Gynecological Oncology. Basic Principles and Clinical Practice

Preface
Contents
Editors and Contributors
About the Editors
Contributors
1: Approach to a Case of Gynae Oncology
	1.1	 Introduction
	1.2	 The Diagnostic Pathway
	1.3	 History and Physical Assessment
	1.4	 Nutritional Assessment
	1.5	 Assessment of Hereditary and Genetic Factors
	1.6	 Psychological and Social Assessment
	1.7	 Investigations
		1.7.1	 Hematological Investigations
		1.7.2	 Tumor Markers
		1.7.3	 Imaging
		1.7.4	 Histopathology and Cytology
		1.7.5	 Other Investigations
	1.8	 Conclusion
		1.8.1	 Cancer Care: The Holistic Approach!!
	References
2: Multidisciplinary Decision Making in Gynaeoncology: Guidance, Conduct and Legalities
	2.1	 Introduction
	2.2	 Characteristics of a Good MDT
	2.3	 People and Processes
	2.4	 Environment
	2.5	 Governance and Responsibilities
	2.6	 Legal Position of MDT Recommendations
	2.7	 Limitations of the MDT
	2.8	 Conclusion
	References
3: Consent and Communication Skills in Management of Gynaeoncology
	3.1	 Introduction
	3.2	 Flaws in Communication
	3.3	 Best Practices for Communication
	3.4	 The CLASS Protocol (CLASS: A Protocol for Effective Communication)
		3.4.1	 C: Context (Setting)
		3.4.2	 L: Listening Skills
		3.4.3	 A: Acknowledge Emotions
		3.4.4	 S: Strategy
		3.4.5	 S: Summary
	3.5	 Communication with Vulnerable Patients
	3.6	 Communication with Other Specialities
	3.7	 Breaking Bad News
	3.8	 Informed Consent
		3.8.1	 Types of Consent
		3.8.2	 Model for Obtaining Consent
	3.9	 Montgomery Ruling
	3.10	 Reviewing Decisions
	3.11	 Conclusion
	References
4: Holistic Approach Towards Managing Patients in Case Management in Gynaeoncology
	4.1	 Introduction
		4.1.1	 Holistic Needs
		4.1.2	 Recovery Package
	4.2	 Global Needs Following a Cancer Diagnosis
		4.2.1	 The Cancer Journey
			4.2.1.1	 Support at Diagnosis
			4.2.1.2	 Support During Treatment
			4.2.1.3	 Remission
			4.2.1.4	 Recurrence
			4.2.1.5	 Palliation and End of Life
		4.2.2	 Coping Mechanisms
		4.2.3	 Support for Families and Carers
	4.3	 Conclusions
	References
5: Clinical Evidence in Gynaeoncology: Sources and Application
	5.1	 Introduction
	5.2	 Structured Questions (Ask)
	5.3	 Searching for Evidence (Acquire)
		5.3.1	 Hierarchy of Evidence
		5.3.2	 Examples of Primary Research Studies
			5.3.2.1	 Randomised Control Trials (RCT)
			5.3.2.2	 Observational Studies
			5.3.2.3	 Translational Research
			5.3.2.4	 Diagnostic Test Accuracy (DTA) Studies
		5.3.3	 Examples of Other Resources to Acquire Evidence
			5.3.3.1	 Systematic Reviews, Scoping Reviews and Meta-Analysis
			5.3.3.2	 Guidelines/Synthesised Summaries
	5.4	 Critical Appraisal (Appraise)
		5.4.1	 The Grading of Recommen
		5.4.2	 Resources to Support Critical Appraisal
	5.5	 Implementing Evidence-Based Practice in Gynaeoncology (Apply)
	5.6	 Evaluation of Clinical Performance (Audit)
	5.7	 Summary
	References
