Contribution of cervical cytology in the diagnostic work-up of patients with endometrial cancer.

INTRODUCTION: Abnormal cervical cytology in patients with endometrial cancer (EC) has been associated with poor outcome. The aim of this study was to evaluate whether cervical cytology could contribute to an improved preoperative identification of high-grade EC (serous, clear cell, carcinosarcoma, high-grade endometrioid EC) in final histology. METHODS: A retrospective cohort study was performed in five hospitals in the Netherlands. A total of 554 patients with EC that underwent primary surgical treatment between 2002 and 2010 were included. Primary outcome was defined as the contribution of abnormal cervical cytology in the preoperative identification of high-grade EC. As secondary outcome, recurrence-free survival (RFS) and disease-specific survival were determined based on preoperative cervical cytology, and compared to the currently established risk factors: myometrial invasion, high-grade and lymph vascular space invasion. RESULTS: Abnormal cervical cytology was present in 45.1%. For patients with preoperative inconclusive and high-grade histology, the presence of abnormal cervical cytology contributed to an improved identification of high-grade EC in final histology (odds ratio [OR] 6.40 [95% confidence interval {CI}: 1.92-21.26]; OR 2.86 [95% CI: 1.14-7.14]), respectively. Patients with abnormal cervical cytology had a significant worse 5-year median RFS. Abnormal cervical cytology was independently related to RFS (hazard ratio 1.67 [95% CI: 1.04-2.68]) and disease-specific survival (hazard ratio 3.15 [95% CI: 1.74-5.71]). CONCLUSIONS: Abnormal cytology contributes to the preoperative identification of patients with high-grade EC, and is associated with compromised outcome. Future studies are warranted to determine whether cervical cytology could be incorporated into preoperative prediction models for lymph node metastasis.

The value of imaging of the lungs in the diagnostic workup of patients with endometrial cancer.

OBJECTIVE: Imaging of the lungs is part of the routine diagnostic workup of patients with endometrial cancer. The present study aimed to determine the incidence of lung metastases in patients with endometrial cancer and to evaluate the clinical relevance of preoperative chest imaging in this population. METHODS: A retrospective cross-sectional study was performed in four regional and one university hospital in the southeastern part of the Netherlands. A total of 784 patients with epithelial endometrial cancer diagnosed between 2002 and 2010 in five hospitals were included. Patients were followed up for at least 1 year. RESULTS: Of 784 patients, 541 (69.0%) underwent thoracic imaging and 11 showed findings suspicious for metastases perioperatively or during the 1-year follow-up period. In eight patients, the thoracic metastases were related to their endometrial cancer, resulting in an overall incidence of 1.0% (8/784, 95% CI=0.3-1.7%). These eight patients had high-risk subtypes of endometrial cancer (serous, clear cell or poorly differentiated endometrioid), and the incidence was 4.1% (8/193, 95% CI=1.9-8.3%) for these subtypes. Lung metastases were not detected in any of the patients with low-risk subtypes of endometrial cancer (n=566) at the time of diagnosis (95% CI=0-0.8%). CONCLUSIONS: The probability of detecting thoracic metastases during the diagnostic workup of patients with endometrial cancer is low. The present data suggest that thoracic imaging could be omitted from the diagnostic workup of patients with low-risk endometrial cancer.

Improving external cephalic version for foetal breech presentation.

OBJECTIVES: If success rate of external cephalic version (ECV) increases, the rate of primary caesarean sections -declines. The aims of this retrospective cohort study were to evaluate the ECV and to identify factors associated with the success rate of ECV for breech presentation at term. The second aim of this study was to analyse the outcome of labour of all patients with a foetus in breech near term. METHODS: All women with a foetus in breech near or at term were included. Logistic regression analyses were -performed to identify the association between patient characteristics and success rate of ECV. RESULTS: The overall rate of successful ECV's was 19%. Foetal and maternal complications after ECV were negligible. BMI, type of breech and amount of amniotic fluid were significantly correlated with a successful ECV. The rate of primary caesarean sections for the group of patients who underwent an ECV was lower than the rate in the group who did not (52.9% vs. 79.6%). The rate of spontaneous deliveries was increased after ECV (36% versus 12%). After successful ECV the rate of spontaneous deliveries was 75%; after unsuccessful ECV 26.8%. CONCLUSION: The overall rate of successful ECV was low (19%). BMI, type of breech and amount of amniotic fluid were significantly correlated with a successful ECV. The rate of primary caesarean sections was significantly lower in patients with ECV (52.9% versus 79.6%). The rate of spontaneous deliveries was significantly higher (36% -versus 12%).

Factors predicting recurrent endometrial cancer.

