In 2016, Gunes Publishing publishes the Textbook of Gynecological Oncology, a gynecological oncology treatise, which was realized through a collaboration of the medical world personalities from several countries. The textbook was realized under the coordination of Ali Ayhan, Nicholas Reed, Murat Gultekin and Polat Dursun.
The work carries out a comprehensive, unified approach to cancer in the genital area, providing an overview of the problem being addressed, while also detailing the latest discoveries. The paper approaches prevention, screening, prognosis and treatment in gynecological oncology.
At the same time, the work has a strong didactic character, having a large amount of information well organized and structured in 15 sections for presentation purposes. We will summarize each section of the work.
The introduction into the history of oncology mentions pioneers in gynecological surgery - starting from Ephraim McDowell, James Marion Sims, known as “the father of gynecology in America”, ​​and continuing with William T. Creasman - considered “the father of modern gynecological oncology”. The beginnings of radiotherapy are linked to Alexander Graham Bell’s (1847-1922) discoveries, who first proposed intravaginal irradiation with Radium of the cervical cancer patients. Chemotherapy was introduced by Min Chu Li (methotrexate administered in coriocarcinoma) and later by Michele Peyrone and Barnett Rosenberg, who discovered platinum salts (cisplatin). Chemotherapy was also promoted by the first scientific societies such as The Gynecological Cancer Foundation, as well as current modern American and European oncology societies. Molecular discoveries and their involvement in different types of cancer allow, on one hand, an orientation regarding the choice of treatment (personalized treatments, targeted), as well as regarding response to the treatment, and on the other hand create the premises of evolution in terms of prevention, screening and diagnosis.
The “Genetic Basics of Cancer”, from Chapter 3, allows the understanding of cancer heredity in general and of genital cancer in particular, widely presenting heredity in breast and ovarian cancer, emphasizing the importance of knowing gene expression - the genetic profile for applying personalized therapies. An entire chapter about the future of stem cells is dedicated in the book; we mention the phenomenon called “Dandelion Hypothesis”, a phenomenon explaining the recurrence of cancers after chemo- and radiotherapy. Currently, chemotherapy addresses and annihilates only progenitor cells, leaving stem cells in the G0 phase of multiplication - cells that are responsible for cancer recurrences. The therapy targeted against stem cells appears to be the premise of success in oncology therapy.
The presented statistical data show the differences in the incidence and mortality across the globe of the several types of genital cancer. Risk and prognostic factors are also presented, providing data on prevention and screening of these types of cancer. There are also highlights regarding the importance of circulating tumor markers identified in gynecological cancers, especially for ovarian, cervical and endometrial cancer.
The importance of imaging in gynecological oncology is recognized and is extensively addressed in the present paper throughout 8 chapters, describing the role of ultrasound imaging, from PET to CT in diagnosis, clinical staging, treatment response assessment (especially for cervical, ovarian and endometrial cancers) and in interventions/therapies (ultrasound-guided interventions, CT or MRI). Are also described small diagnostic and palliative surgical interventions: fine needle biopsy, tru-cut, paracethesis, thoracocentesis, abscess drainage punches, palliative procedures - implantation of peritoneal catheters for drainage of refractory ascites from ovary cancer, for example, thoracic catheters and pleurodesis. The issue of the extemporaneous examination for surgery and implicitly the evolution of the disease are also addressed.
The second section of the paper is reserved to cervical cancer.
Haraldzur Hausen establishes for the first time the causality link between human papillomavirus (HPV) and cervical cancer, a breakthrough for which he received the Nobel Prize in 2008, thus creating the premises for discovering the prophylactic vaccine to prevent HPV infection. It was later discovered that sexually transmitted HPV infection may be the cause of other cancers (vulva, anal, penile, head and neck cancer). The work presents worrying data on the prevalence of cervical cancer worldwide: 530,000 women are diagnosed and 275,000 die annually because of cervical cancer. Biological data supports causality from this type of cancer and the presence of HPV infection. HPV infection is responsible for 70% of squamous carcinomas and for 90% of cervical adenocarcinomas. These worrying worldwide notes point out the importance of screening (for young people with sexual life the pick being considered in 20-25 years interval), and of prophylactic vaccination recommended to girls aged 11-12, with 3 doses. Persistent HPV infection is responsible for the presence of pre-invasive lesions: cervical intraepithelial neoplasia (CIN) documented and imaging. Other factors favoring the development of CIN are presented: immunosuppressant state, smoking (they have synergistic effect on CIN development), Herpex simplex and Chlamidya infections, oral contraception. The existing treatment modality is the surgical treatment, which consists of ablation and excision of injuries. Hysterectomy is not the first option, but there are situations where it is necessary; the “seeing and doing” strategy, which depends on the performance of the colposcopy, should be taken into account considering the rate of false positive results. Other therapeutic options include photodynamic therapy, cyclooxygenase-2 inhibitors, vaccine, local agents (retinoic acid, cidofovir) and oral administrated agents. In the case of CIN 1, no specific treatment is recommended, as lesions regress spontaneously in most cases; tracking HPV testing every 12 months and repeating cytology every 6 to 12 months is enough. Excision or ablation may be considered if CIN 1 lesions persist for 2 years after diagnosis.