6: Surgical Principles and Practices in Gynaecological Oncology: Achieving the Best Outcome
	6.1	 Introduction
	6.2	 Before Operation
		6.2.1	 Multidisciplinary Approach
		6.2.2	 Patient Selection
		6.2.3	 Consenting
		6.2.4	 Prehabilitation
	6.3	 In Theatre
		6.3.1	 Teamwork
		6.3.2	 Theatre Environment
		6.3.3	 Noise Level
		6.3.4	 Surgeon
		6.3.5	 Operation
			6.3.5.1	 Exploration
			6.3.5.2	 Decision-Making
			6.3.5.3	 Resection and Reconstruction
	6.4	 The Postoperative Period
	6.5	 Conclusion
	References
7: Techniques of Enhanced Recovery in Post Operative Care
	7.1	 Introduction
	7.2	 Components of ERAS Programme
		7.2.1	 Cancer Prehabilitation
			7.2.1.1	 Medical Optimization
			7.2.1.2	 Physical Intervention
			7.2.1.3	 Nutritional Intervention
			7.2.1.4	 Psychological and Social Intervention
		7.2.2	 Preoperative Bowel Preparation
		7.2.3	 Maintenance of Peri-operative Normoglycemia
		7.2.4	 Venous Thromboembolism Prophylaxis
		7.2.5	 Surgical Site Infection Reduction Bundles
			7.2.5.1	 Antimicrobial Prophylaxis
			7.2.5.2	 Skin Preparation
			7.2.5.3	 Normothermia
			7.2.5.4	 Drains and Catheters
		7.2.6	 Minimizing Surgical Insult
		7.2.7	 Standard Anaesthetic Protocol
		7.2.8	 Perioperative Fluid Management
		7.2.9	 Pain Management
		7.2.10	 Perioperative Nutrition
		7.2.11	 Prevention of Post-operative Ileus
		7.2.12	 Early Ambulation
		7.2.13	 Discharge
	7.3	 Benefits of ERAS Program: Evidence in Literature
	7.4	 Conclusion
	References
8: Surgical Complications in Gynaecological Oncology
	8.1	 Introduction
	8.2	 Professional Duty of Candour [3]
	8.3	 Complications Versus Adverse Effect/Sequelae of Surgery
	8.4	 Factors Affecting Complications Rates
	8.5	 Surgical Complications in Gynae-Oncology
	8.6	 Intraoperative Complications
		8.6.1	 Haemorrhage
			8.6.1.1	 Management of Vascular Injuries
			8.6.1.2	 Management of Reactionary and Secondary Haemorrhage
		8.6.2	 Thrombosis and Embolism
		8.6.3	 Infections
		8.6.4	 Lymphatic Complication
		8.6.5	 Visceral Injuries
			8.6.5.1	 Ureteric Injuries
			8.6.5.2	 Bladder Injury
			8.6.5.3	 Bowel Injury
			8.6.5.4	 Nerve Injury
		8.6.6	 Paralytic Ileus
		8.6.7	 Shift in Fluid Balance
	8.7	 Late Postoperative Complications
		8.7.1	 Incisional Hernias
	8.8	 Prevention of Complications
	8.9	 Conclusion
	References
9: Minor Procedures in Gynaecological Oncology
	9.1	 Introduction
	9.2	 Colposcopy
		9.2.1	 Procedure
	9.3	 Ablative Techniques
		9.3.1	 Cryotherapy
		9.3.2	 Thermal Ablation
	9.4	 Excisional Methods
		9.4.1	 Large Loop Excision of the Transformation Zone
			9.4.1.1	 Preparation
			9.4.1.2	 Procedure
		9.4.2	 Cold Knife Conisation
			9.4.2.1	 Procedure
	9.5	 Endometrial Biopsy, Dilatation and Curettage
	9.6	 Hysteroscopy
	9.7	 Pyometra Drainage
	9.8	 Vulval Biopsy
	9.9	 Tru Cut Biopsy
	9.10	 Fine Needle Aspiration Biopsy of Superficial Groin Lymph
	9.11	 Paracentesis
		9.11.1	 Procedure
	9.12	 Management of Wound Dehiscence
		9.12.1	 Superficial Dehiscence
