ADVANCED GYNECOLOGIC SURGERY

Surgery

Radiation therapy (also called radiotherapy) is a cancer treatment that uses high doses of radiation to kill cancer cells and stop them from spreading.
At low doses, radiation is used as an X-ray to see inside your body and take pictures, like those taken of your teeth or of broken bones.
Radiation used in cancer treatment works in much the same way, except that it is given at higher doses.

Symptoms

The symptoms of endometriosis vary widely from woman to woman and the severity of symptoms is not necessarily related to the severity of the endometriosis.

Symptoms depend on the extent and location of the endometrial implants and the affected structures.

While some women have few or no symptoms, others experience severe and incapacitating pain that recurs each month for many years.

Many women think that painful periods are normal. If you have bad period pain, you should see your doctor.

Symptoms include:

• Pain during menstruation (dysmenorrhoea)
• Pain during sexual intercourse (dyspareunia)
• Pelvic and abdominal pain outside of menstruation
• Abnormal bleeding – including heavy bleeding, clotting, prolonged bleeding, irregular bleeding, premenstrual spotting
• Bowel disturbances – including painful bowel motions, diarrhea, constipation, bleeding from the bowel
• Difficulty in getting pregnant
• Painful urination
• Lower back, thigh and/or leg pain
• Premenstrual syndrome

Diagnosis

The tests used to help diagnose endometriosis are:

• Laparoscopy – a medical instrument with a video camera attached is used to examine your uterus.
• Ultrasound – instrument which uses sound waves to create a video image.
• Colonoscopy – a medical instrument with a video camera attached is used to examine your bowel. This is done if it is thought that the endometriosis could also be affecting your bowel.

Treatment

Treatment for endometriosis depends on a number of factors including

• The severity of symptoms,
• The extent of the endometriosis,
• The woman’s age
• Her outcome requirements (e.g. reduction in pain, improved fertility).

No treatment can absolutely prevent endometriosis from recurring but a combination of regular medical follow-up, hormone medication and/or surgery and, perhaps, alternative therapy can control the condition.

One of the common misconceptions concerning endometriosis is that having a baby will cure the condition. While endometriosis is suppressed during pregnancy, symptoms generally recur in time, even as early as a few months after giving birth.

Medical treatment is essential for this condition. Hormones can treat endometriosis, but sometimes surgery may be indicated.

Drug Therapy

Drugs used to treat endometriosis include:

• The oral contraceptive pill (occasionally)
• Anti-inflammatory medications
• Painkillers
• Hormonal treatments

Surgery

Surgical options for endometriosis treatment include:

• Laparoscopic surgery – is performed to diagnose endometriosis. Laser surgery may be used to try and remove the adhesions. This may be done to reduce pain and to improve the chances of you becoming pregnant.
• Laparotomy – is used to cut out or burn tissue, or remove cysts.
• Bowel resection – for example, if the bowel has also developed endometriosis with serosa adhesions.
• Hysterectomy – may be an option if endometriosis prevents you from having a normal life and other treatments have not worked.

 Causes

Eggs grow, develop, and mature in the ovaries and then are released during ovulation, part of the monthly menstrual cycle that occurs during the childbearing years.

Ovarian cysts are fluid-filled sacs that form on the ovaries when the follicles (sacs) on the ovary that contain the egg mature, but do not release the egg into the fallopian tube where it would be fertilized.

Symptoms

Most ovarian cysts are small and do not cause symptoms, although some may cause a dull or sharp ache in the abdomen and pain during certain activities.

Larger cysts may cause torsion (twisting) of the ovary that causes pain.

Cysts that bleed or rupture (burst) may lead to serious problems requiring prompt treatment.

Diagnosis

An ovarian cyst may be found during a routine pelvic exam. If your health care provider finds an enlarged ovary, tests may be recommended to provide more information.

Vaginal ultrasound

This procedure uses sound waves to create pictures of the internal organs that can be viewed on a screen. For this test, a slender instrument called a transducer is placed in the vagina. The views created by the sound
waves show the shape, size, location, and makeup of the cyst.