In the case of grade 2 or 3 lesions (CIN 2-3), the statistical data show a regression rate of 32-47% and a rate of 12-40% that can evolve to invasive cancer. The lesion’s excision is required as a treatment method; it is very important to have a complete excision, with free edges that ensure therapeutic success. Positive-margin excision attracts cytology monitoring every 6 months and HPV testing at 12-24 months. Post-treatment management includes: general clinical examination, initially at 6 months, then annually in the first 3 years, Papanicolau test at each visit and colposcopy if necessary, smoking avoidance, providing information about the vaccine, suggesting contraceptive means and including folic acid, vitamins C and E and cathode in the diet.
For in situ adenocarcinoma (AIS), the therapeutic approach is different, as following: for women who have given birth and do not want to procreate, hysterectomy continues to remain the therapeutic choice, while for women who want to preserve their reproductive function, they resort to excision with the indication that getting negative margins is a key factor of favorable prognosis. Also, destructive techniques (cryotherapy, cryotherapy, electrodialysis and laser therapy) can be used in the therapeutic management of precancerous lesions (CIN) if the conditions are met: the entire lesion area can be seen in colposcopy, there are no signs of micro-invasive disease, there are no suspicions of glandular damage, cytology and histopathology allow it. Criotherapy is only suitable for lesions less than 2.5 square centimeters. In the early stages of the disease, conservative treatment is the therapeutic option especially for young women.
Convulsion and pelvic lymphadenectomy in the incipient stages of small cervical cancer or neoadjuvant CHT following conization for patients with high risk of tumor recurrence are new, emerging concepts. In the case of local-advanced uterine cervical cancer, there is an international consensus on radio-chemothe­rapy. For stages III, IVA, IVB Figo we can talk about the surgical approach. However, radical surgery as an individual treatment plan is taken into consideration for patients in stage III who reject radiotherapy after extensive counseling.
Concomitant radio-chemotherapy has improved the prognosis of patients with advanced local disease, especially in the IB-IIA stages of the disease. The local control remains a major problem in stages II, IIIB-IVA; brachytherapy remains the major therapeutic endpoint for improving local control and disease-free survival. Adjuvante CHT is currently being investigated for the purpose of lowering the metastasis rate.
The excretion of the sentinel gland, located at the external iliac or intra-articular region, rarely paraaortic, increases the success rate of surgical intervention. From the biological treatment point of view, bevacizumab is the first accepted drug for cervical cancer. There was a study comparing the results of chemotherapy (carboplatin-5 AUC + paclitaxel 175 mg/square meter), 6 series, and the adminstration of cediranib 20 mg, and the result were in favor of the latter, with an increase in survival rate from 6.7 to 8.1 months. The lack of response to cisplatin therapy should be considered in the presence of BRAC1 and ERCC1 genes; also, existing hypoxic zones in advanced cervical cancer cause radioresistance and, on the other hand, tumor angiogenesis increases. Tissue hypoxia is caused by the HIFI hypoxia inducing factor, leading to increases radiotherapy resistance. The 90 (Hsp90) thermal shock protein (recently discovered) blocks the radioresistance caused by tissue hypoxia. The therapeutic option for cervical cancer recurrences is brachytherapy with good results in small tumors but with disappointing results for bulky tumors.
Section III presents the pathology of uterine cancer by addressing and integrating the latest epidemiological, histopathological, paraclinical investigation methods, surgical, oncological, hormonal and radiotherapy treatment data.
Ovarian cancer is presented in a distinct and wide section that treats sequentially the management of ovarian tumors, including the borderline, with an emphasis on surgical techniques (surgical treatment - “the foundation stone” of therapeutic management for ovarian tumors). From the chemotherapy point of view, platinum compounds are presented for women with medium or increased relapse risk. It is important to note the importance of early detection of ovarian tumors - “the great challenge of gynecological oncology”.
Section V was dedicated to vulvar pathology in which vulvar pre-invasive lesions are treated integrally (intraepithelial vulvar neoplasias, Paget’s disease, melanoma in situ) and vulvar cancer pathology (epithelial, non-epithelial tumors - malignant melanoma, sarcoma) in an epidemiologic point of view, surgical treatment (methods of intervention, post-operative management, defect reconstitution, follow-up). Chemotherapy in vulvar carcinoma is represented by platinum-based adjuvant (cisplatin, carboplatin) associated with 5 FU or capecitabine. The association of platinum salts with paclitaxel is indicated for recurrences. Second-line chemotherapy is described in the paper as a major challenge for oncology, and new therapeutic agents like tyrosine kinase inhibitors (erlotinib) appear in the therapeutic regimen of vulvar tumors.
