Case-Based Gynecological Oncology

✍ Scribed by Kavita Singh (editor), Bindiya Gupta (editor)

• Publisher: Springer
• Year: 2023
• Tongue: English
• Leaves: 330
• Category: Library

✦ Synopsis

This book is a case-based resource detailing the latest diagnostic and management strategies applicable to a number of carefully selected situations in clinical gynecological oncology. It emphasizes the importance of a holistic approach to tackling difficult and unique clinical presentations. Each chapter presents a specific pathology and features descriptions of clinical scenarios and presentations that are both commonly and rarely encountered. Techniques and strategies for ovarian, cervical and endometrial cancer are discussed in accordance with the latest evidence-based knowledge on the topic. Relevant "tips and tricks" are identified in each chapter to assist the reader in developing a thorough understanding of the topics discussed and enhance their decision making skills.

Case-Based Gynecological Oncology is a practical guide to clinical presentations of a range of conditions encountered in the field, making it a valuable resource for all clinicians who encounter these patients in their day-to-day practice.

✦ Table of Contents

Preface
Contents
Part I: Case Based Studies: Ovarian Cancer
1: Management of Adnexal Masses
Introduction
Case 1
Q: What Are the Risk Factors for Ovarian Cancer?
Q: What Are the Clinical Features Suggestive of a Malignant Ovarian Mass?
Q: What Are the Differentiating Features of Benign and Malignant Ovarian Masses on Ultrasound?
Case 2
Q: What Are the Hormone Producing Tumors of Ovary? Why Was Endometrial Sampling Necessary in the Present Case?
Q: Discuss the Role of Tumor Markers in Management of Adnexal Masses? Explain the Decision to Decide Which Tumor Marker Is To Be Done?
Case 3
Q: What Additional Investigations Should Be Done When There Is a Probability of Mucinous Ovarian Tumours?
Q: Describe the Triage Pathway of Adnexal Masses Which Will Benefit from Management by a Gynae-Oncologist?
Case 4
Q: How Can You Differentiate a Benign and Malignant Mucinous Tumor Based on Clinical Presentation and Ultrasound Findings?
Q: Role of Cystectomy Versus Oophorectomy? What Is the Impact of Rupture During Removal?
Q: What Are the Basic Principles of Surgical Staging in Adnexal Masses and What Are the Special Considerations for Mucinous Tumours?
Q: Role of Minimally Invasive Surgery in Adnexal Masses?
References
2: Epithelial Ovarian Cancer: High Grade Serous
Introduction
Case 1: Early Stage Epithelial Ovarian Cancer
Q: What Further Investigations Would You Like To Do for Work Up of Ovarian Cancer?
Q: What Is the Treatment of Choice for HGSOC?
Q: Role of Lymphadenectomy in Ovarian Cancer?
Q: How Do You Assess Intraoperatively the Spread of Disease in Abdomen?
Q: Role of Adjuvant Treatment Post Surgery in Early and Advanced Ovarian Cancer
Q: Role of Anti-angiogenic Treatment in EOC Upfront Setting
Q: Role of HIPEC in Ovarian Cancer
Case 2: Stage 4A
Q: What Is the Selection Criteria for NACT and What Are the Predictors of Inoperability?
Q: Briefly Describe the Protocol of Neoadjuvant Chemotherapy?
Q: What Are the Parameters that Can Be Used for Evaluation of Response to NACT?
Q: What Parameters Should Be Considered for Deciding Surgery After NACT?
Q: What Is the Available Evidence to Support NACT? How Should This Information Guide Initial Treatment?
Case 4: Ca Ovary with Massive Ascites
Q: Role of Laparoscopy in Management of Ovarian Cancer
Case 5: Diffuse Retroperitoneal Lymphadenopathy in High Grade Serous Ovarian Cancer
Q: What Is the Further Management Plan for the Patient?
Q: What Were the Approaches Used for Para-aortic Lymphadenectomy?
Case 6: BRCA Positive Ovarian Cancer
Q: Role of PARP Inhibitors in this Patient
References
3: Low-Grade Serous Ovarian Carcinoma
Introduction
Case: 1 Low Grade Serous Ovarian Cancer Advanced Stage
Q: Role of Neoadjuvant Chemotherapy in Advanced Cases of Low Grade Serous Cancer?
Q: How Many Cycles of Neoadjuvant Chemotherapy Should Be Given 4 Versus 6 cycles? How to Assess Response to NACT?
Q: Discuss Preoperative Optimisation in this Patient?
Q: What Is the Route for Surgery? Is There any Role of Laparoscopy in LGSOC?
Case 2 Low Grade Serous Ovarian Cancer with Liver Metastasis
Q: What Are the Points To Be Considered Which Will Help Us Decide Management? What Are the Management Options?
Q: Discuss the Role of Primary Debulking Surgery Versus Delayed Debulking Surgery in Low Grade Serous Ovarian Cancer?
Q: What Are the Clinical, Histological and Molecular Distinguishing Features of Low-Grade Serous Cancer from High-Grade Epithelial Ovarian Cancer?
