Approximately 80% of cases of cervical cancer are diagnosed at an early stage, when it is amenable to perform radical surgery. Radical surgery is characterized by parametrectomy, which involves the excision of parametrial tissues, including the ventral (the vesicouterine and vesicovaginal ligaments), lateral (the cardinal ligament), and dorsal (the uterosacral and rectovaginal ligaments) parts of parametrial or paracervical tissues. Insufficient excision is associated with an increased risk of cancer recurrence, whereas excessive excision is associated with an increased risk of surgical morbidity. The extent of parametrectomy should be tailored according to the extent of the cancer.

Vulvar cancer is a rare and poorly understood disease. While women with cancers confined to the vulva are generally cured with surgery, metastases to the inguinal lymph node basin are the single most important prognostic indicator and portend a markedly worse prognosis. For the women with multiple positive inguinal nodes, the literature is clear that adjuvant radiation will be required to attempt cure. However, there have been conflicting reports regarding whether or not adjuvant radiation improves survival in women with a single positive node. As groin relapse is almost invariably fatal and there is a large SEER analysis showing benefit to radiation for single node positive vulvar cancer, gynecologic oncologists should err on the side of caution and refer all patients with a positive groin node for adjuvant radiation therapy.

Recently, cancer genetics and molecular profiling have revolutionized epithelial ovarian cancer (EOC) management due to the introduction in the clinical repertoire of therapies directed against specific molecular targets, including PARP inhibitors. While evaluation of BRCA1/2 genes has gained an undeniable role and homologous recombination repair (HRD) analysis is entering into clinical practice, the routine adoption of further molecular profiling is still debated. Even though EOC guidelines do not recommend systematically performing extended molecular panels at diagnosis yet, their routine employment should be considered since they effectively fulfill several purposes. The use of next generation sequencing (NGS) panels not only helps to deeply understand tumor biology, but it also identifies actionable alterations, is an instrument for prediction of prognosis and drug resistance and allows the access in alteration-directed clinical trials. Therefore, based on preliminary evidences, extended molecular profiling, not limited to BRCA and HRD analysis, should be routinely done in EOC.

Two classes of targeted therapies have revealed a progression-free survival prolongation in front-line maintenance in epithelial high-grade ovarian carcinomas: bevacizumab and poly(ADP-ribose) polymerases inhibitors (PARPi). PARPi have demonstrated particular efficacy in patients having BRCA1/2 mutations, or other homologous-recombination repair deficiency (HRD). To date, the question of single maintenance with PARPi versus double maintenance with PARPi + bevacizumab has not been specifically addressed. Three trials (SOLO-1, PRIMA, VELIA) compared PARPi versus placebo without any bevacizumab, and a fourth (PAOLA-1) utilized bevacizumab plus placebo as the control arm comparing it to bevacizumab plus PARPi. In the following article, we support a double maintenance approach with PARPi + bevacizumab in the HRD-positive subgroup based on (i) a never-reached efficiency in this subgroup with bevacizumab+olaparib,better than olaparib alone in a patient-adjusted indirect comparison (ii) a rationale for additive effected (iii) a good safety and cost-effective profile. The FDA and EMA indeed approved double maintenance for HRD-positive patients in 2020.

For recurrent/advanced endometrial cancer (EC), carboplatin in combination with paclitaxel remains the current first-line standard of care globally. In the NRG Oncology/GOG209 phase III trial, the median progression-free survival (PFS) and overall survival (OS) was 13 months and 37 months respectively (NRG/GOG209) [1]. Whilst hormonal therapy (HT) may be the preferred front-line systemic therapy for selected patients with low-grade EC carcinomas without rapidly progressive disease [2], we argue that the efficacy in advanced/recurrent EC post chemotherapy (i.e., chemo-resistant) is limited and alternative options should now be considered in clinical practice.

NACT should be used in women unfit for PDS or those with truly unresectable disease, not just older women. We believe the real question of this debate is how do we safely maximize the number of women ≥75 who are treated with PDS with an optimal resection resulting in the longest survival, while identifying vulnerable women in whom the morbidity of PDS is too great and thus NACT is the better approach. Multiple objective and easy to use tools have been developed to assess a patient’s functional status, something that is rarely represented by chronologic age. We must not forget that clinical trials commonly either do not assess functional status or exclude older women, and the number of trials focusing on the older population is low. An all or nothing approach is never the best answer, especially in the older, commonly more vulnerable, population.

