gynecological cancer

Pathophysiology and classification of the three major gynecologic cancers: Gynecologic cancer is a malignant tumor that occurs in the female reproductive system, mainly classified into ovarian cancer, cervical cancer, and endometrial cancer.

Ovarian Cancer: Characterized mainly by extensive intra-abdominal dissemination (Peritoneal Carcinomatosis), high-grade serous carcinoma accounts for most cases, and many are already stage 3 or higher at diagnosis.

Cervical cancer: It originates from persistent infection with high-risk human papillomavirus (HPV types 16, 18, etc.), and although early diagnosis rates have improved through vaccination and screening cytology, lymph node metastasis within the pelvic cavity is active once it becomes invasive.

Endometrial cancer: Closely associated with obesity, diabetes, and hyperestrogenemia; relatively detected early due to early abnormal vaginal bleeding symptoms, but recurrence risk varies greatly depending on molecular subtypes (POLE, p53, etc.).

Domestic and international epidemiological statistics:

Endometrial cancer has more than 3,000 new cases annually, making it the most common female genital cancer in South Korea, while ovarian cancer ranks first in mortality among gynecologic cancers.

The 5-year relative survival rate for ovarian cancer is about 65%, but for stage 3–4 advanced cancer, it drops sharply to 30–40%. In contrast, cervical cancer (about 80%) and endometrial cancer (about 89%) show very high cure rates with early diagnosis and precise minimally invasive surgery.

The 'silence' of ovarian cancer and misdiagnosis as gastrointestinal disease: In the early stages, there are no clear symptoms, but as cancer progresses, abdominal bloating due to ascites, indigestion, frequent belching, pelvic pain, and frequent urination occur. Most patients are mistaken for having gastrointestinal diseases and repeatedly undergo upper or lower endoscopy, with diagnosis often only made after the cancer has spread throughout the peritoneum.

Abnormal vaginal bleeding warning for cervical and endometrial cancer: Postmenopausal vaginal bleeding, irregular menstrual bleeding, menorrhagia, and postcoital bleeding are the most characteristic signs. In particular, vaginal bleeding in menopausal women carries a 10–15% probability of endometrial cancer, so immediate endometrial biopsy is essential.

Fear of loss of fertility and early menopause: Young unmarried women in their 20s–30s and women of childbearing age report psychological anxiety about permanent infertility and severe menopausal symptoms if both the uterus and ovaries are removed for cancer treatment.

Golden time for entering tertiary/secondary advanced care: In cases where a pelvic ultrasound shows complex ovarian cysts or solid nodules (suspected malignancy according to IOTA guidelines), accompanied by elevated tumor markers (CA-125, HE4), or cancer cells are confirmed in endometrial biopsy, the patient should promptly enter a specialized multidisciplinary gynecologic oncology center capable of multi-organ complex resection and fertility preservation.

Gynecology Precision Fetal Doppler Ultrasound and 3.0T Pelvic MRI:

Evaluate the resistance index of neovascularity within the tumor using Doppler ultrasound, and perform precise interpretation on a 1mm scale of myometrial invasion depth, cervical stromal involvement, and invasion of pelvic organs such as the bladder and rectum in endometrial cancer using 3.0T pelvic MRI.

Screening for systemic metastasis and peritoneal dissemination (abdominal CT & PET-CT):

Comprehensive assessment of ovarian cancer peritoneal dissemination, diaphragmatic involvement, omental metastasis, and para-aortic lymph node enlargement through thoracoabdominal contrast-enhanced CT and whole-body PET-CT to calculate surgical resectability score (Fagotti Score).

ICG fluorescence-guided sentinel lymph node biopsy (SLNB):

In patients with early endometrial and cervical cancer, indocyanine green (ICG) fluorescent contrast is injected into the cervix during surgery to locate the sentinel lymph nodes that the cancer cells first reach, thereby proactively preventing lower limb lymphedema complications associated with unnecessary complete pelvic lymph node dissection.

Precision genomic and molecular pathology analysis:

Ovarian Cancer: Predict PARP inhibitor sensitivity through BRCA1/2 germline/somatic mutations and HRD (homologous recombination deficiency) testing.

Endometrial cancer: POLE mutation, MMR protein deficiency (MSI-H), and p53 abnormality analysis based on the proactive classification method for patient-customized prognosis prediction and assessment of suitability for immunotherapy.

Step 1: Confirmation and multi-organ staging (Day 1 ~ Day 5)

Definitive diagnosis via cervical/endometrial biopsy, transvaginal ultrasound, pelvic 3.0T MRI, abdominal CT, and PET-CT. Complete blood tests for serum biomarkers (CA-125, HE4, SCC).

Step 2: Confirm treatment strategy at the multidisciplinary gynecologic tumor board (Day 5 ~ Day 7)

Advanced ovarian cancer: [Immediate primary tumor reduction surgery] vs [Interval debulking surgery (IDS) after 3 cycles of neoadjuvant chemotherapy].

Early cervical/endometrial cancer: After confirming the patient’s desire for pregnancy, decide between [robotic minimally invasive surgery] vs [fertility-preserving hormone/ectomy].

Locally advanced cervical cancer: Exclude surgery and decide on [concurrent chemoradiotherapy (CCRT)].

Stage 3: Precision surgery and acute treatment (Week 2 ~ Week 3)

Ovarian cancer patients undergo complete tumor debulking surgery in collaboration with gynecologic oncology and surgery (colorectal·hepatopancreatobiliary), including diaphragm resection, partial liver resection, splenectomy, bowel resection, and anastomosis (if necessary, intraoperative HIPEC intraperitoneal hyperthermic chemotherapy is performed).

Patients with endometrial/cervical cancer undergo minimally invasive staging surgery and early ambulation protocols through single-port robotic surgery.

Stage 4: Molecular subtype-tailored maintenance therapy and long-term follow-up (Week 4 ~)

Ovarian cancer patients undergo maintenance therapy with oral PARP inhibitors (Olaparib, Niraparib) according to BRCA/HRD results after completing platinum-based chemotherapy.

For high-risk endometrial cancer and patients with mismatch repair deficiency (dMMR), continue immunotherapy and rehabilitation for prevention of lower limb lymphedema.