Surgical margin status in relation to surgical approach in the management of early-stage cervical Cancer: A Canadian cervical Cancer collaborative (4C) study.

OBJECTIVE: Surgical margin status in women undergoing surgery for early-stage cervical cancer is an important prognostic factor. We sought to determine whether close (<3 mm) and positive surgical margins are associated with surgical approach and survival. METHODS: This is a national retrospective cohort study of cervical cancer patients treated with radical hysterectomy. Patients with stage IA1/LVSI-Ib2(FIGO 2018) with lesions up to 4 cm at 11 Canadian institutions from 2007 to 2019 were included. Surgical approach included robotic/laparoscopic (LRH), abdominal (ARH) or combined laparoscopic-assisted vaginal/vaginal (LVRH) radical hysterectomy. Recurrence free survival(RFS) and overall survival (OS) were estimated using Kaplan-Meier analysis. Chi-square and log-rank tests were used to compare groups. RESULTS: 956 patients met inclusion criteria. Surgical margins were as follows: negative (87.0%), positive (0.4%) or close <3 mm (6.8%), missing (5.8%). Most patients had squamous histology (46.9%); 34.6% had adenocarcinomas and 11.3% adenosquamous. Most were stage IB (75.1%) and 24.9% were IA. Mode of surgery included: LRH(51.8%), ARH (39.2%), LVRH (8.9%). Predictive factors for close/positive margins included stage, tumour diameter, vaginal involvement and parametrial extension. Surgical approach was not associated with margin status (p = 0.27). Close/positive margins were associated with a higher risk of death on univariate analysis (HR = non calculable for positive and HR = 1.83 for close margins, p = 0.017), but not significant for OS when adjusted for stage, histology, surgical approach and adjuvant treatment. There were 7 recurrences in patients with close margins (10.3%, p = 0.25). 71.5% with positive/close margins received adjuvant treatment. In addition, MIS was associated with a higher risk of death (OR = 2.39, p = 0.029). CONCLUSION: Surgical approach was not associated to close or positive margins. Close surgical margins were associated with a higher risk of death. MIS was associated with worse survival, suggesting that margin status may not be the driver of worse survival in these cases.

Oncologic Outcomes of Surgically Treated Cervical Cancer with No Residual Disease on Hysterectomy Specimen: A 4C (Canadian Cervical Cancer Collaborative) Working Group Study.

Minimally invasive surgery for the treatment of macroscopic cervical cancer leads to worse oncologic outcomes than with open surgery. Preoperative conization may mitigate the risk of surgical approach. Our objective was to describe the oncologic outcomes in cases of cervical cancer initially treated with conization, and subsequently found to have no residual cervical cancer after hysterectomy performed via open and minimally invasive approaches. This was a retrospective cohort study of surgically treated cervical cancer at 11 Canadian institutions from 2007 to 2017. Cases initially treated with cervical conization and subsequent hysterectomy, with no residual disease on hysterectomy specimen were included. They were subdivided according to minimally invasive (laparoscopic/robotic (MIS) or laparoscopically assisted vaginal/vaginal hysterectomy (LVH)), or abdominal (AH). Recurrence free survival (RFS) and overall survival (OS) were estimated using Kaplan-Meier analysis. Chi-square and log-rank tests were used to compare between cohorts. Within the total cohort, 238/1696 (14%) had no residual disease on hysterectomy specimen (122 MIS, 103 AH, and 13 VLH). The majority of cases in the cohort were FIGO 2018 stage IB1 (43.7%) and underwent a radical hysterectomy (81.9%). There was no statistical difference between stage, histology, and radical vs simple hysterectomy between the abdominal and minimally invasive groups. There were no significant differences in RFS (5-year: MIS/LVH 97.7%, AH 95.8%, p = 0.23) or OS (5-year: MIS/VLH 98.9%, AH 97.4%, p = 0.10), although event-rates were low. There were only two recurrences. In this large study including only patients with no residual cervical cancer on hysterectomy specimen, no significant differences in survival were seen by surgical approach. This may be due to the small number of events or due to no actual difference between the groups. Further studies are warranted.

