Less-favourable prognosis for low-risk endometrial cancer patients with a discordant pre- versus post-operative risk stratification.

BACKGROUND: Pre-operative risk stratification based on endometrial sampling determines the extent of surgery for endometrial cancer (EC). We investigated the concordance of pre- and post-operative risk stratifications and the impact of discordance on survival. METHODS: Patients diagnosed with EC within the first 6 months of the years 2005-2014 were selected from the Netherlands Cancer Registry (N = 7875). Pre- and post-operative risk stratifications were determined based on grade and/or histological subtype for 3784 eligible patients. RESULTS: A discordant risk stratification was found in 10% of patients: 4% (N = 155) had high pre- and low post-operative risk and 6% (N = 215) had low pre- and high post-operative risk. Overall survival of patients with high pre- and low post-operative risk was less favourable compared to those with a concordant low risk (80% versus 89%, p = 0.002). This difference remained significant when correcting for age, stage, surgical staging and adjuvant therapy (hazard ratio 1.80, 95% confidence interval 1.28-2.53, p = 0.001). Survival of patients with low pre- and high post-operative risk did not differ from those with a concordant high risk (64% versus 62%, p = 0.295). CONCLUSION: Patients with high pre- and low post-operative risk have a less favourable prognosis compared to patients with a concordant low risk. Pre-operative risk stratifications contain independent prognostic information and should be incorporated into clinical decision-making.

Patient satisfaction in treatment for cervical pathology.

This study aimed to analyse the satisfaction levels of patients treated for cervical dysplasia. At the Orbis Medical Center, all cases of abnormal cervical cytology are referred for colposcopy; however, there are three possible routings for patients: i) Patients are informed by the gynecologist about the colposcopy in a visit to the outpatient clinic, and colposcopy is planned in a second visit; ii) patients are informed by the gynecologist immediately before the colposcopy (a single visit); or iii) patients are called by a nurse practitioner 1-2 weeks prior to the colposcopy. The nurse practitioner informs patients about their Pap smear result, the colposcopy procedure and the follow-up (single visit plus telephone conversation). Patient satisfaction was analysed in the diagnostic and occasionally in the therapeutic colposcopies, with regards to information, treatment, appeasement and number of visits. The issue of whether the introduction of nurse practitioners improved patient satisfaction was also assessed. Patient satisfaction questionnaires were sent to all 593 patients who underwent a colposcopic examination for the first time following an abnormal smear test result. Data were analysed using SPSS 14.0. For statistical analyses, χ(2) tests and the Mann-Whitney U test were used. P<0.05 was considered to be statistically significant. The response rates did not differ significantly among the three groups of patients. In general, patient satisfaction regarding care was high (96%). The role of the nurse practitioner was rated highly (8.0-8.4). Although there were differences in the number of visits and satisfaction regarding the information provided, patient satisfaction did not differ significantly between groups 1 and 3. Patients in group 2 were significantly less satisfied with regard to almost all analysed data. In conclusion, the single visit procedure is extremely efficient. Patient satisfaction did not differ significantly between groups 1 and 3, but group 2 patients were significantly less satisfied. The introduction of nurse practitioners improves patients' knowledge, comfort and satisfaction. Furthermore, it reduces the number of visits required. Efficient treatment strategies were introduced and patient satisfaction was increased.

Does urodynamic investigation improve outcome in patients undergoing prolapse surgery?

