Vesna Kesic

Clinical recommendation radical trachelectomy for fertility preservation in patients with early-stage cervical cancer.

Abstract Radical trachelectomy (RT) is a fertility-sparing procedure with the aim to provide adequate oncological safety to patients with cervical cancer while preserving their fertility. In the current review, indications, development of the procedure, technical aspects, preoperative and postoperative management, and oncological, fertility, and obstetric outcomes are discussed and studied with respect to whether the procedure is performed abdominally or vaginally. Complications of RT, staging, and more conservative alternatives to RT are discussed as well. A systematic MEDLINE search was performed, which yielded 218 articles, of which 75 were selected for further analysis based on the number of patients and the quality of the study. Strict morphologic criteria should be applied to the candidates to maintain oncological safety. When limited to a tumor less than 2 cm in diameter, the overall recurrence rate after vaginal RT is 3% to 6% and the death rate is 2% to 5%. Data on fertility and obstetric outcome are mostly based on the results of patients who underwent vaginal RT. More data are needed to be able to draw the same conclusions for abdominal RT. Fertility seems not to be decreased, but the risk for premature delivery is 2 to 3 times higher compared to women with an intact cervix. In locally advanced cervical tumors with a diameter larger than 2 cm, neoadjuvant chemotherapy followed by RT may be offered after explaining the experimental nature to the patient. In conclusion, RT is an oncologically safe technique in women with early invasive cancer. The rate of term pregnancies still needs improvement. Fertility-preserving treatment of women with tumors larger than 2 cm in diameter can be done by combining neoadjuvant chemotherapy and trachelectomy; however, experience is still limited.

Cervical Cancer Burden and Prevention Activities in Europe

Cervical cancer is an important public health care problem in Europe. The overall incidence rate of cervical cancer in Europe is 10.6 per 100,000. However, within Europe, the incidence rates significantly differ, being lower in Western Europe where prevention programs are better developed. Significantly higher are the incidence and mortality rates in Central and Eastern Europe, being in close correlation to the intensity of organized screening. Human papillomavirus (HPV) vaccines are being delivered to the low-incidence populations that already have extensive screening programs, whereas the high-incidence countries have not implemented the vaccination programs yet. The resolution of the problem of cervical cancer control in Europe will be a matter of the implementation of public health care programs across the whole continent. Cancer Epidemiol Biomarkers Prev; 21(9); 1423–33. ©2012 AACR.

Retroperitoneal round-cell liposarcoma associated with paraneoplastic pemphigus presenting as lichen planus pemphigoides-like eruption

A 59‐year old Caucasian woman refugee from Bosnia had been in good health until a year before admission, when she developed painful erosions and ulcerated lesions in the mouth, anogenital area, hands, and feet. Treatment with topical and systemic antibiotics, acyclovir, and antifungal creams was ineffective. Three months before admission, her skin and mucosal lesions had worsened, resulting in the limitation of walking and her daily activities. She had also experienced significant weight loss.

Communications about cervical cancer between women and gynecologists in Serbia

SummaryObjective:The age-standardized incidence rate of cervical cancer in Serbia is 27.2 per 100,000 women, i. e., twice as high as in western European countries. This paper explores the communication which occurs between women and gynecologists in Serbia in relation to cervical cancer screening.Methods:Our study was conducted in two phases: a qualitative phase (focus group discussions and in-depth interviews with women) and a quantitative phase (community-based survey). This paper reports the findings from both phases, and in particular, the in-depth interviews with 22 women with different socio-economic backgrounds residing in the capital city and a regional town. To illustrate women’s experiences and attitudes, we used interview excerpts.Results:Our findings indicate that there is poor communication between women and gynecologists and an absence of proper counseling. Women’s lack of knowledge about reproductive health issues, poor attitudes of gynecologists, and personal barriers that women experience in accessing health care render preventive practices a low priority both for women and gynecologists.Conclusion:We recommend different educational and organizational strategies that may improve the counseling skills of gynecologists and ultimately reduce the prevalence of cervical cancer in Serbia.

