Robert Lotocki

Papillary serous adenocarcinoma of the endometrium.

The clinical outcome of 15 women with papillary serous adenocarcinoma of the endometrium is presented. In 14 instances the diagnosis was made by uterine curettage. Eight cases (53.3%) were clinically understaged based on laparotomy findings. Intraoperative assessment for extrauterine spread of disease was infrequently performed. Recurrent disease developed in 12 patients (80.0%) with ten arising within the abdomen either alone or in conjunction with another site. Eleven patients (73.3%) have died of disease and two of the four alive have been treated for a recurrence. The need to determine appropriate adjuvant therapy for patients with this disease exists. A protocol for patient management is proposed.

Staging laparotomy in early epithelial ovarian carcinoma

It is well known that ovarian carcinoma may have subclinically metastasized at the time of the initial surgical operation when all tumor seemed to be confined to the ovary. A retrospective review of 650 ovarian carcinoma patients from 1976 to 1984 revealed 25 staging laparotomies for early epithelial ovarian carcinoma. Sixteen patients had invasive epithelial ovarian carcinoma, and nine had borderline ovarian carcinomas. Five patients had the stage of their disease changed whereas 20 remained unchanged. Among the staging laparotomy patients, 50% of cases of ovarian carcinoma with ruptured capsules were upstaged as were 33% with those with ascites. Twenty-five percent of cases with invasive epithelial ovarian carcinoma and 12% with borderline ovarian carcinoma were upstaged by a staging laparotomy. As a result of staging laparotomy, 72% of patients were spared treatment. No patient with disease truly confined to the ovaries showed recurrence in spite of receiving no treatment. All patients with disease apparently confined to the ovaries should undergo a staging laparotomy. Only disease remote from the ovary need be treated. If a staging laparotomy is not done, treatment is recommended for apparent Stage I disease.

Twenty-year trends in the incidence and prevalence of diagnosed anogenital warts in Canada.

Background: A vaccine has recently been licensed in many countries that protects against the human papillomavirus types 6, 11, 16, and 18. Types 6 and 11 account for approximately 90% of anogenital warts (AGWs). We describe the 20-year trends in the incidence and prevalence of AGWs in Manitoba, Canada. Methods: We used linked population-based hospital and physician databases for Manitoba for 1984 to 2004. Cases were identified using tariff (billing) and ICD codes. A case was considered to be incident if it was preceded by a 12-month interval free period of AGWs care. Otherwise, it was deemed to be prevalent. An episode was considered over once a 12-month interval had elapsed without an AGW claim. Results: Approximately 25,000 Manitobans were diagnosed with AGWs between 1985 and 2004. The annual age-standardized incidence rates peaked in 1992 (men, 149.9/100,000; women 170.8/100,000). In recent years, the rates have been increasing again, particularly for men. The male:female incidence rate ratio increased from 0.76 in 1985 to 1.25 in 2004. The highest incidence rate tended to be in those aged 20 to 24 years. Trends in prevalence were similar. Prevalence in 2004 was 165.2/100,000 for men and 128.4/100,000 for women. Conclusions: These population-based findings suggest that AGWs are a substantial burden to Manitobans and that their pattern has changed over time, with incidence and prevalence becoming higher in men than women. Monitoring the future trends in AGWs will provide an early marker of the effectiveness and duration of protection of human papillomavirus vaccination at a population level.

Results of prior cytologic screening in patients with a diagnosis of Stage I carcinoma of the cervix

Cervical carcinoma is a disease which lends itself to prevention and diagnosis by cytologic screening. The results of previous Papanicolaou smears were obtained in 84 patients. Of 197 Papanicolaou smear results obtained prior to diagnosis of Stage I carcinoma, 63 (31%) were positive; and of 51 such smears obtained 1 year prior to diagnosis, 30 (59%) were positive. Possible explanations for negative screening prior to development of carcinoma are given. The need for centralized cytologic screening programs on a provincial basis is stressed.

High-risk surgical stage 1 endometrial cancer: outcomes with vault brachytherapy alone

OBJECTIVE Prior to 1995, in our center, patients with surgically staged endometrial cancer with greater than 50% myoinvasion (FIGO 1C) were treated with vault brachytherapy and whole pelvis (WP) radiotherapy despite negative nodes. After October 1, 1995, these patients were treated with vault brachytherapy alone. The aim of this study was to ensure that the survival and recurrence rate had not changed. METHODS A retrospective review of Cancer Care Manitoba charts was undertaken. All patients diagnosed with endometrioid adenocarcinoma between October 1, 1995, and March 1, 2001, were reviewed. Data for all FIGO surgical stage 1 patients, and a subset of stage 1C patients, were analyzed and compared with those of a historical control group, composed of patient data previously collected in our center (1978 to 1990) [Gynecol. Oncol. 55 (1994), 51]. RESULTS A total of 172 patients had negative selective pelvic lymphadenectomy and FIGO stage 1 disease. Fifty-three stage 1C patients were spared WP radiotherapy. Median follow-up was 32 months. Recurrence rate in FIGO stage 1 disease was 2.3% (4/172) and for the subset 1C was 5.7% (3/53). The recurrence rate was not statistically significantly different from that of the historical control group, 3.6% for stage 1 (P = 0.562) and 7.2% for stage 1C (P = 0.51). Two- and five-year survival rates for stage 1 patients in this study were 97 and 95%, respectively. In the historical group, 2- and 5-year survival rates were 97 and 94%. CONCLUSION Whole pelvis radiotherapy can be safely omitted in patients with FIGO stage 1C endometrial cancer if nodal status is known.

