Surgical Management of Gynecologic Cancer
Staging is surgical, but the required operation differs by site
Ovarian cancer staging for apparent early disease requires an adequate midline laparotomy, total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, pelvic and para-aortic lymphadenectomy, peritoneal biopsies from multiple sites, and washings. Incomplete staging is a common reason for reoperation and for upward stage migration. Endometrial cancer surgery is total hysterectomy with bilateral salpingo-oophorectomy plus careful abdominal exploration; sentinel lymph node mapping with indocyanine green has largely replaced routine full lymphadenectomy for apparent uterine-confined disease. If mapping fails on a side, a side-specific lymphadenectomy is performed. Omentectomy is not routine for low-grade endometrioid tumors but is indicated for serous, clear cell, and carcinosarcoma histologies. Cervical cancer: cone biopsy alone for stage IA1 without lymphovascular space invasion; radical hysterectomy with pelvic lymphadenectomy for early-stage disease, with radical trachelectomy as a fertility-sparing option in carefully selected small tumors. Vulvar cancer: radical local excision with a gross margin of about 1 cm; sentinel node biopsy for unifocal tumors under 4 cm with clinically negative groins, otherwise inguinofemoral lymphadenectomy.
Traps
Tumor rupture or spill upstages ovarian cancer; morcellation of a suspected malignancy is contraindicated; lymphadenectomy in endometrial cancer does not improve survival but changes adjuvant therapy; sentinel node interpretation requires ultrastaging and a learning curve.
Worked example
A 55-year-old with biopsy-proven grade 1 endometrioid cancer and no myometrial invasion on MRI undergoes hysterectomy with sentinel node mapping. If no node is identified on the left, perform a left-sided lymphadenectomy rather than assuming node-negative status.