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The treatment of gynecologic cancers

Each year, more than 82,000 American women are diagnosed with gynecological cancers.

Each year, the five main cancer that originate in women’s reproductive organs— ovarian, cervical, uterine, vaginal and vulvar—are diagnosed in almost 82,000 American women and claim more than 28,000 lives. But many of these cancers are highly treatable and even curable given a comprehensive, expert, multidisciplinary preventive and treatment approach.

Gynecologic oncology is the branch of obstetrics/gynecology that treats these illnesses, which together account for about 12 percent of all cancers in women. Fortunately, top-quality comprehensive care in this key specialty is now available to patients in the Hudson Valley, thanks to the establishment of Westchester Medical Center’s Division of Gynecologic Oncology and Center for Robotic Gynecologic Surgery.

The division and center are headed by Sean S. Tedjarati, M.D., M.P.H., who devotes his clinical time exclusively to the medical center’s patients and is also an associate professor of obstetrics and gynecology at New York Medical College. As he explains, most gynecologic cancers are treated with a combination of surgery, radiation therapy and chemotherapy.

In some cases of complex and advanced cancers, the surgery must be a traditional “open” procedure requiring a large incision. But for a growing number of patients, Dr. Tedjarati and his colleagues can offer surgical treatment that employs a minimally invasive laparoscopic approach. In these procedures, the surgeon uses small abdominal incisions and introduces a thin scope with a tiny camera and light attached and special instruments. Laparoscopic surgery results in less pain, quicker recovery and a decreased risk of infection or other complications.

These days, Dr. Tedjarati is taking laparoscopic surgery a step further by using the da Vinci® Robotic Surgical System to treat benign and malignant gynecologic conditions—including early endometrial (uterus), cervical and ovarian cancers. He sits at the da Vinci console near the patient in the operating room. Using special instruments at a control center, he manipulates the robotic arms to complete complex operations with a precision and accuracy afforded by the unique feature of the robotic system that mimics the full range of motion of human hands. The robotic system offers superb three-dimensional visualization of the surgical site, precise suturing, fluid movements and exceptional maneuverability of the surgical instruments. It allows for all the benefits of minimally invasive surgery with the same surgical outcomes.

Radiation and chemo therapy

“One of the things that drew me here was the opportunity to develop a comprehensive, state-of-the-art multi- disciplinary center with experts such as Chitti Moorthy, M.D., Chief of Radiation Oncology, who has more than 30 years of experience in treating gynecologic tumors with all types of radiation therapy,” says Dr. Tedjarati. Dr. Moorthy has helped make Westchester Medical Center a regional leader in the use of brachytherapy to treat advanced cervical and uterine cancers.

“Brachytherapy” (from the Greek root “brachy” meaning “short-distance”) refers to a therapy in which the radiation source is placed inside or next to the tissue to be treated. At the medical center, templates containing tiny rods are temporarily placed directly within the tumor. Using higher doses makes it possible to destroy more cancer cells while minimizing unnecessary radiation to surrounding healthy organs. The choice to employ high or low-dose brachytherapy depends on the stage of the cancer and other clinical parameters.

To treat advanced gynecologic malignancies, Dr. Tedjarati uses combinations of chemotherapy medications and other agents that “starve” tumors of their blood supply. He is also treating patients with stages III and IV ovarian cancer who have undergone surgery with intraperitoneal (IP) chemotherapy, which bathes the pelvic cavity with aggressive cancer-fighting medications after malignant tumors or organs have been removed. The combination of this treatment with standard intravenous chemotherapy has been shown to significantly improve survival in those patients. IP chemotherapy can have difficult side effects (including abdominal pain, nerve irritation and fatigue) that prompt many women to stop treatment before the full course is delivered. But it is an important tool in the armamentarium of ovarian cancer treatment and patients can safely get through most treatments with adjustments and a comprehensive, compassionate, supportive team.
The division has the mission of advancing clinical research to afford patients the benefit of the latest clinical trials and research to optimize their chances of survival and improve quality of life.

Dr. Tedjarati’s team also treats gestational trophoblastic disease, a condition that arises out of an early abnormal pregnancy in which a tumor develops in the cells and tissue that form the placenta, preventing the embryo from developing normally. If benign, the tumor is generally called a molar pregnancy.

In rare cases, the tumor develops into a malignancy that can invade the walls of the uterus or other organs. Trophoblastic disease is usually treated with a dilatation and curettage, a scraping of the uterine walls. In some cases of persistent disease, chemotherapy or additional surgery may be required.

