Overview of gastrointestinal complications including constipation, diarrhea, nausea, and vomiting, feeding tube complications, bowel perforation and obstruction, and neutropenic enterocolitis

Overview of gastrointestinal complications including constipation, diarrhea, nausea, and vomiting, feeding tube complications, bowel perforation and obstruction, and neutropenic enterocolitis

Defines terminology, an overview of cancer types, modes and locations of metastasis, cancer statistics, and treatment modalities.

description, overview, and treatment guidelines for chemotherapy extravasation in cancer patients

Overview of toxicities related to immunotherapy agents, and other complications in the lymphatic system such as tumor lysis, hyperviscosity syndrome, graft vs host disease, and neutropenic fever

Overview of cardiac complicationsincluding arrhythimias, heart failure, acute coronary syndrome, disseminated intravascular coagulation, hyperviscosity syndrome, and pulmonary embolism

Uterine leiomyosarcoma (uLMS) is a relatively rare uterine cancer that behaves aggressively, with high lethality, even in the setting of early-stage disease at diagnosis. Given the propensity for metastases even in apparent early-stage disease, and relative resistance to chemotherapy and radiation, uLMS remains a challenge to treat. In recent years, targeted therapies have been assessed in an effort to provide additional management options to reduce recurrence and improve survival. However, while clinical trials have shown targeted therapies to have activity in uLMS, survival benefits have not been observed. Given the overall meager impact of systemic therapy and radiation on survival in uLMS, surgical management remains an important component of multi-modality treatment.

It is 2021 and conferences around the world still debate the pros and cons of mechanical bowel prep (MBP). It is baffling how a safe intervention used millions of times every day for screening colonoscopies is a subject of fierce discussions amongst colleagues, in book chapters, and lectures when applied to patients undergoing colorectal resection. Although we believe that for patients with advanced ovarian cancer undergoing cytoreductive surgery there are other quintessential questions to debate about, we understand that the debate over this issue is far from resolved and expert majority opinion has vacillated over the past decade. With all this in mind, as a disclaimer the authors are allowed to change their minds.

Cervical cancer is the fourth most commonly diagnosed and one of the deadliest cancers in women worldwide. There is an urgent need for more active treatments and rationally designed targeted therapies for advanced disease. Recently, immunotherapy has been proven to be effective in several solid tumors. There are few phase I/II studies in advanced or recurrent cervical cancer patients, no quality of life analysis in the studies, limited objective responses, and no clear superiority over second-line chemotherapy, but certainly more expense. Therefore, currently there is no role of immunotherapy in treatment of cervical cancer.

Epithelial ovarian cancer (EOC) remains the leading cause of gynecologic cancer death in the United States, with most women diagnosed with advanced-stage disease. The peritoneal cavity is a primary source of spread of this disease at initial presentation and failure at the time of recurrence. While the standard of care remains surgical cytoreduction with platinum and taxane chemotherapy, ovarian cancer’s natural history and disease distribution lend itself toward intraperitoneal chemotherapy. There are data in animal models that demonstrate improved distribution of drug, higher intra-tumoral concentrations, and increased DNA adduct formation when platinum drugs are administered directly into the peritoneal cavity (IP) as compared with intravenous administration (IV). Importantly, there are a number of landmark clinical trials that have established IP chemotherapy as superior to IV chemotherapy in women with newly diagnosed advance EOC with statistically significant improvement in both progression-free survival and overall survival. Despite clearly improved outcomes, a minority of women with EOC are receiving IP therapy.

Leiomyosarcomas (LMS) of the uterus are rare, aggressive malignancies with high rates of recurrence. Both uterine leiomyoma and LMS share common presenting symptoms; because of this, the diagnosis of uterine LMS is commonly made upon pathology evaluation after myomectomy or hysterectomy for suspected benign disease. Uterine LMS commonly expresses estrogen (ER) and progesterone (PR) receptors. However, the role of oophorectomy in premenopausal women with uterine LMS remains controversial. Based on the current literature, there appears to be no added benefit of removing bilateral ovaries following the diagnosis of early stage uterine LMS in premenopausal women. In addition, there remains minimal data demonstrating any increased risk of recurrence or tumor growth following ovarian preservation in this patient population. If the ovaries are preserved, close long-term follow-up is important.

