David E. Parkin

A comparison of bladder and ovarian function two years following hysterectomy or endometrial ablation.

Objective To test the hypothesis that at two years bladder and ovarian function function are no different following either simple hysterectomy or endometrial ablation (transcervical resectiodlaser ablation).

After-effects reported by women following colposcopy, cervical biopsies and LLETZ: results from the TOMBOLA trial.

OBJECTIVEnFew studies have investigated physical after-effects of colposcopy. We compared post-colposcopy self-reported pain, bleeding, discharge and menstrual changes in women who underwent: colposcopic examination only; cervical punch biopsies; and large loop excision of the transformation zone (LLETZ).nnnDESIGNnObservational study nested within a randomised controlled trial.nnnSETTINGnGrampian, Tayside and Nottingham.nnnPOPULATIONnNine hundred-and-twenty-nine women, aged 20-59, with low-grade cytology, who had completed their initial colposcopic management.nnnMETHODSnWomen completed questionnaires on after-effects at approximately 6-weeks, and on menstruation at 4-months, post-colposcopy.nnnMAIN OUTCOME MEASURESnFrequency of pain, bleeding, discharge; changes to first menstrual period post-colposcopy.nnnRESULTSnSeven hundred-and-fifty-one women (80%) completed the 6-week questionnaire. Of women who had only a colposcopic examination, 14-18% reported pain, bleeding or discharge. Around half of women who had biopsies only and two-thirds treated by LLETZ reported pain or discharge (biopsies: 53% pain, 46% discharge; LLETZ: 67% pain, 63% discharge). The frequency of bleeding was similar in the biopsy (79%) and LLETZ groups (87%). Women treated by LLETZ reported bleeding and discharge of significantly longer duration than other women. The duration of pain was similar across management groups. Forty-three percent of women managed by biopsies and 71% managed by LLETZ reported some change to their first period post-colposcopy, as did 29% who only had a colposcopic examination.nnnCONCLUSIONSnCervical punch biopsies and, especially, LLETZ carry a substantial risk of after-effects. After-effects are also reported by women managed solely by colposcopic examination. Ensuring that women are fully informed about after-effects may help to alleviate anxiety and provide reassurance, thereby minimising the harms of screening.

Incomplete excision of CIN in conization: further excision or conservative management?

The aim of this study was to investigate the experience of the further management in 112 cases with histological diagnosis of incomplete excision of CIN in cone biopsy. Two groups of women were studied. The women in the first group (n = 78) had a second excision while the women in the second group (n = 34) underwent conservative management with cytology and colposcopy. The histologic, cytologic and colposcopic findings in the women of both groups were compared. From the first group 38% had a second cone, 62% an hysterectomy; in 5 cases the second cone was followed by hysterectomy and the histology was negative in 75% and 65%, respectively. No indication of residual disease was found within 2-10 years of follow-up in any of the women in the second group. According to our study and being aware of the natural history of CIN, we can conclude that the decision for further excision should not be based exclusively on the histology report of involved margins, but should only be taken after careful cytological and colposcopic selection of the cases.

Magnetic resonance imaging in gynecological oncology.

Magnetic resonance imaging (MRI) has become an indispensable tool in the assessment of malignant disease. With increasingly sophisticated systems and technical advancements, MRI has continued to expand its role in providing crucial information regarding cancer diagnosis and management. In gynecological malignancies, this modality has assumed greater responsibility, particularly in the evaluation of cervical and endometrial cancers. In addition to conventional imaging, innovative techniques such as dynamic contrast-enhanced MRI and diffusion-weighted MRI show promise in offering early assessment of tumor response. This paper reviews the current role of MRI in gynecological cancers and highlights the potential of novel techniques in improving patient care.