Surgery remains the cornerstone of initial treatment for granulosa cell tumors (GCTs). Postoperative cytotoxic chemotherapy has often been given in attempt to improve cure rate with bleomycin, etoposide, and cisplatin (BEP) being the most widely used postoperative treatment. However, because taxanes are active drugs in GCTs, carboplatin plus paclitaxel (PC) is also considered as a reasonable alternative. In the following article, we support the use of BEP based on (i) bleomycin and etoposide as single agents are the most efficient drugs reported in literature, (ii) carboplatin has never shown equivalence to cisplatin in GCTs, (iii) BEP is the regimen associated with the strongest level of evidence, and (iv) comparison between BEP and PC failed to demonstrate a benefit in favor of PC.

Preoperative nutritional status plays a key role in perioperative outcomes in oncologic patients. For those with nutritional deficits, several weeks of nutritional support may be required to induce meaningful metabolic change, representing an unrealistic surgical delay for many patients. In an effort to address nutritional status in surgical patients over shorter periods of time, enhanced recovery after surgery (ERAS) programs have developed nutritional bundles during the perioperative period. One such component is preoperative carbohydrate loading, which consists of consuming carbohydrate-heavy beverages the night before and the day of surgery. Trials assessing the impact of carbohydrate loading across various surgical subspecialties have had mixed results and have not translated to significant differences in clinical outcomes. While many components of ERAS have proven beneficial, preoperative carbohydrate loading in particular may be “too little, too late” and does not appear to improve outcomes in patients undergoing debulking surgery.

Sentinel lymph node (SLN) biopsy is the standard of care for assessing groin nodes in early-stage vulvar cancer, reducing significant morbidity compared to complete inguinofemoral lymph node dissection (IFLD). Adjuvant radiation therapy continues to be an important treatment for those with positive groin nodes. Although patients with a negative SLN can be observed, those with a positive SLN typically undergo a complete IFLD as the next step in management which can introduce increased surgical morbidity and complications. It is tempting to avoid IFLD and give adjuvant radiation therapy instead, raising question whether radiation is a reasonable management plan when there is a positive SLN. However, the data presented here will demonstrate that at present time surgical resection should not be omitted and should remain the standard of care, as radiation therapy alone in positive macrometastatic groin nodes increases risk of groin recurrence which leads to a dismal prognosis.

Surgery represents the mainstay of treatment for uterine leiomyosarcomas (u-LMS) [1]. Resection of disease without fragmentation and with negative surgical margins seemingly provides survival advantage [1]. For macroscopically uterus-limited disease, total abdominal hysterectomy (TAH) should be considered as the standard management of choice [1]. Uterine leiomyosarcomas usually are discovered as incidental findings after hysterectomy or myomectomy for presumed benign pathology (e.g., fibroid uterus). For peri-menopausal or post-menopausal women, routine bilateral salpingo-oophorectomy (BSO) is usually performed; however, amongst pre-menopausal women with uterus-limited disease, the role of ovarian preservation (OP), as part of the staging process, remains to date a field of contention.

Vulvar cancer is a rare and poorly studied disease. Mainstay of treatment is surgical resection, and it is common for margins to be close (≤8 mm) or positive. Margin status is one of the most important predictors for local recurrence, and local recurrence is tightly associated with poor overall survival. Options for management of a close/positive margin are re-excision or adjuvant radiation. Radiation has been studied for this indication for several decades, and can substantially reduce risk of recurrence in women with a close/positive margin after surgical resection. With excellent efficacy and acceptable side effect profile, radiation therapy is the treatment of choice for women with vulvar cancer at high risk of local recurrence.

Given the limited data on the value of mechanical bowel preparation (MBP) prior to gynecologic surgery, the colorectal data is frequently extrapolated and used to guide preoperative management for patients requiring bowel surgery. Review of the colorectal literature, including a Cochrane Review and large National Surgery Quality Improvement Program database review, demonstrates that the use of MBP does not improve overall mortality, surgical site infection, anastomotic leak rates, or reoperation. As a result, several national and international surgical organizations do not support the use of MBP alone prior to bowel surgery including patients planning gynecologic surgery.

Increasing number of women are delaying childbirth and the incidence of endometrial cancer in reproductive age women is rising. As a result, preserving fertility is an essential component of modern care for women with endometrial cancer. In this chapter, we present current fertility preservation options for women with endometrial cancer, ranging from fertility-sparing surgery to assisted-reproductive technologies. Based on the growing evidence, we conclude that fertility preservation is safe and feasible in young women with early-stage endometrial cancer without compromising the cancer treatment outcome.