Q: What Is the Pre-operative Preparation Required in this Case?
Q: What Is the Role of Adjuvant Chemotherapy?
Q: Is There any Role of Maintenance Therapy?
Q: What Is the Role of BRCA/HRD Testing in LGSOC?
Case 3: Recurrent Low Grade Serous Ovarian Cancer
Q: What Are the Treatment Options for Recurrent LGSC?
Q: What Is the Significance of Invasive Implants with Serous Borderline Ovarian Tumours? What Is the Prognosis in Comparison to Low Grade Serous Cancers?
Q: What Is the Further Management in this Patient?
Case 4: Fertility Preservation in Low Grade Serous Ovarian Cancer
Q: What Is the Further Management in this Case? Since both Ovaries Are Involved What Are the Fertility Preservation Options for the Patient?
Q: What Is the Optimal Resection for Low-Grade Serous Carcinoma of Ovary or Peritoneum?
Q: What Are the Adjuvant Treatment Options?
References
4: Non-serous and Rare Histologies of Ovarian Cancer
Case 1: Malignant Brenner Tumour
Case 2: Clear Cell Carcinoma Ovary
Case 3: Endometrioid Ovarian Carcinoma
What Are Appropriate Investigations and Staging?
What Is the Primary Management of Early Stage Disease?
What Is the Primary Management of Advanced Stage Disease?
What Adjuvant Treatment Could Be Considered?
How Would You Manage Recurrent Disease?
How Should These Women Be Best Followed-Up?
References
5: Recurrent Ovarian Cancer
Introduction
Case 1
Case 2
Q. What Are the Diagnostic Pathways for Investigations in Suspected Recurrent Ovarian Cancer?
Q. What Is the Management Strategy for Recurrent Ovarian cancer?
Q. What Are the Criteria for Secondary Debulking Surgery and What Are Its Contraindications?
Q. What Are the Management Options for the Patient?
Q. Role of Antiangiogenic Targeted Therapy in Recurrent Ovarian Cancer?
Q. What Is the Role of Poly (Adenosine Diphosphate Ribose) Polymerases (PARP) Inhibitor as Targeted Therapy?
Q. What Is the Role of Immune Therapy in Recurrent Ovarian Cancer?
References
6: Platinum Resistant Ovarian Cancer
Introduction
Case1: Stage 4a/b High Grade Serous Ovarian Cancer (Pleural Effusion/Hilar Lymph Nodes)
Q. What Are the Mechanisms of Platinum Resistance?
Q. What Are the Biomarkers or Predictors of Platinum Resistance?
Q. What is the Recommended Treatment for Platinum Resistant Ovarian Cancer?
References
7: Metastatic Ovarian Cancer
Introduction
Case Scenarios
Case Scenario 1
Q. What Is the Management Plan?
Q. What Are the Tests to Differentiate Two Primary Malignancies Versus a Metastatic Tumour to the Ovary from the Cervix?
Case Scenario 2
Q. Describe the Clinicopathologic Profile of Krukenberg Tumours
Q. Role of Surgery in Krukenberg Tumours and Further Management
Q. Prognosis
Case Scenario 3
Case Scenario 4
Questions for Case 3 and 4 Combined
Q. Confirmation of Diagnosis. What is the Role of Image Guided Biopsy?
Q. Discuss Management Options: Role of Surgical Excision, Its Usefulness and Impact on Disease Prognosis, Further Management
Q. How to Differentiate Between Metachronous Ovarian Tumour and Metastatic Ovarian Mass? What is the Difference in the Prognosis?
Q. Is Genetic Testing Required and Discuss Their Implications?
References
8: Malignant Ovarian Germ Cell Tumours
Introduction
Case 1: Dysgerminoma
Q. Salient Clinical and Histopathological Features of Dysgerminoma
Q. What Are the Factors Which Are Likely to Influence Management? Discuss Role of Lymphadenectomy and Fertility Preserving Surgery
Q. Further Management, Indications of Chemotherapy, Regimes and Potential Complications
Q. Follow Up
Q. Management of Bilateral Ovarian Dysgerminoma
Case 2: Yolk Sac Tumor
Q. Work Up and Investigations
Q. Further Management
Q. Prognosis
Q. Follow Up
Q. Patient Wants Conception. What Should Be the Further Plan of Management? Is Completion Surgery Required After Completion of Child Bearing?
