This chapter discusses the biology of and therapeutics for gynaecological cancers such as vulval cancer, cervical cancer and ovarian cancer. The most common type of ovarian cancer, high-grade serous cancer, is characterised by mutation of the p53 (TP53) gene. All women with newly diagnosed high-grade serous ovarian carcinoma should have an accurate family history taken, and be referred for genetic assessment and considered for BRCA1 and BRCA2 mutation testing if appropriate. Within clinical trials, central pathological review is needed when treatment depends on morphological sub-type or other pathological parameters. Functional imaging in multicentre trials should be implemented with strict quality control to ensure standardisation and reproducibility. Evaluation of novel surgical strategies, such as robotics, should occur through well-conducted clinical trials. In surgery for ovarian cancer, whether carried out as a primary or a delayed procedure, the aim should be to remove all visible disease.

Vulval cancer is rare and constitutes approximately 3% of gynaecological cancers worldwide. The incidence of vulval cancer has increased since the mid-1990s owing to the increased incidence in younger women, which has doubled over the past 30 years. Clinical trials in vulval cancer can be divided into two categories-trials in women with vulval cancer and, more recently, trials on the prevention of vulval cancer by preventing or treating human papillomavirus (HPV)-related vulval intraepithelial neoplasia (VIN). Numerous studies have tried to evaluate the role of neoadjuvant radiotherapy and/or chemotherapy in this disease to reduce the extent of surgery. Early studies involving the medical treatment of VIN with imiquimod, cidofovir and especially therapeutic vaccines appear promising in the prevention of vulval cancer. However, the greatest effect on preventing cancer is likely to arise as a result of vaccination programmes of the prophylactic HPV vaccines, assuming adequate uptake of the vaccine.

Surgery has various applications in the management of cancer. This chapter discusses the roles performed by surgery such as: diagnosis, staging, treatment, reconstruction, and palliation. It reviews the intraoperative complications of laparotomy. A number of studies have proposed chemotherapy before definitive surgery in patients with advanced ovarian carcinoma. A significant number of women with recurrent disease will develop bowel obstruction, and surgery is often the palliation method of choice. Stage IB disease can be treated by surgery or radiotherapy, and the surgical options are radical vaginal hysterectomy and laparoscopic or extraperitoneal lymph node dissection, and radical trachelectomy with laparoscopic or extraperitoneal lymph node dissection. The standard surgical management for endometrial cancer in the UK has been total abdominal hysterectomy and bilateral salpingo-oophorectomy. Biopsy of a vulval lesion is essential for diagnosis before definitive surgery. Conservative surgery should be considered for young patients with early cervical cancer.

The aim of radiotherapy is to destroy the cancer if possible without damaging the surrounding normal tissues. Two modalities of external beam radiotherapy and brachytherapy can be combined or used individually. Four parameters form the basis of radiobiology: repair, reoxygenation, repopulation and redistribution. The doses of radiotherapy employed in treating carcinoma of the cervix depend particularly on the intracavitary technique and equipment used. The design of radiotherapy for carcinoma of the cervix depends on the extent of the cancer. The radiation tolerance of normal tissues is related to the acute or chronic radiation reactions that occur in them. Primary radiotherapy may be used for patients who are unfit for surgery. Radiotherapy was formerly used in the treatment of ovarian cancer. There is a survival advantage for chemoradiation over radiotherapy alone in cervical cancer. Radiotherapy is widely used in vulval cancer as adjuvant treatment.

The rarity of vulval cancer has meant that few, if any, robust randomised trials have been performed. Women with predisposing conditions should be counselled with regard to risk. This rarity, combined with the modesty that women might feel owing to the intimate location of the problem means that cancer might be easily overlooked, misdiagnosed or ignored. Diagnosis of vulval cancer is made based on biopsy. The major factors that influence treatment planning are the need to assess nodal status, the extent of the disease and the woman's suitability for treatment. Pelvic node involvement tends to follow inguinofemoral spread of disease. Preoperative radiotherapy should be considered if primary surgery is likely to compromise sphincter function. The requirement for reconstruction should be considered in all patients undergoing surgery for vulval cancer. Sentinel node sampling is a recent innovation, which provides diagnostic information to direct further care while minimising morbidity.

This chapter lists the uses of chemotherapy in gynaecological oncology. In endometrial cancer, chemotherapy is used to treat advanced or relapsed cases where surgery and or radiotherapy are considered inappropriate, although hormone treatment is also used in these situations. In some situations, the intent of treatment may be curative, an example being trophoblastic tumours, while in others the intent is palliative, for example in recurrent epithelial ovarian cancer. In all situations, conventional chemotherapy used to kill tumour cells will also kill normal, healthy cells. This gives rise to treatment-related toxicity such as myelosuppression, emesis, alopecia and peripheral neuropathy. In general terms, until recently, the first-line therapy for cervical cancer was a choice between surgery and radiotherapy for early-stage disease with radiotherapy for advanced disease. The malignant non-epithelial tumours comprise mainly sex-cord stromal and germ-cell tumours. Of the sex-cord stromal tumours, granulosa cell tumours may require chemotherapy.