The NICE classification for 'Ultra-radical (extensive) surgery for advanced ovarian cancer' guidance does not meaningfully predict postoperative complications: a cohort study.

OBJECTIVE: To determine which descriptors of cytoreductive surgical extent in advanced ovarian cancer (AOC) best predict postoperative morbidity. DESIGN: Retrospective notes review. SETTING: A gynaecological cancer centre in the UK. POPULATION: Six hundred and eight women operated on for AOC over a period of 114 months at a tertiary cancer centre, between 16 August 2007 and 16 February 2017. METHODS: Outcome data were analysed by six approaches to classify the extent of surgery: standard/ultra-radical surgery; standard/radical/supra-radical surgery; presence/absence of gastrointestinal resections; low/intermediate/high surgical complexity score (SCS); presence of bowel anastomoses and/or diaphragmatic surgery; and the presence/absence of multiple bowel resections. MAIN OUTCOME MEASURES: Major (grades 3-5) postoperative morbidity and mortality. RESULTS: Forty-three (7.1%) patients experienced major complications. Grade-5 complications occurred in six patients (1.0%). Patients who underwent multiple bowel resections had a relative risk (RR) of 7.73 (95% confidence interval, 95% CI 3.92-15.26), patients with a high SCS had an RR of 6.12 (95% CI 3.25-11.52), patients with diaphragmatic surgery and gastrointestinal anastomosis had an RR of 5.57 (95% CI 2.65-11.72), patients with 'any gastrointestinal resection' had an RR of 4.69 (95% CI 2.66-8.24), patients with ultra-radical surgery had an RR of 4.65 (95% CI 2.26-8.79), and patients with supra-radical surgery had an RR of 4.20 (95% CI 2.35-7.51) of grades 3-5 morbidity, compared with patients undergoing standard surgery as defined by the National Institute for Health and Care Excellence (NICE) in the UK. No significant difference was seen in the rate of major morbidity between standard (6/59, 10.2%) and ultra-radical (9/81, 11.1%) surgery within the cohort who had intermediate complex surgery (P > 0.05). CONCLUSIONS: The numbers of procedures performed significantly correlate with major morbidity. The number of procedures performed better predicted major postoperative morbidity than the performance of certain 'high risk' procedures. We recommend using SCS to define a higher risk operation. NICE should re-evaluate the use of the term 'ultra-radical' surgery. TWEETABLE ABSTRACT: Multiple bowel resection is the best predictor of morbidity and is more predictive than 'ultra-radical surgery'.

Histopathological correlation of splenic disease with radiological and surgical findings: should we incorporate splenectomy into standard procedures for disseminated Millerian adenocarcinoma?

PURPOSE OF INVESTIGATION: To determine the positive predictive value (PPV) of both preoperative radiological and intraoperative identification of splenic disease in cases of advanced and recurrent gynaecological malignancy. MATERIALS AND METHODS: A retrospective study of all splenectomies performed during surgeries for disseminated gynaecological malignancy at the Pan Birmingham Gynaecological Cancer Centre between May 21st, 2008 and January 31st, 2015. RESULTS: Forty-one women were identified, most of whom had Stage 3C, high grade, serous Milllerian adenocarcinomas. Thirty-seven (90.2%) spleens were removed because of intraoperative suspicion of disease and the remaining four (9.8%) were removed following inadvertent injury. No spleens were detected radiologically that did not have obvious macroscopic disease. The PPV for the preoperative and intraoperative detection of splenic disease were 88.9% and 91.9%, respectively. Half of the spleens removed following inadvertent injury had disease identified following histopathological examination. CONCLUSION: Intraoperative identification of splenic disease correlates well with histopathological examination. However, in 50% of splenectomies performed following inadvertent trauma and where disease was not suspected, metastases were identified.

Impact of improving outcome guidance in gynaecological cancer on squamous cell carcinoma of the vulva in the West Midlands, UK.

This study aimed to assess the benefits and outcomes of squamous cell carcinoma (SCC) of the vulva managed in a cancer centre post-centralisation of cancer care in the UK. A retrospective study was performed to evaluate the demography and management outcomes of SCC of the vulva in a regional gynaecological cancer centre. The results were then compared with the Rhodes et al. (1998) population-based study. Over the years, disease demography remained largely unchanged. However, centralisation of cancer care has resulted in significant changes in the pattern of care. The number of cases managed has increased by 1.7 times and the permutation of surgeries have reduced from 15 to 4. There is also a significant increased in the number of lymphadenectomies performed (p = 0.003). These changes were accompanied by improvement in 5-year cause-specific survival (p = 0.055).

