Amnon Amit

FDG PET/CT in monitoring response to treatment in gynecological malignancies.

Purpose of review To evaluate the role of fluorodeoxyglucose (FDG) PET/CT as cancer response testing in gynecological malignancies. Recent findings The application of FDG PET/CT in patients with endometrial and ovarian cancer to evaluate treatment response was found to have no clinical benefits. Patients with cervical cancer seem to benefit from the use of PET/CT in estimation of treatment response. The influence of different treatments on FDG uptake, timing, frequency of examination, and survival advantage are evaluated and discussed. Summary Growing evidence supports an important role for functional imaging FDG PET/CT as a monitoring tool in patients with uterine–cervix carcinoma. Further studies are needed to establish the clinical benefits of this modality in this population.

Splenic pregnancy: the role of abdominal imaging.

Splenic pregnancy is extremely rare, with only a few previously well-documented cases reported. It usually presents with upper left abdominal pain and carries a high risk of potentially uncontrollable, life-threatening intraperitoneal bleeding. In the past, preoperative confirmation of this entity was very difficult and often required emergency surgical intervention and splenectomy. However, thanks to modern diagnostic technologies such as sonography and computed tomography (CT), it is now possible to make a diagnosis at an early stage without surgery. This report describes a case of an ectopic splenic pregnancy with an unusual clinical presentation. It highlights the potential benefits and importance of selecting appropriate imaging modalities to identify the implantation site of an ectopic gestational sac.

A life-threatening event: uterine cervical arteriovenous malformation.

BACKGROUND: Uterine cervical arteriovenous malformation is a rare cause of vaginal bleeding. CASE: A 32-year-old multigravida presented with severe vaginal bleeding originating in the cervix, which resulted in a hypovolemic shock. Attempts to control the bleeding included hysterectomy, pelvic arterial embolization, and upper vaginectomy. Each proved unsuccessful. Histopathologic examination revealed an arteriovenous malformation. Despite local packing, suturing of the vault area, and brachytherapy to the vaginal vault, bleeding persisted. Treatment with GnRH agonist and tranexamic acid stopped the bleeding. CONCLUSION: Severe vaginal bleeding can be the result of cervical arteriovenous malformation, and GnRH agonist may be used for treatment.

Diagnostic implications of p16 expression in serous papillary endometrial cancer.

Objective: The purpose of this study was to examine whether the degree of expression of the p16 protein in serous papillary endometrial cancer bears a prognostic significance. The secondary objective was to establish the value of p16 immunohistochemical staining as an adjunct to diagnosis. Study Design: Archived paraffin blocks holding specimens from the uteri of 31 serous papillary and 31 endometrioid endometrial carcinoma patients were recut and restained for p16 and p53. Results: Overexpression of p16 was found in 78% of the serous papillary patients versus 36% of the endometrioid patients. p16 was not found to be an independent prognostic factor in serous papillary endometrial carcinoma. Conclusions: Although p16 was not found to have prognostic significance in serous papillary endometrial carcinoma, it may be valuable as a diagnostic adjunct in histologically ambiguous tumors.

Liposome-encapsulated doxorubicin citrate (Myocet) for treatment of recurrent epithelial ovarian cancer: a retrospective analysis.

The aim of this study was to assess the clinical activity and toxicity of liposome-encapsulated doxorubicin citrate (Myocet) in a retrospective multicenter cohort of epithelial ovarian, primary peritoneal, and tubal cancer patients. Records of patients with recurrent epithelial ovarian, primary peritoneal, and tubal cancer treated with liposome-encapsulated doxorubicin citrate (60 mg/m2 on day 1 of a 21-day cycle) after failure of more than one previous regimen were reviewed. Fifty-three patients were evaluated for efficacy and toxicity. The median age of the patients was 59 (range 39–73). The median follow-up was 6 months (range 1–17). One patient (1.9%) showed a complete response and 13 patients (24.5%) showed a partial response, yielding an overall response rate of 26.4% (14/53 patients). Clinical benefit was achieved in 36 patients (67.9%). The median progression-free survival (PFS) for the entire study population was 4.0 months (range 1.0–14.8). The median PFS for platinum-sensitive and platinum-resistant patients was 4.0 months (ranges 1.0–14.8 and 1.0–9.4, respectively; P=0.652). The median overall survival from the start of liposome-encapsulated doxorubicin citrate was 10.0 months. Multivariate survival analysis showed no association between the liposome-encapsulated doxorubicin citrate line of treatment or platinum sensitivity to PFS in age and BRCA status-adjusted models. Only 11.3% of patients experienced grade 3–4 hematologic toxicities, 80% grade-2 alopecia, and 50% grade-1–2 fatigue. No other grade-4 toxicities, no significant cardiac events, or hand and foot syndromes were reported. Liposome-encapsulated doxorubicin citrate was well tolerated, with a good response and high clinical benefit rate. Further evaluation in a larger prospective cohort is warranted.