Case 3: Immature Teratoma with Growing Teratoma Syndrome
Q. What Is Growing Teratoma Syndrome and Its Management?
Q. Fertility Options and Outcomes in These Patients
Q. Discuss Holistic Care for Young Cancer Survivors
References
9: Stromal Tumours of Ovary: Granulosa Cell Tumours, Leydig Cell Tumours, Thecoma
Introduction
Case 1: Juvenile Granulosa Cell Tumor
Q. Discuss Diagnostic Work Up and Management of This Case
Q. Distinguishing Features of Juvenile GCT from Adult GCT
Q. What Is the Impact of Surgical Treatment of JGCT on Fertility
Q. What Is the Role of Adjuvant Treatment in JGCT?
Q. Future Prognosis and Follow Up of JGCT
Case 2: Adult Granulosa Cell Tumor
Q. What Is the Pathogenesis of Adult Granulosa Cell Tumour?
Q. Discuss Salient Presentation Findings in GCT
Q. Risks of Recurrence and Overall Prognosis
Q. Further Management and Need for Adjuvant Treatment
Case 3: Inadvertent Diagnosis of Adult Granulosa Cell Tumor
Q. Discuss Further Management
Q. Adjuvant Treatment, Follow Up and Prognosis
Case 4: Recurrent Granulosa Cell Tumor (Adult Type)
Q. Further Management and Prognosis?
Case 5: Sertoli- Leydig Cell Tumor
Q. Discuss Management
Q. What Are the Diagnostic Histological Features?
Q. Discuss Prognosis for Sertoli Leydig Cell
Q. What Is the Recommended Adjuvant Treatment?
References
10: Borderline Ovarian Tumours: Early and Advance Stage: Serous, Mucinous, Micro Invasive Cancer, Invasive Implants
Introduction
Case 1: Serous Borderline Ovarian Tumour
Q. Diagnostic Indicators for BOT on Clinical Presentation and Imaging
What is the Procedure of Surgical Staging for Borderline Ovarian Tumours
Q. Role of Frozen Section in Surgery for Borderline Ovarian Masses
Q. Approach for Fertility Preservation in Bilateral Tumours
Q. Role of Surgical Restaging in Patients Who Are Incompletely Staged
Q. Invasive and Non Invasive Implants: How to Diagnose and Their Management
Q. Management of Recurrence
Q. Discuss Role of Adjuvant Chemotherapy in Borderline Tumours
Q. Follow Up and Prognosis of Serous BOT. Role of Completion Surgery Once Family is Complete
Case 2: Mucinous Borderline Ovarian Tumours
Q. What is the Difference Between Serous and Mucinous BOT
Q. What Are the Diagnostic Indicators i.e. Clinical Presentation, Imaging and Tumor Marker Evaluation for Mucinous Borderline Ovarian Tumors?
Q. Compared to Serous BOT What Is the Difference in Surgical Staging?
Case 3: Serous Borderline Tumor with Microinvasion
Q. What Is the Significance of Microinvasion and Micro Papillary Pattern?
References
Part II: Case Based Studies: Cervical Cancer
11: Early Stage Cervical Cancer
Introduction
Case 1: FIGO Stage IA1
Q. Diagnostic Methods and Their Interpretation for Cervical Cancer
Q. What Are the Histological Dilemmas in Ia1
Q. What Are the Different Histological Types, Grades of Cervical Carcinoma and Their Prognosis
Q. Management of Stage IA1 Cervical Cancer
Q. Significance of Excision Margins in IA1 Adenocarcinoma?
Case 2: FIGO Stage IA2
Q. What Investigations Are Needed for Further Management of the Case?
Q. What Is the Further Management of IA2?
Present Case
Q. What Is the Role of Conservative Surgery in Patients with Low-Risk Early-Stage Cervical Cancer?
Case 3: FIGO Stage 1A2
Q. What Is the Role of Sentinel Lymph Nodes in Early Stage Cervical Cancer?
Case 4: FIGO Stage IB2
Q. How Do We Perform Clinical and Radiological Assessment for Stage of Cervical Cancer? What Is the Role of Examination Under Anaesthesia?
