Gynaecological Oncology Program

These form more than one third of all cancers in women in India. The Nanavati Max Institute of Cancer Care is a centre of clinical and surgical excellence for treatment of Gynaecological cancers, backed by the expertise of a highly experienced and specialized team of senior highly qualified Gynaecologic Oncologists, radiation oncologists, medical oncologists, oncopathologists, radiologists, interventional radiologists, nuclear medicine specialists, geneticists etc. and supported by a highly specialized and state of the art infrastructure, working towards ensuring the best outcomes for all patients afflicted with gynaecological cancers.

What Are Gynaecologic Cancers

The gynaecological malignancies represent complex malignancies that affect female reproductive organs, like uterus, ovaries, cervix, vagina, and vulva (external genitalia). We are a tertiary care high volume centre that provides a comprehensive, evidence-based, multidisciplinary, individualized treatment aimed at ensuring the most optimum outcomes in terms of improved cure rates with reduced morbidity; and organ, function, fertility preservation in suitable patients thereby providing a good quality of life to the patients.

We specialize in complex surgical procedures and multiorgan resections for gynaecological cancers. We also offer robotic surgery with the state of the art Da Vinci Xi robot as well as laparoscopic surgery for management of gynaecological cancers where indicated. We are one of the few centres in India to offer ultraradical cytoreductive surgical procedures for ovarian and endometrial cancers. In addition, HIPEC (hyperthermic intraperitoneal chemotherapy) is offered to suitable patients with ovarian cancer following surgery to augment the survivals. The emphasis is on a multidisciplinary approach for optimizing outcomes.

Our centre also specializes in Cancer Prevention strategies through the Preventive Oncology Clinic where women are counseled regarding cancer prevention, lifestyle modification, genetic counseling and undergo clinical examination and suitable imaging for early detection of cancer. Supportive and nursing care by our specialized nursing staff and physiotherapy and occupational therapy departments is also play an integral part of in rehabilitation of our patients after completion of treatment.

Types of gynaecological cancers:

There are several types of Gynaecological cancers, depending on the organ of origin. They are as follows:

• Cervix cancer:

  Second most common cancer in women in India after breast cancer. Every year 1.2 lakh women are newly diagnosed and 77,000 die due to this cancer. It is known to be caused by the Human Papilloma Virus (HPV). It is a largely preventable cancer with lifestyle changes, vaccination and regular screening. It is asymptomatic in precancer stage and in early stages.

• Uterine (Endometrial) cancer:

  Incidence of uterine cancer is increasing in India especially in younger women. Majority of cases are diagnosed at an early stage due to early symptoms of abnormal vaginal bleeding and hence prognosis is good in most cases. Obesity and hormonal imbalance are main contributing factors for uterine cancer. There are some high-risk histological variants which need to be treated aggressively, with multimodality treatment.

• Ovarian cancer:

  It is the most lethal gynaecological cancer and is often diagnosed in advanced stages. It needs aggressive treatment in the form of ultraradical cytoreductive surgery, HIPEC when indicated and combination chemotherapy to achieve optimum outcomes. Family and personal history of ovarian, breast or uterine cancers is an important risk factor. Genetic testing for genetic mutation in BRCA 1 & 2 is an integral part of treatment of ovarian cancer. Targetted therapy and immunotherapy are the novel therapies, which have shown promising results.

• Germ Cell Tumours:

  These are types of ovarian cancer seen predominantly in younger age group. If treated properly, it has very high cure rates even in advanced stages. Fertility can be conserved in majority of cases, with preservation of quality of life post-treatment.

• Vulvar cancer:

  Vulval cancer develops in the external genitalia of women. It is also related to HPV infection and is predispose by certain skin conditions like lichen sclerosis, leucoplakia, Paget’s disease in the vulvar area. Majority of these are treated with conservative surgery with preservation of normal anatomy and sexual function.

• Vaginal cancer:

  It is an uncommon cancer, which is mainly treated by radiation therapy. The Melanoma type of vaginal cancer can be very aggressive and needs urgent treatment.

• Gestational trophoblastic neoplasms:

  This is an uncommon cancer seen mainly after a pregnancy event like molar pregnancy, abortion or rarely after full term live birth. Main symptoms are persistent vaginal bleeding after the pregnancy event. It is highly curable even in metastatic stage but needs prompt management, with the preservation of fertility in the majority.

Symptoms:

While the symptoms of each of these cancers are specific, there are several common symptoms and signs, which may indicate the presence of these cancers, viz.

• Abnormal vaginal bleeding (heavy menstrual bleeding, bleeding between 2 periods, bleeding after intercourse, irregular menses)
• Bleeding or spotting after menopause – even a single episode needs to be investigated.
• Bleeding after intercourse
• Abnormal vaginal discharge – especially blood stained, brownish or fouls smelling
• Abdominal, pelvic pain or backache of recent origin
• Abdominal distension or bloating
• Early satiety – feeling full after consuming small quantities of food
• Nausea, vomiting, change in bowel habits eg constipation or diarrhoea
• Abdominal or pelvic mass
• Swelling (oedema) of the lower extremities
• Itching, growth, ulceration, pain or discolouration of external genitalia
• Difficulty in passing urine, frequency of urination, blood in the urine
• Lump or swelling in the groin
• Cough, breathlessness, blood in the sputum
• Loss of appetite
• Sudden or unexplained weight loss
• Weakness, fatigue

Causes:

Although the precise cause is not known, there are certain associated factors or conditions that predispose to these cancers.