		9.12.2	 Full-Thickness Wound Dehiscence
	9.13	 Cystoscopy
	9.14	 Chest Tube Drainage
		9.14.1	 PleurX Drain
	9.15	 Conclusion
	References
10: Management of Complications: Chemotherapy Related Complications, Acute Bowel Obstruction, Symptomatic Ascites and Pleural Effusion, Pulmonary Embolism, Deep Vein Thrombosis, Severe Pain, Chylous Ascites
	10.1	 Introduction
	10.2	 Chemotherapy-Related Complications
		10.2.1	 Management of Haematologic Toxicities
		10.2.2	 Management of Gastrointestinal Toxicities
	10.3	 Acute Bowel Obstruction
		10.3.1	 Conservative Management
		10.3.2	 Surgical Management
		10.3.3	 Alternative Treatment Options
	10.4	 Symptomatic Ascites and Pleural Effusion
		10.4.1	 Ascites
			10.4.1.1	 Drainage of Ascites
			10.4.1.2	 Indwelling Peritoneal Catheters
			10.4.1.3	 Diuretic Therapy
			10.4.1.4	 Anti-neoplastic Therapy
		10.4.2	 Pleural Effusion
			10.4.2.1	 Therapeutic Thoracentesis
			10.4.2.2	 Pleurodesis
			10.4.2.3	 Tunneled Pleural Catheter (TPC)
			10.4.2.4	 Pleurectomy
			10.4.2.5	 Intrapleural Application of Fibrinolytic
			10.4.2.6	 Anti-neoplastic Treatment
	10.5	 Deep Vein Thrombosis and Pulmonary Embolism
		10.5.1	 Epidemiology and Aetiology
		10.5.2	 Clinical Presentation and Diagnosis
		10.5.3	 Prophylaxis Strategies
			10.5.3.1	 Mechanical Prophylaxis
			10.5.3.2	 Pharmacological Prophylaxis
		10.5.4	 Treatment
	10.6	 Severe Pain
		10.6.1	 Mechanism of Pain
		10.6.2	 General Principles
		10.6.3	 Analgesics
		10.6.4	 Interventions
		10.6.5	 Physical Modalities and Psychotherapy
	10.7	 Chylous Ascites
		10.7.1	 Management
	10.8	 Summary
	References
11: Chemotherapy in Gynaecological Cancers and Newer Developments
	11.1	 Introduction
		11.1.1	 Systemic Anti-cancer Treatment Principles
		11.1.2	 Systemic Anti-cancer Therapy in Ovarian, Fallopian Tube and Primary Peritoneal Cancer
			11.1.2.1	 Early Stage Disease (FIGO I–II)
			11.1.2.2	 Advanced Disease (FIGO III–IV)
			11.1.2.3	 Relapsed Disease: Focus on High Grade Serous Ovarian Cancer
		11.1.3	 PARP Inhibitors in Ovarian Cancer
		11.1.4	 Targeted Treatment in Low Grade Serous Ovarian Cancer
		11.1.5	 Systemic Anti-cancer in Endometrial Cancer
		11.1.6	 Immunotherapy in Endometrial Cancer
		11.1.7	 Cervical, Vulval and Rare Gynaecological Cancers
	11.2	 Conclusions
	References
12: Hormonal Treatment in Gynaecological Malignancies
	12.1	 Introduction
	12.2	 Endometrial Cancer
		12.2.1	 Hormonal Therapy as Treatment for Fertility Preservation in Early-Stage Endometrial Cancer (EC)
		12.2.2	 Hormonal Therapy as Adjuvant Treatment Following Surgical Management in Endometrial Cancer (EC)
		12.2.3	 Hormonal Therapy as Treatment in Advanced and Recurrent Endometrial Cancer (EC)
	12.3	 Uterine Sarcomas
		12.3.1	 Uterine Leiomyosarcomas (u-LMS)
		12.3.2	 Low Grade Endometrial Stromal Sarcoma (LG-ESS)
	12.4	 Ovarian Cancer (OC)
		12.4.1	 Epithelial Ovarian Cancer (EOC)
		12.4.2	 Granulosa Cell Tumours
	12.5	 Summary