Intra-observer variability in defining clinic-pathologic risk factors and the heterogeneity of outcomes has led to challenges in defining the optimal management for endometrial cancer (EC) patients. The Cancer Genome Atlas identification of four distinct molecular subgroups has greatly enhanced our understanding of the biology of EC. Integration of histo-molecular information provides more accurate characterization of disease subgroups and prognosis. This facilitates prognostication and optimization of adjuvant therapy decisions, avoiding the potential for both under and over treatment. Molecular profiling also delivers the potential to predict therapy response and define the optimal approach for a given disease subtype in both adjuvant and recurrent disease settings. We can also more accurately to identify patients and families with Lynch syndrome and institute risk reducing measures. Molecular profiling facilitates more precise and accurate management of our patients with EC and it should become integrated into routine care.

Patients with early-stage granulosa cell tumors (IA or IB) may be treated with surgical therapy alone and expect an excellent prognosis. Patients with stage IC or greater disease, recurrent granulosa cell tumors, and sub-optimally reduced disease may benefit from adjuvant chemotherapy. The type of adjuvant chemotherapy has been controversial and varies based on clinical guidelines. The National Comprehensive Cancer Network (NCCN) guidelines recommend platinum-based chemotherapy and endorses paclitaxel and carboplatin (PC), etoposide and cisplatin, or bleomycin, etoposide, cisplatin (BEP). In this debate the following article, we prefer the authors support the use of paclitaxel plus carboplatin based on (1) BEP lacks durable activity, (2) PC demonstrates favorable outcomes in a retrospective analysis, (3) PC has a better safety profile compared to BEP, (4) the dosing regimen for PC is more convenient, and (5) there is insufficient data comparing PC to BEP.

“Sandwich” adjuvant therapy (radiation therapy sandwiched between six total cycles of chemotherapy) for Stage IIIC endometrial cancer evolved as a solution to reduce distant recurrence and minimize locoregional recurrence while limiting toxicity in order to achieve optimal therapeutic dosing of both radiation and chemotherapy. Multiple retrospective and prospective analyses show superior survival outcomes and acceptable tolerability with “sandwiching” radiation between chemotherapy. A prospective randomized trial including a treatment arm in which chemotherapy is given before radiation or sequenced in a “sandwich” fashion to maximize local and systemic control is necessary to determine the optimal adjuvant therapy for Stage IIIC endometrial cancer.

Uterine papillary serous cancer (UPSC) is commonly more aggressive than the endometrioid subtype and accounts for more than 50% of endometrial cancer deaths annually. Despite the known increased aggressiveness and risk of relapse in USPC, a standardized treatment paradigm for early-stage disease confined to the endometrium remains lacking. Literature is currently limited to small series and retrospective reviews. Various studies have demonstrated no difference in recurrence rates in patients with stage IA UPSC without myometrial invasion who received adjuvant therapy versus those observed. These studies also found that observation alone renders a favorable prognosis in patients with stage IA USPC without myometrial invasion and therefore, these patients may not routinely need to receive adjuvant therapy. Additional answers likely lie within an improved molecular understanding of this disease which can shed light on future directions and individualized treatment strategies.

The endocrine and immunologic systems demonstrate pronounced derangements in response to surgical stress. Such responses are exacerbated by a fasting state and correlate with surgical complexity. Proven reductions in insulin resistance provide the physiologic rationale for the use of oral carbohydrate loading prior to surgery. While evidence of clinical benefit is of low to moderate quality, preoperative carbohydrate loading is neither costly nor labor intensive, improves patient satisfaction and well-being, and should be incorporated into Enhanced Recovery After Surgery protocols given the very low risk of harm. Recognizing the high surgical complexity of cytoreductive surgery in patients with ovarian cancer and the high incidence of mild to moderate nutritional compromise, these patients may have comparatively more to gain from carbohydrate loading. ERAS® Society guidelines for gynecologic surgery provide a strong recommendation grade for preoperative carbohydrates up until two hours prior to induction of anesthesia.