Gordon V. Narayansingh

The Risk of Malignancy Index for Ovarian Tumours in Northeast Scotland – a Population Based Study

Background and Aims The Scottish Intercollegiate Guidelines Network (SIGN) recommends the use of the Risk of Malignancy Index (RMI) for ovarian tumours, a scoring system based on ultrasound findings, menopausal status and CA 125 level, in the pre-operative evaluation of pelvic masses. The aim of this study was to investigate the accuracy of this as a predictive method of discriminating benign from malignant disease. Methods and Results All women who underwent oophorectomy in 2004 at Aberdeen Royal Infirmary for suspected primary ovarian pathology were evaluated. The RMI was calculated and these results were compared with the final histopathology. The sensitivity of the RMI for diagnosing malignant ovarian disease was 94% (32/34) while the specificity was 70% (76/108). Conclusions Compared to previous studies, the RMI score was highly sensitive in detecting malignant disease, although not as specific in excluding benign lesions, particularly cystadenomas and endometriomas. This can be improved by the refinement of imaging techniques as well as the use of laparoscopy in particular cases. The RMI score may also be especially valuable in directing referrals to a specialised centre.

Uterine leiomyosarcomas: a review of the diagnostic and therapeutic pitfalls

• Uterine leiomyosarcomas are the most common uterine sarcoma and they are notoriously aggressive in nature. • Preoperative diagnosis is difficult and they are usually detected as an incidental finding at surgery. • Tumour stage is the most important prognostic factor. • Misdiagnosis or delay in diagnosis can occur following the use of conservative techniques for managing uterine fibroids. • The primary treatment is surgical, while the role of adjuvant therapy is still to be clearly defined.

A Reappraisal of the Role of Chlorambucil in Patients with End Stage Ovarian Cancer Who Have Previously been Treated with Platinum Regimens

The role of chlorambucil in end stage platinum resistant epithelial ovarian cancer was evaluated in women with end stage ovarian cancer. They had received platinum based chemotherapy and all other intravenous chemotherapeutic options had been exhausted. Over a 15 year period, 30 patients were identified. The median age was 64.5 years (range 45–81). The median number of chlorambucil pulses was 4 (range 1–16). The median survival following the introduction of chlorambucil was 5.5 months (range 0.72 – 38.8). The 22 patients who survived for longer than three months were significantly younger than those who did not (p= 0.03). Apart from two patients who developed transient myelosupression there were no toxic side effects. Chlorambucil should be considered as a therapeutic option in end stage ovarian cancer. It is has minimal toxicity, and can be prescribed safely for long term use. In younger women, an increase in benefit may be anticipated.

The performance of screening tests for ovarian cancer: results of a systematic review

Sir, We read with interest the recent article by Zetterstrom et al. (Vol 106, April 1999)’ which showed that infrequent voluntary flatus is a common symptom after vaginal delivery in primiparous women. The prevalence of anal incontinence for gas or feces appears to be more common than previously appreciated and represents an embarrassing social problem. Obstetric trauma is by far the most common cause of anal incontinence in women. The relationship between first childbirth and obstetric trauma is strong, but additional pregnancies and deliveries are aggravating factors as well as ageing and hormonal effects of the menopause. Recent reports showed that a new fecal incontinence and involuntary flatus are the immediate consequences of childbirth after vaginal delivery in primiand multiparous women’-’. These studies have questioned the need for further investigations on the duration of these symptoms. Between January 1998 and December 1998, 287 women (187 primipaxae and mulitparae, and 100 nulliparae) were questioned by one of the authors more than five years after vaginal delivery using a standard questionnaire about anal incontinence for flatus, liquid and solid stool. The questionnaires involved further detailed information on all previous childbirth, medical history, symptoms of urinary incontinence and questions on sexual behaviour. More than five years after childbirth, 20 women (10%) in the primiparae and multiparae groups were incontinent of flatus, but none of the nulliparae had such symptoms (P < 0.05). Twenty-seven women (14.4%) reported having fecal urgency and/or liquid stool since their first delivery, compared with three women (3%) in the nulliparous group (P c 0.05). Dyspareunia was reported by 15 women (7.5%) after vaginal delivery and only by one woman without childbirth (P < 0.05). Urinary incontinence of the first to second degree was reported by 82 women (40%) in the parous group and by 14 women (28%) in the nulliparous group. The majority of women reported the onset of symptoms after the initial delivery. We conclude that years after childbirth incontinence for feces (incontinence of the second to third degree) is rare, but incontinence for flatus and infrequent symptoms are common. The majority of women did not volunteer symptoms of altered anal incontinence at postnatal examination, because they thought the symptoms would eventually improve. Therefore obstetricians and midwives need to be aware of the importance of the problem and focus on potential aspects of reducing obstetric trauma (selective episiotomy, training of staff in perianal anatomy and repair). For all these reasons, we think that obstetricians should ask specifically about urinary and anal incontinence (silent affliction) as one important part of prevention in health care. Regardless of symptoms of anal and/or urinary incontinence, pelvic floor exercises are recommended in pregnancy, puerperium and later on in life.

The genetic causes of the sequential occurrence of multiple primary malignancies in a young woman--5 years on.

The finding of three primary gynaecological malignancies in a young woman attending our unit was documented in 2001. We provide an update on this report as new events have prompted further discussion on the role of clinical guidelines in cancer management. The discovery of a genetic predisposition demonstrates the need for multidisciplinary input and heightened awareness in similar cases while the importance of treating each patient as an individual is emphasized.

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.

Laparoscopic exploration of obturator nerve

Obturator nerve injury is a recognised potential complication of paravaginal repair (Scotti et al., Am J Obstet Gynecol 179:1436, 1998). Non-absorbable sutures are utilised for a paravaginal repair in order to provide permanent support, and they can induce a fibrotic reaction, thereby contributing to the integrity of the repair. We present a case in which we hypothesise that the fibrotic reaction induced resulted in the tethering of the obturator nerve. This was released laparoscopically with immediate resolution of symptoms.