Caring counselors

Some women may be at risk of developing related breast, ovarian or endometrial cancers because of genetic susceptibility— they carry mutations in the BRCA1, BRCA2 or HNPCC genes. For them, the Division of Gynecologic Oncology offers clinical counseling to help implement healthy lifestyle changes or make decisions about undergoing blood tests, genetic counseling or risk reducing surgery. Counseling can also help patients cope with life issues that arise after their cancer treatment, including hair loss, sexual and dietary concerns and staying cancer-free.

“The response to our program from patients and referring doctors has been outstanding,” says Dr. Tedjarati. “In the division’s first six months, we treated almost 170 women, performed nearly 100 operations and opened a state-of-the-art outpatient center. Our patients enjoy beautiful private rooms in the hospital. We are in the process of expanding our chemotherapy infusion center. We have established our robotic gynecology surgery program and begun a da Vinci robot training program for other gynecologists at the medical center.

“We aim to be the only comprehensive, state-of-the-art, multidisciplinary center between New York City and Albany for treatment of all forms of gynecologic cancers,” says Dr. Tedjarati. “We will offer counseling, prevention and treatment for women at risk for developing gynecologic precancerous and cancerous conditions, state-of-the-art surgical care including da Vinci robotic surgery, and a research program as well as programs of support for our patients and their families.”

A young woman's cancer treatment

Twenty-five-year-old Danielle Osorio of Suffern wanted to concentrate on what to do during her winter break from Rockland Community College. Instead, on December 28, 2009, the aspiring scientist underwent complex cancer surgery for Stage I ovarian cancer at Westchester Medical Center.

Sean S. Tedjarati, M.D., M.P.H., chief of gynecologic oncology, removed her right ovary and a watermelon-sized tumor that was engulfing the ovary. To determine the extent (stage) of the cancer, he also took out her appendix, several lymph nodes and nodules and her omentum, a layer of fatty tissue that covers the abdominal organs like an apron. during the four-hour surgical procedure, an exploratory laparotomy, Dr. Tedjarati also removed tissue samples and abdominal fluid to be sent for pathological examination so that he could properly stage the cancer. Because of her age and desire to have children someday, he did not remove her left ovary, uterus or fallopian tubes, which did not show evidence of cancer.

The tumor was discovered by Osorio’s gynecologist during a routine gynecologic checkup. as is often the case with ovarian cancer, osorio did not experience any of the disease’s known symptoms, which include bloating, abdominal pain, a bloated feeling after eating, urinary urgency and/or frequency, back pain, constipation, fatigue and menstrual changes. The common nature of these symptoms is one reason ovarian cancer is rarely found early and causes about half of all deaths from gynecologic cancers each year in the United States. Though most women treated for stage i ovarian cancer are alive five years later, overall survival for women with all stages of the disease remains difficult because of the way it grows and spreads without warning. The challenge is that the majority are at risk of recurrence.“After recovering from the shock of hearing about the tumor, i went home, did my research, and called Dr. Tedjarati the next day,” says Osorio. “I felt comfortable with him right from the start.”

Pathological samples revealed that osorio’s tumor was an immature teratoma, an aggressive, malignant type of tumor made up of germ cells—cells found inside the ovary that normally develop into eggs. less than 2 percent of all ovarian cancers are germ-cell cancers, which tend to occur in girls and young women. dr. Tedjarati recommended three courses of combination intensive chemotherapy following surgery to reduce the risk of recurrence.

Because she is young and may wish to have children someday, before her chemotherapy osorio chose to undergo fertility preservation treatment by Kutluk Oktay, M.D., Westchester Medical Center’s director of reproductive medicine, infertility and fertility preservation, who works closely with Dr. Tedjarati. Dr. oktay harvested five eggs from Osorio’s healthy ovary, inseminated them with donor sperm and then froze the resulting embryos in liquid nitrogen. With embryos preserved in this way, Osorio has an “insurance policy” against the possibility of becoming infertile from the effects of the chemotherapy on her remaining ovary and its eggs. in the future, she may choose to use one or more of the frozen embryos to become pregnant.

“Danielle’s prognosis for cancer-free survival is very good,” says Dr. Tedjarati. “i expect that with continued diligent surveillance, she will continue to do well and lead a normal and productive life.”

Osorio is looking forward to going back to college in the fall of 2010. She says selecting Dr. Tedjarati for her care was like choosing a wedding dress. “You know right away when you’ve found the perfect one. I trust him with my life.”

To find out more about GYNECOLOGIC ONCOLOGY CARE at Westchester Medical Center , pleas call 914-493-2250 or visit www.worldclassmedicine.com/OBGYN

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