Laura Hopkins

The Definition of Optimal Inguinal Femoral Nodal Dissection in the Management of Vulva Squamous Cell Carcinoma

ObjectivesTo reject the hypothesis that the number of nodes removed at time of surgical staging for vulva cancer is not an important prognostic factor.MethodsRetrospective chart reviews were carried out from 1980-2004 to identify patients with squamous cell vulva carcinoma treated with radical vulvectomy and bilateral inguinal femoral lymph node dissection. Patients’ demographics, disease characteristics, the number of lymph nodes removed at surgery, and standard oncologic outcomes were recorded. Cox proportional hazard models were built to model times to clinical progression and death using predictor variables of: age, tumor size and maximum depth of invasion, resection margin status, and total number of nodes removed.ResultsFifty-eight patients were identified. The median lesion size was 3.5 cm. The median depth of invasion was 7.5 mm. The 20th percentile for total number of lymph nodes removed was 10. Adjuvant radiation therapy was given in 31% of patients. At a median follow-up of 37 months, recurrence was observed in 17 patients (29.3%). Cox regressions showed the total number of nodes removed less than 10 to be the only significantly predictive of shorter time to first progression (HR = 12.88, 95% CI = 1.47-112.89, P = .021) and shorter disease specific survivals (HR = 11.41, 95% CI = 2.21-58.86, P = .004) (HR, hazard ratio; CI, confidence interval).ConclusionThe total number of nodes removed at time of surgical staging is an independent survival prognostic factor. A total of at least 10 nodes from a bilateral dissection can be used to define an optimal evaluation.

Mullerian Adenosarcoma of the Cervix in a 10-Year-Old Girl: Case Report and Review of the Literature

UNLABELLED Müllerian adenosarcoma is a rare neoplasm usually found in postmenopausal women. It usually presents as a polypoid mass within the endometrium. It is a biphasic tumor, composed of a benign epithelial component and a malignant stromal component. To date, this neoplasm has been reported in only 16 adolescent girls. We present a case of a 10-year-old girl who was diagnosed with müllerian adenosarcoma arising from the endocervix, the youngest female ever reported. CASE REPORT A 10-year-old previously healthy girl presented to the Emergency Department at the Childrens Hospital of Eastern Ontario with a painless mass protruding from her vagina. She had experienced mild vaginal bleeding for two weeks prior to her presentation. On physical examination, her vital signs were stable, and pubertal development was Tanner III breast and Tanner II pubic development. Rectoabdominal examination was negative. Two polypoid lesions were seen protruding past the hymenal ring and were removed in the emergency department. On gross examination, they were a dark tan color and had a fleshy appearance with a gelatinous consistency. They measured 5.5 x 1.5 x 1.0 cm and 3.5 x 1.5 x 1.5 cm. The final pathology revealed müllerian adenosarcoma, favoring an endocervical origin. Further investigations, including an abdominal/pelvic ultrasound and MRI and chest radiography, were negative. The patient subsequently underwent examination under anesthesia, vaginoscopy, hysteroscopy, polypectomy, and dilatation and curettage. The vagina appeared normal. At the level of the cervix, there were 3 polypoid gelatinous structures arising from the endocervix and extruding past the exocervix. They measured 0.8 x 0.5 x 0.2 cm up to 1.1 x 0.7 x 0.5 cm. The lesions were removed. Hysteroscopic inspection of the uterine cavity did not find any abnormalities. An endometrial curettage was performed. Pathology confirmed a diagnosis of müllerian adenosarcoma originating from the endocervix. Uterine curettings were negative for malignancy. After a thorough evaluation of the available literature, review with the Regional Tumor Board and extensive discussions with the family, a decision was made to perform a radical hysterectomy, bilateral salpingectomy, bilateral pelvic lymph node dissection, upper vaginectomy and preservation of ovaries. The procedure was uncomplicated. Clinically, there was no evidence of residual disease. The final pathology was negative for malignancy. CONCLUSION Müllerian adenosarcoma of the endocervix is a very rare pediatric tumor. Due to the rarity of this tumor in this age group, optimal therapy is uncertain. Most experts recommend hysterectomy. The review of literature reveals a high recurrence rate following conservative surgical management. Chemotherapy and radiation have not been used in the absence of extensive pelvic and/or residual disease. Poor prognostic factors include depth of invasion, sarcomatous overgrowth and high-grade malignant features in the stromal component. If recurrence occurs, it tends to be local and following prior conservative treatments such as cone biopsy or trachelectomy. Recurrences may occur late and thus long term follow-up of these patients is recommended.