ESGO Statement on the Role of CA/125 Measurement in Follow-Up of Epithelial Ovarian Cancer

T he recent publication of the OV05/EORTC 55955 study on the use of Cancer Antigen 125 (CA-125) in the followup of patients with ovarian cancer after primary treatment has challenged the assumed advantage of early detection of recurrent disease on the basis of a CA-125 rise. This study suggests that despite earlier initiation of second-line treatment, there is no survival benefit. Publication and subsequent review of these European data gave rise to a generalized conclusion that CA-125 monitoring should be abandoned routinely for disease monitoring after treatment. In an accompanying paper in this issue, a European Society of Gynaecological Oncology (ESGO) consensus group has reviewed current data on the use of CA-125 in the follow-up of patients with ovarian cancer. As the conclusions of the OV05/EORTC 55955 study are only applicable for a particular group of patients with ovarian cancer, there is a danger that the conclusion that CA-125 follow-up does more harm than good is also extended to patients that would or could possibly benefit from CA-125 follow-up. The ESGO therefore advises that the use of CA-125 should not be universally abandoned in the routine follow-up of all patients with ovarian cancer. We recommend to consider CA-125 follow-up in the following cases: Patients after complete response on primary treatment for epithelial ovarian cancer who: & have been or are being treated as part of a clinical trial; & are considered for (future) studies on second-line treatment; & will not have routine (3 monthly) follow-up including regular imaging; and & are eligible for secondary surgery at recurrence.

ESGO statement on cervical cancer vaccination

In 2004, almost 31,000 women in the EU25 were diagnosed with cervical cancer and 14,000 died from the disease. Assuming that the proportion of uterine cancer of cervical origin in the 12 countries not belonging to the European Economic Area was similar to that in the ten new European Union (EU) member states brings us to a rough estimate of 52,000 cases and 27,000 deaths for the whole European continent. Despite screening for early detection, cervical cancer remains the second most common cause of death from cancer (after breast cancer) among young women (aged 15–44 years) in EU countries. It is currently estimated that systematic cytological screening of the cervix can reduce death rates from cervical cancer by 70%. Unfortunately, the benefits of screening have not been available to countries in the developing world, where 80% of cases and deaths from cervical cancer occur, due to lack of resources, and this has been disastrous for women in these countries. In Western Europe, the coverage of cervical cancer screening ranges from 27% in Spain to 93% in Finland. Unfortunately, the high-risk group of patients is often not covered by the screening programs. By the end of the 1980s, a substantial degree of knowledge on human papillomavirus (HPV) had accumulated: the DNA of specific HPV types was consistently found in cervical cancer biopsies throughout the world, and it was established that these genes were essential for the maintenance of the malignant phenotype of cervical cancer cells. HPV infections are both extremely common and readily transmitted between sexually active adolescents and young adults. Prevalence studies in adolescent or college-aged women report that at any single point in time approximately 20–25% are HPV DNA positive. After 2–3 years of follow-up, the cumulative detection of HPV in the sexually active young women in the Western world is as high as 60–80%. Today, it is firmly established that the so-called high-risk infections cause almost all (99.7%) cervical cancers and that the association applies equally to both squamous cell and adenocarcinoma worldwide. HPV 16 and 18 are the most common causing types responsible for 71.5% of all cervical cancers in Europe. The identification of these cancer-provoking virus infections paved the way for preventive vaccines against primary high-risk HPV infections, intended to act as a vaccine against cervical cancer. Vaccines using viruslike particles were developed against HPV 16 and 18 and also against the HPV types 6 and 11 causing genital warts. Large-scale trials in women proved the preventive potential of these vaccines against HPV 6, 11, 16, and 18 infections and the development of premalignant cervical disease caused by these viruses. Combined studies include more than 30,000 vaccinated children, adolescents, and adults, all without serious adverse events. While actual cancer events will not be measurable for several decades, HPV infection and the development of precancerous cervical lesions are appropriate surrogate biologic end points. The first cervical cancer vaccine was licensed in the United States in June 2006 and in the EU in September 2006. To date, it is licensed in over 55 countries worldwide. Vaccination programs to prevent cervical cancer have so far been instigated and funded in the United States, Canada, Australia, and some EU countries. Organizations such as the US Advisory Committee on Immunization Practices, the Society of Gynecologic doi:10.1111/j.1525-1438.2007.01129.x