Vulval cancer: what is an adequate surgical margin?

OBJECTIVE: To determine the accuracy of naked eye assessment of surgical margins after formalin fixation in vulval cancer in comparison with microscopic assessment. DESIGN: Retrospective review. SETTING: The Gynaecological Cancer Centre, St Bartholomew's Hospital, London, U.K. POPULATION: Patients with primary vulval cancer who underwent surgery from 1997 to 2006. METHODS: Histopathology reports were reviewed and data on surgical margins were analysed. After formalin fixation, pathologists analysed surgical margins and measured them with a ruler. This measurement was compared with microscopic measurement. Other clinicopathologic variables were also recorded and compared. MAIN OUTCOME MEASURE: Comparison between macroscopic and microscopic measurement, and the relation to clinicopathological variables. RESULTS: Naked eye assessment of surgical margins was within 2 mm of correlated microscopic measurement in 29 patients (Group 1). In ten patients the macroscopic measurement of clear margins was less than the microscopic (Group 2). In the remaining 11 cases (22%) naked eye observation overestimated the normal skin margins (Group 3). Seven patients from this group eventually fell into the unfavourable prognostic category of surgical margins <8 mm. The presence of LVSI was significantly more frequent in Group 3 than in the other two groups (p = 0.01). The difference between other variables of the study groups was statistically non-significant. CONCLUSION: Our study demonstrates that naked eye assessment of surgical margins after formalin fixation is inaccurate and that surgical margins are often inadequate. We conclude that tumours with LVSI should be considered for a wider surgical excision.

The sentinel node in gynaecological malignancies.

As lymph node metastasis is one of the earliest features of tumour cell spread in most human cancers, assessment of the regional lymph nodes is required for tumour staging, determining prognosis and planning adjuvant therapeutic strategies. However, complete lymph node dissections are frequently associated with significant complications. Conjugating the diagnostic advantages with decreased morbidity, the sentinel node concept represents one of the most recent advances in surgical oncology. In this review we briefly highlight the historical background of the development of the sentinel node concept, the anatomical evidence for applying the sentinel node concept in pelvic gynaecological cancers and the technical aspects of sentinel node detection. We discuss recent studies in vulval, cervical and endometrial cancer.

The risk of nodal metastasis in early adenocarcinoma of the uterine cervix.

A functional and widely accepted definition of microinvasive cervical adenocarcinoma remains elusive. The purpose of this study was to determine at which depth of invasion the likelihood of lymph node metastasis or disease recurrence was so small that conservative surgery could be considered appropriate. Charts of patients with adenocarcinoma of the cervix (ACC) who underwent radical hysterectomy and pelvic lymphadenectomy (n = 98) at Indiana University Medical Center from 1987 to 1998 were retrospectively reviewed. Patients with stage IA1-IB1 lesions were included in the study. Patients treated with preoperative radiotherapy were excluded. Pathologic parameters evaluated included histologic type, depth of stromal invasion (DOI), and the presence of lymphatic vascular space invasion, or lymph node metastases. The patient median age was 39 years (20-65). The median time of follow-up was 30 months (4-124). Lymph node metastases were found in ten patients and 11 developed recurrences. The precise DOI could be measured in 84 patients. Of the 48 patients with cancers with a DOI 5 mm had nodal metastases (P = 0.00069). None of these 48 patients with a tumor DOI 5 mm developed recurrent disease (P = 0.0048). The risk of nodal metastases and recurrence is so low in patients with ACC and DOI

Adjuvant chemotherapy following surgery in the management of uterine sarcomas.