AIMS: Without solid evidence, it has been advocated to perform urodynamic investigation in all patients scheduled for prolapse surgery. If urodynamic investigations were to be valuable in the diagnostic work-up, patients with normal and abnormal findings would have different treatment results. Our policy to never combine prolapse surgery and stress-incontinence surgery allowed us to study whether incontinence after surgery can be predicted from urodynamic investigation results. METHODS: A retrospective study was performed in consecutive patients undergoing vaginal prolapse surgery (anterior colporraphy and/or posterior colporraphy, and/or vaginal hysterectomy) between 2002 and 2004. All patients underwent pre-operative urodynamic investigation, including filling cystometry, urethral pressure profile measurement, and free flow cystometry. Data were collected from the files about medical history, findings at pelvic examination, findings at urodynamic investigation and presence of stress- and/or urge-incontinence after surgery. RESULTS: We studied 76 patients, of whom 5 (7%) patients reported stress-incontinence and 5 (7%) patients reported urge-incontinence after surgery. Findings at urodynamic investigation could not predict the presence of stress- or urge-incontinence after surgery. Likelihood ratios (LR) of prior presence of urge and stress-incontinence for the presence of post-operative urge- and stress-incontinence were 4.5 and 1.2, respectively. Of all findings at urodynamic investigation, only negative transmission during cough test was associated with presence of stress-incontinence (LR = 1.5). CONCLUSIONS: The prevalence of incontinence after prolapse surgery is low. None of the investigated parameters of the urodynamic investigation tests was associated with the presence of urinary incontinence after surgery.

[Transvaginal contrast sonography of the uterus in the diagnosis of abnormal uterine blood loss: less hysteroscopies needed]. / Transvaginale contrastechoscopie van de uterus in de diagnostiek van abnormaal uterien bloedverlies: minder hysteroscopieën nodig.

OBJECTIVE: To determine the value of transvaginal saline-infusion sonography of the uterus in patients with abnormal uterine blood loss in terms of avoiding hysteroscopy. DESIGN: Prospective. METHOD: According to the protocol, transvaginal saline-infusion sonography was carried out on all consecutive patients with abnormal uterine blood loss (post-menopausal patients with an endometrial thickness of > or = 5 mm and all pre-menopausal patients with menorrhagia or metrorrhagia) in the St. Joseph hospital in Veldhoven, the Netherlands, during the period 1999-2001. If sonography did not provide an image suitable for assessment, or if intracavitary (pedunculated) lesions such as polyps or myomas were suspected, a planned therapeutic hysteroscopy was carried out. Patients indicated their perception of pain on a visual analogue scale. RESULTS: Saline-infusion sonography of the uterus was performed in 457 patients (age: 40-69 years). In 32 patients (7%) it did not result in a representative image. In 138 (32%) of the remaining 425 patients, a pedunculated lesion was suspected. In 262 (59%) of the 457 patients, diagnostic efforts were restricted to ultrasonic examination. This was combined with endometrial aspiration in 161 (61%) of these patients. In total, hysteroscopy was carried out in 195 of the 457 patients (43%). There were no complications. Pain was scored as 'none-little' by 292 patients (64%), 'moderate' by 76 (17%) and 'a great deal' by 48 (10%) patients. CONCLUSION: Saline-infusion sonography of the uterus is a safe diagnostic method in patients with abnormal uterine blood loss, which, in more than half the cases, can replace less well-tolerated diagnostic procedures.

Paraneoplastic cerebellar degeneration: neurological symptoms pointing to occult ovarian cancer.

Paraneoplastic cerebellar degeneration with anti-Yo antibodies is a rare but disabling neurodegenerative disease that may point to an occult ovarian cancer. Symptoms usually accompanying paraneoplastic cerebellar degeneration include truncal and limb ataxia, dysarthria, dysphagia, nystagmus, vertigo, and diplopia. The pathogenesis of paraneoplastic neurological syndromes is unknown. Treatment results of the neurological symptoms are disappointing. The present case illustrates how neurological symptoms pointed to an occult ovarian cancer.

Tumor angiogenesis: an independent prognostic parameter in cervical cancer.

OBJECTIVE: The purpose of this study was to investigate whether the intensity of tumor angiogenesis, expressed as microvessel density, is a parameter predicting the probability of lymph node metastasis and survival in patients with cervical cancer stages IB and IIA. STUDY DESIGN: In a retrospective study of 114 patients with cervical cancer stages IB and IIA, microvessel density, lymph node status, and several other prognostic parameters were correlated with disease-free survival by a multivariate analysis according to Cox proportional-hazards model. RESULTS: There was a significant difference in mean microvessel density between tumors with and without pelvic lymph node metastasis (p = 0.002). Both microvessel density (vessels per square millimeter of stroma). (p = 0.05) and pelvic lymph node metastasis (p = 0.007) correlated significantly and independently with disease-free survival. CONCLUSION: This study demonstrates that microvessel density is an independent prognostic parameter for disease-free survival in patients with cervical cancer stages Ib and IIa.

p53 tumor suppressor gene protein expression in cervical cancer: relationship to prognosis.