Comparison of outcomes between abdominal, minimally invasive and combined vaginal-laparoscopic hysterectomy in patients with stage IAI/IA2 cervical cancer: 4C (Canadian Cervical Cancer Collaborative) study.

OBJECTIVE: Although minimally invasive hysterectomy (MIS-H) has been associated with worse survival compared to abdominal hysterectomy (AH) for cervical cancer, only 8% of patients in the LACC trial had microinvasive disease (Stage IA1/IA2). We sought to determine differences in outcome among patients undergoing MIS-H, AH or combined vaginal-laparoscopic hysterectomy (CVLH) for microinvasive cervical cancer. METHODS: A retrospective cohort study of all patients undergoing hysterectomy (radical and non radical) for FIGO 2018, microinvasive cervical cancer across 10 Canadian centers between 2007 and 2019 was performed. Recurrence free survival (RFS) was estimated using Kaplan Meier Survival analysis. Chi-square and log-rank tests were used to compare outcomes. RESULTS: 423 patients with microinvasive cervical cancer were included; 259 (61.2%) Stage IA1 (22/8.5% with LVSI) and 164(38.8%) IA2. The median age was 44 years (range 24-81). The most frequent histology was squamous (59.4%). Surgical approach was: 50.1% MIS-H (robotic or laparoscopic), 35.0% AH and 14.9% CVLH. Overall, 70.9% underwent radical hysterectomy and 76.5% had pelvic lymph node assessment. There were 16 recurrences (MIS-H:4, AH:9, CVLH: 3). No significant difference in 5-year RFS was found (96.7% MIS-H, 93.7% AH, 90.0% CVLH, p = 0.34). In a sub-analysis of patients with IA1 LVSI+/IA2(n = 186), survival results were similar. Further, there was no significant difference in peri-operative complications (p = 0.19). Patients undergoing MIS-H had a shorter median length of stay(0 days vs 3 (AH) vs. 1.5 (CVLH), p < 0.001), but had more ER visits (16.0% vs 3.6% (AH), 3.5% (CVLH), p = 0.036). CONCLUSION: In this cohort, including only patients with microinvasive cervical cancer, no difference in recurrence was found by surgical approach. This may be due to the low rate of recurrence making differences hard to detect or due to a true lack of difference. Hence, this patient population may benefit from MIS without compromising oncologic outcomes.

Epithelioid trophoblastic tumor presenting as a Caesarean scar defect: A case report.

BACKGROUND: Epithelioid trophoblastic tumor is a rare form of gestational trophoblastic neoplasia. We present the first known case of this rare malignancy presenting as a Caesarean scar defect. CASE: A patient with 3 prior Caesarean sections presented with vaginal bleeding 2 months following management of retained products of conception. Her hCG was negative. She underwent surgical repair of a Caesarean scar defect, and pathology was consistent with epithelioid trophoblastic tumor. CONCLUSION: This case highlights the possibility of malignancy presenting to the general gynecologist as a Caesarean scar defect. The diagnosis of gestational trophoblastic neoplasia should always be considered in the differential diagnosis of a patient with postpartum vaginal bleeding. Limited evidence on fertility conserving treatment of epithelioid trophoblastic tumors does not seem favorable.

Experiences of breastfeeding among women residents in Alberta: a cross-sectional survey.