OBJECTIVE: The aim of this study was to investigate the use of imaging tools in the diagnosis of uterine sarcomas, and to evaluate the effect of the adjuvant chemotherapy for uterine sarcomas. PATIENTS AND METHODS: The data of 29 patients with uterine sarcomas who received cytostatic polychemotherapy between 1990 and 2000 at the Oncological Division of the Ist Department of Obstetrics and Gynecology, Semmelweis University were evaluated by the authors. Symptoms leading to diagnosis and methods of diagnosis were examined. Vascular changes shown by two-dimensional, color and pulsed Doppler ultrasonography were observed. For staging the currently accepted FIGO method was adopted. Most of the patients underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH & BSO). In each case we administered adjuvant combination chemotherapy according to the CYVADIC-protocol. The effect of adjuvant chemotherapy was evaluated. RESULTS: Six patients had Stage I, ten had Stage II, 11 had Stage III, and two had Stage IV disease. The mean age of the patients was 53.6 years with a range of 22 to 77 years. Histopathologic distribution included nine leiomyosarcomas (LMS), 13 mixed mesodermal sarcomas (MMS), and seven endometrial stromal sarcomas (ESS). Although most patients experienced neutropenia following cytotoxic chemotherapy, other non-hematologic adverse effects were easy to control. The average progression-free interval was 22.14 months, in which no significant difference was found between the histologic types. Different stages showed highly varied responses: surprisingly, patients in Stage IV with lung metastases were documented to have the longest progression-free survival. The three-year survival rate for all stages was demonstrated in 34.4% of cases. Patients with progressive disease had an average survival period of 4.4 months. CONCLUSIONS: These findings suggest that adjuvant cytostatic therapy for patients with distant metastasis confined to a single organ may produce better results than expected.

Primary non-Hodgkin's lymphoma of the uterine cervix successfully treated by neoadjuvant chemotherapy: case report.

INTRODUCTION: Primary non-Hodgkin's lymphoma of the uterine cervix is a rare malignancy. The mainstay of therapy consists of irradiation alone or irradiation with either surgery or chemotherapy. CASE REPORT: We present the case of a 56-year-old woman diagnosed with a bulky, Ann Arbor stage IE, primary, diffuse, large B-cell non Hodgkin's lymphoma of the uterine cervix. We administered neoadjuvant chemotherapy according to CHOP protocol (cyclophosphamide, adriamycin, vincristine, and prednisone) followed by radical hysterectomy, bilateral salpingo-oophorectomy, and regional lymph node dissection. Clinical and pathological responses to the chemotherapy were complete. The patient is alive 5 years after the initial diagnosis. CONCLUSION: Our case emphasizes the importance of neoadjuvant chemotherapy that can provide a control of the distant microscopic metastases.

A retrospective study of 27 ovarian tumors of low malignant potential.

INTRODUCTION: This study was undertaken to retrospectively review the fertility-sparing surgical treatment and long-term outcome of 27 patients with ovarian tumors of low malignant potential treated at the 1st Department of Obstetrics and Gynecology of Semmelweis University Faculty of Medicine between 1990 and 2000. MATERIALS AND METHODS: Between 1990 and 2000, 163 patients with epithelial ovarian tumors were diagnosed and treated. Of these, 27 patients were diagnosed as having low malignant potential (LMP) ovarian tumors. The authors evalutated the effect of histopathologic parameters (histologic type, grade of nuclear atypia, tumor size and tumor growth on the ovarian surface) and clinical parameters (age at diagnosis, stage of disease, and treatment modalities) on prognosis in this group of patients with a long observation time. We reviewed our experience to assess the safety of conservative surgical management of patients younger than age 40 with early stage disease, and to determine the long-term outcome of low malignant potential ovarian tumors. Medical records were reviewed on all 27 patients to determine age, gravidity, size of tumor, bilaterality, sites of extraovarian involvement, stage of disease and the operative procedure. Follow-up information was obtained from hospital records, and in some cases, by direct patient contact. Statistical comparisions were made by the chi2 test. RESULTS: The incidence of LMP tumors in our patient population was 16.5%. The patients ranged in age from 15 to 82 years (median, 45 years). The lesions were staged according to FIGO. The stage distribution was Stage IA in 20 patients, Stage IB in one patient, Stage IC in one patient, Stage IIA in one patient, Stage IIB in one patient, Stage IIC in one patient and Stage IIIA in two patients. The ovarian tumors ranged in size from 3 to 19 cm (median 9 cm) and 15% of the tumors were bilateral. All patients with LMP ovarian tumors were treated with primary surgery; those who were older than 40 (14 patients) were treated with total trans-abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO), while patients younger than 40 with early stage disease (12 patients) who wished to retain their fertility potential were treated with fertility-sparing surgery, namely unilateral salpingo-oophorectomy (USO). One patient who was younger than 40 with a Stage IIIA LMP ovarian tumor was also treated with TAH and BSO. Follow-up information was available for all 27 patients with LMP ovarian tumors. Only those patients with a minimum of two years of follow-up were included. Follow-up information from two to ten years (median, 6 years; mean, 6.5 years) revealed that all 27 patients were alive. During the period of follow-up one patient who initially had stage IIIA disease developed recurrent tumor. Fifty percent of patients who underwent conservative fertility-sparing surgical treatment (6/12) subsequently conceived. CONCLUSIONS: This study confirms the excellent prognosis for patients with low malignant potential ovarian tumors. Conservative fertility-saving surgical treatment can be offered to young patients (< 40 years) with early stage (stage I-II) disease who wish to retain their fertility potential. Up to 50% of women in this study who underwent conservative surgery subsequently conceived. The long-term outcome of LMP ovarian tumors is extremely favorable, even when long-term follow-up is extended to ten years.