OBJECTIVES: The aim of this study was to identify (prognostic) factors that may predict the development of recurrent endometrial cancer and may improve the choice of adjuvant therapy subsequently. METHODS: Data of all patients, diagnosed with primary endometrial cancer in Orbis Medical Center Sittard between 2002 and 2010, were analyzed retrospectively. Cox regression analysis was performed for identification of independent prognostic factors; survival was calculated by using the Kaplan-Meier method. STUDY DESIGN: Data of all patients, diagnosed with primary endometrial cancer in Orbis Medical Center Sittard between 2002 and 2010, were analyzed retrospectively. Cox regression analysis was performed for identification of independent prognostic factors; survival was calculated by using the Kaplan-Meier method. Multiple factors were associated with recurrence. Age, histological type and progesteron receptor expression (PR) were identified as independent prognostic factors. Risk profile (according to the PORTEC-1 study) and PR were also independent prognostic factors. Furthermore, PR (p < 0.001) and histological type (p = 0.013) were associated with disease specific survival after recurrence. CONCLUSION: Although the survival of endometrial cancer is good, the prognosis of recurrent disease is poor. Recurrence- of endometrial cancer and disease free survival rates are associated with several (independent) factors. The effect of adjuvant treatment may improve through more sufficient selection of patients by using the new prognostic- factors and through better selection of the type of adjuvant therapy. KEY WORDS: Endometrial cancer, recurrence, survival, prognostic factors, progesterone receptor expression.

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.

Treatment strategies in intermediate cervical neoplasia: Implications of radical surgery.

Treatment strategies for cervical intraepithelial neoplase (CIN)2 lesions differ among gynaecologists. To evaluate the differences in management of treatment with subsequent implications, all surgical treatment strategies and follow-up methods were retrospectively analysed for patients with intermediate dysplasia of the cervix. This study aimed to evaluate expectant management strategies and the effect of biopsy prior to radical surgery in CIN2. Patients diagnosed with a CIN2 lesion at the Orbis Medical Center in The Netherlands between 2006 and 2007 were retrospectively analysed. The follow-up ended on 1st January 2009. All 141 patients with CIN2 lesions were included; 109 had no previous history of any CIN lesion. Of the 109 patients, 12% (n=13) underwent an immediate radical surgical excision of the transformation zone (LLETZ procedure) and 85% (n=93) underwent a local biopsy. After the lesion was biopsied, expectant management was selected for 59% of the patients. Subsequent smears were normal in 40% of the patients. Of the patients with abnormal smears in follow-up, the LLETZ procedure was performed in 86% of the patients (n=25). Of these cases, persistent disease was observed in 14% of the patients. After an immediate LLETZ procedure without prior biopsy, follow-up smears were abnormal in 31% of the patients. Persistent disease was significantly lower following radical excision of the lesion with a diagnostic biopsy versus without one (14 versus 31%). After expectant management, the rate of persistent disease was 53% (p<0.001). Overall, the rate of persistent disease was 7%. Due to the high rate of persistent disease and the lower rate of overtreatment, CIN2 lesions should be treated by the excisional procedure. To restrict persistent disease, a biopsy is recommended prior to the actual treatment, since a higher rate of abnormal smears was observed in the follow-up after immediate radical excisions in the first visit.

Endometrial cancer patients: a cohort previous to changes in tumour behaviour and treatment strategies.

Nowadays, the incidence of endometrial cancer is rising, especially of high-grade endometrial tumours. Recently, the FIGO classification of endometrial cancer has changed worldwide. Besides that, treatment strategies are changing. The purpose of this study was to analyse the adherence to the national guidelines of cancer treatment and to analyse patterns of disease relapse and survival. We focused on a group of patients (n = 191) with endometrial cancer, in a time period in which new treatment strategies are not yet completely implemented. Because of multiple upcoming changes in patient characteristics, tumour classification, as well as treatment regimens, a more heterogeneous cohort of patients diagnosed with endometrial cancer will appear. From now on, all those changes will have their effects on the followup of conventional endometrial cancer treatment. In our opinion, it is, therefore, valuable to have the current, more homogenous, cohort clearly described.

[Diagnostic image (261). A woman with vulval ulcera and uveitis]. / Diagnose in beeld (261). Een vrouw met vulvaire ulcera en uveitis.

A 49-year-old woman suffered from vulval and vaginal ulcera and from oral mucosal lesions and uveitis due to Behçet's disease.

Multiparameter flow cytometry in the diagnosis of a gynaecologic double tumor: a case report.

PURPOSE: An uncommon clinical presentation of metastatic tumor will often lead to additional diagnostic examinations. The patient of the present study was known to have endometrial cancer which was thought to be limited to the endometrium. Three months postoperatively, she developed ascites due to spread of the tumor, which is rarely seen in low-stage endometrial cancer. METHOD: Multiparameter flow cytometry using both cell phenotype information and DNA ploidy was performed. RESULTS: Retrospectively, the patient was diagnosed as having a DNA-diploid epithelial tumor of the endometrium as well as a DNA-aneuploid epithelial tumor in the left fallopian tube. It was shown that 3 months after primary surgery she developed ascites caused by metastatic tumor from the primary fallopian tube cancer. CONCLUSION: The complete diagnosis was made using multiparameter flow cytometry which, at present, is not routinely applied in gynecologic pathology.