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The purpose of this paper is to review the surgical care related to training in gynecologic oncology, from past, present and future perspectives. A marked decline in the incidence of cervical cancer as well as improvements in radiation therapy have led to a reduction in the numbers of radical hysterectomies and exenterations being performed. Utilization of neoadjuvant chemotherapy is reducing the extent of cytoreductive operations, including intestinal surgery. The incorporation of sentinel lymphatic mapping has reduced the number of pelvic, paraaortic and inguinal lymphadenectomies being performed. Coupled with these changes are other factors limiting time for surgical training including an explosion in targeted anticancer therapies and more individualized options beyond simple cytotoxic therapy. With what is likely to be a sustained impact on training, gynecologic oncologists will still provide a broad range of care for women with gynecologic cancer but may be quite limited in surgical scope and rely on colleagues from other surgical disciplines. Enhancement of surgical training by off-service rotations, simulation, attending advanced surgical training courses and/or a longer duration of training are currently incorporated into some programs. Programs must ensure that fellows take full advantage of the clinical materials available, particularly those related to the potential deficiencies described. Changing required research training to an additional elective year could also be considered. Based on the perspectives noted, we believe it is time for our subspecialty to reevaluate its scope of surgical training and practice., Competing Interests: Declaration of competing interest The authors of this paper report that they have no conflicts of interest related to any of the content of this manuscript., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Fanconi's anemia (FA), an autosomal-recessive aplastic anemia, was first described in 1927. Patients usually die from complications of pancytopenia. The longer patients survive the underlying anemia, the higher the risk of other cancers, particularly leukemias, hepatocellular cancer and squamous cell tumors. This report is the sixth reported case of vulvar cancer in a young woman with FA since 1966., Case: A 25-year-old woman with FA was admitted with neutropenic fever; a rapidly growing, suppurative vulvar mass; and Trichomonas vaginalis. The patient had maintained routine, preventive gynecologic care, and 4 months prior to admission she had complete removal of a benign vulvar condyloma and no evidence of genital tract cancer. We removed the vulvar mass to relieve discomfort and eliminate an infectious source. The mass was an invasive squamous cell carcinoma of the vulva arising in a vulvar condyloma. Within 2 months of the diagnosis, the patient developed bulky disease metastatic to the lungs and inguinal lymph nodes., Conclusion: FA patients are at high risk of squamous cell tumors, and gynecologic examinations should begin at menarche. However, despite adequate screening, rapidly progressing solid tumors of the genital tract can develop in these immunosuppressed patients, who have a defect in DNA repair genes.

Background: The Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia) is an autosomal dominant disorder of blood vessels associated with mucocutaneous telangiectasis and arteriovenous malformations of internal organs., Case: A 23-year-old woman was found on routine gynecologic examination to have asymptomatic vaginal telangiectasias, a previously unreported initial site of involvement in this syndrome., Conclusion: The finding of asymptomatic vaginal telangiectasias on routine pelvic examination should alert the clinician to the possibility of the Osler-Weber-Rendu syndrome.

A review of primary vaginal carcinoma treated at the Medical University of South Carolina from January 1970 through December 1989 included 76 squamous carcinomas, 12 adenocarcinomas, and 3 undifferentiated carcinomas. Staging was done according to the system of the International Federal of Gynecology and Obstetrics as modified by Perez et al. Stages I, II, III, and IV included 25, 39, 15, and 12 patients, respectively. Corrected 5-year survival rates were 73% for stage I, 39% for stage II, 38% for stage III, and 25% for stage IV. Sixteen percent of patients had received prior pelvic radiation. Invasive cervical cancer preceded vaginal cancer in 21% of patients. Detection of cancer was accomplished by routine cytologic testing in 17% of patients, palpation of an asymptomatic mass in 10% of patients, or palpation of a symptomatic mass in 72% of patients. Eighty-seven percent of patients were treated with radiation therapy. Survival curves of patients grouped by stage and other potential prognostic factors were compared. Lower stage (p less than 0.01), younger age (p less than 0.02), and no symptoms at detection (p less than 0.01) were statistically significant favorable prognostic factors. Histologic type, extent of vaginal involvement, vaginal location, prior radiation therapy, prior cervical cancer, and prior hysterectomy are factors that did not significantly affect survival.

A case is presented of white sponge nevus involving the vaginal, labial, and oral mucosae of a 34-year-old woman. White sponge nevus is a rare, benign, autosomal dominant leukokeratosis that predominantly affects the oral mucosa. Less frequently, it affects extraoral sites including the vulvovaginal mucosa. In this case, histopathologic study of vulvovaginal lesions, subsequent examination of extragenital mucosae, and inquiry into the family history led to the correct diagnosis. The genetics, clinical appearance, and histopathology of white sponge nevus are discussed in relation to the differential diagnosis of oral and vaginal leukokeratoses.

Endodermal sinus tumor of the vagina, a rare pediatric malignancy, was managed with primary chemotherapy (vincristine, dactinomycin, cyclophosphamide [VAC]) followed by local excision without radical surgery or pelvic irradiation. Treatment-related complications were acceptable, and there is no evidence of disease 30 months after discontinuing all therapy (50 months after diagnosis). As a treatment option, primary chemotherapy is viewed as a highly attractive alternative modality, preserving potential reproductive and sexual function in long-term survivors, and appears to be the treatment of choice.