Human Papilloma Virus Testing Knowledge and Attitudes Among Women Attending Colposcopy Clinic with ASCUS/LGSIL Pap Smears

OBJECTIVE To study womens knowledge regarding the role of human papilloma virus (HPV) in cervical intraepithelial neoplasia and their attitudes toward the integration of HPV testing as part of routine follow-up of atypical squamous cell of uncertain significance/low-grade squamous intraepithelial lesion (ASCUS/LGSIL) abnormalities. METHODS Over a 12-month period, all women attending the University of Ottawa colposcopy clinic for evaluation and follow-up of ASCUS/LGSIL Pap smears were recruited. Demographic data included age, nature of the Pap smear abnormality, gravidity, parity, occupation and education level, smoking history, previous history of abnormal smears, colposcopic examination and treatment, and current method of contraception. The women were asked to rate their level of concern over their Pap smear abnormality, from 0 (not concerned) to 10 (very concerned). Womens knowledge regarding the role of HPV in cervical intraepithelial neoplasia and the rationale behind the use of HPV testing was assessed by the clinic nurse as being minimal, moderate, or good, as defined by pre-specified criteria. Upon explanation by the nurses of the results of the recent ALTS (ASCUS/LGSIL Triage Study) trial, the women were asked to state whether they preferred to continue with regular colposcopic surveillance every 6 months, or to use the results of the HPV test, if negative, to reduce the number of colposcopy examinations to one annually. Descriptive statistics and logistic regression analysis were used to identify significant demographic factors associated with the womens preference for incorporation of HPV testing in their follow-up. All P values less than.10 were considered to be statistically significant, due to the exploratory nature of the study. RESULTS Of the 100 women who participated in the study, 42% presented with ASCUS. The mean age (+/- SD) of the women was 33.63 +/- 11.25 years (range, 18-75 years); 66% were office workers with at least a community college degree, 86% reported previous abnormal Pap smears, and 67% had previously been seen for colposcopy. Fifty-eight percent of the women rated their concern level as being 6 or more, while 15% ranked their concerns as maximal at 10. In terms of knowledge about HPV, 75% of the women had no or very minimal knowledge of the role of HPV in cervical intraepithelial neoplasia. With regard to HPV testing, 84% of the study group had either never heard of the test or had only a minimal knowledge of HPV testing. After being informed of the ALTS results, 64% of the women chose to use HPV testing to help in triaging the needs for frequent colposcopy. Logistic regression modelling showed that a college level education (odds ratio [OR], 2.27; 95% confidence interval [CI], 0.95-;5.45; P =.06) and history of previous treatment for abnormal Pap smears (OR, 3.31; CI, 0.88- 12.46; P =.07) were closely associated with the adoption of HPV testing in clinical management. CONCLUSION There exists a significant lack of knowledge about HPV and its role in the pathogenesis of cervical intraepithelial neoplasia. Women who have received previous treatments for cervical intraepithelial neoplasia and those with college-level educations were more likely to adopt this new technology as part of their care.

Technical Update on Tissue Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy

OBJECTIVE To review the use of tissue morcellation in minimally invasive gynaecological surgery. OUTCOMES Morcellation may be used in gynaecological surgery to allow removal of large uterine specimens, providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion. EVIDENCE Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyomsarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, morcellation, and MRI). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to August 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. (Table 1) BENEFITS, HARMS, AND COSTS: Gynaecologists may offer women minimally invasive surgery and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine sarcoma or endometrial cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Appropriate training and safe practices should be in place before offering tissue morcellation. SUMMARY STATEMENTS: 1. Uterine sarcomas may be difficult to diagnose preoperatively. The risk of an unexpected uterine sarcoma following surgery for presumed benign uterine leiomyoma is approximately 1 in 350, and the rate of leiomyosarcoma is 1 in 500. (II-2) This risk increases with age. (II-2) 2. An unexpected uterine sarcoma treated by primary surgery involving tumour disruption, including morcellation of the tumour, has the potential for intra-abdominal tumour-spread and a worse prognosis. (II-2) 3. Uterus-sparing surgery remains a safe option for patients with symptomatic leiomyomas who desire future fertility. (II-1) RECOMMENDATIONS: 1. Techniques for morcellation of a uterine specimen vary, and physicians should consider employing techniques that minimize specimen disruption and intra-abdominal spread. (III-C) 2. Each patient presenting with uterine leiomyoma should be assessed for the possible presence of malignancy, based on her risk factors and preoperative imaging, although the value of these is limited. (III-C) 3. Preoperative endometrial biopsy and cervical assessment to avoid morcellation of potentially detectable malignant and premalignant conditions is recommended. (II-2A) 4. Hereditary cancer syndromes that increase the risk of uterine malignancy should be considered a contraindication to uncontained uterine morcellation. (III-C) 5. Uterine morcellation is contraindicated in women with established or suspected cancer. (II-2A) If there is a high index of suspicion of a uterine sarcoma prior to surgery, patients should be advised to proceed with a total abdominal hysterectomy, bilateral salpingectomy, and possible oophorectomy. (II-2C) A gynaecologic oncology consultation should be obtained. 6. Tissue morcellation techniques require appropriate training and experience. Safe practice initiatives surrounding morcellation technique and the use of equipment should be implemented at the local level. (II-3B) 7. Morcellation is an acceptable option for retrieval of benign uterine specimens and may facilitate a minimally invasive surgical approach, which is associated with decreased perioperative risks. Each patient should be counselled about the possible risks associated with the use of morcellation, including the risks associated with underlying malignancy. (III-C).

