Arjun Jeyarajah

Women's experiences after a radical vaginal trachelectomy for early stage cervical cancer. A descriptive phenomenological study

PURPOSEnThis paper reports on a phenomenological study of womens experiences 1-10 years following a radical vaginal trachelectomy and describes the impact on health, sexuality, fertility and perceived supportive care needs.nnnMETHOD AND SAMPLEnQualitative telephone interviews employing a descriptive phenomenological approach were conducted using a purposive sample of 12 women.nnnKEY RESULTSnSeveral felt their cancer experience was positive; bringing them closer to family and changed their outlook on life. A few experienced delayed psychological reactions and/or fears of recurrence. Many experienced isolation and the desire to contact others with similar experiences. Women recovered well but a few experienced fears/concerns about lymphoedema and intermenstrual bleeding. Sexual function was not a long-term issue for most. Some that could feel the cerclage (stitch) during intercourse, developed techniques to reduce this. Single women felt vulnerable in new relationships. Pregnancy was an anxious time, especially for those that experienced a miscarriage or pre-term birth. Sources of support included the clinical nurse specialist, family/friends, surgical consultant, online patient forums and a support group. Women needed more information on trachelectomy statistics, pregnancy care recommendations as well as access to counselling, peer support, being seen by the same person and increased public awareness.nnnCONCLUSIONSnThis study has provided an interesting and detailed insight into womens experiences in the years following a trachelectomy, with results that have important considerations for practice such as provision of statistical information; counselling; peer support; consistent pregnancy recommendations; increased public awareness and increased identification and management or prevention of long-term physical effects.

Surgical treatment of stage IA2 cervical cancer.

BACKGROUNDnCervical cancer is the second most common cancer among women up to 65 years of age and is the most frequent cause of death from gynaecological cancers worldwide. Women with International Federation of Gynecology and Obstetrics (FIGO) stage IA2 cervical cancer have measured stromal invasion (when the cancer breaks through the basement membrane of the epithelium) of greater than 3 mm and no greater than 5 mm in depth with a horizontal surface extension of no more than 7 mm. For stage IA2 disease, radical hysterectomy with pelvic lymphadenectomy or radiotherapy is the standard treatment. In order to avoid complications of more radical surgical methods, less invasive options, such as simple hysterectomy, simple trachelectomy or conisation, with or without pelvic lymphadenectomy, may be feasible for stage IA2 disease, considering the relative low risk of local or distant metastatic disease. The evidence for less radical tumour excision and for the role of systematic lymphadenectomy in stage IA2 cervical cancer is not clear.nnnOBJECTIVESnTo evaluate the effectiveness and safety of less radical surgery in stage IA2 cervical cancer.nnnSEARCH METHODSnWe searched the Cochrane Gynaecological Cancer Group trials register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to September 2013. We also searched registers of clinical trials and abstracts of scientific meetings.nnnSELECTION CRITERIAnWe searched for randomised controlled trials (RCTs) that compared surgical techniques in women with stage IA2 cervical cancer.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently assessed whether potentially relevant studies met the inclusion criteria. We found no trials and, therefore, no data were analysed.nnnMAIN RESULTSnThe search strategy identified 982 unique references, which were all excluded on the basis of title and abstract because it was clear that they did not meet the inclusion criteria. We identified one relevant large ongoing trial, so it is anticipated that we will be able to add this evidence to this review in the future.nnnAUTHORS CONCLUSIONSnWe found no evidence to inform decisions about different surgical techniques in women with stage IA2 cervical cancer. In the future, the results of one large ongoing RCT should allow comparison of different types of surgery.

Interesting case of ovarian sarcoidosis: the value of multi disciplinary team working.

BackgroundSarcoidosis of the genital tract is a rare condition. Ovarian manifestation of this disease is rarer still.Case presentationThe case presented here represents ovarian manifestation of sarcoidosis. At the point of referral to our hospital, based on computerised tomography (CT) ovarian carcinoma was a differential diagnosis. Further magnetic resonance imaging along with CT guided biopsy aided by laboratory study supported a diagnosis of sarcoidosis. Patient responded to medical management by a multidisciplinary team.ConclusionThe case shows the importance of FNAC and biopsy in case or ovarian masses and multi disciplinary team approach to management.