OBJECTIVES: Breastfeeding at work is recommended by pediatric society guidelines and is protected by employment and human rights law in many countries. Despite this, previous studies have found that residents report important structural barriers to breastfeeding at work. METHOD: We administered a cross-sectional, electronic, multicenter survey of all women residents in Alberta who were parents in 2017. The study aimed to characterize respondents' experiences of breastfeeding, including duration, goals, barriers, and support from colleagues. RESULTS: There were 110 respondents, of whom 53 individuals had breastfed 83 children during residency. While nearly all felt that breastfeeding was important to them, only 69.2% reported meeting their breastfeeding duration goal. Surgical residents were less likely to meet their breastfeeding duration goal than residents in other disciplines (40.0% (n = 6/15) compared to 80.0% of non-surgical (n = 28/35) and 80.0% of family medicine residents (n = 12/15)). Residents reported stopping breastfeeding earlier than they desired due to lack of adequate space (48.7%, n = 19) and lack of time (57.1%, n = 24). Twelve participants (10.9%) reported hearing a derogatory comment from a staff physician about their breastfeeding. CONCLUSIONS: Women residents face barriers to breastfeeding at work which require systems-level intervention. Residents from surgical programs may be the most vulnerable to these barriers. Program directors, residency wellness committees, and hospital administrators should prioritize addressing these barriers for women residents returning to work after maternity leave. Examples of interventions that may address these barriers include policies, designation of lactation spaces, and flexible return-to-work schedules.

Single or two drug combination therapy as initial treatment for low risk, gestational trophoblastic neoplasia. A Canadian analysis.

INTRODUCTION: Low risk gestational trophoblastic neoplasia, WHO prognostic score of 0 to 6, is highly curable. There is no consensus on the optimal chemotherapy. Common regimens are q2wk actinomycin-D (ACT-D), weekly intramuscular methotrexate (MTX) or multi-day MTX. Combination MTX/ACT-D is rarely used. METHODS: A four centre, retrospective cohort study was carried out comparing commonly used regimens: weekly MTX, q2weekly ACT-D and q2 weekly MTX and ACT-D. RESULTS: 412 patients - 196 MTX/ACT-D, 107 MTX, 109 ACT-D - were treated between October 1994 and January 2019. Initial regimen failure (secondary to resistance or toxicity) occurred in 37% (MTX), 21% (ACT-D) and 5% (MTX/ACT-D). Relapse after completion of primary therapy (initial plus switch to another therapy if needed) was rare (0-5%). All eventually were cured. Mean number of cycles required to achieve remission were 10.1 (MTX), 7 (ACT-D) and 5.6 (MTX/ACT-D) with corresponding mean treatment durations of 3.12, 2.9 and 2.26 months. Dosage reductions occurred in 3% (MTX), 0% (ACT-D) and 29% (MTX/ACT-D). Higher failure rates occurred with WHO prognostic scores of 5 to 6 and HCG levels ≥10,000. SUMMARY: Initial regimen failure ie the need to switch to an alternative treatment was more common with MTX. ACT-D and MTX/ACT-D were similar within prognostic score 0-4 or HCG < 10,000. ACT-D then appears the better initial choice with its superior convenience. Above these levels primary failure rates are less with MTX/ACT-D, making it a better choice.

Vesicovaginal Fistula Following Loop Electrosurgical Excision Procedure: A Case Report.

BACKGROUND: The loop electrosurgical excision procedure (LEEP) is commonly used to treat cervical dysplasia and has few procedural risks. We report a rare complication: vesicovaginal fistula (VFF). CASE: A 47-year-old G3P1 woman with a previous LEEP underwent a second procedure 9 years later and was diagnosed as having microinvasive cervical cancer. Subsequently, at the time of her scheduled robotic-assisted laparoscopic total hysterectomy, examination under anaesthesia revealed a VFF, confirmed with cystoscopy. A joint VFF repair and total abdominal hysterectomy bilateral salpigo-oophorectomy subsequently ensued with an uncomplicated postoperative course. CONCLUSION: VFF is a rare but recognized complication of LEEP, particularly in women with risk factors, such as a prior LEEP. Examination under anesthesia prior to commencing surgery facilitated recognition and appropriate management of this case.

Squamous intraepithelial lesions in cervical tissue samples of limited adequacy and insufficient for grading as low or high grade: outcome, clinico-pathological correlates, and predictive role of p16INK4a and Ki67 biomarker staining.