Does intraperitoneal chemotherapy benefit optimally debulked epithelial ovarian cancer patients after neoadjuvant chemotherapy

OBJECTIVE To compare survival of ovarian cancer patients treated with neoadjuvant chemotherapy followed by intraperitoneal (IP) versus intravenous (IV) chemotherapy after optimal interval debulking. METHODS Optimally debulked patients after neoadjuvant IV platinum paclitaxel based chemotherapy followed by postoperative IP chemotherapy were reviewed. A similar cohort of patients treated postoperatively with IV platinum paclitaxel based chemotherapy was chosen as control. Patient and disease-related demographics were abstracted from electronic hospital medical records. Associations between categorical variables were determined using Chi square test. Cox regression and Kaplan-Meier method estimated progression-free and overall survival. RESULTS Fifty-four IV and 17 IP treated patients after interval debulking were studied. The majority of patients had serous histology and grade 3 tumours. There was no significant difference between the two groups with respect to age and proportion of microscopic residual disease. Patients with macroscopic residual disease had a significantly worse prognosis (HR=2.17, 95% CI=1.23-3.85, p=0.008). Clinical complete response after primary treatment was 67% and 88% in the IV and IP group, respectively (p=0.36). Estimated mean progression-free survival was 18 months in the IV group and 14.1 months in the IP group (p=0.42). IP chemotherapy was not predictive of progression-free survival in the Cox model adjusted for age and residual disease status (HR=1.22, 95% CI=0.62-2.4, p=0.56). Estimated mean survival was 68.9 months in the IV group and 37.5 months in the IP group (p=0.85). CONCLUSIONS Survival benefit associated with IP chemotherapy after optimal upfront surgery may not translate to the neoadjuvant setting.

Variations in Ultrasound Reporting on Patients Referred for Investigation of Ovarian Masses

OBJECTIVE Ultrasound characteristics play an important role in the evaluation and management of patients with an ovarian mass. We sought to quantify the variability in the reporting practices of radiologists in different practice environments. METHOD We carried out a prospective audit of all patients referred to a tertiary care gynaecologic oncology clinic over a three-month period for management of an ovarian mass. Each patients presenting symptoms, level of CA125 in serum, and previous ultrasound report were reviewed in detail, and both the environment where the ultrasound examination had been performed and the description of important predictive ultrasound characteristics for underlying risk of malignancy were noted. Descriptive statistics were used to summarize demographic variables. Cross-tabulations and chi-square tests were used to detect significant associations between categorical variables. RESULTS In the three-month period, 42 patients were referred to our clinic. The most common presenting symptom was abdominal or pelvic pain (65% of patients). Ultrasound examinations had been conducted in private clinics, community hospitals, and teaching hospitals. Significant variations in the reporting were noted. The important ultrasound characteristic most often not reported (approximately 80% of reports) was Doppler flow assessment of the mass. Five reports (12%) did not include information that would be needed to make a recommendation resulting in repeat ultrasound examination. We found no significant variation in reporting practices between private clinics and community hospitals. CONCLUSION Current reporting practices for ultrasound assessments in women with an ovarian mass vary considerably. They could be improved by use of a standardized synoptic reporting template.

To the point: medical education, technology, and the millennial learner

&NA; This article, from the “To The Point” series that was prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, provides an overview of the characteristics of millennials and describes how medical educators can customize and reframe their curricula and teaching methods to maximize millennial learning. A literature search was performed to identify articles on generational learning. We summarize the importance of understanding the attitudes, ideas, and priorities of millennials to tailor educational methods to stimulate and enhance learning. Where relevant, a special focus on the obstetrics and gynecology curriculum is highlighted.

Omental chemotherapy effects as a prognostic factor in ovarian cancer patients treated with neoadjuvant chemotherapy and delayed primary surgical debulking.

