Marielle Nobbenhuis

Fistulas in Malignant Gynecologic Disease: Etiology, Imaging, and Management

A fistula that occurs in association with a malignancy of the female reproductive tract may be caused by a primary or recurrent tumor or may be a complication of surgery or radiation therapy. Identification of the cause, complexity, and location of a fistula is essential for optimal management planning. Radiologic imaging, particularly with computed tomography and magnetic resonance techniques, is invaluable for the assessment of gynecologic fistulas and may help direct the clinician toward the most appropriate management pathway. The modality and technique selected for the initial imaging evaluation depend largely on the clinical history and manifestations. However, imaging with a combination of techniques often is required for accurate diagnosis and effective treatment planning. Radiologists should be familiar with suggestive clinical signs and symptoms as well as with the characteristic appearances of rectovaginal, vesicovaginal, ureterovaginal, enterovesical, enterocutaneous, and other pelvic fistulas at multimodality imaging.

Laparoscopic staging for apparent early stage ovarian or fallopian tube cancer. First case series from a UK cancer centre and systematic literature review

OBJECTIVE To describe the experience of laparoscopic staging of apparent early stage adnexal cancers. METHODS Prospectively collected data on women who had laparoscopic staging for apparent early stage adnexal cancers from May 2008 to September 2012 was reviewed. All women had had a prior surgical procedure at which the diagnosis was made, without comprehensive staging. A systematic MEDLINE search from 1980 to 2012 for publications on laparoscopic staging was performed. RESULTS Thirty-five women had laparoscopic staging. Median age was 45 years (range 21-73). Median operative time was 210 min (range 90-210). Four intra-operative and one post-operative complication occurred; overall complication rate 5/35 (14%). One vena cava and one transverse colon injury underwent laparotomies for repair. Laparotomy conversion rate 2/35 (6%). Following laparoscopic staging, the cancer was upstaged for eight (23%) women; microscopic omental involvement (four women), pelvic lymph node involvement (two women), para-aortic lymph node involvement (one woman) and contra-lateral ovarian involvement (one woman). After follow up for a median of 18 months (range 3-59) the disease free survival was 94% and overall survival was 100%. Nine studies were identified on laparoscopic staging of adnexal cancer, of which this is the largest single institution series. CONCLUSIONS This study adds to the evidence that laparoscopic staging is at least as safe as staging by laparotomy with appropriate and similar oncological outcomes, but with the advantages of minimal access surgery. We therefore advocate the use of laparoscopy to achieve surgical staging for women with presumed early stage adnexal cancer.

Introducing robotic surgery into an endometrial cancer service–a prospective evaluation of clinical and economic outcomes in a UK institution

We have assessed how the introduction of robotics in a publicly funded endometrial cancer service affects clinical and economic outcomes.

Management of melanomas of the gynaecological tract.

Purpose of review Primary melanomas originating from the gynaecological tract are rare and aggressive cancers. The 5-year survival is around 10%. The majority of tumours differ from cutaneous melanomas, which arise from the skin, by developing from melanocytes located in mucosal epithelium. The clinical behaviour, prognosis and the biology of mucosal melanomas are distinct from cutaneous melanomas. In this article, we summarize the current management of melanomas of the gynaecological tract (vulva, vagina, ovary and cervix) and discuss the progress in developing new treatments. Recent findings The management of mucosal melanomas has not changed substantially over the last decade and the prognosis remains poor. Surgery remains the primary treatment of choice in all localized melanomas of the genital tract. Radiotherapy and chemotherapy are options but have limited success for the majority of women. Activation of c-KIT occurs in vulvar melanomas. Clinical trials of targeted agents are underway. Summary As a result of the rarity of gynaecological tract melanomas, challenges associated with their anatomical locations and resistance to conventional radiotherapy and chemotherapy, this group of conditions remain difficult to treat and continue to have a poor prognosis. A greater understanding of the molecular profile of these cancers may provide promising targeted approaches.

Outcome of Appendicectomies at Surgery for Mucinous Ovarian Neoplasms: Report From A UK Center and Review of Literature.

