Current Women's Health Reviews - Volume 7, Issue 4, 2011

Endometrial adenocarcinoma is a high prevalence tumor in the industrialized world, and whose incidence is progressively increasing. Its association with obesity, diabetes and sedentary lifestyles explain the increase of cases in urban cultures and possibly it should be considered as an indicator of poor social health, in this case, secondary to the progress of an industrialized population. Globally analyzed, it can be considered a tumor of good prognosis. Survival rates are around 81% in industrialized countries. The reason for this may be its frequent early diagnosis due to symptoms appearing fairly soon. It is mainly detected in menopausal women by abnormal bleeding, generally at stage I; thus not requiring an expensive early diagnostic system. However, even though survival at stage I is about 97%, advanced stage cases or those with poor prognostic factors are also diagnosed, with a mortality rate that has been unchanged for ages despite the use of adjuvant techniques to surgery. Since Creasman's work in 1987 [1] myometrial invasion, tumor grading and nodal involvement have been considered the most important prognostic factors. Despite the development of current diagnostic techniques, the International Federation of Gynecology and Obstetrics (FIGO) calls for a surgical classification establishing the above mentioned prognostic factors. The disagreement on establishing the extent of the staging surgery causes great controversy. Since a hysterectomy is mandatory in the treatment, uterine prognostic factors will always be analyzed, but not usually with lymph nodes. There are supporters and detractors of performing a lymphadenectomy in endometrial adenocarcinoma. However, in 1988 the FIGO [2] stated that correct staging of endometrial cancer required both a pelvic and a para-aortic lymphadenectomy. Since then it has been proposed that radiotherapy is not necessary when the lymphadenectomy shows no node involvement. Nevertheless, there is little clinical evidence regarding the benefits of lymphadenectomy, a procedure that increases morbidity as well [3]. Although large series have reported an improvement in survival rates following a lymphadenectomy [4, 5], with some considering that its scope is a determining factor [6-10], the ASTEC study [11] found no impact on survival. The results of the ASTEC study are complemented by the findings of an Italian multicentre study [12] which randomized 500 patients and also reported no differences in survival rates between the groups. However, both these studies were criticized by Hockel and Dornhofer [13], who pointed out that the disease was only treated at the pelvic level. Another criticism of this study was that in the standard surgery group the surgeon could remove the pelvic nodes if s/he considered that this would benefit the woman. This concession contradicts the stated aim of the study. Moreover, the fact that 43% of patients included were low risk dilutes the possible therapeutic effect of lymphadenectomy [14, 15]. Just recently Todo et al. [16] from Japan have published a retrospective cohort study (SEPAL) in which they compare intermediate- and high- risk patients, who had been treated with pelvic lymphadenectomy or pelvic and para-aortic lymphadenectomy. They show that overall and disease-free survival is significantly improved in the pelvic and para-aortic lymphadenectomy group. They conclude that pelvic limphadenectomy alone might be an insufficient surgical procedure for endometrial cancer in patients at risk of limph node metastasis and also suggest that adjuvant chemotherapy could further improve survival of patients at high risk of limph node metastasis. Although this is a retrospective study, it confirms the clinical suspicion that para-aortic lymphadenectomy has a therapeutic benefit in intermediate- and high-risk patients but not in low-risk patients. Even though nodal status is controversial, the prognosis is significantly poorer when there is lymph node involvement. Lymphadenectomy varies depending on the medical centre where it is performed. It ranges from ignoring the nodal study, to selective biopsy of palpable nodes, to pelvic or pelvic-aortic lymphadenectomy. The particular uterine lymphatic drainage following two different paths, either the uterine artery or the utero-ovarian vessels, explains lymph node metastases in atypical areas. The progression from the pelvic to the para-aortic region is not as constant as to the cervix and even frequent involvement sites are not definable. Sentinel lymph node determination is considered a technique of better prospects to locate the area of higher involvement risk in each particular case, although experience in its application is still needed.....

Endometrial cancer is the most common gynecologic malignancy in western countries. In United States, 42000 estimated new cases were diagnosed in 2009, approximately 7780 women died from this cancer last year. This malignancy has a five year survival rate around 80%, thanks to its early diagnosis. The surgical management of endometrial cancer includes hysterectomy as main surgical procedure. The role of lymphadenectomy, pelvic and para aortic is still controversial. The authors discuss in this article the risk factors for lymph node metastases and recurrence for endometrial cancer by reviewing the international literature. Conclusions: Lymphadenectomy is a crucial surgical procedure for an adequate staging of endometrial cancer. It is necessary a to evaluate the prognostic factors of this disease in order to properly select the most adequate adjuvant therapy. Since last trials on lymphadenectomy in endometrial cancer have not been convincing, further studies are warranted.