Pathology of the vagina (vaginal cancer) is a rare gynecological malignancy for which no trials have been conducted to guide its management. The surgical treatment is limited to stage I and stage II of the disease. Radiotherapy is being used successfully, especially brachytherapy. The role of chemotherapy and advanced radiotherapy techniques (IMRT) is still controversial. The role of chemotherapy in vaginal tumors is neoadjuvant when cisplatin plus 5FU or capecitabine, vinorelbine, gemcitabine or paclitaxel can be used (although small surgical excision is recommended for small tumor formations)
Section VII shows the gestational trophoblastic pathology (GTD), which is a group of gestational diseases that appear from the trophoblast and include molar tumors (hydatidiform mole) and trophoblastic tumors. Hydatidiform mole must be evacuated as soon as it is diagnosed without having recourse to hysterectomy (approach approved by the authors and denied by others). After evacuation, the patient should be reviewed for one week to diagnose the potential trauma as quickly as possible.
The chapter “Surgery in gynecological oncology” aims at describing the key anatomical concepts detailed for each oncological pathology in the sphere of gynecology, to understand the latest surgical procedures.
In the chaper “Cancer and human reproduction” it is mentioned that diagnosing cancer during pregnancy is rare, but is getting increased attention nowadays. Addressing the issue requires collaboration of an oncologist, gynecologist, neonatologist and a specialist in clinical pharmacology; the therapeutic decision belongs to the patient who needs not only scientific data related to the disease and communication, but above all, humanity. The approach is different for each type and location of genital tumors. The current trend is to keep pregnancies in cancers diagnosed in pregnancy trimesters 2 or 3 (such as ovarian cancer) with the use of chemotherapy schemes immediately after birth.
The section “Medical oncology” presents the basic principles of chemotherapy and drugs used, the biological therapies and the relationship with chemotherapy, pharmacological factors that influence treatment, resistance to treatment, principles of drug combination, antineoplastic medication and their toxicity, as well as new directions in research and development of medication in oncology. Targeted therapy, intraperitoneal chemotherapy (especially in ovarian epithelial cancer) and new biological therapies are being used more and more frequently. The role of immune therapy is particularly important in ovarian cancer. The principles of chemotherapy in elderly patients are presented, considering the fragility of this age group and involving a special approach to the management of gynecological tumors, taking into account the existing comorbidities.
Radiotherapy is used in the curative and palliative treatment of gynecological neoplasms, and the work provides basic notions that allow the understanding of the physical and biological principles of radiation action and methods of use for therapeutic purposes. Radiotherapy protocols for each type of gynecological cancer are presented, both conventional methods and the latest techniques, the management, as well as the complications and the late toxicity of radiotherapy.
Palliative care in gynecological oncology is a distinct field that focuses on improving the quality of life of genital cancer patients, involving multidisciplinary cooperation and psychological, physical, social and spiritual evaluation. Palliative care should support the obstetrician and gynecologist in their efforts to treat their patients. Palpation also includes the management of vomiting and nausea, chemotherapy, pain management and nutrition. The paper also addresses the issue of complementary medicine and alternative medicine in genital cancer. Euthanasia and assisted death are presented as part of end-stage disease care in several countries around the world and involve ethical, ethnic and legal aspects.
In Section XIV, it is mentioned that breast cancer is the most common form of cancer and the second leading cause of death worldwide. Screening methods and their efficacy, heredity data, therapeutic management (surgical interventions, the role of the sentinel ganglion - biopsy, metastatic sentinel ganglion management, medical treatment, IHC role) are presented. The management of metastatic breast cancer and radiotherapy (adjuvant indications, modern irradiation techniques, radiotherapy after reconstruction) are detailed in this section.
Pregnancy associated with breast cancer - the therapeutic management of breast cancer discovered during pregnancy remains a challenge for medicine and involves an individualized plan that takes into account some principles and wishes of the future mother. In the first trimester of pregnancy, CHT is contraindicated due to the risk of abortion and teratogenic effects. In the second trimester of pregnancy, CHT can be done under certain safety conditions, and radiotherapy is a risky therapeutic approach due to the vicinity with the baby of the area irradiated and it is preferable to be postponed until after birth. Prognosis is not different from non-pregnant women; the worst prognosis is described in nursing patients. Regarding the effect of exposure to CHT/RT of the fetus, additional studies are needed.
The last chapter of the paper presents the training opportunities in gynecological oncology existing in Europe and USA, which is a starting point for the specialists in the field.   n

Beatrice Bulai 
Resident in Medical Oncology, 
„Prof. Dr. Al. Trestioreanu” 
Institute of Oncology Bucharest