Predicting the Response of Advanced Cervical and Ovarian Tumors to Therapy

The management of advanced cervical and ovarian cancers remains a significant challenge as many women fail to respond to recommended therapy, resulting in disease progression and ultimately patient death. Because of tumor heterogeneity, it is rare for all cancers of a particular type to respond to a specific therapy; and, as a result, many patients receive treatment from which they derive little or no benefit, leading to increased morbidity and undue costs. A marker that could rapidly predict or forecast disease outcome would clearly be beneficial in allowing the administration of a tailored regime for each patient while reducing toxicity and cost. Traditional prognostic factors of tumor size, grade, and stage are not ideal for predicting patient outcome, whereas the use of in vitro assays to detect chemosensitivity or resistance has not yet translated into routine clinical practice. Similarly, biomarkers and tumor markers vary in their predictive ability. DNA array technology offers great promise in predicting the response to therapy based on gene expression profiles, and can allow for targeted therapies against specific molecular alterations that cause disease. Imaging techniques, particularly those with the ability to characterize biological tissues and provide functional, structural, and molecular information, have the potential to noninvasively integrate physical and metabolic information. These include F-18-fluorodeoxyglucose positron emission tomography, dynamic contrast-enhanced magnetic resonance imaging, and diffusion weighted magnetic resonance imaging, all techniques that attempt to evaluate and predict therapy response and so influence clinical outcome. This review examines different methods of predicting the response to treatment in advanced cervical and ovarian tumors. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to describe why prediction of response to therapy for cervical and ovarian cancers is important, describe obstacles to use of in vitro assays to predict outcomes for therapy for ovarian and cervical cancers, and explain potentially new predictive markers.

The cost of microwave endometrial ablation under different anaesthetic and clinical settings

Objective To compare the costs of microwave endometrial ablation under local anaesthetic and general anaesthetic in an operating theatre and to estimate the cost of performing treatment under local anaesthetic in a dedicated clinic setting.

An update on the management of uterine carcinosarcoma.

Carcinosarcomas are rare aggressive neoplasms with a poor prognosis. The recent International Federation of Gynecology and Obstetrics (FIGO) 2009 categorizes uterine carcinosarcoma into the endometrial carcinoma group. This review highlights the prognosis, recurrence rate, and the treatment modalities. The primary treatment is surgery. Lymphadenectomy as part of the surgical procedure has shown to prolong survival even for early-stage disease. A combined chemo-radiotherapeutic approach has shown a survival benefit. Radiotherapy from various studies has shown a significant effect on local control of the disease, with no obvious benefit on overall survival. Various trials led by the gynecologic oncology group looking into different chemotherapeutic combinations have showed differing response rates. In the future, the emergence of combination of chemotherapeutic agents with molecular-targeted agents may show promising results. Target Audience: Obstetricians & Gynecologists and Family Physicians Learning Objectives: After completing this CME activity, physicians should be better able to appraise the aggressive nature of uterine carcinosarcoma and factors which would help in delaying or preventing recurrence, assess the importance of lymphadenectomy for uterine carcinosarcoma and its effect on survival, and evaluate various recent trials addressing the chemo-radiotherapeutic combinations as adjuvant therapy.

Long-Term Worries after Colposcopy: Which Women Are at Increased Risk?

BACKGROUNDnA colposcopy examination is the main management option for women with an abnormal cervical screening test result. Although some women experience adverse psychological effects after colposcopy, those at greatest risk are unknown. We investigated predictors of worries about cervical cancer, sex, future fertility and general health during 12 to 30xa0months after colposcopy.nnnMETHODSnWe invited 1,515 women, aged 20 to 59xa0years with low-grade cervical cytology who attended colposcopy to complete questionnaires at recruitment (∼8 weeks after cytology result) and after 12, 18, 24, and 30 months of follow up. Outcomes were worries about having cervical cancer, having sex, future fertility, and general health at any time during follow-up. Factors significantly associated with each outcome were identified using multiple logistic regression.nnnRESULTSnAt one or more time points during follow-up, 40% of women reported worries about having cervical cancer, 26% about having sex, 24% about future fertility, and 60% about general health. For all outcomes except sex, worries reported at recruitment were associated with significantly increased risk of worries during follow-up. Significant anxiety at recruitment was associated with all worries during follow-up. Women diagnosed with CIN2+ had significantly higher risks of worries about cervical cancer and future fertility. Management received was associated significantly with worries about cervical cancer and having sex. Younger women significantly more often reported worries about future fertility, whereas women who had children had reduced risk of future fertility worries but increased risk of cervical cancer worries.nnnCONCLUSIONnClinical, sociodemographic, lifestyle, and psychological factors predicted risk of reporting worries after colposcopy.