• Human papilloma virus (HPV) infection
• Hormone replacement therapy without medical supervision
• Obesity
• Tobacco use or smoking
• Family history or personal history of breast, ovarian, uterine or large intestine cancer
• Poor genital hygiene
• Immunocompromised states eg HIV infection, post-transplant patients
• Endometriosis
• Polycystic ovarian syndrome
• Use of tamoxifen for treatment of breast cancer

Treatment options:

The management of gynaecological cancers is multimodal, with surgery as the mainstay of treatment, supported by systemic chemotherapy or immunotherapy and radiation therapy.

Surgery:

Surgical treatment of gynaecological cancers is often complex and requires a high degree of expertise, skill, precision, and experience. Early stage endometrial cancers can be managed by advanced robotic surgery, which reduces the recovery time and hospital stay; and ensures a faster return to full daily activities.

Our surgical team has a huge experience in treating these cancers for over 35 years, with excellent outcomes. In fact, one of our Gynaecologic Oncologists has been an important member of the team that has pioneered these surgeries and other treatment approaches in India. Our team has among the largest experience in ultraradical cytoreductive surgeries for advanced stage ovarian and endometrial cancers, with good survival outcomes and minimal morbidity. Many patients from across the country and abroad that need extensive or complex surgical options for Gynaecological cancers are referred to our centre for surgical treatment. Our focus is also on organ, function and fertility preservation through conservative surgery (for ovarian cancer in young and vulval cancer) or with use of non-surgical modalities of treatment (cervical and vaginal cancers).

At our centre, we offer a comprehensive array of surgical interventions including but not limited to the following:

Cervical cancer:

• Radical Hysterectomy for early stage cancer
• Exenterative surgery for Selected patients with recurrent cervical cancer
• Conization and ablative procedures for precancerous or preinvasive lesions

Uterine cancer:

• Total hysterectomy with bilateral salpingo-oophorectomy and tailored lymph node dissection (Open, laparoscopic or robotic)
• Complete pelvic and para-aortic lymphadenectomy up to renal hilum
• Ultraradical cytoreductive surgery in advanced uterine cancer
• Uterine sarcoma

Ovarian cancer:

• Surgical staging
• Primary Cytoreductive surgery
• Interval Cytoreductive surgery
• Secondary cytoreductive surgery
• Ultraradical surgery with multiorgan resections
• Bowel resections, diaphragmatic stripping or excision
• Extensive lymphadenectomy
• Peritonectomy
• Resection of liver or splenic metastatic lesions, followed by HIPEC in suitable patients

Germ Cell Tumour:

• Conservative fertility-sparing surgery with preservation of normal contralateral ovary and uterus

Vulval cancer:

• Wide local radical excision
• Hemivulvectomy
• Radical vulvectomy
• Therapeutic inguino-iliac lymph node dissection
• Prophylactic modified groin node dissection
• Reconstructive surgery for preservation of normal vulval anatomy

Risk reducing surgery:

• These are for patients at high risk of ovarian or uterine cancer based on positive family history and specific genetic mutations – prophylactic bilateral salpingo-oophorectomy with or without hysterectomy

Preventive Procedures:

• Cervical screening
• Pap smear
• HPV test
• Liquid based cytology
• LEEP procedure
• Ablative procedures
• Conization

Systemic chemotherapy:

Chemotherapy involves the use of a combination of drugs that make the existing tumours smaller by killing the cancer cells and/or prevent the growth of new cancer cells. Since these drugs are injected into the bloodstream, they reach all parts of the body and act on cancer cells even at sites distant from the primary tumours. In gynaecological cancers management, chemotherapy is used either before surgical treatment or after surgical treatment to improve the outcomes. It can also be used with radiation therapy in cervical and vaginal cancers treatment. It is the main line of treatment when the cancer has spread to distant organs.

Radiation therapy:

External radiation is the main line of treatment in advanced cervical and vaginal cancer and sometimes in vulval cancers if surgery is not possible. It is given as an adjuvant treatment after surgery in uterine and early-stage cervical cancers. Internal radiation requires expertise and experience and is routinely given at our centre for cervical and vaginal cancers by highly experienced radiation oncologists. With modern radiotherapy machines and advanced techniques of radiation delivery, the results of radiation therapy in properly selected patients are good in terms of survival and side effects.

Immunotherapy:

This boosts the patient’s own immune system to target and destroy cancer cells. It is now being increasingly used in the treatment of ovarian, endometrial, and cervical cancers.

Other novel therapies:

Targeted drug therapy implies the use of drugs that target specific molecular targets associated with certain cancers, e.g., in ovarian cancer, PARP inhibitors are used to improve survival outcomes.