Training in Bowel and Upper Abdominal Surgery in Gynaecological Oncology European Society of Gynecological Oncology (ESGO) Statement

To the Editor: I n contrast with the treatment of other gynecological malignancies, the radicality of surgery for advanced ovarian cancer is increasing. The significance of complete cytoreduction for survival has been well documented in many observational studies, and recently, the principle has been confirmed by prospective randomized trials.3,4 The achievement of no residual disease in the pelvis and abdomen requires extensive debulking of upper abdominal disease in more than one third of the patients and bowel resections in up to 60% of them. Making high-quality surgery accessible to all patients currently presents an important challenge for gynecological oncology. The situation about the quality and complexity of surgical treatment of advanced ovarian cancer shows a high degree of variation across Europe.7 Existing differences are well presented in a survey, which is published in this issue.8 Colorectal resections, splenectomies, or procedures on diaphragm are already performed by gynecological oncologists in growing proportion of the centers without well-established postgraduate training. Postgraduate training should always reflect relevant evidence-based data and development in clinical practice. Surgical training in gynecological oncology must take into account new requirements for the treatment of ovarian cancer and implement training in selected procedures of bowel and upper abdominal surgery. In large gynecological on cology centers, it is currently easier to offer an adequate volume of bowel resections for postgraduate training than it is in performing radical hysterectomies or pelvic exenterations, the latter procedures being required by current logbooks. In the United States, the American Board of Obstetrics and Gynecology already presents the list of procedures required for training in gynecological oncology, including 12 gastrointestinal procedures, among them resections and re-anastomosis of small and large bowel (http://www.abog.org/ publications). Traditional curricula in European countries without a training program in extended abdominal surgical procedures constitute a significant barrier to the development of the discipline and to achieving ultimate quality care. Training in selected bowel and upper abdominal procedures should be part of the gynecological oncology curriculum. This process will rather stimulate than replace the interdisciplinary cooperation, which shall always be necessary in complex cases. This statement represents an opinion of the ESGO Council. It reflects recent changes in the requirements for the surgical treatment of advanced ovarian cancer. It promotes the introduction of selected bowel and upper abdominal procedures into the postgraduate training in gynecological oncology and supports the role of gynecological oncologist in its performance.

Sister Society Meeting on Global Education Development and Collaboration: Meeting Report.

Objectives To identify common barriers to teaching and training and to identify strategies that would be useful in developing future training programs in gynecologic oncology in low- and middle- income countries. Methods There is a lack of overall strategy to meet the needs of education and training in gynecologic oncology in low- and middle- income countries, the leaderships of sister societies and global health volunteers met at the European Society of Gynecologic Oncology in October 23, 2015. The challenges of the training programs supported by gynecologic oncology societies, major universities and individual efforts were presented and discussed. Strategies to improve education and training were identified. Results Major challenges include language barriers, limited surgical equipment, inadequate internet access, lack of local support for sustainability in training programs, inadequate pathology and radiation oncology, finance and a global deficiency in identifying sites and personnel in partnering or developing training programs. The leaderships identified various key components including consultation with the local Ministry of Health, local educational institutions; inclusion of the program into existing local programs, a needs assessment, and the development of curriculum and regional centers of excellence. Conclusions Proper preparation of training sites and trainers, the development of global curriculum, the establishment of centers of excellence, and the ability to measure outcomes are important to improve education and training in gynecologic oncology in low- and middle- income countries.