	References
13: Radiation Protocols Relevant for Gynaecological Oncology and Management of Complications
	13.1	 Introduction to Radiotherapy
		13.1.1	 Radiation Physics
		13.1.2	 Radiobiology
	13.2	 Radiotherapy Toxicity
		13.2.1	 Radiotherapy Dose-Fractionation
	13.3	 Radiotherapy Treatment Planning and Delivery
	13.4	 Brachytherapy
	13.5	 Radiotherapy in Endometrial Cancer
	13.6	 Radiotherapy in Cervical Cancer
	13.7	 Radiotherapy in Vulval Cancer
	13.8	 Radiotherapy in Vaginal Cancer
	13.9	 Radiotherapy for Palliation
	13.10	 Summary
	References
14: Palliative Care in Gynaecologic Oncology
	14.1	 Introduction
	14.2	 Current Status of Palliative Care Services
	14.3	 Provision of Palliative Care Services
	14.4	 Timing of Palliative Care Among Gynaecological Cancer Patients
	14.5	 Symptom Management
		14.5.1	 Bleeding in Advanced Gynaecological Cancers
		14.5.2	 Malignant Ascites
		14.5.3	 Breathlessness
		14.5.4	 Malignant Bowel Obstruction
			14.5.4.1	 Pathophysiology
			14.5.4.2	 Management
		14.5.5	 Pain
		14.5.6	 Management of Other Symptoms
	14.6	 End-of-Life Care
	14.7	 Conclusion
	References
15: Clinical Interpretation of Immunohistochemistry in Gynaecological Cancers
	15.1	 Introduction
	15.2	 Purposes of Immunohistochemistry
		15.2.1	 To Help Make a Diagnosis
		15.2.2	 To Provide Prognostic Information
		15.2.3	 To Provide Predictive Information
	15.3	 Ovary
		15.3.1	 Carcinomas
			15.3.1.1	 p53
			15.3.1.2	 WT1
		15.3.2	 Sex-Cord Stromal Tumours
		15.3.3	 Germ Cell Tumours
		15.3.4	 Neuroendocrine Neoplasms
		15.3.5	 Metastases
		15.3.6	 Pseudomxyoma Peritoneii
	15.4	 Fallopian Tube
	15.5	 Uterine Corpus
		15.5.1	 Mismatch Repair (MMR) Immunohistochemistry
	15.6	 Uterine Mesenchymal Neoplasms
	15.7	 Vulva
		15.7.1	 Extramammary Paget’s Disease (EMPD)
		15.7.2	 Vulval Squamous Neoplasia
	15.8	 Cervix
		15.8.1	 Cervical Squamous Neoplasia
		15.8.2	 Cervical Glandular Neoplasia
		15.8.3	 HPV In Situ Hybridisation (ISH)
	15.9	 Undifferentiated Malignancies
	15.10	 Serous Fluid Cytology
	15.11	 Summary
	References
16: Genomics in Gynaecological Cancer: What the Clinician Needs to Know
	16.1	 Introduction
	16.2	 Ovarian Tumours
		16.2.1	 Ovarian Carcinomas
			16.2.1.1	 High Grade Serous Carcinoma (HGS)
				TP53 Mutations
				Homologous Recombinant Deficiency (HRD)
			16.2.1.2	 Low Grade Serous Carcinoma (LGSC)
			16.2.1.3	 Ovarian Endometrioid Carcinoma (OEC)
			16.2.1.4	 Ovarian Clear Cell Carcinoma (OCCC)
			16.2.1.5	 Mucinous Carcinoma (MC)
			16.2.1.6	 Undifferentiated/De-Differentiated Carcinoma
		16.2.2	 Sex Cord Stromal Tumours (SCST)
			16.2.2.1	 Adult Granulosa Cell Tumour (AGCT)
			16.2.2.2	 Sertoli Leydig Cell Tumour (SLCT)
			16.2.2.3	 Microcystic Stromal Tumour
			16.2.2.4	 Juvenile Granulosa Cell Tumour and Gynandroblastoma
			16.2.2.5	 Sex Cord Tumour with Annular Tubules (SCTAT)
		16.2.3	 Small Cell Carcinoma of Hypercalcaemic Type
		16.2.4	 Germ Cell Tumours
