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I148 Modern management of vulvar cancer
Invited presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S1–S92
to be made. Future changes may need to take into account patients having sentinel node biopsies, or more sophisticated imaging of the groin without full groin dissection. Improved molecular markers may also eventually provide better prognostic discrimination than the current histological indices. I148 Modern management of vulvar cancer N.F. Hacker. Royal Hospital for Women and University of New South Wales, Sydney, Australia In recent years, vulvar cancer management has been revolutionised with a more conservative approach for the primary lesion, and a more rational approach to the management of the lymph nodes. Treatment has become individualised, with consideration being given independently to the optimal approach for the primary lesion and the regional lymph nodes. The primary vulvar lesion can be effectively treated by radical local excision, thereby avoiding the psychosexual consequences of radical vulvectomy in most patients. Local recurrence can usually be effectively treated by further surgery and/or radiation. By contrast, recurrence in the groin in usually fatal, so any patient with a T1 lesion and more than 1mm stromal invasion should have at least an ipsilateral inguinal-femoral lymphadenectomy performed. Postoperative groin and pelvic radiation should be given for patients with 3 or more micrometastases in lymph nodes, one macrometastasis (≤5 mm diameter), or any evidence of extracapsular nodal spread. Lymphatic mapping to decrease the morbidity, particularly lymphedema, associated with complete groin dissection is being used in some centres for lesions up to 4 cm diameter. There is a small but definite false negative rate, and it should only be used after proper informed consent, because most patients are not willing to risk groin recurrence. Patient’s with advanced lesions should have preoperative radiation if surgery would necessitate a stoma. Bulky positive lymph nodes should be resected prior to radiation. I149 Medical treatment of male infertility G. Haidl Controlled randomized, prospective studies are lacking for the most treatment options available for male infertility. However, it must be considered that, frequently, several factors contribute to disturbed male fertility, and different degrees of severity of male fertility disorders may exist. Moreover, the female factor has to be taken into account, in particular the advanced female age in many of the infertile couples. So, even in the future it will be very difficult to find a sufficient number of men with fertility disorders of the same kind and severity suitable for controlled studies, and the question arises whether or not an approach of “personalized” medicine, i.e. exploration of individual selection criteria for a subsequent treatment will be superior to application of standardized treatment regimens according to general guidelines. Treatment of male fertility aims at a “natural” pregnancy; however, “downgrading” of a method of assisted fertilization or even significantly improved fertilization rates during ICSI following previous failures can be considered as successful therapy as well. The current treatment options should be discussed in light of these considerations. Causal treatment regimens are only available for male infertility resulting from hypogonadotrophic hypogonadism. Drug treatment of retrograde ejaculation is also effective. Recent studies on genital tract inflammations resulting in disturbed DNAintegrity have shown good results after anti-inflammatory and antioxidative therapy. For the large group of moderate “idiopathic” male infertility at present only a trial with antiestrogens, potentially in combination with androgens may be recommended with some reservation.
S37
I150 Publisher’s insight – citations, usage and service improvement: post publication responsibilities C. Hammond. Elsevier The hard work is done. The article has been accepted, you’ve followed it through the production process and it is now finally published. You have a copy of the print issue in your hand and your thoughts now turn to who will read it. This presentation will give a brief overview of what you can expect from the Publisher post publication. Maximising accessibility to the article and driving online usage is the immediate goal, as is encouraging citations to the content and increasing the impact factor of the journal. In addition, we will look at quality control metrics such as ‘author, editor and referee feedback’ reports that are core to journal development and improved services over time. I151 Anatomical training I. Hammond In recent years many observers have noted that anatomical education no longer dominates the early undergraduate medical curriculum and cadaveric dissection as a means of learning topographical anatomy is becoming increasingly rare in many countries including the UK and Australia. In postgraduate surgical/obstetric and gynaecological curricula, a practical anatomical training is not considered essential. Most learning is gained from books and operative exposure. Radical gynaecologic cancer surgery requires extensive anatomical knowledge including: pelvic organs, vasculature, gastrointestinal-urological tracts, and the major abdominal vessels. The trend towards ultraradical cytoreductive surgery requires knowledge of the critical anatomy in the upper abdomen including the diaphragm, liver, pancreas and spleen. Trainees and subspecialists in gynaecologic oncology recognise the need for more formalised training in surgically relevant anatomy. The challenge to mentors is to provide relevant teaching. A range of learning opportunities is available and will be determined by the trainee, training institution and academic environment. Whilst basic anatomical knowledge can be readily acquired from textbooks, anatomical charts, computer generated 3-D programs and internet-based materials, surgical anatomical training obtained in the operating room is the mainstay of postgraduate educational experience. Surgical trainers must take the opportunity to reinforce surgical anatomical learning at every operation. Useful training may be gained by examination of relevant prosected cadaver specimens, formal cadaveric dissection and operating on fresh frozen cadavers (see www.acworkshop.com) which provide a realistic surgical simulation. Formal assessment of anatomical learning should be encouraged. This presentation details a “utopian” anatomical curriculum and assessment relevant to gynaecologic oncology training. I152 Raising age at marriage and first birth Y.A. Haque The age at first marriage for women in developing countries is closely linked to age at first birth and is considered an important determinant of maternal and child well-being and survival. Early marriage and its consequences affect not only the health and well-being of millions of girls in developing countries it also has long-term effect on their agency, empowerment and human development. Strategies and interventions to reduce the prevalence of early marriage gained momentum with the increase and prioritisation of global investment in family planning and child survival programmes. Promoting girl’s education, making necessary legislative provisions, strengthening women’s