Laparoscopy for the treatment of endometrial cancer has been shown to be technically feasible and safe with a reduction in perioperative complications and length of hospital stay (cost-efficiency). We should consider laparoscopy as the surgical technique of choice reserving laparotomy when there is a formal contraindication to the laparoscopic-vaginal approaches.

Robotic surgery is becoming increasingly popular in most surgical specialties, including gynecology. This review describes the technology of the da Vinci systems and the results obtained for the robotic approach to endometrial cancer as compared to conventional laparoscopy and laparotomy.

The lymph node status is a key factor in staging, prognosis and adjuvant treatment planning of endometrial cancer (EC). Systematic pelvic and para-aortic lymphadenectomy is the only reliable procedure to assess the lymph-node status and it should be the standard of care in most cases with risk factors for node metastasis. However, it has no therapeutic benefit on the course of the disease for the majority of patients without nodal disease. The procedure is difficult, costly, time consuming, and it is not free of potentially severe complications and long-term disabling morbidities. Therefore, the real challenge would be to identify a surgical technique that provided accurate staging information about nodal status while avoiding the potential for overtreating low-risk patients and undertreating patients with metastasic disease. Lymphatic mapping and sentinel lymph node (SLN) selective biopsy is a promising technique for this purpose, avoiding a systematic lymphadenectomy in most cases, and providing useful information for surgical planning and approach. However, research on SLN in EC is very much behind vulvar or cervix cancer. The lack of standardization of the procedure is probably the main cause of the delay in the investigation and final implementation of SLN technique in EC.

Background: In endometrial adenocarcinoma the assessment of depth myometrial invasion (DMI) is one of the most important features for staging and prognostic factor. It is also important to determine the therapeutical procedure. Although it can be establish by image techniques, the intraoperative assessment by frozen sections is a more accurate method. Material and Methods: This is a retrospective study of 93 endometrioid adenocarcinomas surgically treated with pelvic lymphadenectomy with or without aortic lymphadenectomy. In all cases frozen sections of the tumor was performed to determine the DMI. It was correlated with the feauters in defeinitive sections, histological grade and lymph node involvement. Results: Intraoperative study revealed absence of myometrial invasion in 19 cases, IH in 61 and of OH in 13. Definitive study showed absence of myometrial invasion in 9 cases, invasion of the IH in 68 and invasion of the OH in 16. Myometrial invasion showed statistically significant relationship with age, histological grade and lymph node involvement. Conclusion: intraoperative assessment of myometrial invasion is a useful tool to establish the involvement of the inner or outer half. The absence of myometrial invasion by frozen section is less accurate

Endometrial cancer is the most frequent gynaecological carcinoma with an increasing incidence. However, this tumour is usually identified in its early stages due to its symptomatology appearing fairly soon. This fact allows for a diagnosis in early stages in most patients, thus providing a good prognosis with an overall survival rate at 5 years higher than 95%. The classical management has been hysterectomy with bilateral salpingo-oophorectomy and pelvic-aortic lymphadenectomy, but we know that many patients in early stages may be treated with only hysterectomy plus salpingooophorectomy. The role of lymphadenectomy in the surgical treatment of these patients is a controversial issue. Assessment of regional nodes varies from elective omission to sampling (selective assessment) to systematic pelvic and para-aortic lymphadenectomy. In order to prevent under or overtreatment, some authors also propose pelvic lymphadenectomy and, in case of it being positive proceed to an aortic lymphadenectomy. At present this technical procedure seems to be useful only in high-risk patients since low-risk patients would not obtain real benefits. Taking into account that in endometrial cancer the drainage is through the pelvic and para-aortic lymph nodes, lymphadenectomy should include all the nodal regions mentioned. Lymphadenectomy allows for a selection of high-risk patients candidates for adjuvant therapy.