OBJECTIVE: Cervical tissue samples of limited adequacy but with pathological features of squamous intraepithelial lesions (SIL) may not be gradable and result in a diagnosis of ungraded SIL (SILQ). SILQ outcome, clinico-pathological correlates, and the predictive role of biomarker staining are unknown. MATERIALS AND METHODS: Among 17,551 colposcopy attendees, 478 (2.7%) had SILQ. Glass slides of 472 were reviewed. Positive [high SIL (HSIL), adenocarcinoma in situ (AIS), or carcinoma] and negative [negative for intraepithelial lesion or malignancy (NILM) or low SIL (LSIL)] outcomes were based on the worst pathology in 24 months of follow-up. p16 and Ki67 immunohistochemistry of 80 random SILQ and 149 controls (44 NILM, 15 LSIL, 75 HSIL, and 15 AIS) was scored as unsatisfactory, positive, or negative. Biomarker and outcome status were correlated, and sensitivity, specificity positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: Of the total cases, 332 (1.9%) were reviewed as SILQ, and follow-up for 329 was positive in 134 (41%). Atypical glandular cells, AIS, atypical squamous cells (cannot exclude HSIL), HSIL referral Pap test (70% vs. 47%, p < .001), and HSIL colposcopic impression (33% vs. 19%, p < .001) were more frequent among positive compared with negative outcomes. Best SILQ sensitivity (89%) and NPV (77%) occurred with combined biomarkers, and best specificity (52%) and PPV (58%) occurred with Ki67. All 4 performance metrics among the controls were high. CONCLUSIONS: The 2% frequency and 41% positive outcome highlight the clinical importance of SILQ. The referral Pap test and colposcopic impression could prioritize follow-up colposcopy for some SILQ, and negative staining with both biomarkers could eliminate further colposcopy in others.

Confidence in performing normal vaginal delivery in the obstetrics clerkship: a randomized trial of two simulators.

OBJECTIVE: To compare clerkship medical students' confidence in performing a simulated normal vaginal delivery (NVD) after participating in a simulation training session using two different models. METHODS: Medical students were randomized to participate in a simulated NVD session using either an obstetrics mannequin or a birthing pelvis model. Questionnaires were used to assess confidence and evaluate the simulation before and immediately after the session and on the last day of the obstetrics clerkship rotation. RESULTS: One hundred ten students were randomized. At the start of the clerkship, both groups had similar obstetrics exposure and confidence levels. Only 15 students (13.9%) agreed they were ready to attempt a NVD with minimal supervision or independently. This increased significantly to 43 students (39.4%) immediately after the session. At the end of the clerkship, 79 of 81 responding students (97.5%) were confident that they could attempt a NVD with minimal supervision or independently. There were no significant differences noted between simulator groups at any point. The sessions were rated as equally useful and realistic, and this remained unchanged at the end of the clerkship. CONCLUSION: Simulated NVD training using either an obstetrics mannequin or a birthing pelvis model provides clerkship students with a positive experience and increases confidence immediately. It should be implemented early in the rotation, as it appears the clerkship experience also plays a large role in terms of students' confidence. Despite this, students maintain this type of learning is useful. Effective simulation training can easily be incorporated into clerkship training.

Objectif : Comparer la confiance des étudiants de médecine en stage clinique, pour ce qui est de l'exécution d'une simulation d'accouchement vaginal normal (AVN), à la suite de leur participation à une session de formation en simulation au moyen de deux modèles différents. Méthodes : Des étudiants de médecine ont été affectés, au hasard, à une session de simulation d'AVN faisant appel à un mannequin obstétrical ou à une session de simulation faisant appel à un modèle de bassin simulant l'accouchement. Des questionnaires ont été utilisés pour évaluer la confiance et la simulation avant et immédiatement après la session, ainsi qu'au cours de la dernière journée de la rotation en obstétrique. Résultats : Cent dix étudiants ont été affectés au hasard à l'un ou l'autre des groupes de simulation. Au début du stage clinique, les deux groupes présentaient des niveaux de confiance et d'exposition à la pratique obstétricale semblables. Seulement 15 étudiants (13,9 %) étaient d'avis qu'ils étaient prêts à tenter un AVN de façon indépendante ou sous une supervision minimale. Cette proportion a connu une hausse considérable en passant à 43 étudiants (39,4 %) immédiatement après la session de simulation. À la fin du stage clinique, 79 des 81 étudiants répondants (97,5 %) étaient confiants de pouvoir tenter un AVN de façon indépendante ou sous une supervision minimale. Aucune différence significative n'a été constatée entre les groupes de simulation à quelque moment que ce soit. Les sessions ont été évaluées comme étant tout aussi utiles et réalistes les unes que les autres; cette constatation est demeurée la même à la fin du stage clinique. Conclusion : La formation faisant appel à la simulation d'un AVN au moyen d'un mannequin obstétrical ou d'un modèle de bassin simulant l'accouchement offre aux étudiants en stage clinique une expérience positive et accroît immédiatement leur confiance. Une telle formation devrait être mise en œuvre tôt au cours de la rotation, puisqu'il semble que l'expérience vécue au cours du stage clinique joue également un rôle important pour ce qui est de la confiance des étudiants. Peu importe la chronologie de la simulation, les étudiants soutiennent que ce type d'apprentissage leur est utile. Une formation efficace en simulation peut facilement être intégrée au stage clinique.

