Mathias Onsrud

Evaluation of a risk of malignancy index based on serum CA125, ultrasound findings and menopausal status in the pre-operative diagnosis of pelvic masses

Objective To evaluate the ability of a risk of malignancy index (RMI), based on a serum CA125 level, ultrasound findings and menopausal status, to discriminate a benign from a malignant pelvic mass and to discriminate early stage (Figo Stage I) from Stages II, III and IV of ovarian cancer.

The risk-of-malignancy index to evaluate potential ovarian cancers in local hospitals.

OBJECTIVE To assess the risk-of-malignancy index (a scoring system based on menopausal status, ultrasound features, and serum CA 125) at district hospitals for referral of women with suspected malignant pelvic masses for primary surgery at a central gynecologic oncology unit. METHODS All seven hospitals in Health Region IV, Norway, agreed to refer women with pelvic masses and risk-of-malignancy indices of 200 or more for centralized primary surgery. In total, 365 women 30 years of age or older, admitted consecutively at the local hospitals, were enrolled in the study from February 1, 1995, to January 31, 1997. RESULTS Compliance with the study was satisfactory; 84% (65 of 77) of women with risk-of-malignancy indices of at least 200 were referred for centralized primary surgery. Sensitivity and specificity to malignancy were 71% and 92%, respectively, which is in agreement with previous validation of the risk-of-malignancy index in teaching hospital settings. False negatives were due mainly to stage Ia (18 of 24) ovarian cancer, whereas 27 of 28 stage II-IV ovarian cancer cases were identified correctly. CONCLUSION The risk-of-malignancy index identified women with malignant pelvic masses efficiently. Our study showed the risk-of-malignancy index strategy in a practical setting to be able to centralize primary surgery for advanced ovarian cancer from local hospitals to a subspecialty unit. We recommend the risk-of-malignancy index for detection of patients with advanced ovarian cancer for centralized primary surgery.

Postoperative external pelvic irradiation in carcinoma of the corpus stage I: A controlled clinical trial

Abstract During the years 1968–1972, 386 patients entered a controlled clinical trial with the aim of assessing the value of external high voltage irradiation in carcinoma of the corpus Stage I. After primary surgery, all patients received intravaginal radium application delivering 6000 rads to the vaginal wall. They were then allocated to one of two groups by random numbers. Group A received no further treatment, while Group B was given 4000 rads of high voltage irradiation to a pelvic field. During a follow-up period of between 2.5 and 7 years no difference was found in the number of deaths and recurrences between the two treatment groups. The frequency of local recurrences in the vagina and the pelvis was higher in Group A. This was outweighed by a higher number of distant metastases in Group B. It is concluded that possibly only those cases with anaplastic tumours infiltrating deep in the myometrium may benefit from additional external radiotherapy.

Sexual violence-related fistulas in the Democratic Republic of Congo

To determine the magnitude of traumatic gynecologic fistulas caused by sexual violence in the Democratic Republic of Congo.

Comparison of Laparoscopy and Laparotomy in Patients with Endometrial Cancer

STUDY OBJECTIVE To evaluate results and feasibility of laparoscopic surgery in patients with stage I endometrial cancer. DESIGN Prospective, nonrandomized study (Canadian Task Force classification II-I). SETTING University tertiary referring center. PATIENTS Fifty-one women with stage I endometrial cancer followed for 1 year. INTERVENTION Laparoscopy (27 women) and open surgery (24). MEASUREMENTS AND MAIN RESULTS We recorded operating time, complications, and length of hospital stay. Operating time differed between groups, 87 versus 143 minutes for laparotomy and laparoscopy, respectively. Hospital stay was 6.2 days and 4.3 days, respectively. In the laparotomy group one patient experienced wound dehiscence and another had a vesicovaginal fistula requiring secondary repair. Complications in the laparoscopy group were one conversion to laparotomy because of bladder perforation and one case of septicemia that required laparotomy on the second postoperative day. Perioperative transfusions were administered to two women in the laparotomy group and none in the laparoscopy group. CONCLUSION Laparoscopy may play an important role in treatment of early endometrial cancer. The procedure is difficult, however, and should be reserved to dedicated laparoscopists. It has low morbidity and, contrary to earlier recommendations, may be performed in older women with comorbidity.

Late reactions after postoperative high-dose-rate intravaginal brachytherapy for endometrial cancer: a comparison of standardized and individualized target volumes

PURPOSE To compare retrospectively two treatment protocols for postoperative intravaginal brachytherapy as to frequency of late radiation reactions and vaginal recurrence of disease. METHODS AND MATERIALS Two hundred seventeen patients with Stage I-II endometrial carcinoma underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy, followed by high-dose-rate (HDR) intracavitary irradiation, 5.5 Gy x 4 (22 Gy), to the upper 5 cm of the vagina. From 1988 to August 1991, the reference isodose was at 5 mm from the mucosal surface (standard treatment, 96 pts). From September 1991 to June 1996, the reference isodoses were chosen at 3 mm, 4 mm, or 5 mm depth depending on a clinical estimation of the mucosal thickness (individualized treatment, 121 pts). Maximum bladder and rectum doses were calculated from orthogonal X-ray films. RESULTS The patients were followed for 3 to 10 years. The rate of late vaginal reactions Grade 1 and 2 were 26% and 8%, respectively, after standard treatment, vs. 17% and 1% after individualized treatment (p = 0.005). Bladder reaction rates were 9% Grade 1 and 1% Grade 2 after standard treatment vs. 1% Grade 1 after individualized treatment (p = 0.005). Rectum reactions Grade 1 were seen in 5% and 1%, respectively. No Grade 3 reactions were observed. The reactions appeared after a median time interval of 9 months and 11 months, respectively. The rate of vaginal reactions was strongly correlated to the dose on the surface of the vaginal applicator, and the bladder reaction rate correlated with the calculated maximum bladder dose. Local vaginal recurrences were seen in 1 patient (1.0%) in the standard treatment group and in 3 patients (2.5%) in the individualized treatment group (p = 0.78). CONCLUSIONS By individualizing the depth of the reference dose in the vaginal mucosa according to its thickness and avoiding applicators with small diameters, the rate of reactions can be reduced without any significant increase in vaginal recurrences.