Prevention of Cervical Cancer in Central and Eastern Europe and Central Asia: A Challenge for the Future

Cervical cancer is frequently referred to as a disease of disparity. urope is not an exception. This is clearly illustrated when comaring cervical cancer incidence and mortality between Western nd Eastern Europe. The overall incidence rate of cervical cancer n Europe is 10.6/100,000 [1]. However, the incidence rates for entral and Eastern Europe are more than twice as high as in Westrn Europe (16.6 and 6.9/100,000 respectively—estimation for the ear 2008) [1]. Fifteen countries with the highest incidence of cerical cancer in Europe belong to Central and Eastern Europe [1]. ome of the countries in these two regions have incidence rates ver 20/100,000 (Romania, Bulgaria, the Former Yugoslav Republic FYR) of Macedonia, Serbia and Lithuania), in some regions and ome age groups reaching over 40/100,000. Cumulative risk for etting the disease before 75 years of age in Eastern Europe is 4–5 imes higher when compared with Western and Nordic countries 1]. Higher incidence rates are also observed in Russian Federaion and countries of the former Soviet Union (above 17/100,000 in rmenia and Republic of Moldova) with the highest rates being eported in Central Asia (Kazakhstan 19.1/100,000 and Kyrgyztan 26.5/100,000) [1]. Additionally, there is an increasing trend of ncidence and mortality from cervical cancer in several countries [2] and Bray F et al., Vaccine, this issue [3]). This Regional Report describes HPV-related cancer epidemiolgy and cancer control efforts, including screening and vaccination, n Central and Eastern Europe and Central Asia (CEECA). It compares nd contrasts prevention efforts in 28 countries from CEECA (Fig. 1). e defined Central and Eastern Europe as the region comprising 6 countries: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, zech Republic, Estonia, Hungary, Latvia, Lithuania, Montenegro, oland, Romania, Serbia, Slovakia, Slovenia, and FYR of Macedonia. he second region targeted comprises the Russian Federation, three estern Countries of the former Soviet Union: Belarus, Republic f Moldova and Ukraine, and 8 countries in the Caucasus region nd Central Asia: Armenia, Azerbaijan, Georgia, Kazakhstan, Kyryzstan, Tajikistan, Turkmenistan, and Uzbekistan. Several factors contribute to the regional differences in cervial cancer rates and their trends. Cancer of the cervix is related o sexual activity. Infection with oncogenic types of human papilomaviruses (HPV) is central to the etiology and considered to e the necessary (although not sufficient) etiological factor. The revalence of HPV infection differs within Europe, being in close orrelation with the incidence of cervical cancer. In Eastern Europe, he prevalence (21.4%) is much higher than in the other parts of urope (Western Europe 9.0% and Northern Europe 10.0%). This ate is comparable with rates of Sub-Saharan Africa (24.0%), and

Psycho-Oncology Structure and Profiles of European Centers Treating Patients With Gynecological Cancer

Objective Psycho-oncological counseling should be an integrated part of modern cancer therapy. The aim of this study was to assess the structures and interests of psycho-oncology services within European Society of Gynecological Oncology (ESGO) centers. Methods In 2010, a survey, which consisted of 15 questions regarding organization of psycho-oncological services and interests in training and research, was sent to all ESGO-accredited centers (n = 41). Results The response rate was 65.8% (27 centers). 96.3% (n = 26) of the surveys came from universities, and 3.7% (n = 1) came from nonacademic institutions. Most of the institutions (92.6%, n = 25) offer psycho-oncological care, mainly by psychologists (64%, n = 16) or psycho-oncologists (48%, n = 12). Fifty-two percent of patients are evaluated for sexual dysfunction as sequelae of their disease or treatment-related adverse effects. Fifty-two percent (n = 14) of institutions offer psychological support for cancer care providers. Eighty-five percent (n = 23) of all centers are interested in psycho-oncological training, and the preferred teaching tools are educational workshops (87%). The main issues of interest are sexual problems in patients with cancer, communication and interpersonal skills, responses of patients and their families, anxiety and adjustment disorders, and palliative care. Eighty-five percent (n = 17) of the 20 institutions look for research in the field of psycho-oncology, and 55% (n = 11) of those are already involved in some kind of research. Conclusions Although psycho-oncological care is provided in most of the consulted ESGO accredited centers, almost 50% of women lack information about sexual problems. The results of the survey show the need for and interest in psycho-oncology training and research, including sexual dysfunction. Furthermore, psychological support should be offered to all cancer care providers.