Objective This study aimed to determine the frequency of malignant pathology in a macroscopically normal appendix during surgery for a borderline or malignant mucinous ovarian tumor (MOT). Methods Women with borderline and malignant MOT were identified from the pathology database from 2000 to 2014. Women who had a benign MOT and had an appendicectomy were excluded from the study. Data were collected from the electronic patient record and case notes. Results Of 310 women identified with MOT, 203 patients with benign MOT were excluded. Of the remaining 107 patients, 15 patients with previous appendicectomy were also excluded. The study population consisted of 92 patients. There were 57 (62%) patients with borderline MOT and 35 (38%) patients with malignant MOT. In the borderline subgroup, 40/57 (70%) patients had appendicectomy of whom 8 (20%) had macroscopically abnormal appendices. One patient had pseudomyxoma peritonei secondarily involving the appendix and 7 patients had a histologically normal appendix. Normal histology was found in all macroscopically normal appendices. In the malignant subgroup, 29/35 (83%) patients had an appendicectomy. There were 8 (27.5%) macroscopically abnormal appendices with a malignant pathology in 7 (87.5%) patients and 1 patient had a resolving appendicitis. There were 21 macroscopically normal appendices of which, serrated adenoma was found in 1 (4.8%) patient, whereas the remaining 20 (95.2%) patients had normal histology. Conclusions In MOT, an abnormal appearing appendix should be excised. If the appendix is grossly normal, our data do not support performing an appendicectomy as part of a surgical staging procedure.

Venous thromboembolism at time of diagnosis of ovarian cancer: Survival differs in symptomatic and asymptomatic cases

OBJECTIVES To determine the impact on survival of symptomatic and asymptomatic venous thromboembolism (VTE) at time of diagnosis of primary ovarian malignancy. MATERIALS AND METHODS The clinical records of 397 consecutive cases of primary ovarian malignancy were studied. Clinical, pathological and survival data were obtained. RESULTS AND CONCLUSIONS Of 397 cases, 19 (4.8%) were found to have VTE at diagnosis, of which 63.2% (n=12) were asymptomatic. VTE was significantly associated with reduced overall median survival (28 vs. 45 months, p=0.004). Decreased survival was associated with symptomatic VTE compared to patients with asymptomatic VTE (21 vs. 36 months, p=0.02) whose survival was similar to that of patients without VTE. Decreased survival remained significant in symptomatic patients after controlling for stage of disease at diagnosis, cytoreductive status and adjuvant chemotherapy use. Overall these data suggest for the first time that symptomatic but not asymptomatic VTE prior to primary treatment of ovarian cancer is an independent adverse prognostic factor.

Poor performance status (PS) is an indication for an aggressive approach to neoadjuvant chemotherapy in patients with advanced epithelial ovarian cancer (EOC)

BACKGROUND Some guidelines suggest that poor performance status (PS) is a contraindication to 1st line chemotherapy. Poor PS is a known adverse prognostic factor in advanced epithelial ovarian cancer (EOC). We show in this retrospective analysis that 1st line chemotherapy in this patient group is not only safe but is associated with good outcomes. PATIENTS AND METHODS A retrospective review of 114 patients with stage III/IV EOC, who presented with a PS ≥3 at diagnosis and treated as inpatients with upfront platinum-based chemotherapy between 2000 and 2013, at the Royal Marsden Hospital, was conducted. The association between clinical parameters and the likelihood of completion of chemotherapy and overall survival (OS) was assessed. RESULTS 66% of patients completed ≥6cycles of platinum-based chemotherapy. Prognostic factors for completion of chemotherapy were improvement of PS during hospital stay (p<0.001) and doublet-chemotherapy with carboplatin/paclitaxel compared to single-agent carboplatin (p=0.004). A negative trend for completion of treatment was seen for patients with low albumin (<25g/l) and low CA125 levels at baseline. The median OS for all patients was 13.1months (95% CI: 10.4-15.8) and 21.2months (95% CI: 16.5-25.8) for those who completed 6cycles of chemotherapy. CONCLUSION Upfront platinum-based chemotherapy is feasible, beneficial and tolerable for the majority of patients with advanced EOC and poor PS. Guidelines suggesting that best supportive care is the preferred option for poor PS patients with solid tumours should be revised to exclude those with advanced EOC. An aggressive approach utilising neoadjuvant carboplatin plus paclitaxel should be regarded as standard of care.