Q. What Is the Recommended Management of IB1 Cancer Cervix?
Q. Role of Minimally Invasive Surgery
Q. Adjuvant Treatment?
Case 5 FIGO Stage IB2
Q. Further Investigations
Q. Management
Q. What Are the Prognostic Factors for Early Stage Cervical Cancer?
Q. Recommended Follow Up for Early Stage Cervical Cancer
References
12: Advanced Stage Cervical Cancer
Introduction
Case Scenarios
Case 1: Squamous Cell Cancer Cervix Stage 3C1
Q. Discuss further Management
Q. Evaluation of Lymph Node Metastasis in LACC: Surgical Staging Versus Radiologic Staging
Q. Discuss Neoadjuvant Chemotherapy Versus Surgical Debulking Prior to RT for Bulky Nodes >1.5 cm
Q. Prognosis and Follow Up
Q. Implications of Revised Staging of Cervical Cancer in Tumour Prognosis
Case 2: Cervical Adenocarcinoma 1B3
Q. Discuss Further Management
Q. Discuss Role and Benefits of Neoadjuvant Chemotherapy (NACT)
Q: Surgical Modifications to Improve Morbidity from Radiotherapy
Q. Discuss Biologic Behaviour of Adenocarcinoma Versus Squamous Cell Carcinoma and Their Response to Treatment
Q. Prognosis and Follow Up
Case 3: Squamous Cell Cancer Cervix Stage IVa
Q. Describe Further Work Up and Management
Q. What Are the Different Chemotherapy Regimens, Rationale and Response Rates
Q. Discuss Exenteration Versus Urinary Diversion Followed by Chemoradiation
Case 4: Squamous Cell Cancer Cervix Stage IVB
Q. Benefits of PET CT in Stage IVB Disease
Q. Further Management
Q. Prognosis
Case 5: Cervical Cancer with Ovarian Metastasis
Q. Incidence of Ovarian Metastasis in Cervical Cancer
Q. Management
Q. Explain the Prognosis and Follow Up
References
13: Incompletely Treated and Recurrent Cervical Cancer
Introduction
Case 1: Incompletely Operated Cancer Cervix
Q. Further Investigations
Q. Further Management
Q. Prognosis
Case 2: Persistent Disease After Chemo Radiation
Q. How to Assess Response to Treatment
Q. Discuss Causes of Persistent Disease
Q. Discuss Indications of Salvage Surgery
Management Plan
Q. Prognosis
Case 3: Incomplete Treatment Following Chemoradiation: Selectron Perforation
Q. Causes of Selectron Perforation
Q. Further Management
Q. Prognosis
Case 4: Recurrent Cancer Cervix: Nodal Recurrence Post Chemoradiation
Q. Further Management
Q. Prognosis
Case 5: Recurrent Cancer Cervix: Post Surgery
Q. Further Management
Q. Prognosis
References
14: Rare Histology: Clear Cell Cancer, Mucinous, Mesonephric Duct Cancer
Introduction
Case 1: Mesonephric Duct Cancer of Cervix
Q. What Are Unique Clinical Features of Mesonephric Duct Cancers?
Q. What Are Unique Pathological Features of Mesonephric Duct Cancer?
Q. What Is the Prognosis of These Tumours?
Q. What Is the Management for Mesonephric Duct Cancer?
Q. What Are the Types of Pelvic Exenteration?
Q. What Is Laterally Extended Endo Pelvic Resection (LEER)?
Q. How Should We Select Cases for Pelvic Exenteration?
Case 2: Clear Cell Cancer Cervix
Q. What Are Unique Features of Cervical Clear Cell Cancer (CCC)?
Q. What Are the Management Options? What Are the Prognostic Factors?
Case 3: Gastric Type Adenocarcinoma Cervix
Q. What Are the Unique Clinico Pathological Features of HPV Independent Gastric Type Adenocarcinoma of Cervix?
Q. What Is the Oncological Outcome of Gastric Type Cervical Adenocarcinoma
References
Part III: Case Based Studies: Endometrial Cancer
15: Diagnostic Pathways of Postmenopausal Bleeding
Introduction
Case 1: Post Menopausal Bleeding in Tamoxifen Users
Q. What Is the Impact of Tamoxifen on the Endometrium and What Is Its Influence in the Diagnosis of PMB?
Q. What Are the Ultrasound Features of Tamoxifen Induced Hyperplasia? Should These Women Be Periodically Screened?
Q. What Is the Diagnostic Work-Up for Tamoxifen Users Who Develop PMB?
Q. What Is the Management of Tamoxifen-Induced Endometrial Hyperplasia Without Atypia?
Q. Does LNG-IUS have a Role in Endometrial Protection in Tamoxifen Users in the Current Practice?
Case 2: Hyperplasia with Atypia in Women with High BMI
Q. What Is the Relation Between Obesity and Endometrial Hyperplasia and Cancer?
Q. What Are the Challenges in Management of High Surgical Risks Patients with Endometrial Hyperplasia?
Q. Are There Any Biomarkers Associated with Response to Progestogen Therapy in Women with Endometrial Hyperplasia or Cancer?
Case 3: Fluid in the Uterine Cavity
Q. How Is ET Measured When There Is Fluid in the Uterine Cavity?
Q. What Are the Causes of Fluid Presence in the Uterine Cavity?
Q. What Is the Risk of Malignancy When There Is Fluid in the Uterine Cavity?
Case 4: Recurrent PMB
Q. What Is the Definition of Recurrent PMB?
Q. What Is the Common Causes of Recurrent PMB?
Q. What Is the Diagnostic Pathway in Women with Recurrent PMB?
Case 5: Incidental Finding of Thickened Endometrium
Q. What Is the Clinical Significance of the Incidental Finding of Thickened Endometrium in Postmenopausal Women with no PMB?