A prospective study was established in August, 1967, to treat all adenocarcinomas of the endometrium by protocols of preoperative radiation followed immediately by operation. Two hundred and ninety-five women have been treated, 220 of whom had Stage I disease. In these cases, factors known to be associated with survival were studied, and their influence upon survival was noted. Preoperative radium followed immediately by operation was the primary method of therapy. Life tables demonstrated a five-year survival rate of 91 per cent with a low complication rate in patients with Stage I disease. Cell type, degree of differentiation, and depth of myomentrial invasion were the primary factors influencing survival.

Ureters tolerate radiation well as manifested by the low incidence of injury. However, ureteral injury can occur with high-dose radiation especially when the majority is delivered by radium. Eight such cases are presented. A retrospective study of 100 asymptomatic women treated with radiation for cervical carcinoma over 5 years previously demonstrated only 4 incidences of ureteral injury if dilatation was used as the indicator. To the contrary, 5 patients had improvement of their pre-treatment intravenous pyelogram following radiation. Emphasis was placed on closer followup of the ureters by intravenous pyelograms after high-dose radiation.

Typical circumscribed mottled calcifications in the pelvis are a frequent finding in gonadoblastomas. Six patients with this tumor are reviewed. Radiologically visible calcifying gonadoblastomas were found in three cases.

One hundred seventy-eight patients who had radical hysterectomy performed for management of invasive carcinoma of the cervix over 22 year period at the Medical University of South Carolina were critically analyzed. The degree of differentiation of the malignancy appeared to be of more significance than tumor size in Stage 1 lesions. With proper patient selection and excellent operative technique, survival rates well over 90% with minimal complications can be obtained. The radical hysterectomy should never be used in association with irradiation.

Everyone is conscious of the prime role of the ovaries in making a female a "female." However, too little attention has been directed toward the systemic mechanism of estrogens that protects against coronary artery disease and osteoporosis. Exogenous estrogen appears to be almost as effective as the ovaries are in protecting a female from these diseases. The incidence of neoplasia in preserved ovaries after previous pelvic surgery is low. Emphasis has been placed on ovarian conservatism in the young female because a clearer benefit can be demonstrated in them than in postmenopausal females.

Six patients with a total of nine gonadoblastomas are presented; three--and possibly a fourth--had dysgerminomatous overgrowth which was massive in two patients. Calcification detected by abdominal films was present in three sufficient for preoperative diagnosis. All patients were found to have a Y stem line on peripheral leukocyte chromosome cultures except one patient, who had a 46 XX/45 XO karyotype. She was found to have Y chromatin bodies in the germ cells of her tumor which was in a normal ovary found at exploration for an ectopic pregnancy. Three were found in virilized phenotypic females investigated for amenorrhea, and two for therapy of pelvic masses due to dysgerminomatous overgrowth. Y chromatin studies are reported on gonadal tissue.

During a two-and-one-half year period, 317 women were seen in the Colposcopy Clinic for evaluation of an abnormal Pap smear. Seventy-four (23%) desired to maintain their childbearing potential and were treated conservatively. Ten (14%) had inadequate colposcopy and underwent cold knife conization of the cervx. The remaining 64 were treated by adequate colposcopy, combined with cryosurgery; they are discussed in detail. All were managed economically as outpatients without anesthesia and no serious complications occurred. To date, only four have recurrent abnormal cervical cytology and several have delivered children. Adequate colposcopic examination combined with biopsies must proceed all cryosurgical procedures performed for abnormal cervical cytology.

Between September 1984 and February 1985, cervical cytologic smears were collected from 510 patients using a spatula and an endocervical swab. These smears were compared with those collected from 510 patients between September 1985 and February 1986 using a spatula and an endocervical brush. The use of the endocervical brush increased the number of smears that contained endocervical cells, for both reproductive-age and postmenopausal women. In women without previous radiation therapy, the rate of suboptimal smears (those without endocervical cells) fell from 12.0 to 1.7% when the endocervical brush was used. This modified smear collection technique improved the quality of the cytologic material.

In an effort to find a safe, efficient, and inexpensive means of ruling out the existence of a neoplastic process causing abnormal vaginal bleeding form the uterine cavity, 103 patients over 34 years of age had preoperative aspiration (Vabra aspirator) of the endometrial cavity. The tissue obtained at the time of D&C and hysterectomy was correlated with that obtained by the outpatient diagnostic procedure. In this pilot study, the aspirator was 98% accurate in evaluating high-risk women with abnormal uterine bleeding for malignant disease. In the two neoplasms missed, both women had had a recent D&C.

The clinical problems associated with the presence of genital malignancies occurring during pregnancy are presented. This report represents the clinical experience at one medical institution over a 20 year period. Eighty cases of cervical neoplasm, four cases of ovarian carcinoma, five vulva carcinomas, and one vaginal carcinoma are presented. The diagnostic and therapeutic approaches to malignant neoplasia of each area are discussed separately.