2015, Vol 13, No 4
The impact of combination therapy for ovarian carcinoma on the urinary tract
Curr Gynecol Oncol 2015, 13 (4), p. 217–223
DOI: 10.15557/CGO.2015.0024

The incidence of ovarian carcinoma in Poland is 11.2/100,000. It is the second most common cancer of the genital tract. First-line treatment involves surgery and chemotherapy, which leads to adverse effects. They include urinary tract disorders that affect the quality of life. The aim of the study was to compare the function of the urinary tract and quality of life in women after ovarian cancer treatment with women after hysterectomy with salpingo-oophorectomy performed for non-oncological indications. Urodynamic tests and questionnaires were conducted in 40 patients divided into two groups. The investigated group included 17 patients after ovarian cancer therapy in whom complete cytoreduction was obtained in surgery and first-line chemotherapy was administered. The control group consisted of 23 patients after hysterectomy performed for non-oncological indications. In all cases, medical history was collected, pelvic examination and urodynamic test were carried out and a quality of life questionnaire was conducted. The percentage of patients with no changes in the urogynecologic examination was higher among non-oncological patients (65.2%). In cancer patients, no changes were detected in 41.2% of cases. Cancer patients suffered from stress incontinence, mixed urinary incontinence and overactive bladder more frequently than controls. The differences obtained in the urogynecologic examination were not statistically significant (p = 0.4573). It was demonstrated, however, that the quality of life differed between the two groups in a statistically significant way (p = 0.0345). Worse quality of life was seen significantly more frequently in cancer patients (58.8%) than in controls (26.1%). Moreover, the improvement of the quality of life was observed more rarely (11.8% in cancer patients vs. 47.8% in controls). Chemotherapy does not have a significant influence on an increase in the number of urogenital disorders but can be one of the factors responsible for the deterioration of the quality of life.

Keywords: ovarian carcinoma, chemotherapy, urinary incontinence, urodynamics, quality of life
Clear cell carcinoma of the ovary
Curr Gynecol Oncol 2015, 13 (4), p. 224–233
DOI: 10.15557/CGO.2015.0025

Ovarian clear cell carcinoma belongs to rather rare ovarian neoplasms and is believed to be a separate disease with a specific pathogenetic mechanism. It is diagnosed in women younger than 60 years of age, usually in early stages (FIGO I–II in 60% of cases). The National Comprehensive Cancer Network recommends surgical staging in early cancers and cytoreduction with adjuvant platinum- or taxane-based chemotherapy in later stages. Clear cell carcinoma of the ovary is characterized by worse response to chemotherapy and high carboplatin resistance. The mechanisms of its chemoresistance are unknown. The response to first-line chemotherapy is observed in only 11–27% of cases (vs. 73–81% for high grade carcinoma). Progression during chemotherapy is noted in 52% of patients (vs. 29% for high grade carcinoma). A relapse is associated with poor prognosis since it usually means considerable chemoresistance. Mean overall survival amounts to 25.3 months (vs. 42 months in epithelial ovarian carcinoma). Due to poor treatment outcomes in advanced stages of ovarian clear cell carcinoma, molecular targeted therapies are being developed. Research is being conducted in three directions: to develop new cytostatics, angiogenesis inhibitors and immunomodulators. Moreover, combinations of these drugs are also being investigated. It occurs that the future treatment is a therapy targeted to specifically impaired cell proliferation mechanisms in ovarian clear cell carcinoma. Moreover, the importance of adjuvant radiotherapy in stages FIGO IC–II must be emphasized.

Keywords: ovarian carcinoma, clear cell carcinoma, chemoresistance, endometriosis
Borderline ovarian tumors – diagnosis, treatment and follow-up
Curr Gynecol Oncol 2015, 13 (4), p. 234–244
DOI: 10.15557/CGO.2015.0026

Tumors of borderline malignancy account for approximately 20% of all ovarian tumors. Their diagnostic criteria mainly include: the absence of destructive stromal invasion, stratification of epithelial cells, moderate mitotic activity and non-intensified nuclear atypia. The mainstay of treatment is surgery. Indications for radical treatment include older patient’s age and considerable advancement of the disease. The surgery should involve hysterectomy with salpingo-oophorectomy and removal of all macroscopic tumor foci as well as staging, which includes: peritoneal fluid sampling, omentectomy and peritoneal biopsy. Adjuvant treatment is not recommended except for cases with invasive implants. Over 50% of patients with borderline tumors are women at the child-bearing age. In these patients, the wish to preserve fertility should be considered. Conservative treatment consists of tumor removal, preservation of the uterus and at least a part of one ovary as well as staging. The follow-up period should be long since the disease can recur after several or even a dozen or so years. Patients with risk factors (advanced FIGO stage, presence of implants, incomplete staging or a residual tumor mass) should be followed every 3–4 months for the first 2 years, and subsequently, every 6 months. A similar follow-up pattern is recommended in patients after conservative treatment, particularly because most recurrences typically occur within the first 2 years after surgery. The total frequency of relapse is approximately 10–11%. These cases usually involve recurring borderline tumors, but approximately 30% are invasive (2.5–3% of malignant transformation). Conservative treatment is associated with a higher risk of relapse (up to 35%). However, in such cases, tumors are usually of borderline malignancy and can be effectively managed surgically. Invasive relapse is associated with poor prognosis.