Cervical intraepithelial neoplasia 2, 3 in pregnancy: time to consider loop cone excision in the first trimester of pregnancy?

Objectives To report the outcome of patients diagnosed with cervical intraepithelial neoplasia 2, 3 (CIN 2, 3) during pregnancy, who were treated by large loop excision of the transformation zone (LLETZ) in the first trimester or were followed up conservatively and treated after delivery. Methods Patients diagnosed with CIN 2, 3 during pregnancy who were treated with LLETZ or were conservatively followed up were included. Complications of the LLETZ, pathologic results, and pregnancy outcome of both groups were examined after delivery. Results Thirty-one patients were included in the study. Eighteen were conservatively followed up and 13 underwent LLETZ during the first 14 weeks of pregnancy. Four patients (12.9%) in the study group were diagnosed with invasive cervical cancer. From women who underwent LLETZ, 9 patients continued their pregnancy, 7 of which had term normal deliveries and 2 had late preterm deliveries. No complications of severe bleeding or miscarriage were reported in any of the treated patients. Conclusions Large loop excision of the transformation zone procedure in the first trimester of pregnancy is a safe procedure, with the advantage of treating definitively CIN 2, 3 lesions and preventing the devastating consequences of undiagnosed cervical cancer. We suggest that LLETZ should be performed more liberally in the first trimester of pregnancy.

Single Port Robotic Assisted Sacrocolpopexy: Our Experience With the First 25 Cases

Objectives In single-port surgery, the surgeon operates almost exclusively through a single entry point, typically the patients navel, leaving only a single small scar. The aims of this study were to share some tips and tricks of single-port robotic-assisted sacrocolpopexy and to evaluate the learning curve of mastering the skills to operate this procedure. Methods This is a retrospective study of the first 25 single-port; robotic-assisted sacrocolpopexy surgeries performed during July to December 2015 at Rambam Health Care Campus by a single surgeon. Primary points of interest included intraoperative bleeding, length of surgery, length of hospitalization, and surgical complications. Results The median age was 59 years (range, 35–74); the median “pelvic organ prolapse quantification” stage was 3 (range, 2–4). The median total operative time was 190 minutes (range, 114–308), and console time was 130 minutes (85–261). Comparisons between the first 15 cases and the following 10 cases demonstrated significant decreases in median total operative and console times: 226 minutes (range, 142–308) versus 156 minutes (range, 114–180), and 170 minutes (range, 85–261) versus 115 minutes (range, 90–270), respectively (P < 0.008). There were no intraoperative adverse events. Postoperative adverse events were also rare, including 1 case of small bowel adhesions that required a second laparoscopic surgery for adhesiolysis. After this incident, we peritonalized the mesh in all 13 successive cases; median time was 8 minutes (range, 5–15 minutes). Conclusions Single-port robotic-assisted sacrocolpopexy is a feasible procedure with low complication rates, minimal blood loss and postsurgical pain, fast recovery, short hospitalization, and virtually scar-free results. Outcomes of long-term follow-up should be investigated.

The prognostic significance of hematological parameters in women with uterine serous papillary carcinoma (USPC).