Laparoscopy

In this type of surgery, a laparoscope—a thin tube with a camera—is inserted into the abdomen to view the pelvic organs. Laparoscopy also can be used to treat cysts.

Blood tests

If you are past menopause, in addition to an ultrasound exam, you may be given a test that measures the amount of a substance called CA 125 in your blood.
An increased CA 125 level may be a sign of ovarian cancer in women past menopause. In premenopausal women, an increased CA 125 level can be caused by many other conditions besides cancer. Therefore, this test is not a good indicator of ovarian cancer in premenopausal women.

OVA1

OVA1 is a simple blood test to help evaluate an ovarian mass prior to surgery. A woman’s likelihood of cancer depends largely on how high or low the score is using a zero to 10 scale. It also depends on whether she is pre- or post-menopausal. A high OVA1 score is not a diagnosis of cancer, but rather it indicates an increased risk.

Treatment

Birth control pills may be prescribed to treat some types of ovarian cysts. This treatment will not make cysts you already have go away, but it will prevent new cysts from forming.
If your cyst is large or causing symptoms, your health care provider may suggest surgery. The extent and type of surgery that is needed depends on several factors:
• Size and type of cyst
• Your age
• Your symptoms
• Your desire to have children

Sometimes, a cyst can be removed without having to remove the ovary. This surgery is called cystectomy.

In other cases, one or both of the ovaries may have to be removed. Your doctor may not know which procedure is needed until after the surgery begins.

HNPCC

Endometrial cancer is the second most common type of cancer in patients with HNPCC mutations. Patients with HNPCC mutations need to be screened more aggressively for endometrial cancers, breast cancers, skin cancers, and many other cancers. With endometrial cancer, the gynecologic oncology physician may recommend an early hysterectomy as prophylaxis.

Hereditary nonpolyposis colorectal cancer (HNPCC) is the most common known hereditary cause of colon cancer. In fact, HNPCC accounts for between two and five percent of all colon cancer cases.

HNPCC is a hereditary syndrome that is caused when a person inherits a mutation in one of five different genes. If people born with HNPCC do not undergo early and regular screening, they have a much higher risk of developing colon cancer than the general population if they do not undergo early and regular screening.

About two to five percent of all colon cancer cases are attributed to HNPCC, also called Lynch Syndrome, after Dr. Henry Lynch who realized that it was a separate disorder from other hereditary colon cancer syndromes.

Certain things are misleading about the name of the syndrome — hereditary nonpolyposis colon cancer. First, HNPCC is not a form of cancer, but only a syndrome that puts people at high risk for colon cancer. Second, even though the name has nonpolyposis in it, people with HNPCC will still develop colon polyps as a precursor to colon cancer. Scientists simply use this term to distinguish HNPCC, which causes a small number of polyps to develop, from another hereditary colon cancer — familial adenomatous polyposis syndrome — in which thousands of polyps develop.

BRCA1 and BRCA2

BRCA1 and BRCA2 are human genes that belong to a class of genes known as tumor suppressors.

In normal cells, BRCA1 and BRCA2 help ensure the stability of the cell’s genetic material (DNA) and help prevent uncontrolled cell growth. Mutation of these genes has been linked to the development of hereditary breast and ovarian cancer.

The names BRCA1 and BRCA2 stand for breast cancer susceptibility gene 1 and breast cancer susceptibility gene 2, respectively.
How do BRCA1 and BRCA2 gene mutations affect a person’s risk of cancer?

Not all gene changes, or mutations, are harmful. Some mutations may be beneficial, whereas others may have no obvious effect.
Harmful mutations can increase a person’s risk of developing a disease, such as cancer.

A woman’s lifetime risk of developing breast and/or ovarian cancer is greatly increased if she inherits a harmful mutation in BRCA1 or BRCA2. Such a woman has an increased risk of developing breast and/or ovarian cancer at an early age (before menopause) and often has multiple, close family members who have been diagnosed with these diseases.