Keywords: borderline tumors, surgical treatment, relapse, follow-up
Abdominal hysterectomy – spatial model of surgical resection
Curr Gynecol Oncol 2015, 13 (4), p. 245–255
DOI: 10.15557/CGO.2015.0027
The paper presents current views on radical hysterectomy classification, including descriptive comments regarding the surgical extent and medical indications. Radical hysterectomy remains the primary surgical procedure in gynecologic oncology and is of particular importance for the treatment of patients with cervical cancer. A number of publications of the last decades failed to anatomically define radical hysterectomy – it was assumed that the issue is familiar based on Wertheim’s description. Attempts to systematize the therapeutic procedure resulted in a classification adapted to the current state of knowledge. Classification of radical hysterectomy published by Querleu and Morrow’s and later modified by Cibula and Abu-Rustum is the most current and commonly accepted system. The authors systematized previous, less precise classification, thus allowing to standardize terminology used in surgery reports, medical publications, clinical protocols and randomized trials. The uniqueness of this concept is due to the use of a three-dimensional model – Cibula and Abu-Rustum describe pelvic anatomical landmarks, allowing for a proper spatial orientation at different stages of surgical procedure, as well as the borders of resection for different anatomical elements (parametrium in particular). Standardization of radical hysterectomy procedure is also a key element in the education of gynecologic oncologists. Therefore, the presented classification should be known and used in everyday surgical practice.
Keywords: hysterectomy, parametrium, classification
Angiogenesis in gynecologic malignancies
Curr Gynecol Oncol 2015, 13 (4), p. 256–262
DOI: 10.15557/CGO.2015.0028

Angiogenesis is crucial for the development and progression of malignant neoplasms. In terms of molecular mechanisms leading to the development of genital malignancies, the development has contributed to improved survival of patients as a result of antiangiogenic therapy, which is targeted against the vascular endothelial growth factor. Vascular endothelial growth factor is a key promoter of angiogenesis and disease progression. Bevacizumab, a humanized anti-vascular endothelial growth factor monoclonal antibody, has shown single-agent activity in women with recurrent tumors. This article reviews the results of studies using bevacizumab in ovarian cancer, which gave rise to its registration by the European Medicines Agency in 2011 in Poland. In addition, the effects of bevacizumab in recurrent, platinum-resistant ovarian cancer (AURELIA), the drug’s safety profile (ROSIA), other routes of administration (intraperitoneal) as well as an assessment of the efficacy and safety of neoadjuvant bevacizumab (ANTHALYA) were presented. Attention was paid to the location of recurrence after treatment with bevacizumab and escape from antiangiogenic therapy and therapeutic resistance. Bevacizumab combined with chemotherapy in persistent or recurrent cervical cancer improved both – overall survival and time to progression. That has become the baseline for an open-label global safety study (CECILIA) evaluating the efficacy and complications of bevacizumab. The presented study on the use of bevacizumab in the treatment of endometrial cancer shows promising results.

Keywords: bevacizumab, ovarian cancer, cervical cancer, endometrial cancer
Venous thromboembolism as an essential clinical problem in the group of patients with gynecologic cancer
Curr Gynecol Oncol 2015, 13 (4), p. 263–268
DOI: 10.15557/CGO.2015.0029

Malignancies are a high and a very high risk factor for thrombotic complications. The risk of venous thromboembolism is 4–7 fold increased in patients with cancer, and is particularly high in the first months after diagnosis. Venous thromboembolism most often occurs as deep vein thrombosis and pulmonary embolism. It is the most common complication and, at the same time, the second leading cause of death in cancer patients, after cancer itself. At present, low molecular weight heparins are recommended for both, prophylaxis and treatment of venous thromboembolism. Pharmacological antithrombotic prophylaxis is recommended for cancer patients undergoing abdominal or pelvic surgical procedures, and should be extended to at least 4 weeks after the procedure. Prophylaxis of up to 6 months or even for an indefinite period of time can be considered. Risk assessment for thromboembolic complications as well as the inclusion of appropriate antithrombotic prevention/treatment are essential components of care for cancer patients. At the same time, there is a need to educate cancer patients on their increased risk of venous thromboembolism. The growing awareness of patients will help them accept medications they use.

Keywords: venous thromboembolism, prophylaxis, cancer, heparin
Is venous thromboembolism prophylaxis necessary during laparoscopic procedures? A commentary to SAGES guidelines – Guidelines for Deep Venous Thrombosis Prophylaxis During Laparoscopic Surgery
Curr Gynecol Oncol 2015, 13 (4), p. 269–276
DOI: 10.15557/CGO.2015.0030

Venous thromboembolism is a disease that includes both deep vein thrombosis and pulmonary embolism, which are associated with the formation of a blood clot (thrombus) within a deep vein, mainly in the lower limbs. So far, the scale of the problem of deep vein thrombosis and pulmonary embolism has not been thoroughly estimated in Poland. About 200,000 new cases per year are reported in the United States, and between 50,000 and 60,000 in Poland. Mortality due to pulmonary embolism, usually as a consequence of deep vein thrombosis, is estimated at 15–25%. Increasingly used minimally invasive surgical techniques are currently of interest to both, the young generation of surgeons and their patients. Laparoscopic cholecystectomy or bariatric surgery have become a standard. There is much controversy regarding the need for thromboprophylaxis in patients undergoing laparoscopic procedures. Efforts have been made by the Society of American Gastrointestinal and Endoscopic Surgeons to help medical practitioners decide in this regard. All laparoscopic procedures cause serum hypercoagualability. Polish societies have not specified their decisions regarding prophylaxis in laparoscopic surgery. Following general rules was only recommended. It seems fully justified to develop such indications or adopt the already existing standards based on literature data and experience.

Keywords: venous thromboembolism, pulmonary embolism, laparoscopy, prophylaxis, guidelines