Q. What Is the Endometrial Thickness Cut-Off that Triggers Investigations in Postmenopausal Women with no PMB?
Case 6: Endometrial Polyps
Q. What Is the Prevalence of Endometrial Hyperplasia or Cancer in Polyps Diagnosed in Women with PMB?
Q. What Are the Hysteroscopic Features Suggestive of Hyperplasia or Cancer in Endometrial Polyps?
Q. What Are the Predictors of Endometrial Hyperplasia or Cancer in Postmenopausal Women with Endometrial Polyps?
Q. Should All Endometrial Polyps Be Removed in Postmenopausal Women?
References
16: Type I Endometrial Cancer: Early Stage
Introduction
Case 1: Atypical Endometrial Hyperplasia
Q. Classification of Endometrial Hyperplasia. Incidence of Cancer in Atypical Endometrial Hyperplasia?
Q. Does Atypical Hyperplasia on Endometrial Biopsy Require Hysteroscopic Evaluation of Endometrial Cavity?
Q. Is There a Role of MRI Assessment in Atypical Hyperplasia?
Q. What Is the Management of Atypical Hyperplasia?
Q. Further Management and Follow Up Protocol?
Case 2: Endometrial Cancer Stage 1B
Q. Role of Lymph Node Assessment in Early Stage Endometrial Cancer?
Q. Discuss Prognostic Risk Groups of Endometrial Cancers?
Q. Discuss Adjuvant Therapy for This Case
Q. Can Adjuvant Treatment Be Tailored According to the Molecular Classification of Endometrial Cancer
Case 3: Endometrioid Cancer Medically Unfit
Q. Further Management in This Case?
Case 4: Endometrial Cancer with Morbid Obesity
Q. Discuss the Management
References
17: Type I Endometrial Cancer: Advanced Stage
Introduction
Case 1: Endometrioid Carcinoma with Omental Metastasis
Indications of Systematic Lymphadenectomy in Endometrial Cancer? What Are the Indications of Para Aortic Lymphadenectomy?
Q. What Is Incidence of Microscopic and Macroscopic Omental Involvement in Endometrial Cancer? What Are the Indications of Routine Omentectomy in Endometrial Cancer?
How Much Sampling Is Adequate for Microscopic Examination? Should It Be an Omental Biopsy, an Infracolic Omentectomy, or a Total Omentectomy?
Q. What Are the High Risk Factors Associated with Omental Metastasis
Q. Prognosis and Adjuvant Treatment?
Case 2
Q. Further Management?
Q. Role of Upfront Surgery Versus Neo-Adjuvant Chemotherapy Followed by Surgery?
Q. Prognosis?
Case 3
Q. What Further Investigative Work Up Should Be Done in This Case?
Q. Further Management?
Q. Prognosis and Adjuvant Treatment?
References
18: Endometrial Cancer with High-Risk Histology
Introduction
Q: What Is WHO Classification of Endometrial Cancer. How To Classify Endometrial Cancer into Risk Categories (Low, Intermediate, High Intermediate, Intermediate)?
Endometrial Epithelial Tumours and Precursors
Tumour-Like Lesions
Mesenchymal Tumours Specific To the Uterus
Mixed Epithelial and Mesenchymal Tumours
Miscellaneous Tumours
Risk Categories
Risk Stratification if Molecular Characterization Is not Available
Q: Discuss Type 1 and Type 2 Endometrial Cancers? [3]
Comments
Case 1
Q: How Do You Tailor Pelvic and Para-aortic Lymphadenectomy in High Risk Endometrial Cancer?
Q: Discuss Transperitoneal Versus Extraperitoneal Approach to Lymphadenectomy?
Q: Role of Omentectomy Versus Omental Biopsy in High-Risk Endometrial Cancer
Q: Role of MIS in High-Risk Endometrial Cancer?
Q: What Are the Histological Prognostic Indicators
Lymphovascular Space Invasion (LVSI)
Depth of Myometrial Invasion
FIGO stage
Molecular Alterations in USC
Others
Q: Discuss Further Management and Adjuvant Therapy?
Q: Discuss the Prognosis of the Case
Q: Follow Up Protocol for High-Risk Early-Stage Endometrial Cancer?
Case 2
Q: What Are the Pathological Hallmarks and Immunohistochemical Markers for Diagnosing Clear Cell Endometrial Cancer
Q: Discuss Adjuvant Therapy in this Case? (EBRT Versus VBT, Role of Chemotherapy)
Q: What Is the Prognosis?
Case 3
Q: Discuss Further Management of the Above Case. Role of Neoadjuvant Chemotherapy Versus Surgery? Discuss the Type of Surgery
Q: Adjuvant Treatment
Q: What Are the Recent Developments in Management of Advanced Uterine Serous Cancers
References
19: Incompletely Operated Malignant Uterine Neoplasms
Introduction
Case 1
Q 1: When Should the Endometrium Be Assessed Prior to Surgery in a Post-menopausal Patient?
Q: Is Oophorectomy Imperative Along with Hysterectomy in Endometrial Cancer?
Q: How Should this Case Be Managed Further?
Q: Discuss the Prognosis of the Case
Q: Further Management?
Case 2
Q: Options for Further Management?
Q: Further Management?
Case 3
Q: What Is the Role of MRI in Identification of Endometrial Stromal Sarcomas?
Q: What Are the Further Management Options? Surveillance Vs Completion Surgery—Critically Evaluate
Q: Discuss Management with Regard to the Current Scenario
Q: What Would Be the Adjuvant Treatment Advised?
Case 4
Q: Discuss the Possibility of Preoperative Diagnosis of Leiomyosarcoma
Q: What Would Be the Further Management?
Q: Discuss Further Management
Conclusion
References
20: Recurrent Endometrial Cancer
Introduction
Case 1
Q: Decision Making for Management of this Patient
Case 2
Q: Discuss Further Investigation, Management and Prognosis of this Case
Case 3
Q: Discuss Management of this Case?
