Gynecologic Oncology in Istanbul: Women’s Cancer Surgery

What is gynecologic oncology?

Gynecologic oncology is the subspecialty that covers diagnosis, surgical treatment and multidisciplinary planning of cancers and pre-cancerous diseases of the female reproductive organs. Cancers of the ovary, fallopian tube, uterus (endometrium), cervix, vulva and vagina fall within this field. Treatment is rarely one thing: surgery, chemotherapy, radiotherapy and targeted treatment are sequenced according to the type and stage of the disease.

Which are the gynecologic cancers?

Which symptoms should be assessed?

The complaints below are often due to benign causes, but if they are new or persistent they always need an examination:

• Any vaginal bleeding or spotting after menopause
• Unusual bleeding outside the period pattern, after intercourse or lasting a long time
• Persistent abdominal bloating, fullness or pain; early satiety
• A pelvic or abdominal mass you can feel; frequent urination or bowel changes that do not settle
• A vulvar sore, lump, colour change or itch that does not go away; foul-smelling or bloody discharge
• Unexplained weight loss and tiredness

Risk factors and prevention

Each gynecologic cancer has its own risk factors and ways to prevent or catch it early. No single risk factor causes the disease, and the absence of risk factors does not exclude it entirely.

• Cervix: persistent high-risk HPV; smoking; weakened immunity. Prevention: HPV vaccination, regular HPV/smear screening and treatment of pre-cancer.
• Uterus: obesity, long-term unopposed oestrogen, diabetes, some genetic syndromes. Early sign: bleeding after menopause.
• Ovary: age, family history, BRCA1/BRCA2 and other hereditary syndromes. There is no reliable general screening test, so family history assessment matters.
• Vulva/vagina: HPV, chronic skin disease such as lichen sclerosus, smoking.

A suspicious mass has been found: first steps

Finding a mass in the ovary or uterus does not always mean cancer; most cysts and masses are benign. The decision is made by examining the appearance:

• Specialist ultrasound assesses size, wall structure, solid components, blood flow and the presence of fluid in the abdomen.
• MRI adds detail when the ultrasound picture is uncertain.
• Tumour markers (such as CA-125) are a guide but not a diagnosis: a high value is not the same as cancer, and a normal value does not exclude it.

Benign-looking masses can be monitored or treated with limited surgery; suspicious ones are treated with planned surgery that anticipates the possibility of cancer.

Ovarian, fallopian tube and peritoneal cancers

Most ovarian cancers are epithelial; fallopian tube and primary peritoneal cancers are handled in the same family. Germ-cell and stromal tumours, rarer in young women, are managed differently. Diagnosis usually combines imaging, tumour markers and surgical sampling; the pathology result (type and grade) strongly influences the plan. Borderline ovarian tumours behave less aggressively and are often treated by surgery with fertility-sparing options in selected patients.

In advanced disease, surgery aims to remove all visible tumour (cytoreduction), often combined with chemotherapy. HIPEC (heated intraperitoneal chemotherapy) is an option only in carefully selected patients. Recurrent disease is assessed individually.

Uterine (endometrial) cancer

Uterine cancer most often presents with bleeding after menopause, so it is frequently found at an early stage. Diagnosis is made by sampling the lining of the uterus (endometrial biopsy or hysteroscopy). Treatment usually includes removal of the uterus, tubes and ovaries, with lymph node assessment according to the type and risk; in selected early cases minimally invasive surgery is suitable. Further treatment depends on the final pathology. Uterine sarcomas and carcinosarcoma are rarer and are managed differently from the common endometrial type.

Cervical cancer

Cervical cancer is almost always related to persistent high-risk HPV, and screening and treatment of pre-cancerous lesions largely prevent it. Early disease may cause no symptoms; later signs include bleeding after intercourse, bleeding outside periods or after menopause, foul-smelling discharge and pain. Treatment depends on the stage: for small early tumours, surgery (sometimes fertility-sparing) is possible; locally advanced disease is usually treated with chemoradiotherapy. Staging uses examination, imaging and pathology.

Vulvar and vaginal cancer

These are rarer cancers. A sore that does not heal, a lump, colour change, long-lasting itch or bleeding of the vulva or vagina needs examination and, if suspicious, a biopsy. Treatment is mainly surgical, planned to remove the disease while preserving function as far as possible, and sometimes combined with radiotherapy. Pre-cancerous conditions (such as vulvar intraepithelial neoplasia) are managed separately.

Diagnosis, imaging and staging

Staging describes how far the disease has spread, and it determines the treatment. It is built from the examination, imaging (ultrasound, MRI, CT, sometimes PET-CT), laboratory tests and, above all, the pathology of tissue removed at surgery. Staging may be refined after the operation when the final pathology and lymph node results are available; this is a normal part of the process.

Principles of surgery and minimally invasive surgery

The first aim of cancer surgery is safe and complete removal of the disease, the second is to preserve function and quality of life wherever possible. Where it is oncologically safe and suited to the patient, keyhole (laparoscopic or robotic) surgery can offer smaller incisions and faster recovery; for some cancers and stages, open surgery remains the standard. The choice is made individually and disease safety always comes first.

On the day of surgery the plan, its extent and possible additional steps (for example lymph node removal or, rarely, a temporary stoma when the bowel is involved) are explained beforehand. Recovery depends on the extent of the operation; complications such as infection, bleeding, thrombosis or lymphoedema after lymph node surgery are discussed and prevented where possible.

Fertility and hormone function

In selected young patients with early disease, fertility-sparing treatment can be considered (for example preserving the uterus or an ovary), with strict follow-up. It is not suitable for every tumour type or stage. Hormone therapy after treatment is decided individually; some cancers allow it and some do not.

Genetic risk and high-risk families

A proportion of ovarian, tubal and uterine cancers are related to inherited changes (for example BRCA1/BRCA2 and Lynch syndrome). Genetic testing may be recommended after a diagnosis, or for relatives in families with several cases, and the result can influence both treatment (including targeted drugs) and prevention for relatives.

Chemotherapy, radiotherapy and targeted treatment

Many patients need treatment in addition to surgery. Chemotherapy may be given before surgery to shrink advanced disease or after surgery to lower the risk of recurrence; radiotherapy and targeted or immune-based treatments are used for specific cancers and situations. These are planned in cooperation with a medical oncologist and radiation oncologist, and discussed in a multidisciplinary meeting where possible.

Follow-up and quality of life after treatment

Follow-up after treatment usually includes regular examination, tests and imaging when indicated, with visits more frequent in the first years. Sexual health, menopausal symptoms, lymphoedema, nutrition, exercise and psychological support are part of care. Seek advice promptly after treatment for fever, severe pain, heavy bleeding, leg swelling or new symptoms. Supportive and palliative care, clinical trials and new treatments are discussed where appropriate.

Second opinion and planning before surgery

If surgery or treatment has been advised at another centre, re-reading the pathology and imaging, and clarifying the surgical plan, can be valuable. A second opinion done in good time does not delay treatment. Please bring the pathology report (and, if possible, the slides), imaging reports and images, tumour marker results, previous operation and treatment information, and the family history. Useful questions to ask: what is the stage and how certain is it; what are the alternatives; what are the risks; what is the plan for fertility and hormones; who will be in the surgical team.

Sources and content principles

This guide helps patients understand basic concepts and does not replace a personal examination, diagnosis or treatment advice. Medical decisions must be made on current clinical findings, with the patient’s preferences.

• ESGO (European Society of Gynaecological Oncology) guidelines
• NCCN Guidelines for ovarian, uterine and cervical cancers
• FIGO cancer staging and report