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OBGYN.net Conference CoverageFrom First Congress on Controversies in Obstetrics, Gynecology & Infertility Prague CZECH REPUBLIC - October, 1999
Professor Rami Dgani: "I'd like to introduce Professor Chambers from the Irvine Medical Center in the United States. He talked on ovarian cancer, the place of conservative surgery, limitations, and pathological evaluation."
Professor Joseph Chambers: "This morning, I had the opportunity to present ovarian cancer and the conservative management. I discussed how to take care of epithelial ovarian cancer and pointed out that in early epithelial ovarian cancer, both for invasive cancer and for borderline tumors, there definitely is a role for treating conservatively. Thus, permitting patients to be able to have fertility in the future. There are limited studies, and most of them come out of the Italian literature on this particular topic. With regards to germ cell tumors and tumors of stromal nature, I did not present the literature. In fact, this is pretty much well known that conservative management is important. In addition, I think I would like to make some comments on one of the other topics, which was presented this morning by Dr. Bellor from Israel. He outlined the evaluation of the asymptomatic woman with endometrial cancer or with an ovarian cyst. Unfortunately, because of technology that's available, these patients who don't even have symptoms are often being scanned with endovaginal ultrasounds or abdominal ultrasounds. The literature to date unfortunately does not prove that we really can impact or increase the identification of women with the endometrial cancer or with ovarian cancer. So currently, I think, we need to concern our evaluations to patients who are symptomatic. Don't you agree?"
Professor Rami Dgani: "Sure."
Professor Joseph Chambers: "But I think I would like my colleague here, Dr. Dgani, to talk about the other aspects with regard to cervical cancer - Dr. Dgani."
Professor Rami Dgani: "I would like to discuss the conservative approach to cervical cancer in young patients during reproductive years. Professor Jean Claude pioneers this approach, and actually it's done now in a few centers in the world. This approach is consistent of radical surgery, which is conservative on patients with early stages of cervical cancer. The main cervical cancer that is reported is mostly squamous cell cancers that are less than 2 cm in diameter and exophytic on the cervix. This cancer in a young patient with no children or a young patient who is interested in keeping her reproduction protection, we can now consider a new approach, as I stated before. This approach consists of doing a laparoscopic lymphoidectomy, and after the laparoscopic lymphoidectomy the nodes are evaluated by frozen sections. If the frozen section is negative and there are no nodes involved, we can go to the next step in the procedure of doing a radical vaginectomy. This procedure, the radical vaginectomy procedure, is consisting of actually a shortcut procedure - it takes the cervix without the upper 5-mm, and it also takes the parametrium - so it's actually a radical operation on the cervix. We actually keep the round part of the cervix, which is later sutured to the vagina, and by doing this procedure; up to now there were over one hundred procedures like this reported in the literature. There's about twenty-two patients delivered and in some sense this is a very important and a very unusual approach to this cancer in young patients. There's about three or four centers in the world that are doing this approach. I do feel that this interesting approach should be counted on only in a specialized center. Maybe in the future after we have more data, this approach can be adopted by a few other centers in the world."
Professor Joseph Chambers: "One of the important aspects in all of the conservative therapy, which is for young women to preserve fertility either for cervix or ovary, is the psychological counseling that is necessary. Because it turns out when you look at some of the literature, a fair number of women in whom you do this conservative therapy eventually do not get pregnant, have fears, and then eventually have more radical surgery. So that coupled with, I think, long-term follow-ups in patients in whom we're going to do conservative management - is very important to make sure that in the long run it is the appropriate surgery."
Professor Rami Dgani: "I agree with you. We actually summarized the conservative approaches to doing oncology, which is as Professor Chambers indicated, it's very important in these young patients with cervical cancer, ovarian cancer, and also with endometrial cancer. What Professor Chambers didn't mention, and I think it should be added, we know in a few studies in the literature that even in young patients with endometrial cancer can have conservative surgery. If the cancer is early stage with like stage I endometrial cancer, we can probably consider in some very, unusual cases - and I mean very exceptional - we can even consider for these patients doing a conservative surgery by just giving these patients progestin. If after two or three months of hydroprogestin, we do repeat curettage, and the pathology is negative - we can very carefully follow these patients. I don't know if you use this approach, but I think it's something else that should be mentioned."
Professor Joseph Chambers: "I agree, it has to be mentioned, but if you look at the literature on the few large series which generally are around twenty patients each, only about 20%-25% of the patients ever become pregnant in the future because many of the patients have anovulation as the basis of their problem. So you have to be careful, if in fact, infertility is the cause to begin with, progestins may not be the simple solution, but it has been used in a limited number of patients."
Professor Rami Dgani: "It's something to be considered."
Professor Joseph Chambers: "Yes. Thank you."
Professor Rami Dgani: "Thank you very much."