Advances in the Treatment of Gynecologic Malignancies

Historically, two-thirds of patients with endometrial carcinoma had disease confined to the uterus, and the cornerstone of treatment was total abdominal hysterectomy and bilateral salpingo-oophorectomy. Since the introduction of surgical staging in 1988, however, more patients are found to have disease outside the uterine cavity. Unfortunately, the current rules for staging are not followed by every practitioner, and the required specimens for pathologic examination are not always obtained. Therefore, recommendations for postoperative adjuvant therapy are usually based on the surgico-pathologic information available for each patient.

Before the introduction of surgicopathologic staging, the use of preoperative radiotherapy was quite popular, particularly for patients considered to be at "high risk," such as those with poorly differentiated histologies or obvious cervical involvement. Nowadays, a number of issues regarding the value of postoperative radiotherapy are controversial and its use depends upon reported surgico-pathologic findings.

Unfortunately, only a minority of patients undergo surgical staging, and few prospective studies have evaluated adjuvant therapy in patients at high risk for recurrence. On the other hand, with adequate surgical exploration and resection, a significant number of patients are found to have "low-risk" tumors and may not require adjuvant therapy. For patients who need postoperative radiotherapy, surgical staging allows management to be tailored accordingly.

Epithelial ovarian cancers represent the most challenging of all gynecologic malignancies. The disease remains asymptomatic for most of its natural history, and subsequently, becomes evident in locally advanced and metastatic stages. Although the cure rate for ovarian cancer is quite poor, we have seen significant improvement in survival with meticulous staging, aggressive surgical resection, and multiagent chemotherapy.

Surgery remains the cornerstone of treatment for early-stage disease. As summarized by Drs. Kim, Alvarez, and Omura, prospective clinical trials by the Gynecologic Oncology Group (GOG) show that no overall survival benefit was associated with adjuvant therapy for patients who were optimally staged and resected.

A recent publication by Bristow et al[1] evaluated the survival effect of optimal cytoreductive surgery and platinum-based chemotherapy. The authors concluded that platinum-based chemotherapy increases the median survival of patients with advanced-stage ovarian cancer. The strongest predictor of survival was maximal resection of the primary tumor and its extension. It is of great interest that the authors’ review of surgical outcomes revealed a wide disparity in the success rates of cytoreductive surgery because, in some reports, the rates of optimal resection were 25% or less.

Given the chemosensitivity of this tumor, platinum compounds represent one of the most significant advances in the treatment of ovarian cancer. Nevertheless, every effort must be made to ensure that patients with locally advanced disease (and a select group with metastatic disease) be considered for optimal cytoreductive surgery. Such a surgical procedure needs to be performed by adequately trained gynecologic oncologists.

In both uterine and ovarian cancers, surgicopathologic staging has changed the way we treat patients: Treatment recommendations can be tailored to the findings, thereby minimizing morbidity. Most importantly, surgical staging has led to improvement of cancer-related symptoms and optimization of quality of life. Among patients in whom optimal cytoreductive surgery is performed, such staging has improved overall survival.