References
Part IV: Case Based Studies: Gynaecological Sarcoma and Carcinosarcoma
21: Leiomyosarcoma, Endometrial Stromal Sarcoma, Undifferentiated Stromal Sarcomas, Adenosarcoma, Smooth Muscle Tumor of Unknown Malignant Potential
Introduction
Case 1: Uterine Leiomyosarcoma
Q: Describe the Pre Operative Work Up in uLMS?
Q: What Is the Management Plan?
Q: What Is the Percentage of Lymph Node Metastasis and Role of Lymphadenectomy? Role of Ovarian Conservation in uLMS
Q: Role of Adjuvant Treatment in Stage 1 uLMS?
Q: Follow Up Protocol
Q: What Is the Treatment for Advanced Stage uLMS?
Q: Treatment of Recurrent/Metastatic uLMS?
Q: What Are the Prognostic Markers of Leiomyosarcoma?
Q: Management of uLMS Diagnosed After Hysterectomy Done for Benign Fibroid?
Q: What Are the Current Guidelines for Morcellation in Uterine Fibroids and How Does It Affect the Prognosis in an Occult uLMS?
Q: Role of Hormone Replacement Therapy (HRT) After Treatment of uLMS?
Case-2: Low Grade Endometrial Stromal Sarcoma
Q: What Is the Recommended Surgical Treatment for LG –ESS?
Q: Role of Hormone Therapy in LG-ESS? How Does Histological Expression of Steroid Receptors Guide Response To Hormonal Treatment?
Q: Role of Post Operative RT in ESS?
Q: What Is the Follow Up Protocol?
Q: What Is the Prognosis of LG- ESS?
Q: What Is the Management of High Grade ESS?
Case 3: Adenosarcoma
Q: What Is the Initial Work Up and Staging for Adenosarcoma?
Q: What Is the Prognosis of Adenosarcoma?
Q: What Is the Treatment for Adenosarcoma?
Case 4 Undifferentiated Uterine Sarcoma
Q: What Is the Management of UUS?
Case 5: Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP)
Q: Clinical Presentation, Pathological Diagnosis and Management of STUMP
References
22: Carcinosarcoma of the Mullerian Tract: Uterine, Ovarian, Fallopian Tube
Introduction
Uterine Carcinosarcoma
Case 1
Case 2
Q: What Investigations Should Be Done for this Case?
Q: Discuss the Management Plan
Q: Role of Adjuvant Treatment in Uterine Carcinosarcomas?
Q: Management of Recurrent/Metastatic Carcinosarcoma
Q: Prognosis of Uterine Carcinosarcoma
Q: What Is the Further Treatment in Case When Incidental Diagnosis Is Made Postoperatively?
Q: Explain the Follow Up Post Treatment
Ovarian Carcinosarcoma
Case 3
Q: Explanation of Revision of Histological Subtype After Cytoreductive Surgery from High Grade Serous Ovarian Carcinoma (HGSOC) to Ovarian Carcinosarcoma (OCS)?
Q: What Are the Salient Features to Raise Suspicion of Ovarian Carcinosarcoma in the Above Case?
Q: What Is the Management of Ovarian Carcinosarcoma?
Q: Prognosis of OCS
Fallopian Tube Carcinosarcoma
Case 4
Q: What Is the Management and Prognosis of Fallopian Tube Carcinosarcoma?
Conclusion
References
Part V: Case Based Studies: Vaginal and Vulval Cancer
23: Malignant Diseases of Vagina
Introduction
Case 1: Early Stage
Q: Etiology of Vaginal Cancer
Q: Clinical Presentation and Patterns of Spread of Vaginal Cancer
Q: Pre Operative Workup
Q: Indications for Primary Surgery, Type of Surgery
Q: Role of Radiotherapy in the Present Case
Q: Adjuvant Treatment
Q: Prognosis
Case 2: Advanced Stage
Q: Further Management
Case 3: Rare Vaginal Tumor: Papillary Serous Cancer
Q: Discuss Serous Cancers of Vagina
Case 4: Vaginal Melanoma
Q: Discuss Management of Vaginal Melanoma
References
24: Vulval Squamous Cell Cancer: Preneoplastic Conditions, Early Stage, Advanced Stage
Introduction
Case 1: Squamous Cell Cancer Vulva: Early Stage
Q: What Investigations Are Recommended in Women Diagnosed with VSCC?
Examination
Biopsy
Imaging
Q: What Is the Management of Patients with Early and Locally Advanced Stage VSCC?
Locally Advanced VSCC
Q: What Is the Difference Between a Lateral and Central Tumour?
Q: When Is Nodal Staging Required?
Q: Who Is a Candidate for Sentinel Lymph Node Biopsy (SLNB)?
Q: Describe the Management of Positive Groin Nodes
What Is the Role of Radiotherapy and/or Chemotherapy in VSCC?
Primary
Neoadjuvant
Adjuvant
Palliative
Q: Briefly Describe the Treatment of Advanced Vulval Cancer?
Management of the Primary Tumour
Management of Groin Nodes
Q: Follow Up After Treatment?
Case 2: Recurrent Vulval Cancer
Q: How Are Patients with a Confirmed Recurrence of VSCC Managed?