Surgical management and follow-up of patients with cervical cancer: Survey of gynaecological oncologists in the UK

We investigated current surgical management and follow-up of women with cervical cancer focusing on treatment of recurrent disease and the use of routine imaging during follow-up among gynaecological oncologists in the UK. A questionnaire including questions regarding perioperative management of primary disease in cervical cancer, follow-up post-treatment, assessment and management of recurrent cervical cancer, was sent to 84 gynaecological oncologists. Some 87% responded. Considerable variations in surgical management and follow-up were identified. With central recurrence of cervical cancer without prior radiotherapy, 90% would recommend radiotherapy instead of an exenteration. For central recurrence in irradiated women, only three (4%) would not recommend an exenteration. In women with pelvic sidewall relapse without prior radiotherapy, 65 responders (96%) would offer radiotherapy, while in pelvic sidewall relapse post-radiation 25 (37%) would recommend pelvic sidewall resection in a specialised centre. A total of 21% used routine imaging during follow-up. The wide variation in clinical practice indicates that there is a need to establish national guidelines for surgical management and follow-up of primary and recurrent cervical cancer.

Screening for ovarian cancer in women with varying levels of risk, using annual tests, results in high recall for repeat screening tests.

BackgroundWe assessed ovarian cancer screening outcomes in women with a positive family history of ovarian cancer divided into a low-, moderate- or high-risk group for development of ovarian cancer.Methods545 women with a positive family history of ovarian cancer referred to the Ovarian Screening Service at the Royal Marsden Hospital, London from January 2000- December 2008 were included. They were stratified into three risk-groups according to family history (high-, moderate- and low-risk) of developing ovarian cancer and offered annual serum CA 125 and transvaginal ultrasound screening. The high-risk group was offered genetic testing.ResultsThe median age at entry was 44 years. The number of women in the high, moderate and low-risk groups was 397, 112, and 36, respectively. During 2266 women years of follow-up two ovarian cancer cases were found: one advanced stage at her fourth annual screening, and one early stage at prophylactic bilateral salpingo-oophorectomy (BSO). Prophylactic BSO was performed in 138 women (25.3%). Forty-three women had an abnormal CA125, resulting in 59 repeat tests. The re-call rate in the high, moderate and low-risk group was 14%, 3% and 6%. Equivocal transvaginal ultrasound results required 108 recalls in 71 women. The re-call rate in the high, moderate, and low-risk group was 25%, 6% and 17%.ConclusionNo early stage ovarian cancer was picked up at annual screening and a significant number of re-calls for repeat screening tests was identified.

Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme: Correspondence

roscopically-assisted and robotically-assisted radical hysterectomy in our unit. As highlighted in the accompanying comments in Editor’s choice, there are a number of competing factors that may or actually do undermine subspecialty training, and provide a strong argument for extending the clinical training programme to 3 years. The workforce planning assessment in GO highlights that too many trainees are in post in the UK. The training arrangements in Australia have ensured that the number of Australian trainee fellows matches the needs of the whole country, and that overseas fellows are in post when the demand for local fellows falls. Such a model may need to be adopted in the UK. Newly appointed consultants in GO require close mentoring by senior colleagues during the first 12 months of their consultancy. This mentoring process would replace the formal post-fellowship programme recommended by Naik et al., and would address some of the concerns expressed by Nevin et al. With the new consultant contract, most new appointees will have two or at most three sessions per week for surgery. This is hardly sufficient to maintain let alone develop surgical skills. Our colleagues overseas typically have more operating sessions per week. Counter to current trends, it could be argued (Nevin et al.) that fewer gynaecological oncologists should be performing more surgery, not less. This need not be achieved on an individual practice basis, and although this could be achieved with two consultants operating together on major cases this may not be the best use of resources. Conceivably, certain diseases or problems should be managed on a supra-regional basis. But who decides? How is the balance to be struck between local needs to provide service and national training needs? There are also complex funding issues involved. The surgical community is only just beginning to understand what surgical competency means and how it should be assessed: at present, no surgical examination scrutinises surgical technique, and the assessments made by the trainers are solely relied upon. It is clear that a subspecialty training programme in GO must provide a high volume of surgical cases, and provide experience in surgical management of complex primary and recurrent disease. Selfevidently not all UK programmes do this. Perhaps training programmes should be amalgamated to achieve training goals, and to maintain and improve standards. There is no formal examination in GO and no specific GO-related appraisal/revalidation is carried out in the UK, in contrast to North America, where both are compulsory. If GO is to survive as a subspecialty then the core strength will be comprehensive surgical training in approved centres. Two-year programmes do not, we believe, provide this level of training. The issues raised by Naik et al. and Nevin et al. are relevant to all GO trainers and trainees alike. Their solution rests with stakeholders such as the British Gynaecological Cancer Society (BGCS) and the Royal College of Obstetricians and Gynaecologists (RCOG), but most importantly with the GO surgical community. Maintaining the status quo of too many training centres and too many trainees will ultimately undermine the very basis of subspecialty training. j