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Advances in the Treatment of Gynecologic Malignancies

Advances in the Treatment of Gynecologic Malignancies

The article by Kim et al is a
comprehensive summary of
several decades of research in the management of cervical and vulvar cancer. It
describes the current status of treatment and possible future trials.

Surgical Staging

For the management of cervical cancer, two issues need to be further
addressed. The first is surgical staging of cervical cancer. For decades it has
been known that nodal metastasis to the pelvic and para-aortic regions is common
in cervical cancer including clinical stage I disease. Moreover, nodal
metastasis is a well-documented indicator of poor prognosis, particularly in
apparent early-localized disease. Identification of microscopic nodal disease
may alter the treatment plan, especially if the para-aortic nodes are involved.

Despite the poor accuracy of currently available imaging modalities in
detecting pelvic and para-aortic metastasis, cervical cancer continues to be
clinically staged in most institutions in the United States. The use of clinical
staging may be justified in the absence of technology to accurately determine
disease status, particularly in developing nations with limited medical
resources. However, with the advent of minimally invasive surgical approaches,
surgical staging of apparent local cervical cancer can be adequately performed
through transperitoneal or extraperitoneal laparoscopic pelvic and bilateral
para-aortic lymph node dissection with minimal morbidity and delay in treatment.

The laparoscopic approach has been used for the past decade by many national
and international investigators with excellent lymph node yield, limited
operative time, short hospital stay, and a very low overall complication
rate.[1-4] Pathologic evaluation of retroperitoneal lymph nodes remains the gold
standard for detecting metastasis.

Until accurate imaging techniques are commonly available, surgical staging
should be offered to women with cervical cancer who have access to minimally
invasive surgery and are at risk for para-aortic nodal metastasis as well as to
those for whom identification of retroperitoneal nodal metastasis will modify
the treatment plan. The results of randomized trials in cervical cancer are most
informative when the protocol mandates pretreatment surgical staging.

Compliance Issues

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