Assessment of myometrial and cervical invasion of endometrial cancer by transvaginal sonography.

INTRODUCTION: The aim of this study was to determine the efficiency of transvaginal ultrasonography in the assessment of myometrial invasion and cervical involvement (preoperative staging) of endometrial cancer. MATERIALS AND METHODS: Transvaginal ultrasonography was performed on 52 women to classify endometrial cancer with respect to myometrial invasion and cervical involvement according to the International Federation of Gynaecologists and Obstetricians recommendations for surgical staging of endometrial cancer. Endometrial cancer was diagnosed on the basis of dilatation and curettage and the degree of invasion was evaluated preoperatively by transvaginal ultrasonography. Ultrasonographic findings were compared to the surgical staging and histopathology of the surgical specimen. RESULTS: Myometrial invasion evaluated by transvaginal sonography was accurate in 46 of 52 cases (accuracy 88%, sensitivity 86%, specificity 90%, positive predictive value 92%, negative predictive value 83%). Tumor extension to the cervix was properly diagnosed in seven of ten women in which it was present. CONCLUSION: Transvaginal ultrasonography is a reliable method for assessing myometrial invasion and cervical involvement. This non-invasive method should be included as an important tool in the establishment of individualized treatment programs for women with endometrial cancer.

Coexistence of metastatic neuroendocrine carcinoma of the uterine cervix with human immunodeficiency virus infection.

Women now constitute 28% of new cases of human immunodeficiency virus (HIV) infection. Cervical cancer in HIV-infected women has a high recurrence and death rate, as well as decreased intervals to recurrence and death. Neuroendocrine carcinomas of the cervix are characterized by a high frequency of early nodal and distant metastases. We present the first report of a neuroendocrine carcinoma of the cervix in an HIV-positive patient. A 28 year old with a 9-year history of HIV succumbed to metastatic neuroendocrine carcinoma of the cervix 5 months after diagnosis. Given the aggressive nature of the cell type, an extended metastatic workup should be considered prior to surgery. The immune suppression present in HIV-positive patients with neuroendocrine cervical carcinoma may make such a workup particularly crucial, such that surgery is offered only to those who can be expected to benefit.

[Ovarian carcinoma of low malignant potential treated at the 1(st) Department of Obstetrics and Gynecology Semmelweis University Faculty of Medicine, between 1990 and 2000] / Az alacsony malignitású petefészek-daganatok kezelésével szerzett tapasztalataink Klinikánk 10 éves beteganyagában (1990-2000).

The authors analyzed the epidemiologic and histological characteristics and the management of ovarian carcinoma of low malignant potential (LMP) at a university hospital between 1990 and 2000. The authors carried out a retrospective study reviewing hospital charts. Based on the records experience with 29 such tumors is peresented. Of these 20 (74%) were of the serous variety, 7 (26%) were mucinous. LMP tumors accounted for 16% of proliferating epithelial ovarian tumors. They occured at a mean age of 45 years. The LMP tumors were bilateral in 12% of the cases. The majority of patients (87%) with LMP tumors presented with early stage disease. Tumor markers such as CA-125 were not always elevated as in invasive ovarian carcinoma. Laboratory investigations have not demonstrated that these tumors represent an intermediate step between benign ovarian tumors and carcinoma. The recommended therapy is surgical, consisting of total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal washings, and tumor debulking. Conservative surgery consisting of unilateral salpingo-oophorectomy is considered to be an appropriate treatment for young women with early stage LMP ovarian tumors who wish to retain their fertility potential. 50 percent of women who underwent conservative surgery subsequently conceived in this study. There were no recurrences in the study group, so the authors conclude that the long term outcome of LMP tumors is extremely favorable.