Five to 10 percent of endometrial cancer (EC) patients are presented at advanced stage with a poor prognosis. There is no optimal treatment for stage III–IV EC. Combination of chemotherapy and radiation improved survival compared to monotherapy. Although the effect of combination treatment proves to be effective, optimal sequence of treatment is not clear. One approach is the sandwich method (three cycles of chemotherapy followed by radiation and then three more cycles of chemotherapy), other regimes are six cycles of chemotherapy followed by radiation (sequential treatment) or concomitant chemoradiotherapy. There are no randomized trials comparing these regimes but each has its own advantages and also some drawbacks. Either sandwich therapy or sequential regime seems to be reasonable approaches with similar oncologic outcome but sequential regime, particularly for stage IIIC2, is well tolerated with less toxicity and treatment breaks. Despite well-established combination therapies, prognosis of stage IIIC disease is still poor with a high rate of distant recurrences pointing out need for a better systemic therapy.

High-grade endometrial cancers are rare and carry a poor prognosis. Unlike low-grade endometrial histologies, these tend to metastasize regardless of myometrial invasion and uterine factors. Evidence reveals sentinel lymph node mapping (SLN) versus complete lymphadenectomy (LND) for staging is noninferior in terms of detection of metastatic disease and adverse events. Proponents of LND would argue there is limited detection of metastatic disease and decreased therapeutic benefits. Several studies, including prospective trials, reveal high detection rate and sensitivity with SLN. Multiple retrospective cohort studies reveal there is no difference in overall survival and progression-free survival when comparing SLN versus LND. As such, this should be the standard of care for staging patients with high-grade endometrial cancer.

Mucinous carcinomas of the ovary are a rare histologic subtype of epithelial ovarian carcinoma. These tumors occur in younger women and are more likely to be diagnosed when confined to the ovary. While these tumors have traditionally been treated in a manner similar to serous carcinomas, emerging evidence suggests that these tumors are biologically distinct and follow a unique natural history. Women with stage IC mucinous carcinomas have historically been treated with adjuvant platinum and taxane-based therapy. However, in addition to recognize the unique molecular underpinnings of mucinous carcinomas, currently available data suggests that women with mucinous tumors are less likely to respond to chemotherapy and that women with stage IC tumors do not have improved survival when treated with chemotherapy. As such, observation appears to be appropriate in women with stage IC mucinous tumors who have undergone complete resection and surgical staging.

Poly ADP ribose polymerase (PARP) inhibitors have led to a step change in the management of advanced ovarian cancer following the first approval of these inhibitors in 2014. PARP is an enzyme needed for DNA repair and its inhibition results in the accumulation of single-strand DNA breaks. PARP inhibitors were initially hypothesized to have maximum efficacy in ovarian cancer with BRCA1/2 mutations or homologous recombination (HR) deficiency (HRD) ) given the role of these pathways in repairing double-stranded DNA breaks. The accumulation of both single-strand and double-strand breaks would result in synthetic lethality and preferential cancer cell cytotoxicity with BCRA1/2 mutations and HRD being a predictive biomarker of response. Here we present data that patients with recurrent ovarian cancer will benefit from PARP inhibitors, given as maintenance therapy irrespective of BRCA or HR status. This has been shown with olaparib, niraparib, and rucaparib; all three PARP inhibitors are licensed for the treatment of recurrent ovarian cancer following a response to platinum-based therapy in both BRCA-mutant and wild-type patients.

Age is an independent predictor of survival in advanced ovarian cancer. However, inadequate therapy appears to be a driver for decreased survival among elderly patients with cancer. Multiple randomized control trials have demonstrated equivalent oncologic outcomes with neoadjuvant chemotherapy compared to primary cytoreduction with reduced perioperative complications and mortality, decided by a gynecologic oncology surgeon. A national database study demonstrates an improvement in the receipt of both surgery and chemotherapy over time with high adoption of NACT contributing to an improvement in outcomes. In an elderly population, NACT results in a 70% reduction in perioperative mortality. All patients 75 years of age or older with one medical co-morbidity are the highest risk group for postoperative mortality (average 30-day post-operative mortality of 13% with primary surgery). These patients likely will benefit the most from NACT and should be considered routine practice for elderly patients with advanced ovarian cancer.

The results of the LACC trial, along with numerous observational studies, demonstrating worse disease-free survival and overall survival when performing minimally invasive radical hysterectomy have led NCCN, ESGO, ESMO, and FIGO guidelines to support the open approach when performing radical hysterectomy for early cervical cancer. Some have suggested avoiding use of uterine manipulator or performing vaginal protective maneuvers to avoid tumor spillage; however, these recommendations are based on retrospective observations in studies where evaluation of those factors was not the primary objective nor were they powered to answer such questions. Until further evidence, open radical hysterectomy should be the standard of care.