OBJECTIVES Preoperative hematologic parameters: thrombocytosis, leukocytosis and anemia have been demonstrated to be independent poor prognostic factors in ovarian and endometrial cancers. However, little is known about their relation to uterine serous papillary carcinoma (USPC). We evaluated several preoperative hematologic parameters and their association with clinicopathologic features, disease progression and overall survival in USPC patients. STUDY DESIGN This was a retrospective cohort study reviewing charts of all patients with a histologic pure USPC at two gynecologic oncology centers from January 2000 through July 2012. All patients had comprehensive hematologic tests prior to primary surgical treatment and were exposed to the same adjuvant treatment protocol. RESULTS The study included 56 patients, mean age at diagnosis 69.4±15. Six (11%) had platelet count above 400000 10(6)/L, of them four (66%) were dead at the end of follow up (HR=1.4, p=0.48; CI 95% 0.5-4.3). The mean hemoglobin level was 12.3g/dl, fibrinogen 437.5mg/dL and lymphocytes 2013/μL. None of these parameters was significantly associated with 5 year survival. Leukocyte and neutrophil levels were adversely associated with survival. Of 15 patients with leukocytosis >10000/μL, 67% were dead at the end of follow up (HR=3.98, p=0.003; CI 95% 1.6-9.8). Of the 27 with neutrophils above 65%, 14 (52%) were dead at the end of follow up (HR=3.1; p=0.015; CI 95% 1.2-7.8). CONCLUSIONS In patients with USPC, leukocytosis and neutrophilia are associated with aggressive tumor biology, and may predict a lower 5 year survival.

Is there a survival advantage in diagnosing endometrial cancer in asymptomatic postmenopausal patients? An Israeli Gynecology Oncology Group study

BACKGROUND: Incidental ultrasonographic findings in asymptomatic postmenopausal women, such as thickened endometrium or polyps, often lead to invasive procedures and to the occasional diagnosis of endometrial cancer. Data supporting a survival advantage of endometrial cancer diagnosed prior to the onset of postmenopausal bleeding are lacking. OBJECTIVE: To compare the survival of asymptomatic and bleeding postmenopausal patients diagnosed with endometrial cancer. STUDY DESIGN: This was an Israeli Gynecology Oncology Group retrospective multicenter study of 1607 postmenopausal patients with endometrial cancer: 233 asymptomatic patients and 1374 presenting with postmenopausal bleeding. Clinical, pathological, and survival measures were compared. RESULTS: There was no significant difference between the asymptomatic and the postmenopausal bleeding groups in the proportion of patients in stage II–IV (23.5% vs 23.8%; P = .9) or in high‐grade histology (41.0% vs 38.4%; P = .12). Among patients with stage‐I tumors, asymptomatic patients had a greater proportion than postmenopausal bleeding patients of stage IA (82.1% vs 66.2%; P < .01) and a smaller proportion received adjuvant postoperative radiotherapy (30.5% vs 40.6%; P = .02). There was no difference between asymptomatic and postmenopausal bleeding patients in the 5‐year recurrence‐free survival (79.1% vs 79.4%; P = .85), disease‐specific survival (83.2% vs 82.2%; P = .57), or overall survival (79.7% vs 76.8%; P = .37). CONCLUSION: Endometrial cancer diagnosed in asymptomatic postmenopausal women is not associated with higher survival rates. Operative hysteroscopy/curettage procedures in asymptomatic patients with ultrasonographically diagnosed endometrial polyps or thick endometrium are rarely indicated. It is reasonable to reserve these procedures for patients whose ultrasonographic findings demonstrate significant change over time.

The role of F18-FDG PET/CT in predicting secondary optimal de-bulking in patients with recurrent ovarian cancer

BACKGROUND AND OBJECTIVES The decision to perform secondary cytoreductive surgery for recurrent ovarian cancer is generally determined by clinical criteria. The aim of this study was to assess the predictive capability of FDG-PET/CT in identifying patients for whom secondary optimal debulking can be obtained. METHODS We reviewed the records of all women with suspected recurrent ovarian cancer (CA-125 levels >35 U/ml and/or clinical symptoms), at two medical centers, between January 2004 and December 2013. Patients in whom CT scans were negative, indeterminate or indicative of localized disease, were referred for preoperative FDG-PET/CT study. We analyzed the outcomes of those who subsequently underwent cytoreductive surgery. RESULTS Of 282 women with suspected recurrent ovarian cancer, 48 underwent FDG-PET/CT. The 24 for whom localized disease was detected on PET/CT, subsequently underwent secondary debulking surgery. Patients with PET/CT evidence of multifocal recurrent sites were referred for chemotherapy. Tumor debulking was optimal in 20 patients, and suboptimal in 4. The positive predictive value of PET/CT for optimal debulking was 83.3%. CONCLUSIONS The findings extend prior reports on the role of FDG-PET/CT in the management of recurrent ovarian cancer, to the prediction of secondary optimal debulking. Future studies should aim to investigate the impact on survival.