of surgical specimens. Clinical analysis included cases reported in available world literature. Determined were both incidence of leiomyoma angiogenes among patients with a postoperative diagnosis of myoma and those with myoma coexisting with intrauterine genital endometriosis. Results: Among women operated on for myoma (n = 179; 60.9%) and for myoma with intrauterine genital endometriosis (n = 115; 39.1%) – a total of 294 cases – angioleiomyoma was found twice in postoperative histological studies. This accounted for 0.68% of the entire group of women with myoma. On the other hand, among those with myoma and endometriosis, this proportion was twice as high, reaching 1.74%. Discussion: Both patients had BMI value indicating obesity (54.6 kg/m2 and 36.6 kg/m2 – class III and II) and poor healing of their surgical wounds. Conclusions: Diagnosis of genital angioleiomyoma is possible only based on histological studies. The tumor was located in the uterine body and in the broad ligament, respectively. Incidence rate of this tumor among patients operated on for genital myoma is 0.68%.

Keywords: uterine leiomyoma, uterine angioleiomyoma, angioleiomyoma in the broad ligament of the uterus, cellular myoma, parametrial myoma
Clear cell cancer of the ovary developing within an advanced postmenopausal endometriosis. Case report and review of the literature
CURR. GYNECOL. ONCOL. 2013, 11 (1), p. 82–88
DOI: 10.15557/CGO.2013.0008

Endometriosis has a multifactorial etiology and its association with ovarian cancer is known since the beginning of the past century. As has been well documented, endometriosis possesses all the features of cancer phenotype, but a matter of debate remains whether ovarian cancer develops as a result of malignant transformation of pre-existing endometriosis or both conditions develop synchronously on a common basis. Active endometriosis is estrogen-dependent and rarely develops in postmenopausal women. Endometriosis-associated ovarian cancer (EAOC) is a distinct clinical entity, differing by age at diagnosis, histological type, clinical stage and prognosis. EAOC may develop both before and after menopause and the commonest histological types are clear cell and endometrioid. The purpose of this paper was to present a rare case of EAOC developing within the wall of an endometrial cyst, 7 years after menopause in a slim woman, not presenting features of estrogenization. A 54 years old female, on long-term oral anticoagulant (Sintrom) after mitral valve surgery, was admitted for surgical treatment due to an adnexal tumor on the right detected by sonography with CA-125 level of 354.7 U/ml. Intraoperative inspection revealed advanced endometriosis manifesting by numerous endometrial implants to the pelvic parietal peritoneum, visceral peritoneum and greater omentum as well as endometrial cysts within both ovaries. Intraoperative histological study revealed grade 2 clear cell carcinoma (CCC), while final histological study showed the area of transition from endometriosis to CCC with an intermediate stage of atypical endometriosis. The patient’s FIGO stage was defined as IA and her TNM stage – as T1aN0M0 G2. Conclusion: Active endometriosis resulting in presence of endometrial implants and endometrial cysts may manifest at postmenopausal age. Endometrial cyst may undergo malignant transformation, as suggested by documented evolution of endometriosis to clear cell ovarian cancer with intermediate stage of atypical endometriosis

Keywords: endometriosis, cancer, ovarian cancer, clear cell carcinoma, malignant transformation