Perforation of a malignant ovarian tumor into the recto-sigmoid colon

Ovarian cancer often presents at an advanced stage, but tends to be an intra‐peritoneal disease that respects peritoneal planes. Thus, colo‐rectal perforation of the tumor is an extremely rare presentation. The surgical treatment of malignant colo‐ovarian fistula should include complete cyto‐reduction at the same time as the treatment of the fistula. However, prognosis remains poor, because of the advanced stage of neoplasia. We report the case of a patient with an ovarian malignant tumor perforating into the recto‐sigmoid colon. CT scan was the cornerstone of the radiological diagnosis. We managed to perform a complete cyto‐reduction, including an en‐bloc resection of the uterus, the mass, adnexa and recto‐sigmoid with removal of the associated pelvic abscess.

Cervical lymphadenopathy – an unusual presentation of carcinoma of the cervix: a case report

IntroductionThe clinical presentation of carcinoma of the cervix as cervical lymphadenopathy has not been described before. We report a case of this unusual manifestation of cervical cancer.Case presentationA 51-year-old woman presented to our Head and Neck department with cervical lymphadenopathy. A positron emission tomography scan revealed the primary tumour to be in the cervix and a cervical biopsy confirmed carcinoma of the cervix.ConclusionRecurrences of carcinoma of the cervix presenting as lymphadenopathy have been described before but this is the first time a clinical presentation of carcinoma of the cervix as cervical lymphadenopathy has been described. Although metastasis from the cervix to the cervical lymph nodes is rare, this can be explained by outlining the drainage of the lymphatic system from the cervix.

Ovarian recurrence from a Stage 1b1 cervical adenocarcinoma previously treated with radical vaginal trachelectomy: A case report.

► Post cervical cancer treatment new pelvic abnormality must be regarded as recurrence. ► Benign MRI features does not exclude recurrence from previous cervical adenocarcinoma.

An ultra‐radical surgical approach for recurrent vulvar cancer involving en‐bloc excision of the infra‐renal aorta

Distant recurrences in vulvar cancer are very rare events and they are usually treated with chemoradiation. The present study reports the first description, to the authors’ knowledge, of an aggressive surgical approach for the treatment of a para-aortic nodal recurrence in vulvar cancer. Informed consent was obtained from the patient for the present study. A patient 69 years of agewas diagnosedwith a 3.2-cmsquamous cell carcinoma of the vulva. The patient underwent radical vulvectomy and a bilateral inguinal lymphadenectomy. Histology identified a stage IIIC squamous cell carcinomawith bilateral positive lymph nodes. Adjuvant chemoradiation was used to complete treatment. Computerized tomography, performed 1 year after surgery, revealed a 3.7-cm mass of enlarged lymph nodes in the lower paraaortic region. Positron emission tomography found metabolically active tissue encasing the infra-renal aorta with no evidence of disease elsewhere (Fig. 1). Non-surgical treatment options were considered unlikely to be effective in view of the tumor bulk. A decision was made to excise the recurrence surgically. The nodal disease was found to be inseparable from the aorta posteriorly and was resected en-bloc with the infrarenal aorta and common iliac arteries. Aortic reconstruction with graft replacement was performed (Fig. 1). No complications occurred during the postoperative period. Additionally, no lymphedemawas observed at the patient’s first follow-up visit after 3 months. Final histology identified a grade 2 squamous cell carcinoma involving the para-aortic nodes and invading the tunica media of the aorta. Under microscopy, the peripheral soft-tissue margins and the psoas margin were found to be positive. Treatment was completed using radiotherapy on the tumor bed. The patient died owing to multiple lung metastasis that were identified 5 months after surgery. Distant-recurrence rates of approximately 3% have been reported in vulvar cancer [1,2]. Para-aortic metastasis secondary to vulvar carcinoma is a very rare event. Adjuvant treatments are limited for recurrent vulvar cancer. Radical radiotherapy can be used in treating patients who have inoperable disease. Chemotherapy can also be used to treat distant multifocal metastasis but data have demonstrated no clear evidence of an improvement in survival in comparison with primary surgery [3]. Currently, none of the treatment modalities described in the present study can be generally recommended for routine application. Conversely, radical surgery could be considered if it is technically feasible for the patient. When recurrence affects blood vessels it is usually considered inoperable [4]. Radical resection including reconstruction with vascular grafting has been described in the treatment of recurrent vulvar cancer involving the femoral vessels [5]. Although retrospectively, the surgical treatment attempted was not beneficial in the present study, we do believe that, in similar patients with a better tumor biological profile, an aggressive operation could confer good survival outcomes. In the absence of other therapeutic options, ultra-radical surgery should be offered for localized recurrence; this could improve the selection of patients for this procedure.