OBJECTIVE: Mutation of the p53 gene can be found in several human tumors. We tested the hypothesis whether overexpression of p53 protein is a parameter of more aggressive disease in patients with cervical cancer. STUDY DESIGN: In this study, we describe the effects of p53 overexpression in 156 patients with cervical cancer (Figo stage IB-IV) by assessing expression patterns of the p53 gene product using a monoclonal anti-p53 antibody (DO7). RESULTS: Overexpression of p53 tumor suppressor gene protein was observed in 30.2% of the tumors, low expression in 30.7% and 39.1% of the tumors showed no p53 immunoreactivity. With increase in stage, p53 overexpression raised from 20.1% in stage IB to 60% in stage IV. A significant correlation between p53 overexpression and disease-free survival of patients was observed, however, after stratification for stage, this effect disappeared. CONCLUSIONS: The p53 mutation expressed as p53 tumor suppressor gene protein overexpression is a late event in cervical cancer genesis and does not appear to be of prognostic significance in cervical cancer.

Basement membranes in cervical cancer: relationship to pelvic lymph node metastasis and prognosis.

In this retrospective study, the pattern of basement membrane expressed by type IV collagen immunostaining was evaluated in 156 patients with cervical cancer FIGO stage IB-IV. Staining patterns were assessed semiquantitatively and divided into three patterns, according to intensity and continuity of staining: thick basement membranes with minimal discontinuity (pattern I), thin basement membranes with moderate discontinuity (pattern II), and fragmentary or absent basement membranes (pattern III). Correlations between basement membrane pattern, FIGO stage, and pelvic lymph node status were tested using chi 2 statistics. Kaplan-Meier estimates of disease-free survival were calculated for groups of patients with basement membrane pattern I, II, or III and compared using the log-rank test. A fragmented or absent basement membrane, pattern III, was more frequently observed in advanced cervical cancer stage IIB/IV (P = 0.02). In patients with early cervical cancer stage Ib/IIA this pattern was associated with the presence of pelvic lymph node metastasis (P < 0.0001) and significantly associated with a decreased survival rate (P = 0.05). In advanced-stage disease no prognostic value was observed. These data indicate that in patients with early-stage cervical cancer the basement membrane pattern, expressed as the type IV collagen staining pattern, may be a useful marker in predicting lymph node metastasis and survival.

Five different histological subtypes of germ cell malignancies in an XY female.

A case of a 19-year-old female with 46 XY gonadal dysgenesis and five different histological subtypes of germ cell malignancies is described. Both adnexa were removed, preserving the uterus. Pathology revealed gonadoblastoma with dysgerminoma differentiation present in both gonads and in the left gonad mature teratoma, embryonal carcinoma, and endodermal sinus tumor were identified as well. She received no adjuvant treatment and has remained well 30 months after diagnosis.

Early stage cervical cancer: aborted versus completed radical hysterectomy.

In a retrospective study, the treatment results of patients with stage IB and IIA cervical cancer were evaluated. In 26 patients radical hysterectomy was discontinued after intra-operative finding of positive lymph nodes. These patients received radiotherapy. In 57 patients lymph nodes were negative, and radical hysterectomy was completed. Of these, 13 patients received adjuvant radiotherapy because of positive surgical margins or parametrial involvement, and 44 patients received no adjuvant therapy. Five-year survival was 61% in patients with positive pelvic lymph nodes and 88% in patients with negative pelvic lymph nodes, comparable with the results mentioned in the literature. The complication rate did not differ from similar other reports. This management shows treatment results comparable with other reports with minimal morbidity.