Surgery, Chemotherapy, and Radiotherapy for Gynaecological Cancer: What Are the Main Complications to Overcome?

Surgery, Chemotherapy, and Radiotherapy for Gynaecological Cancer: What Are the Main Complications to Overcome?

Konstantinos Pantazis (2nd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Greece), Ioannis Andronikidis (Radiation Oncology Department, Interbalkan Medical Center, Thessaloniki, Greece), Lazaros Nikiforidis (Independent Researcher, Greece), Anne Floquet (Medical Oncology Unit, Institut Bergonie, France) and Konstantinos Dinas (2nd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Greece)
DOI: 10.4018/978-1-7998-4213-2.ch024

Abstract

Gynaecological oncology treatment yields no fewer complications and side effects than those met in any other oncology field. Patients and clinicians are highly alerted by the ominous diagnosis and sometimes seek for high risk, experimental, or even unproven therapies and are consequently prepared to accept high complication rates that would otherwise be unacceptable. Still, risk reduction remains a high priority. This is achieved by appropriate risk assessment, risk-to-benefit ratio balancing, treatment individualisation, close follow up through all treatment stages, and prompt patient informing and participation in decision making. The chapter aims to summarize the main complications of surgery, chemotherapy, and radiotherapy as well as the main ways to overcome them.
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Introduction

Gynaecological oncology treatment yields no less complications and side effects than those met in any other oncology field. Patients and clinicians are highly alerted by the ominous diagnosis and sometimes seek for high risk, experimental or even unproven therapies and are consequently prepared to accept high complication rates that would otherwise be unacceptable. Still, risk reduction remains high priority. This is achieved by appropriate risk assessment, risk to benefit ratio balancing, treatment individualisation, close follow up through all treatment stages and prompt patient informing and participation in decision making.

Cardiovascular and Thrombosis

Malignant disease is known to increase risk of thrombosis and oncology treatment is a standalone additional risk factor for thrombosis (Horsted). Women who undergo surgery for gynaecological cancer face 25% increased risk for thrombosis (Nicolaides). This risk increase may be associated with complicated and time lengthy surgical procedures and is observed in both open and laparoscopic operations. A successful risk reduction strategy includes mechanical alongside with pharmaceutical thromboprophylaxis. The use of intermittent compression devices in operating theatre, graded compression stockings post-operatively, leg elevation and early mobilisation may be beneficial (Clarke-Pearson). Administration of heparin or low molecular weight heparin should commence 2 hours pre- operatively or 8 hours post-operatively. The combination of mechanical and pharmaceutical thromboprophylaxis appears to be superior to one or the other and should be used concomitantly (Zheng). The duration of thromboprophylaxis should well exceed that of hospitalisation, as it has been shown that most thrombosis incidents occur later than the 21st post operative day in oncology patients (Agnelli G).

Several classical chemotherapy medications, as well as newer ones that target angiogenetic agents, which are associated with tumur metastases, may exhibit angiotoxicity, which, in turn increases risk of hypertension, thrombosis, heart failure, myocardiopathy and arrythmias (Cameron 2016). The prevalence of cardiovascular disease that is potentially attributable to chemotherapy is expected to rise in the future due to the increase in life expectancy of oncology patients, as well as the general population. Angiotoxicity effects are short and long term; management of these includes early recognition with prompt cardiology review and monitoring of appropriate indices that may include blood pressure, electrrocardiogramme, ultrasound and flow studies and renal function tests. Women must be informed when an increased long term or even life long cardiovasular disease risk is anticipated, so as, they seek for continuing care after oncology follow up may be completed.

The effect of radiotherapy on the cardiovascular system has not been extensively researched. In vitro studies have shown that irradiation activates the vascular endothelium via an inflammatory reaction, also interferes with vitamin C and exhibits a thrombogenic capacity in total (Halle). Notably irradiation has been used for palliative coagulative treatment. Limited clinical data indicate that patients who received radiotherapy have an increased risk of thrombosis and cerebrovascular bleeding (Guy). Based on these data, those who undergo chemotherapy may also receive individualised thromboprophylaxis.

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