الفهرس 
AnatomyOnly 14 pages are availabe for public view
 |  | from | 153 |  |  |
| | | from | 153 | | |
Abstract
Uterus(cervix, corpus) and ovarian cancers are the leading types of gynecologic cancers. Vulvovagina, fallopian tubes cancers and chorion epithelioma are less frequent sites for female genital malignancies (Bilir et al, 2008). Worldwide incidence and mortality rates (per 100.000) of gynecological cancers are respectively as follows: cervical cancer 16.1 and 7.99, endometrial cancer accounts 1/3 of entire female malignancies (Globocan,2001). Cancer of the uterine cervix is the second most common cancer among women worldwide .The American Cancer Society estimates that there will be 11,150 new c ases diagnosed and 3670 deaths due to cervical cancer in the US this year, although the incidence and mortality of cervical cancer in the United States has dropped steadily from 1940 through 1990 .This decline has slowed since 1991 .the death rate per 100,000 women has decreased from 3.49 to 2.48 between 1991 and 2003 (Jenal et al, 2007). While the majority of cases present with early stage disease ,there are still patients who present with more advanced disease (FIGO stages IB2-IVA) for whom potentially curative therapy consist of combination radiation and chemotherapy (Morris et al, 1999). Treatment failures which occur among patients with locally advanced disease are ,in most cases ,incurable .One factor which may contribute to treatment failure is the fact that cervical cancer remains the only major gynecologic malignancy that is clinically staged and such staging is accurate in only 60% of cases .Errors in staging are often related to undiagnosed para-aortic lymph node metastases, thepresence of which negatively impact prognosis with 3-and 4- year overall survival rates of 39 and 29% respectively (Ballon et al,1981). Although not permitted to alter FIGO staging ,imaging modalities have been employed to determine the extent of the disease prior to therapy .In a clinical-pathological study performed by the gynecologic oncology group ,the sensitivity and specificity of computed tomography (CT) was only 34 and 96% respectively . A more recent meta-analysis ,however ,found the positive predective value to be 91% for detection of reteroperitoneal disease but large scale studies are lacking . Given the importatnce of lymph node metastasis to overall survival ,some clinician perform a staging lymphadenectomy prior to anticipated combination chemotherapy and radiation,although this practice remain controversial (Kathleen N.Moore et al,2008) . However , the use of lymphadenectomy in early stage cervical cancer is debtable. routine lymphadenectomy involves removal of lymphatic tissue along the external iliac and internal iliac , obturator and common iliac regions, para aortic lymphadenectomy is optional. We have noticed that the criteria for para aortic lymphadenectomy are not mentioned in the International Federation of Gynecology and Obstetrics (FIGO) guidelines, wherease according to the National Comprehensive Cancer Network guidelines para aortic lymphadenectomy is an option for early stage cervical carcinoma patients. Carcinoma of the endometrium is the most common genital malignancy in western socities .the presence of early disease is often accompanied by vaginal bleeding .this symptomatic presentation lt in a high proportion of patients being diagnosed with curable cancer and an overall favorable prognosis ,nevertheless ,approaches to diagnose the extent of the disease and management of the patient thereafter have evolved extensively over the past two decades especially after 1998 when FIGO (International Federation of Gynacologists and Obstricians ) require a change from clinical to surgical staging including pelvic & para aortic lymphadenectomy (FIGO 2001) . It is recognized that involvment of lymph nodes ,both pelvic and para aortic ,in endometrial cancer significantly worse disease with poorer outcomes .while knowledge of their presence as well as the presence of other sites of extra uterine disease may change treatment approaches and direct different treatment intervention : the impact of those changes on survival is much less clear (Jan and Gillian 2007) . Epithelial ovarian cancer is a clinically significant health problem in Western countries, ranking fifth highest in cancer incidence and fourth highest in site-specific causes of cancer deaths in women. In the United States, approximately 25000 new ovarian cancer cases and 16000 ovarian cancer deaths were expected in 2004. Although ovarian cancer is potentially curable by surgery and chemotherapy, most cases are still diagnosed at advanced stages, and the 5-year overall survival (OS) of the patients diagnosed lingers at approximately 30% (Jemal et al, 2004) Primary cytoreductive surgery (i.e., the removal of as much of the tumor as possible at the time of initial surgery, with resection of bulky nodes only) has been an integral part of the treatment of advanced ovarian cancer since the observation that postoperative residual tumor is a clinically significant prognostic factor ,recent metaanalysis has confirmed that maximal surgical cytoreduction is one of the most powerful determinants of cohort survival in International Federation of Gynecology and Obstetrics (FIGO) stage III IV ovarian cancer (Burghardt et al, 1991). Treatment Plans Note that complete surgical staging and debulking is required even if uterus and contralateral ovary are to be preserved A. Epithelial carcinomas 1. Low malignant potential a. Stage I, II: unilateral salpingo-oophorectomy (USO) or TAH-BSO, depending on reproductive desires. Complete surgical staging and debulking is required. No adjuvant therapy if no residual disease. b. Stage III-IV: TAH-BSO. Complete surgical staging and debulking is required. Then: i. No adjuvant therapy if no residual disease ii. If residual disease is present or for either invasive implants or micropapillary architecture, then carboplatin and paclitaxel (Taxol) IV chemo x 6 cycles. Consider intraperitoneal therapy if residual disease / adhesions minimal iii. Consider clinical trial for primary, consolidation or recurrent disease therapy iv. Second look laparotomy only if on clinical trial 2. Invasive epithelial carcinoma a. Stage Ia grade 1, Ib grade 1: USO, BSO or TAH-BSO, depending on reproductive desires. Complete surgical staging and debulking is required. No adjuvant therapy. b. Stage Ia grade 2, Ia grade 3, Ib grade 2, Ib grade 3, Ic; IIa, IIb, IIc: TAH-BSO Complete surgical staging and debulking is required. Then: i. Carboplatin and paclitaxel (Taxol) IV chemotherapy x 3-6 cycles, or ii. Consider clinical trial for primary, consolidation or recurrent disease therapy, or iii. Consider intraperitoneal chemotherapy if residual disease and adhesions minimal c. Stage III, IV: TAH-BSO. Complete surgical staging and debulking is required. Then: i. Carboplatin and paclitaxel (Taxol) chemotherapy x 6 cycles, or ii. Consider clinical trial for primary, consolidation or recurrent disease therapy, or iii. Strongly consider intraperitoneal chemotherapy if, or iv. Consider whole abdominal radiation therapy, if residual disease < 5 mm (not a standard therapy) v. Second look laparotomy only if on clinical trial vi. If unable to be debulked, consider neo adjuvant chemotherapy followed by secondary cytoreductive surgery Whether systematic removal of retroperitoneal lymph nodes should be part of maximal cytoreductive surgery is still unclear. Retroperitoneal lymph node involvement occurs in approximately 50% to 80% of women with advanced ovarian cancer .In 2004, in recognition of the prognostic importance of retroperitoneal spread, the FIGO staging classification was amended to include a substage for node involvement (Pierluigi et al. 2005). Retrospective studies have suggested a clinically significant survival advantage following systematic lymphadenectomy in patients undergoing cytoreductive surgery for advanced disease; however, no prospective randomized clinical trial has been published (Scarabelli et al, 1995).