	16.3	 Uterine Tumours
		16.3.1	 Endometrial Carcinomas
			16.3.1.1	 Endometrioid Carcinomas of the Endometrium
			16.3.1.2	 Serous Carcinomas of the Endometrium
			16.3.1.3	 Clear Cell Carcinomas of the Endometrium
			16.3.1.4	 Carcinosarcomas
		16.3.2	 Uterine Sarcomas with Focus on Common Tumours such as Leiomyosarcomas and Uterine Stromal Sarcomas
			16.3.2.1	 Leiomyosarcomas
			16.3.2.2	 Uterine Stromal Sarcomas
	16.4	 Cervical Tumours
		16.4.1	 Cervical Epithelial Neoplasia
	16.5	 Vulval and Vaginal Tumours
		16.5.1	 Vulval Squamous Neoplasia
		16.5.2	 Malignant Melanoma
		16.5.3	 Mesenchymal Tumours
	16.6	 Summary
	References
17: Role of Genetics in Gynaecological Cancers
	17.1	 Introduction
	17.2	 Cancer Syndromes
	17.3	 Classes of Variants
	17.4	 Advantages of Genetic Testing
	17.5	 Disadvantages of Genetic Testing
	17.6	 The Traditional Family History (FH) Based Approach to Genetic Testing
	17.7	 Limitations to the Traditional FH Approach
	17.8	 Unselected Genetic Testing at Ovarian Cancer Diagnosis
	17.9	 Unselected Genetic Testing at Endometrial Cancer Diagnosis
	17.10	 Population Testing
	17.11	 Summary
	References
18: Radiology Investigations and Interventions in Gynaeoncology
	18.1	 Introduction
	18.2	 Ultrasound
	18.3	 Computed Tomography
	18.4	 MRI
	18.5	 FDG PET CT
	18.6	 Lymph Node Evaluation
	18.7	 Image Guided Interventions
	18.8	 Recommended Imaging Pathways
	18.9	 Other Malignancies
	18.10	 Advances in Imaging
	18.11	 Conclusion
	References
19: Post-operative Care in Gynaecological Oncology
	19.1	 Introduction
	19.2	 Identifying the Patient at Risk
	19.3	 Cardiovascular Complications
		19.3.1	 Arterial and Central Venous Pressure Measurements
		19.3.2	 Factors Influencing Need for Haemodynamic Support
		19.3.3	 Colloids and Crystalloids
		19.3.4	 Inotropic Agents
	19.4	 Respiratory Complications
		19.4.1	 Understanding of ABGs and Acid-Base Balance
		19.4.2	 Common Surgical Respiratory Problems
	19.5	 Renal Failure, Prevention and Management
		19.5.1	 Management of Life-Threatening Complications
	19.6	 Sepsis and Multiple Organ Failure
	19.7	 Surgical Site Management
		19.7.1	 Specific Surgical Site Complications
	19.8	 Peri-operative Enteral and Parenteral Nutrition
		19.8.1	 Treatment and Methods of Nutritional Support
			19.8.1.1	 Enteral Feeding
			19.8.1.2	 Parenteral Feeding
	19.9	 Post-op Analgesia
		19.9.1	 Principles of Acute Pain Management
	19.10	 Summary and Conclusion
	References
Annexure: Staging of Gynaecological Cancers
	Cancer Cervix (FIGO 2019 Staging)
	Ovarian Cancer (FIGO Staging 2014)
	Cancer of Corpus Uteri (FIGO Staging 2009 and American Joint Committee on Cancer (AJCC))
	Cancer Vulva (FIGO 2021 Staging)
	Cancer Vagina (FIGO 2009 Staging)
	TNM and Corresponding FIGO 2009 Staging for Vaginal Cancer
	FIGO Staging System for Uterine Leiomyosarcomas and Endometrial Stromal Sarcomas (2009)
	FIGO Staging System for Adenosarcomas (2009)
	References
Index