Complications

The complications of gynecologic malignancies are related to the natural progression of disease, surgery, chemotherapy, or radiation. Any combination of these complications can occur depending on the type and stage of neoplasm and treatment modality.

The complications related to the natural progression of disease often represent the symptoms that help to diagnose the disease. These include, but are not limited to, genital tract bleeding, gastrointestinal obstruction, masses or ascites, fistulas (both genitourinary and gastrointestinal), obstructive uropathy, metastasis, lymphedema, and hypercoagulable states leading to deep venous thrombosis or pulmonary embolism.

By far the most common oncologic complication (most frequently seen with cervical or uterine cancer) is bleeding. It may be acute or chronic, massive or minimal, external or internal. Sources include friable tissue, tumor erosion into iliac or femoral vessels, adnexal mass rupture, or coagulopathies that develop secondary to chemotherapy or radiation. Assessment and management begin with the principles of emergency care. Then a thorough history and physical examination including prior diagnoses and treatment should be undertaken to find the likely source and cause of bleeding. Where externally accessible sites of bleeding occur, apply direct pressure. If this fails to control the bleeding, next use topical silver nitrate or Monsel's solution. If bleeding persists, topical absorbable hemostat material can be applied such as Gelfoam, Instal, or Surgicel. Where the vagina is the source of bleeding, vaginal packing may become necessary. Use a long strip of continuous gauze, and place a Foley catheter to prevent retention. Regardless of the causes of bleeding, after stabilization, the gynecology service should be consulted.

Patients occasionally present with abdominal distention and discomfort. This often is concomitant with other complications of cancer and therefore may be accompanied by early satiety, nausea, vomiting, anorexia, weight loss, constipation or diarrhea, urinary frequency, urgency, incontinence, dyspnea, or orthopnea. As always, the first step is complete history and physical examination, including both pelvic and rectal examinations. Diagnostic testing may reveal worsening of known disease, recurrence of cancer, new cancer, torsion of a large ovary, bowel perforation, or intraabdominal hemorrhage. Consultation with a gynecologist, gynecologic oncologist, or surgeon is indicated.

Gastrointestinal complications include obstructions and fistulas. Obstruction is common as a progressive symptom of malignancy, especially with ovarian and uterine tumors that are associated with enlarging masses or ascites. The resulting obstruction may be mechanical or due to tumor ileus from encasement of the nerve plexus leading to dysfunction of a segment of bowel. Patients often present with nausea, vomiting, early satiety, abdominal pain, distention, constipation, and/or obstipation. The normal management scheme for obstruction applies (as discussed in Chap...75 in more depth). Surgical palliation may give temporary symptomatic relief, but recurrence rates are extremely high. Consultation with a gynecologist, gynecologic oncologist, or surgeon is indicated to discuss and provide permanent proximal decompression and supplemental nutrition.

Fistula formation occurs secondary to bowel encasement or obstruction. Fistula may drain to the abdominal wall, peritoneal cavity, vagina, uterus, or bladder. Instillation of colored medium (e.g., charcoal, food dye in tube feeds), upper gastrointestinal series, barium enema, or a fistulogram often aids diagnosis. Consultation with a gynecologist, gynecologic oncologist, or surgeon is indicated to determine the best treatment.

Urinary tract complications also include obstruction and fistula. Ureteral obstruction classically is seen in cervical cancer but also occurs with progression or recurrence of other pelvic malignancies. Radiation also may cause permanent scarring of the lumen leading to obstruction. Patients may present with acute renal failure and require percutaneous or cystoscopic emergent decompression. A vesicovaginal or ureterovaginal fistula may develop at the site of untreated cancer or recurrent cancer or after radiation therapy. Fistulas follow radical pelvic surgery about 1 percent of the time and radiation therapy approximately 2.6 percent of the time.

Chronic mild lymphedema of the lower extremities often follows inguinal node resection. Pedal lymphedema is seen after pelvic radiation therapy. Aside from the associated discomfort, the greatest concern is deep veinous thrombosis, especially if lymphedema is unilateral. Duplex ultrasound is necessary. Lymphedema is treated supportively with elevation and support stockings.

Thromboembolic disease has long been associated with gynecologic malignancies and is discussed in Chap 55..

Most of the side effects of chemotherapeutic agents are predictable and can be lessened with adjuvant medications. Risk factors for poor tolerability of chemotherapy are advanced age, advanced disease, poor nutritional status, or severe systemic involvement. Chemotherapeutic agents may have debilitating effects on many organ systems (Table 1.0.7.-2).

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