to be made. Future changes may need to take into account patients having sentinel node biopsies, or more sophisticated imaging of the groin without full groin dissection. Improved molecular markers may also eventually provide better prognostic discrimination than the current histological indices. I148 Modern management of vulvar cancer N.F. Hacker. Royal Hospital for Women and University of New South Wales, Sydney, Australia In recent years, vulvar cancer management has been revolutionised with a more conservative approach for the primary lesion, and a more rational approach to the management of the lymph nodes. Treatment has become individualised, with consideration being given independently to the optimal approach for the primary lesion and the regional lymph nodes. The primary vulvar lesion can be effectively treated by radical local excision, thereby avoiding the psychosexual consequences of radical vulvectomy in most patients. Local recurrence can usually be effectively treated by further surgery and/or radiation. By contrast, recurrence in the groin in usually fatal, so any patient with a T1 lesion and more than 1mm stromal invasion should have at least an ipsilateral inguinal-femoral lymphadenectomy performed. Postoperative groin and pelvic radiation should be given for patients with 3 or more micrometastases in lymph nodes, one macrometastasis (≤5 mm diameter), or any evidence of extracapsular nodal spread. Lymphatic mapping to decrease the morbidity, particularly lymphedema, associated with complete groin dissection is being used in some centres for lesions up to 4 cm diameter. There is a small but definite false negative rate, and it should only be used after proper informed consent, because most patients are not willing to risk groin recurrence. Patient’s with advanced lesions should have preoperative radiation if surgery would necessitate a stoma. Bulky positive lymph nodes should be resected prior to radiation. I149 Medical treatment of male infertility G. Haidl Controlled randomized, prospective studies are lacking for the most treatment options available for male infertility. However, it must be considered that, frequently, several factors contribute to disturbed male fertility, and different degrees of severity of male fertility disorders may exist. Moreover, the female factor has to be taken into account, in particular the advanced female age in many of the infertile couples. So, even in the future it will be very difficult to find a sufficient number of men with fertility disorders of the same kind and severity suitable for controlled studies, and the question arises whether or not an approach of “personalized” medicine, i.e. exploration of individual selection criteria for a subsequent treatment will be superior to application of standardized treatment regimens according to general guidelines. Treatment of male fertility aims at a “natural” pregnancy; however, “downgrading” of a method of assisted fertilization or even significantly improved fertilization rates during ICSI following previous failures can be considered as successful therapy as well. The current treatment options should be discussed in light of these considerations. Causal treatment regimens are only available for male infertility resulting from hypogonadotrophic hypogonadism. Drug treatment of retrograde ejaculation is also effective. Recent studies on genital tract inflammations resulting in disturbed DNAintegrity have shown good results after anti-inflammatory and antioxidative therapy. For the large group of moderate “idiopathic” male infertility at present only a trial with antiestrogens, potentially in combination with androgens may be recommended with some reservation.
S37
I150 Publisher’s insight – citations, usage and service improvement: post publication responsibilities C. Hammond. Elsevier The hard work is done. The article has been accepted, you’ve followed it through the production process and it is now finally published. You have a copy of the print issue in your hand and your thoughts now turn to who will read it. This presentation will give a brief overview of what you can expect from the Publisher post publication. Maximising accessibility to the article and driving online usage is the immediate goal, as is encouraging citations to the content and increasing the impact factor of the journal. In addition, we will look at quality control metrics such as ‘author, editor and referee feedback’ reports that are core to journal development and improved services over time. I151 Anatomical training I. Hammond In recent years many observers have noted that anatomical education no longer dominates the early undergraduate medical curriculum and cadaveric dissection as a means of learning topographical anatomy is becoming increasingly rare in many countries including the UK and Australia. In postgraduate surgical/obstetric and gynaecological curricula, a practical anatomical training is not considered essential. Most learning is gained from books and operative exposure. Radical gynaecologic cancer surgery requires extensive anatomical knowledge including: pelvic organs, vasculature, gastrointestinal-urological tracts, and the major abdominal vessels. The trend towards ultraradical cytoreductive surgery requires knowledge of the critical anatomy in the upper abdomen including the diaphragm, liver, pancreas and spleen. Trainees and subspecialists in gynaecologic oncology recognise the need for more formalised training in surgically relevant anatomy. The challenge to mentors is to provide relevant teaching. A range of learning opportunities is available and will be determined by the trainee, training institution and academic environment. Whilst basic anatomical knowledge can be readily acquired from textbooks, anatomical charts, computer generated 3-D programs and internet-based materials, surgical anatomical training obtained in the operating room is the mainstay of postgraduate educational experience. Surgical trainers must take the opportunity to reinforce surgical anatomical learning at every operation. Useful training may be gained by examination of relevant prosected cadaver specimens, formal cadaveric dissection and operating on fresh frozen cadavers (see www.acworkshop.com) which provide a realistic surgical simulation. Formal assessment of anatomical learning should be encouraged. This presentation details a “utopian” anatomical curriculum and assessment relevant to gynaecologic oncology training. I152 Raising age at marriage and first birth Y.A. Haque The age at first marriage for women in developing countries is closely linked to age at first birth and is considered an important determinant of maternal and child well-being and survival. Early marriage and its consequences affect not only the health and well-being of millions of girls in developing countries it also has long-term effect on their agency, empowerment and human development. Strategies and interventions to reduce the prevalence of early marriage gained momentum with the increase and prioritisation of global investment in family planning and child survival programmes. Promoting girl’s education, making necessary legislative provisions, strengthening women’s