References
25: Vulval Cancer with Rare Histology Subtypes
Introduction
Case 1: Verrucous Tumours
Q: What Are the Signs and Symptoms of a Verrucous Carcinoma?
Q: How Are Verrucous Carcinomas Managed?
Case 2: Bartholin Gland Tumours
Q: What Are the Signs and Symptoms Associated with a Bartholin Carcinoma?
Q: What Is the Prognosis?
Q: What Investigations are Usually Requested Preoperatively?
Q: How Are Malignant Tumours of the Bartholin Gland Managed?
Case 3: Vulval Melanomas
Q: How Do Women with Vulval Melanoma Usually Present?
Q: What Is the Prognosis for VM?
Q: What Variables Are Associated with Oncological Outcomes?
Q: What Molecular Mutations Are Prevalent in Vulvovaginal Melanomas?
Q: What Investigations Should Be Requested?
Q: How Are Women with VM Managed?
Surgical Excision
Radiotherapy
Immunotherapy [19]
Case 4: Basal Cell Carcinoma
Q: What Are the Common Signs and Symptoms Associated with BCCs?
Q: How Are Women with BCCs Managed?
Case 5: Vulval Paget’s Disease
Q: What Are the Clinical Features of Vulval Paget’s Disease?
Q: What Is the Prognosis of Women with VPD?
Q: How Are Women with VPD Managed?
Surgical Excision
Radiotherapy
Imiquimod 5%
Topical Chemotherapeutic Agents
References
Part VI: Case Based Studies: Cancer in Pregnancy
26: Management of Gynaecological Malignancies in Pregnancy: Borderline Ovarian Tumor, Ovarian Cancer
Introduction
Case 1: Borderline Ovarian Tumour
Q: What Investigations Are Required To Aid Management?
Q: What Is the Plan of Management?
Q: What Is the Prognosis?
Case 2: High Grade Serous Ovarian Cancer
Q: What Should Be the Further Management of Ovarian Malignancy?
What Should Be the Further Management of the Pregnancy?
What Is the Effect of Chemotherapy on Fetal Outcome?
Q: What Is the Likely Prognosis and Outcome?
Case 3: Germ Cell Tumour
Q: What Is the Reliability of Tumour Markers in Pregnancy?
Q: What Is the Further Management?
Q: What Are the Fetal and Maternal Outcomes in Germ Cell Tumours Complicating Pregnancy?
References
27: Gestational Trophoblastic Disease
Introduction
Case 1 Molar Pregnancy
Q1: How Will You Manage this Case?
Evacuation
Management After Evacuation
Q2: Is There any Role of Hysterectomy in Management of H Mole?
Q3: How Will You Follow Her Up?
Q4: Is There any Role of Prophylactic Chemotherapy
Q5: What Is the Risk of Recurrence in Next Pregnancy and When To Plan and How To Manage Next Pregnancy?
Q6: How to Manage Twin Pregnancy with One Mole (CMF-Coexistent Mole and Fetus)
Q7: Do All Pregnancies Need hCG Follow Up To Detect GTN?
Case 2 Low Risk GTN
Q1: Differential Diagnosis and Further Investigations Required for Management
Q2: How Will You Further Investigate this Case?
Q3: How Will You Manage this Case?
Q4: How To Follow Up this Case After Start of Methotrexate Chemotherapy?
Q5: Is There any Indication of Starting Primary Combination Chemotherapy for Low Risk Disease?
Q6: What Are the Indications for Change of Therapy?
Q7: When Will You Switch Over to Multiagent Chemotherapy in Low Risk GTN?
Q8: How To Follow Up on Second Line Therapy? Is It Different from Primary Therapy FU?
Q9: Is There any Role of Surgery for Managing Low Risk GTN?
Q10: Is There any Role of Repeat D&C in Managing Such Cases?
Case 3 High Risk GTN
Q1: How Will You Manage this Case?
Q2: How Will You Further Investigate this Patient and What Is the Stage and Prognostic Score of this Patient?
Q3: What Are Treatment Options for Her? How Many Cycles of Chemotherapy Are Recommended?
Q4: What Is the Efficacy and Complications of EMACO Regimen?
Q5: Will Treatment Differ if There Is Brain or Liver Metastasis?
Q6: How Will You Manage Ultrahigh Risk GTN?
Q7: When and How Will You Use Salvage Therapy?
Q8: At End of Treatment if Low Levels of b hCG Persist with no Clinical Evidence of Disease, What Should Be the Next Step in Management?
Q9: Indications for Hysterectomy for High-Risk GTN?
Q10: What Is the Follow Up Protocol After Completion of Treatment and What Contraceptive Choices She Has and When Should She Plan Her Next Pregnancy?
Case 4 Placental Site Trophoblastic Tumor
Q1: What Is the Differential Diagnosis of Above Case?
Q2: What Are the Peculiar Features of the PSTT
Peculiar Features of PSTT
Q3: What Are High Risk Factors for PSTT? Is this Patient Belonging To High-Risk Case/What Is the Risk Category of this Patient?