Prognostic significance of positive peritoneal cytology in endometrial carcinoma

A retrospective review of 280 patients with endometrial carcinoma who had peritoneal cytologic examination done at the time of laparotomy was undertaken. A positive cytologic finding was the only manifestation of extrauterine disease in 16 patients (6%). Four (25%) of these patients had a recurrence. Only 13 (5%) of 237 patients with negative cytologic findings had a recurrence. Positive peritoneal cytology is a marker for potential recurrence.

Initial Evaluation and Referral Guidelines for Management of Pelvic/Ovarian Masses

OBJECTIVES To optimize the management of adnexal masses and to assist primary care physicians and gynaecologists determine which patients presenting with an ovarian mass with a significant risk of malignancy should be considered for gynaecologic oncology referral and management. OPTIONS Laparoscopic evaluation, comprehensive surgical staging for early ovarian cancer, or tumour debulking for advanced stage ovarian cancer. OUTCOMES To optimize conservative versus operative management of women with possible ovarian malignancy and to optimize the involvement of gynaecologic oncologists in planning and delivery of treatment. EVIDENCE Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified by searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. RECOMMENDATIONS 1. Primary care physicians and gynaecologists should always consider the possibility of an underlying ovarian cancer in patients in any age group who present with an adnexal or ovarian mass. (II-2B) 2. Appropriate workup of a perimenopausal or postmenopausal woman presenting with an adnexal mass should include evaluation of symptoms and signs suggestive of malignancy, such as persistent pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating. In addition, CA125 measurement should be considered. (II-2B) 3. Transvaginal or transabdominal ultrasound examination is recommended as part of the initial workup of a complex adnexal/ovarian mass. (II-2B) 4. Ultrasound reports should be standardized to include size and unilateral/bilateral location of the adnexal mass and its possible origin, thickness of septations, presence of excrescences and internal solid components, vascular flow distribution pattern, and presence or absence of ascites. This information is essential for calculating the risk of malignancy index II score to identify pelvic mass with high malignant potential. (IIIC) 5. Patients deemed to have a high risk of an underlying malignancy should be reviewed in consultation with a gynaecologic oncologist for assessment and optimal surgical management. (II-2B).

Quality of pathology reports for advanced ovarian cancer: are we missing essential information? An audit of 479 pathology reports from the EORTC-GCG 55971/NCIC-CTG OV13 neoadjuvant trial.

OBJECTIVE To assess the quality of surgical pathology reports of advanced stage ovarian, fallopian tube and primary peritoneal cancer. This quality assurance project was performed within the EORTC-GCG 55971/NCIC-CTG OV13 study comparing primary debulking surgery followed by chemotherapy with neoadjuvant chemotherapy and interval debulking surgery. METHODS Four hundred and seventy nine pathology reports from 40 institutions in 11 different countries were checked for the following quality indicators: macroscopic description of all specimens, measuring and weighing of major specimens, description of tumour origin and differentiation. RESULTS All specimens were macroscopically described in 92.3% of the reports. All major samples were measured and weighed in 59.9% of the reports. A description of the origin of the tumour was missing in 20.5% of reports of the primary debulking group and in 23.4% of the interval debulking group. Assessment of tumour differentiation was missing in 10% of the reports after primary debulking and in 20.8% of the reports after interval debulking. Completeness of reports is positively correlated with accrual volume and adversely with hospital volume or type of hospital (academic versus non-academic). Quality of reports differs significantly by country. CONCLUSION This audit of ovarian cancer pathology reports reveals that in a substantial number of reports basic pathologic data are missing, with possible adverse consequences for the quality of cancer care. Specialisation by pathologists and the use of standardised synoptic reports can lead to improved quality of reporting. Further research is needed to better define pre- and post-operative diagnostic criteria for ovarian cancer treated with neoadjuvant chemotherapy.

Tubular Krukenberg tumor in pregnancy with virilization

A case of tubular Krukenberg tumor in pregnancy with virilization is presented. The pathology is reviewed. This rare tumor must be distinguished from a Sertoli-Leydig tumor. The index case adds to the previously recorded eight cases. All nine cases reviewed presented with progressive virilization between the third and eighth month of gestation, which regressed after surgery. The fetal outcomes of seven cases have been recorded. The fetuses were all female and of these five were virilized. A gastric primary was found in five cases. A primary breast carcinoma was postulated in another. In the remaining cases either no autopsy was performed or no primary tumor was found.

Management of squamous cell cancer of the vulva.

Abstract Objectives To review and make recommendations regarding the management of early and advanced squamous cell cancer of the vulva. Options Radical vulvectomy and groin dissection or more conservative surgery in early squamous cell vulvar cancer; chemotherapy and radiation followed by consideration of surgery in advanced disease. Outcomes Risk of inguinal lymph node metastases, risk of tumour recurrence, patient morbidity, patient survival. Evidence Follows the quality of evidence assessment of the Canadian Task Force on the Periodic Health Examination (Table 1). Recommendations 1.Stage IA lesions (≤ 2cm diameter and≤1mm stromal invasion) can be managed by radical local tumour excision without inguinofemoral node dissection. (II-2B) 2.Stage IB unilateral lesion (≤ 2cm diameter, > 1mm stromal invasion and ≥ 1cm from the midline) is treated by radical wide local excision completed by an ipsilateral inguinofemoral node dissection; a central lesion (within 1cm from the midline) requires bilateral inguinofemoral node dissection. (II-2B) 3.Patients with either three or more micrometastases in the groin with node size>10mm, with extracapsular spread, or with bilateral microscopic groin metastases should receive postoperative bilateral groin and pelvic radiation. (II-2B) 4.Advanced cancer of the vulva should be treated with primary radiation and concomitant chemotherapy, followed by consideration of surgical resection. (II-2B)