Se acabaron las citologías con discariosis moderada

Objetivo. La British Society for Clinical Cytology ha propuesto recientemente una modificación de la terminología para los informes de frotis cervicales, pasando de un sistema de 3 tipos (discariosis leve, moderada o grave) a otro de dos tipos, denominados discariosis de bajo grado y de alto grado. Esta modificación elimina la categoría central de discariosis moderada que se incorporaría al grupo de alto grado. El objetivo de este estudio fue investigar el papel de las citologías con discariosis moderada en la práctica clínica. Material y métodos. Se llevó a cabo una revisión retrospectiva de todas las mujeres que fueron remitidas a una exploración colposcópica debido a una citología con discariosis moderada a lo largo de un periodo de 6 meses. Los datos recogidos incluyeron la impresión colposcópica, la intervención realizada y el diagnóstico histopatológico final. Se pidió a dos citólogos, que no conocían el informe inicial de las citologías, que volvieran a clasificarlos con el empleo del nuevo sistema de sólo dos clases. Se compararón sus resultados con los resultados documentados de la colposcopia e histopatología. Resultados. Un total de cien mujeres con citologías con discariosis moderada fueron remitidas a colposcopia durante el período de estudio. La mayoría de ellas fueron clasificadas en la categoría de discariosis de alto grado utilizando el nuevo sistema. En 56 (72%) de las citologías con discariosis moderada que fueron clasificados correctamente como de alto grado por el citólogo 1 se observó una neoplasia cervical intraepitelial 2‐3 en la histopatología final, mientras que en el caso del citólogo 2, en 66 (68%) se observó una neoplasia cervical intraepitelial de alto grado. Conclusión. La conservación del término de discariosis moderada no aporta ninguna ventaja clínica. Este estudio resalta la necesidad de utilizar un sistema uniforme de dos clases.

Is this the end of the line for the moderate dyskaryotic smear

Objective. The British Society for Clinical Cytology has recently proposed that the terminology for cervical smear reporting is to be changed from a 3-tier system (mild, moderate, severe dyskaryosis) to a 2-tier system of low-grade and high-grade dyskaryosis. This modification eliminates the central category of moderate dyskaryosis which would be incorporated into the high-grade group. The aim of this study was to investigate the role of the moderate dyskaryotic smear in clinical practice. Materials and Methods. A retrospective review of all women who were referred for colposcopy because of a moderate dyskaryotic smear was carried out for a 6-month period. Data collected included colposcopic impression, procedure performed and final histopathology. Two cytologists who were unaware of the original smear report were asked to reclassify these smears using the new 2-tier system. Their findings were compared with the documented colposcopic and histopathology results. Results. One hundred women with moderate dyskaryotic smears were referred for colposcopy during the study period. Most of these were reclassified as high-grade dyskaryosis using the new system. Fifty-six (72%) of the moderate dyskaryotic smears which were correctly regraded as high grade by cytologist 1 were found to have cervical intraepithelial neoplasia 2/3 on final histopathology, whereas for cytologist 2, 66 (68%) were found to have high-grade cervical intraepithelial neoplasia. Conclusion. There is no clinical benefit in retaining the term moderate dyskaryosis. This study emphasizes the need for a uniform 2-tier system.