The past several years have witnessed a growing level of attention devoted to understand how cancer affects the lives of those touched by this illness. This understanding goes beyond the physical suffering and sequalae, the limited focus on the cure to embrace a broader dimension that concerns psychological adjustments and mental well-being during the cancer trajectory. It would be rudimentary not to perceive this trajectory a complex path in an individual lives, which does not start when the diagnosis is made and it does not finish when the treatment ends. It would be also rudimentary not to acknowledge that during this path many issues, decisions, demands, changes are at a multidimensional level and constitute great threats and unique challenges for the individual diagnosed with cancer and those involved in the care. These can have a great impact on one's psychological functioning and quality of life. Each type of cancer brings a uniqueness of challenges and consequences, for example differing rates of morbidity and mortality. When designing this special issue, one imperative matter was to bring to light relevant issues related to women's health, inevitably. Another priority was to compile a collection of reviews on which the main topic would be cancer. Another concern was to bring to light issues and concerns that are underreported or less attention have been paid to them. Bringing these concerns together, it is not only appropriate, but also timely to offer a compilation of reviews about psychological impact of gynaecological cancers. Gynaecological cancers are a frequent group of malignancies in women accounting for approximately 18% of all female cancers worldwide [1]. The most common are endometrial, ovarian and cervical cancer. Vaginal and vulvar cancers are rare [2]. Something that unites these malignancies is their effect on the reproductive organs that represent the physiologic core of femininity, motherhood and sexuality. Over the years, improvements in screening programmes and new advances in treatments have contributed greatly to extend the length of life following the diagnosis. These urged the need to investigate and understand quality of life and psychological adjustment to a series of ongoing life events, for example diagnosis, pregnancy, etc, that a woman diagnosed with gynaecological cancer has to face. Concomitantly to this understanding arises the urgency to provide psychological care to women to face different challenges imposed by their illness. The five reviews included in this special issue have a common theme the psychological aspects of gynaecological cancers. The reviews, however, focus on psychological challenges faced by women to different events or issues that are associated with gynaecological cancers. Psychological aspects of gynaecological cancers are a broad field and several different issues can be discussed and explored. I trust that the readers of this special issue will find reviews with information about novel and pertinent topics, such as for example psychological implications about pregnancy during the illness. This is a pioneer attempt to compile what is known in the field, which aims to make a substantial contribution to summarise and provide updated knowledge on the psychological impact of gynaecological cancer on different issues and events faced by these women. Much was accomplished with this special issue; nevertheless, much remains to be done and answered. However, I believe that this special issue is an important source of information about this topic of research, which will contribute to stimulate further and future discussions and hopefully, research.

Since the widespread introduction of cervical cancer screening programs the incidence and mortality of cervical cancer has declined. In general, cervical cancer screening programs are viewed as a valuable component of preventive health services, but are also associated with negative effects for participants. The side effects of cervical cancer screening include anxiety, false reassurance and overdiagnosis. The purpose of the present review was to study the research literature on psychological adjustment among women undergoing cervical cancer screening. The review revealed two main areas with barriers to cervical cancer screening, the pelvic examination and Pap smear results. Women felt anxiety and embarrassment during the pelvic examination and highlighted the importance of a suitable examiner. Fear of negative results played a major role in women's decisions to participate. Fearing results of the Pap smear could be a source of distress.

Ovarian cancer is the most lethal of gynaecological malignancies. Although early detection efforts have been relatively unsuccessful in reducing mortality at the population level, ovarian cancer screening continues to be offered to some women. Testing for mutations in the BRCA1/2 genes can determine whether women have a heightened risk of developing ovarian cancer and those found to be at high risk are closely followed and offered cancer risk-reducing strategies. Yet, ovarian cancer screening and genetic testing have potential psychological sequelae. The purpose of this article is to present an overview of these psychological sequelae. Overall, women who receive normal ovarian cancer screening results benefit emotionally and the emotional distress associated with abnormal results subsides once a cancer diagnosis is excluded. There are psychological benefits of genetic testing as well as potential challenges that include interpreting results, feelings of anxiety, distress and depression, changes in self-concept, experiencing guilt and worry regarding family members, communicating with family and making decisions about ovarian cancer screening and riskreducing oophorectomy. Psychological support that addresses the unique psychological sequelae associated with hereditary ovarian cancer risk and targets the subgroup of women who are more likely to experience difficulties would likely be beneficial.

