Test of cure and beyond: superiority of thermal ablation over LLETZ in the treatment of high-grade CIN.

PURPOSE: Among the treatment modalities for high-grade cervical intraepithelial neoplasia (CIN), large-loop excision of the transformation zone (LLETZ) is the commonest offered in the UK, whereas thermal ablation (TA) has not been common in several decades, despite several notable advantages. TA and LLETZ are both routinely undertaken in our colposcopy unit, and extensive follow-up data have been used to interrogate outcomes between the two modalities and determine whether one modality may be preferred over the other. METHODS: Up to 8 years of follow-up data (cytology and histology) were collected for patients who have undergone LLETZ or TA and failed post-treatment test of cure (ToC). These data were analysed and used to plot Kaplan-Meier survival curves, in order to compare outcomes: negative cytology, dyskaryosis, low- and high-grade CIN and invasive squamous cell carcinoma. RESULTS: i) Very few women treated with TA developed recurrent high-grade CIN in the follow-up period; (ii) LLETZ-treated women had a significantly higher rate of recurrence than those treated by TA; (iii) women who failed both virology and cytology components of post-treatment ToC had higher recurrence than those who failed only one, and the rate of recurrence was highest in those treated by LLETZ (> 65%). CONCLUSION: TA is an effective treatment of high-grade CIN, with a high chance of achieving double-negative ToC and low recurrence relative to LLETZ. We recommend the wider adoption of TA, so that young women of reproductive age have a choice of treatment with no reported adverse effects on pregnancy outcomes.

Attitudes towards risk-reducing early salpingectomy with delayed oophorectomy for ovarian cancer prevention: a cohort study.

OBJECTIVE: To determine risk-reducing early salpingectomy and delayed oophorectomy (RRESDO) acceptability and effect of surgical prevention on menopausal sequelae/satisfaction/regret in women at increased ovarian cancer (OC) risk. DESIGN: Multicentre, cohort, questionnaire study (IRSCTN:12310993). SETTING: United Kingdom (UK). POPULATION: UK women without OC ≥18 years, at increased OC risk, with/without previous RRSO, ascertained through specialist familial cancer/genetic clinics and BRCA support groups. METHODS: Participants completed a 39-item questionnaire. Baseline characteristics were described using descriptive statistics. Logistic/linear regression models analysed the impact of variables on RRESDO acceptability and health outcomes. MAIN OUTCOMES: RRESDO acceptability, menopausal sequelae, satisfaction/regret. RESULTS: In all, 346 of 683 participants underwent risk-reducing salpingo-oophorectomy (RRSO). Of premenopausal women who had not undergone RRSO, 69.1% (181/262) found it acceptable to participate in a research study offering RRESDO. Premenopausal women concerned about sexual dysfunction were more likely to find RRESDO acceptable (odds ratio [OR] = 2.9, 95% CI 1.2-7.7, P = 0.025). Women experiencing sexual dysfunction after premenopausal RRSO were more likely to find RRESDO acceptable in retrospect (OR = 5.3, 95% CI 1.2-27.5, P < 0.031). In all, 88.8% (143/161) premenopausal and 95.2% (80/84) postmenopausal women who underwent RRSO, respectively, were satisfied with their decision, whereas 9.4% (15/160) premenopausal and 1.2% (1/81) postmenopausal women who underwent RRSO regretted their decision. HRT uptake in premenopausal individuals without breast cancer (BC) was 74.1% (80/108). HRT use did not significantly affect satisfaction/regret levels but did reduce symptoms of vaginal dryness (OR = 0.4, 95% CI 0.2-0.9, P = 0.025). CONCLUSION: Data show high RRESDO acceptability, particularly in women concerned about sexual dysfunction. Although RRSO satisfaction remains high, regret rates are much higher for premenopausal women than for postmenopausal women. HRT use following premenopausal RRSO does not increase satisfaction but does reduce vaginal dryness. TWEETABLE ABSTRACT: RRESDO has high acceptability among premenopausal women at increased ovarian cancer risk, particularly those concerned about sexual dysfunction.