Intramuscular Administration of Hydroxyprogesterone Caproate in patients with Endometrial Carcinoma: Pharmacokinetics and effects on adrenal function

Abstract. A radio‐immunoassay for the determination of the serum concentration of hydroxyprogesterone caproate (HPC) was established. After a single intramuscular injection of 1 000 mg, the mean serum level reached its maximum (44–81 nmol/1) after 2–7 days. Patients on long‐term adjuvant HPC treatment (consisting of 1000 mg daily for 5 days followed by 1000 mg every 2 weeks) presented peak hormone levels 2 weeks after commencing treatment. After a drop at 5 weeks, the mean serum level slowly increased again to 130 nmol/1 after 25 weeks of treatment. Patients being treated with weekly injections had significantly higher serum levels than those treated every 2 weeks. Considerable inter‐individual differences were observed. the serum concentrations of HPC measured in this study compare favorably with those previously found in patients treated with medroxyprogesterone acetate. the patients on adjuvant HPC showed no significant change in the levels of cortisol, dehydroepiandrosterone sulphate, androstenedione, or estrone during the first 25 weeks of treatment.

Cesarean delivery-related fistulae in the Democratic Republic of Congo

To compare the characteristics of urogenital fistulae after cesarean delivery with those after spontaneous vaginal delivery.

Long-Term Outcomes After Pelvic Radiation for Early-Stage Endometrial Cancer

PURPOSE This follow-up of a randomized study was conducted to assess the long-term effects of external beam radiation therapy (EBRT) in the adjuvant treatment of early-stage endometrial cancer. PATIENTS AND METHODS Between 1968 and 1974, 568 patients with stage I endometrial cancer were included. After primary surgery, patients were randomly assigned to either vaginal radium brachytherapy followed by EBRT (n = 288) or brachytherapy alone (n = 280). Overall survival was analyzed by using the Kaplan-Meier method. A Cox proportional hazards model was used to estimate hazard ratios (HRs) with 95% CIs. We also conducted analyses stratified by age groups. RESULTS After median 20.5 years (range, 0 to 43.4 years) of follow-up, no statistically significant difference was revealed in overall survival (P = .186) between treatment groups. However, women younger than age 60 years had significantly higher mortality rates after EBRT (HR, 1.36; 95% CI, 1.06 to 1.76) than the control group. The risk of secondary cancer increased after EBRT, especially in women younger than age 60 years (HR, 2.02; 95% CI, 1.30 to 3.15). CONCLUSION We observed no survival benefit of external pelvic radiation in early-stage endometrial carcinoma. In women younger than age 60 years, pelvic radiation decreased survival and increased the risk of secondary cancer. Adjuvant EBRT should be used with caution, especially in women with a long life expectancy.

Surgical outcome of obstetric fistula: a retrospective analysis of 595 patients

Objective. The aim of the study was to investigate obstetric fistula in terms of patient demographics, fistula characteristics and predictors of surgical outcome. Design. Retrospective cross‐sectional study. Setting. Fistula referral hospital in eastern Democratic Republic of Congo. Population. Five hundred and ninety‐five women receiving fistula repair from November 2005 to November 2007. Methods. Review of patient records for information on patient demographics, obstetric history, clinical data for index pregnancy, fistula characteristics and surgical information. Cross‐tabulations and multivariate logistic regression models were used to predict surgical outcome. Main Outcome Measures. Fistula closure and incontinence despite fistula closure. Results. 82.9% had developed fistula following obstructed labor, 17.1% after medical interventions of which 71.1% involved cesarean section or peripartum hysterectomy. Median age at fistula development was 23 years; 40.8% were primiparous and 43.2% were parity three or more. Women took a median of two years to seek treatment. Closure rate was 87.1%, with 15.6% remaining incontinent. Failure to close the fistula was significantly associated with previous repairs, amount of fibrosis and fistula size. Compared with primary repairs, the odds ratio of failure was almost five times greater for three or more repairs (odds ratio 4.7, 95% confidence interval 2.2–10.0). Incontinence was significantly associated with previous repairs, amount of fibrosis and fistula location. Compared with fistulas with a high location, the odds ratio of incontinence for low, circumferential fistulas was 6.3 (95% confidence interval 2.5–16.4). Conclusions. Fistula in Democratic Republic of Congo was found in both primiparous and multiparous women, indicating a need for increased access to obstetric care for all pregnant women. Fistulas repaired for the first time, with no fibrosis and size <2 cm, had the best surgical outcome.