Gynecological cancer is the fourth most common form of cancer among women. Over the past few decades, the growing number of survivors has been forced to cope with the consequences of the disease. Of these consequences, the impact of cancer on reproduction has been receiving increasing attention. Research shows that the health care of these women poses challenges other than medical ones. Although the inclusion of psychologists in health care teams has been particularly valued, studies focusing on the psychological implications of the impact of gynecological cancer on reproduction are scarce. Therefore, the first aim of this review is to critically reflect on the psychological implications of infertility, decision-making regarding childbirth, and pregnancy in the context of gynecological cancer. The second purpose of this review is to provide practice guidelines that account for the specificities and demands of these patients. Our findings suggest that gynecological cancer entails specific emotional and decisional challenges regarding reproductive issues, highlighting the importance of specialized psychological interventions with patients and their families. Providing emotional support and education about sexual and reproductive difficulties, supporting decisionmaking about fertility preservation and childbirth, promoting adjustment to cancer during pregnancy and supporting transition to motherhood are the main areas of intervention suggested. A multidisciplinary treatment approach also seems to be essential, and the role of psychological teams can be particularly important because these professionals may enlighten and encourage skills in other health care providers.

This study reviews articles describing cultural and ethnic influences on health outcomes for women diagnosed with gynecological cancer along the cancer continuum: 1) early detection and screening, 2) treatment, and 3) survivorship. Specifically, this study investigates what ethnic and cultural differences influence cancer outcomes and explores cultural factors that are active along the cancer continuum. Studies addressing the roles of culture and ethnicity in the adjustment to gynecological cancer are relatively rare. Overall, most cultural and ethnic studies have focused on either cancer screening or survivorship, while a number of studies regarding medical issues have focused on ethnic differences in cancer treatment and survival. Studies focused on early detection and screening, cultural variables, including cultural beliefs, acculturation, lack of information, and individual- and area-level socio-economic status, have been used as indicators to investigate the effect of culture on outcomes. In survivorship studies, social support, acculturation, socioeconomic status, and religiosity have been included in the analyses. However, only the social support variable has been investigated as a cultural factor in the treatment stage. The development of standardized definitions and assessments of culture, the inclusion of diverse cultural factors in studies and practice, the establishment of evidence-based practice, and health care policy changes are recommended as strategies to maximize adjustment and improve quality of life for women at risk of and diagnosed with gynecological cancer.

Gynaecological cancer patients experience psychological morbidity due to the aggressive nature of the illness and treatment. In the last three decades, researchers have been developing studies to investigate the efficacy of psychological interventions to be used in this group of patients. The present review addresses the most recent knowledge about counselling and cognitive behaviour interventions to improve psychological morbidity and emotional functioning in patients suffering from gynaecological cancers. Five studies met our review inclusion criteria and were evaluated. Despite our inability to provide firm conclusions about the efficacy of counselling and cognitive behaviour interventions in these patients, given the limited amount of data accumulated to date, methodological and intervention differences between studies and the mixed findings obtained, there is an urgent need for further larger and rigorous research in order to understand the effects and value of these interventions. This would hopefully provide clearer answers for those working in the field and essential information to establish evidence based services.

External cephalic version (ECV) is an obstetric maneuver that rotates the fetus to a cephalic presentation in case of breech, oblique or transverse lie presentations. During the past 14 years, the most relevant studies (n >200 patients) reveal success rates ranging from 37% to 78.7%. The contraindications of ECV are: when a clear indication for a cesarean delivery exists, fetal compromise, placenta praevia, placenta abruption, intrauterine fetal death, rupture of membranes, multiple gestation, Rh sensitivization, uterine abnormalities and coagulation disorders. ECV was only contraindicated in 4% of breech presentations. Many authors have examined the factors associated with ECV success rate. We did not identify any factor that showed a constant association across all studies. The goal of describing factors associated with ECV success rate is to determine whether they can be enhanced, thus contributing to improve ECV success rate. Studies have focused on three different actuations: tocolysis, regional analgesia and amnioinfusion. ECV is not alien to complications, although the risk of complications remains low when performed correctly. The reported complications are transitory alteration of cardiotocography, feto-maternal transfusion, urgent cesarean delivery, perinatal mortality, vaginal hemorrhage, premature detachment of the placenta. The final goal of ECV is to decrease the presence of breech presentations at the time of labor and thus reduce the rate of cesarean sections. A meta-analysis of the Cochrane review observed a significant decrease in the rate of cesarean sections (RR=0.52; CI95%=0.39-0.71) in patients subject to ECV at term without worse perinatal outcomes.