We sought to assess the prognostic significance of chemotherapy effect on upper abdominal metastatic disease. Retrospective chart reviews were carried out from 1997 to 2005 to identify ovarian cancer patients treated with neoadjuvant chemotherapy. Pathologic examinations of resected omental and ovarian tumors for the presence of chemotherapy effect were performed. Cox proportional hazard models were built to model time to progression and death by using predictor variables of age, tumor grade, amount and location of largest residual disease, and the presence of chemotherapy effects on resected tumors. Sixty-six patients with available slides and clinical information were identified. The presence of omental chemotherapy effects was observed in 58 patients (88%). Identified independent statistically significant predictors for progression-free survival included presence of omental chemotherapy effect (hazard ratio [HR], .38; 95% confidence interval [95% CI], .17–.89; P = .026) and suboptimal tumor residuals in upper abdominal location compared with pelvic location (HR, 2.41; 95% CI, 1.06–5.48; P = .035). The presence of omental chemotherapy effect was the only statistically significant predictor of disease specific survival (HR, .21; 95% CI, .068–.639; P = .006). The estimated median survival for the group with positive omental chemotherapy effect was 84.45 months (95% CI, 69.63–99.28). The corresponding statistic in patients with no observed response to chemotherapy was 31.15 months (95% CI, 21.84–40.47). Upper abdominal disease location and its response to chemotherapy were independent prognostic factors for progression-free survival. Aggressive upper abdominal debulking procedures are recommended to improve oncologic outcomes.

Comparative study of grade 3/4 toxicity associated with intraperitoneal chemotherapy administered after primary versus interval surgical debulking in ovarian cancer.

Objective: To determine the prevalence of grade 3 or 4 toxicity associated with intraperitoneal (IP) chemotherapy subsequent to primary surgical debulking compared to post-neoadjuvant chemotherapy and interval debulking in advanced ovarian cancer. Methods: Patients receiving IP chemotherapy from 2006 to 2010 were reviewed. Study cohort was stratified by initial treatment (upfront surgery vs neoadjuvant chemotherapy). The National Cancer Institute toxicity grading scale was used to assess treatment-related toxicities immediately before each cycle. The &khgr;2 test was used to check for association between categorical variables. Results: Thirty-three patients received IP chemotherapy after optimal debulking. Sixteen patients had upfront surgery. The total number of IP chemotherapy cycles administered was 134. Significantly, more patients treated with IP chemotherapy after intravenous neoadjuvant chemotherapy experienced fatigue (P = 0.038) compared to those treated after upfront surgery. During the course of IP regimen, the patients having upfront surgery tended to experience more grade 3/4 hematologic toxicities (P = 0.06) and abdominal pain (P = 0.08). Twenty-four (73%) of 33 patients completed all prescribed IP chemotherapy cycles. There was no significant difference between the 2 groups in need for dose reduction or delays, use of paclitaxel on day 8, neurologic/gastrointestinal/metabolic toxicities, and IP port complications. Conclusions: Intraperitoneal chemotherapy can be given after optimal primary surgery or interval surgery after neoadjuvant chemotherapy with similar toxicity profile. Toxicity data can be used to plan for optimal IP chemotherapy delivery, patient counseling, and ongoing supportive care.

Incidence of Tissue Morcellation During Surgery for Uterine Sarcoma at a Canadian Academic Centre

OBJECTIVES To determine the incidence of tissue morcellation during surgery for uterine sarcoma in a Canadian tertiary academic centre. METHODS In this retrospective cohort study, the clinical charts of all women who underwent hysterectomy for uterine sarcoma at the Ottawa Hospital between April 1, 2007, and March 31, 2014, were reviewed for their clinical characteristics and details of surgical treatment. RESULTS Sixty-six cases of uterine sarcoma were identified. The mean (± SD) age of patients was 62.1 ± 10 years, and 81.8% were postmenopausal. Of the tumours, 43.9% were carcinosarcomas, 28.8% were leiomyosarcomas, 13.6% were endometrial stromal sarcomas, 6.1% were adenosarcomas, 1.5% were uterine rhabdomyosarcomas, and 6.1% were undifferentiated sarcomas. None of the surgical specimens were morcellated by laparoscopic power morcellation, and 61/66 (92.4%) of patients had their surgery performed by a gynaecologic oncologist. In the remaining five women whose surgery was performed by a general gynaecologist (4 with leiomyosarcomas and 1 with undifferentiated uterine sarcoma), two surgical specimens were morcellated manually using a scalpel during the removal of presumed fibroids at hysterectomy performed by midline laparotomy. The first of these was a case performed as an emergency because of acute pelvic symptoms secondary to leiomyosarcoma, and the second case had a solitary leiomyosarcoma among multiple benign leiomyomata. CONCLUSION Uterine sarcomas are uncommon, and morcellation is rarely performed but may nevertheless be performed in the surgical management of presumed fibroids. Further studies and the establishment of a national registry are needed to better quantify the risk of morcellation, to characterize clinical risk factors, and to provide surgical alternatives for women undergoing uterine surgery.