Mirenas against malignancy: an alternative to operative management.

BACKGROUND: Complex atypical hyperplasia is a recognised precursor to endometrial cancer, the most common gynaecological cancer of the Western World, with hysterectomy being the first line of management. With the increasing elderly population size and BMI, optimal surgical management can be challenging in a sub-set of patients. Levonorgestrol releasing IUS system (Mirena coil) has been identified as a treatment for those unsuitable for surgical management. AIMS: To assess the efficacy of Mirena coils in the treatment of endometrial cancers and complex atypical hyperplasia in our patient population. METHOD: Retrospective analysis of all type 1 endometrial cancers and CAH diagnosed in Tayside from April 2011 to March 2016 (duration 5 years) managed by a Mirena coil. Primary outcome was resolution of malignancy on biopsy. Secondary outcome was continuation of treatment. RESULTS: Two hundred nineteen out of 245 eligible endometrial cancers and 38 of 41 CAH case notes were available for assessment. A Mirena coil was the primary mode of treatment in eight endometrial cancers (3.6%) and 18 cases of CAH (47.4%). Of the eight endometrial cancers treated, five (62%) continued with the Mirena coil as the primary mode of treatment. Two patients died during their follow-up due to unrelated illnesses and one patient proceeded to hysterectomy due to the absence of progestogenic effect on repeat Pipelle biopsy at six months (12.5%). Four patients have been followed for one year and of those; two showed no evidence of malignancy, one was unable to be biopsied and the last showed persistent disease but was too frail for intervention. At two-year follow-up, two patients remain with one showing disease recurrence. Thirteen patients (87%) have continued to use the Mirena as management of CAH out of 18 treatments. Of the five patients who did not continue with the IUS; two patients had progressive disease, despite the coil (11%), two patients lost enough weight to proceed to hysterectomy and one patient died unexpectedly. Medical co-morbidities and BMI were the main cited reasons for proceeding with the IUS as the primary treatment. Average BMI of endometrial cancer cases was 43.9 and 45.1 for CAH. CONCLUSIONS: Mirena coil is effective in treating or controlling the progression of endometrial malignancy in the subgroup of patients where there is an increased risk associated with definitive surgery. The treatment failure rate appears to be consistent at about one-tenth of the cohort of women with both endometrial cancers and complex atypical hyperplasia.

Laparoscopic hysterectomy for endometrial cancer: impact of age on clinical outcomes.

INTRODUCTION: Improvement in preoperative care for the ageing population has resulted in an increasing number of elderly patients to be considered for surgery. With an increased incidence of endometrial cancer, it is inevitable that a significant number of elderly patients are referred for surgery, despite the concerns over co-morbid conditions and diminished cardiopulmonary reserves. AIM: To evaluate the clinical outcomes of laparoscopic hysterectomy for elderly women operated on for endometrial cancer with comparison to younger patients. METHODS: A retrospective study of women who had undergone total laparoscopic hysterectomy for endometrial cancer at Ninewells Hospital between January 2015 and January 2017 was conducted. Patients were identified from the gynaecology oncology multidisciplinary team e-case database and were categorised into younger and older group according to their age. Both groups were compared and analysed for demographics details, pre-existing comorbidity, METS score, perioperative and postoperative data. RESULTS: There were 100 women meeting the study criteria. Of these, 79 patients were aged ≤75 (Group A) and 21 patients were aged >75 (Group B). The mean age was 62.9 (age range 37-75) and 80.6 (age range 76-90) in Group A and Group B, respectively. Group A presented with higher mean BMI (̄ = 33.8) compared to Group B (̄ = 28.8). With the increase in patient's age, reduced METS score was observed. No difference was found between the groups in the incidence of estimated blood loss and postoperative hospital stay. Fisher's exact test was used to evaluate the postoperative complication in both groups. The two-tailed p value (p = .1108) had illustrated that the observation was statistically insignificant between both groups. One patient in Group A (n = 79) was found to have pelvic haematoma after the procedure; while two patients in Group B (n = 21) developed port site haematoma. Otherwise, no other patients from both groups developed postoperative complication regardless of their pre-existing medical conditions. Only one patient in Group A (n = 79) required conversion to open surgery due to difficult access and large uterine fibroid. CONCLUSIONS: Total laparoscopic hysterectomy appears to be feasible and safe in elderly women with no significant difference between groups. Minimally invasive surgery has shown to extend considerable benefits to patient safety regardless of their age.