Harmful BRCA1 mutations may also increase a woman’s risk of developing cervical, uterine, pancreatic, and colon cancer. Harmful BRCA2 mutations may additionally increase the risk of pancreatic cancer, stomach cancer, gallbladder and bile duct cancer, and melanoma.

The likelihood that a breast and/or ovarian cancer is associated with a harmful mutation in BRCA1 or BRCA2 is highest in families with a history of multiple cases of breast cancer, cases of both breast and ovarian cancer, one or more family members with two primary cancers (original tumors that develop at different sites in the body), or an Ashkenazi (Central and Eastern European) Jewish background.

However, not every woman in such families carries a harmful BRCA1 or BRCA2 mutation, and not every cancer in such families is linked to a harmful mutation in one of these genes. Furthermore, not every woman who has a harmful BRCA1 or BRCA2 mutation will develop breast and/or ovarian cancer.

According to estimates of lifetime risk, about 12.0 percent of women (120 out of 1,000) in the general population will develop breast cancer sometime during their lives compared with about 60 percent of women (600 out of 1,000) who have inherited a harmful mutation in BRCA1 or BRCA2. In other words, a woman who has inherited a harmful mutation in BRCA1 or BRCA2 is about five times more likely to develop breast cancer than a woman who does not have such a mutation.

Lifetime risk estimates for ovarian cancer among women in the general population indicate that 1.4 percent (14 out of 1,000) will be diagnosed with ovarian cancer compared with 15 to 40 percent of women (150–400 out of 1,000) who have a harmful BRCA1 or BRCA2 mutation.

It is important to note, however, that most research related to BRCA1 and BRCA2 has been done on large families with many individuals affected by cancer. Estimates of breast and ovarian cancer risk associated with BRCA1 and BRCA2 mutations have been calculated from studies of these families.

Because family members share a proportion of their genes and, often, their environment, it is possible that the large number of cancer cases seen in these families may be due in part to other genetic or environmental factors. Therefore, risk estimates that are based on families with many affected members may not accurately reflect the levels of risk for BRCA1 and BRCA2 mutation carriers in the general population.

In addition, no data are available from long-term studies of the general population comparing cancer risk in women who have harmful BRCA1 or BRCA2 mutations with women who do not have such mutations. Therefore, the percentages given above are estimates that may change as more data become available.

Are genetic tests available to detect BRCA1 and BRCA2 mutations, and how are they performed?

Yes, there are tests. Several are available for BRCA1 and BRCA2 mutations (14). Most of these methods look for changes in BRCA1 and BRCA2 DNA. At least one method looks for changes in the proteins produced by these genes. Frequently, a combination of methods is used.

How are they performed? A blood sample is needed. The blood is drawn in a laboratory, doctor’s office, hospital, or clinic and then sent to a laboratory that specializes in the tests. It usually takes several weeks or longer to get the test results. Individuals who decide to get tested should check with their health care provider to find out when their test results might be available.

Genetic counseling is generally recommended before and after a genetic test. This counseling should be performed by a health care professional who is experienced in cancer genetics.

Genetic counseling usually involves a risk assessment based on:
• The individual’s personal and family medical history and discussions about the appropriateness of genetic testing
• The specific test(s) that might be used and the technical accuracy of the test(s)
• The medical implications of a positive or a negative test result
• The possibility that a test result might not be informative (an ambiguous result)
• The psychological risks and benefits of genetic test results, and
• The risk of passing a mutation to children.

Symptoms

In many cases, fibroids are asymptomatic. Symptoms may include:

• Heavy periods
• Lengthy periods
• Period pain
• Spotting between periods
• Painful intercourse
• A sensation of heaviness or pressure in the back, bowel and bladder
• Frequent urination
• A lump or swelling in the lower abdomen

Different types

Fibroids are categorized by their locations, which include:

• Intramural – growing in the uterine wall. Intramural fibroids are the most common variety.
• Submucosal – growing in the uterine lining (endometrium). This type tends to cause excessive menstrual bleeding and period pain.
• Subserosal – growing on the exterior wall of the uterus. They sometimes appear like long stalks.