Q4: Current Management Strategies of PSTT? What Is the Role of Lymphadenectomy?
Q5: Is There any Role of Conservative Surgery?
Q6: How Will You Follow Up this Case?
References
28: Cervical Cancer in Pregnancy
Introduction
Case 1: Cervical Cancer in Pregnancy: First Trimester
Q: What Investigative Work Up Should Be Done in These Cases?
Q: What Are the Challenges Seen in Pregnancy with Respect to Cytology in Pregnancy?
Q: Describe the Treatment of Histological LSIL and HSIL in Pregnancy
Q: What Is the Effect of Pregnancy on Cervical Cancer and What Additional Problems Do We Anticipate in the Management of These Cases?
Q: Comment of the Safety of Conization in Pregnancy?
Q: Briefly Describe the Management of Cervical Cancer Diagnosed Before 22 Weeks
Case 2: Cervical Cancer in Pregnancy: Second Trimester
Q: Discuss Management Beyond 22 Weeks of Pregnancy and Role of Neoadjuvant Chemotherapy in Cervical Cancer
Case-3 Cervical Cancer in Pregnancy: Third Trimester
Q: Which Investigations Are Required to Aid Management
What Is the Further Management?
Q: What Is the Prognosis?
References
Part VII: Fertility Preservation in Gynaecological Cancers
29: Fertility Sparing in Cervical, Endometrial and Ovarian Cancer
Introduction
Case 1: Fertility Preservation in Cervical Cancer
Q: What Are the Selection Criteria for Fertility Preservation
Q: What Are the Fertility Sparing Options in Cancer of the Cervix
Q: Discuss the Pregnancy Rates and Oncologic Outcomes After Fertility Sparing Surgery
Case 2: Fertility Preservation in Endometrial Cancer
Q: What Are the Risk Factors of Complex Atypical Hyperplasia (AH)/Endometrial Cancer (EC) in Premenopausal Women?
Q: What Are the Selection Criteria for Fertility Preservation?
Q: What Investigative Work Up Should Be Done in this Case?
Q: What Are the Available Management Options?
Q: What Is the Surveillance Protocol?
Q: What Is the Safety of Ovulation Induction in Women Previously Treated for EC?
Q: Role of Completion Surgery?
Q: Role of Fertility Preserving Treatment in Patients with Lynch Syndrome
Q: What Are the Oncologic and Fertility Outcomes After Conservative Management of Endometrial Cancer
Case 3: Fertility Preservation in Borderline Ovarian Tumours
Q: Describe Fertility Sparing Surgery, Oncologic and Pregnancy Outcomes for Borderline Tumours (BOT) both Unilateral and Bilateral?
Q: Further Management?
Case 4: Fertility Preservation in Ovarian Cancer
Q: How Should the Patient Be Counselled as She Is Very Keen on Fertility Preservation?
Q: What Are the Criteria for Fertility Preservation in Ovarian Cancer?
Q: Discuss Oncologic Outcomes and Pregnancy Rates of Fertility Sparing Surgery in Ovarian Cancer
Q: Effect of Chemotherapy on Future Fertility?
Q: Chemoprevention Strategies to Prevent Gonadotoxic Effect of Chemotherapy—How to Protect Ovarian Function Before and During Chemotherapy?
References
30: Techniques of Assisted Conception in Gynaecological Oncology
Introduction
Case 1
Discuss the Work Up for Assessment of Fertility Potential of this Couple
What Are the Treatment Options?
What Are the Success Rates of Fertility Treatment?
Adverse Impact of Assisted Conception in this Case
Case 2
Effect of Chemotherapy on Future Fertility?
What Are the Options for Fertility Preservation in this Case?
Explain the Regulations around Oocyte Preservation, How Long Can They Be Preserved
Case 3
Benefits of Ovarian Suppression with Gonadotropins and Other Chemoprevention Strategies to Reduce the Impact of Chemotherapy on the Remaining Ovary
Discuss the Assessment of Fertility Potential
When Should She Consider Assisted Conception and What Are the Available Options
Fertility Outcomes in Germ Cell Tumour After Treatment?
Case 4
Diagnostic Work Up for this Case
Treatment Options
Case 5
What Is the Fertility Treatment to Be Considered in the Present Case?
What Is the Role of Assisted Conception in this Patient as She Is High Risk for Endometrial Cancer and Needs Endometrial Protection Long Term?
Intra-Abdominal Adhesions Secondary to Surgery Could Increase Risk of Subfertility and Chances of Ectopic. What Precautions Should Be Taken?
References
Part VIII: Miscellaneous
31: Hereditary Gynaecologic Cancer Syndromes
Introduction
Case 1: Lynch Syndrome
Implications of MMR Testing on Patient Management
Implications of Lynch Testing on Other Disease Screening
Implication on Other Family Members
Impact on Insurance
Case 2: BRCA Positive Ovarian and Breast Cancer
Screening in Ovarian Cancer
Germline and Somatic Tests
Clinical Implications
Somatic Testing
Germline Testing
HRD Testing
Case 3: BRCA 2 Mutation in Family
References