Non-assessable endometrium in women with post-menopausal bleeding: to investigate or ignore.

BACKGROUND: In women presenting with post-menopausal bleeding (PMB), the incidence of endometrial cancer is 1-10 %; Trans-vaginal scan (TVS) is offered as the first line of investigation to triage women further and a thick endometrium (>4 mm) merits endometrial tissue sampling for further evaluation. When it is difficult and not possible to assess the endometrium sonographically, decision to investigate further lies with the clinician. AIM: Study outcomes for women with PMB and endometrium not assessable on TVS. METHODS: We collected data retrospectively between September 2007 and December 2010. We identified our study group from the radiology database. Data collected include ultrasound findings, methods of endometrial sampling, and the result of cytology/histology. RESULTS: In our study period of 40 months, 671 women with post-menopausal bleeding were referred to the ultrasound department for TVS to assess endometrial thickness. 92 % (614/671) women had the assessment. In 57 women (8 %), endometrial thickness was not assessable and this formed our study group. 3/57 records were not retrievable and excluded from our study. 43/54 (79 %) had some form of endometrial sampling done. Among the 81 % adequate samples (35/43), 7 (20 %) had endometrial cancer; 1 (3 %) had CAH, 1 (3 %) was diagnosed with cervical cancer. In women who had thickened endometrium (>4 mm; n = 448), there were 29 cases of endometrial cancers detected giving an incidence of 6.4 %. In women with PMB and non-assessable endometrial thickness, there is increased incidence of endometrial cancer when compared to the group where endometrial thickness could be measured. (Odds ratio = 3.3 [95 % CI = 1.2-9]). This is a statistically (p = 0.017) and clinically significant finding. CONCLUSION: In women with PMB, there will be a subgroup in which ultrasound cannot assess endometrial thickness. When compared to women where endometrial thickness is measurable, this group stands a higher risk of endometrial cancer and hysteroscopy/ hysterosonography with endometrial sampling is recommended in this group.

Pattern and chemosensitivity of ovarian cancer in patients with BRCA1/2 mutations.

Our study adds to the BRCAness theory that hereditary ovarian cancers with BRCA 1 or 2 mutations show better chemosensitivity when compared with sporadic ovarian cancers.

The use of STAN monitoring in the labour ward.

Continuous intrapartum cardiotocography (CTG) augmented by fetal ECG ST segment analysis (STAN) has the potential to reduce the rates of neonatal metabolic acidosis and obstetric interventions. STAN was introduced at Ninewells Hospital, Dundee in October 2007. Data were collected prospectively from all women who received continuous intrapartum CTG and STAN between 1 October 2007 and 31 March 2008. A total of 253 women had continuous CTG and STAN. The median number of ST events was one (range = 1-32). Most (556/719, 77%) ST events were associated with a normal CTG; 46/144 (32%) patients with an ST event required immediate action. Three of the 253 (1.2%) women were delivered based on an ST event with a normal CTG; four (1.5%) had severe neonatal metabolic acidosis and all four cases had intrapartum ST events and were not managed according to STAN guidelines. ST events are common but the majority of ST events require no action. The high incidence of false-positive ST events might have contributed to the failure to act when a significant ST event occurred.