Emergency contraception: no. 280 (replaces No. 131, August 2003).

OBJECTIVE: To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting. OPTIONS: The combined estradiol-levonorgestrel (Yuzpe regimen) and the levonorgestrel-only regimen, as well as post-coital use of copper intrauterine devices, are reviewed. OUTCOMES: Efficacy in terms of reduction in risk of pregnancy, safety, and side effects of methods for EC and the effect of the means of access to EC on its appropriate use and the use of consistent contraception. EVIDENCE: Studies published in English between January 1998 and March 2010 were retrieved though searches of Medline and the Cochrane Database, using appropriate key words (emergency contraception, post-coital contraception, emergency contraceptive pills, post-coital copper IUD). Clinical guidelines and position papers developed by health or family planning organizations were also reviewed. VALUES: The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendations for practice were ranked according to this classification (Table 1). BENEFITS, HARMS, AND COSTS: These guidelines are intended to help reduce unintended pregnancies by increasing awareness and appropriate use of EC. SPONSOR: The Society of Obstetricians and Gynecologists of Canada.

Indications for, timing of, and modes of delivery in a national cohort of women admitted with antepartum hemorrhage at 22+0 to 28+6 weeks' gestation.

OBJECTIVE: Antepartum hemorrhage is associated with preterm birth and operative delivery. Since the Canadian Perinatal Network records obstetric interventions for women admitted to tertiary care hospitals with antepartum hemorrhage, our objective was to describe the delivery characteristics of this cohort. METHODS: Trained abstractors collected data by chart review from women admitted with antepartum hemorrhage between 22+0 and 28+6 weeks' gestation. We included all women with complete follow-up postpartum and used descriptive statistics to report the indications for, timing of, and modes of delivery. RESULTS: The study cohort included 806 women from 13 tertiary perinatal centres in six provinces. The most common causes of bleeding were placental abruption (n = 256) and placenta previa (n = 171). The median gestational age at delivery was 30 weeks, and 497 (61.7%) births occurred at less than 34 weeks. Over one half of the women began labour spontaneously, and 238 (29.5%) were delivered prior to the onset of labour. Overall, 370 (45.9%) women delivered vaginally, including 98 who had induction of labour. Of the 436 Caesarean sections (54.1%), 345 (79.1%) were emergencies. The most common indications for Caesarean section were placenta previa, abnormal fetal presentation, and placental abruption or vaginal bleeding. CONCLUSION: This inpatient cohort of women with antepartum hemorrhage had high rates of spontaneous labour, preterm birth, and emergency Caesarean section. These results can be used as current Canadian benchmark rates of preterm delivery, induction of labour, and Caesarean section in women admitted to tertiary care centres with antepartum hemorrhage between 22+0 and 28+6 weeks' gestation, and can aid in the counselling of similar women.

Improving resident competence and knowledge regarding tension-free vaginal tape procedure: an educational module.

OBJECTIVE: The purpose of this study was to determine the effectiveness of a teaching module using simulation for the tension-free vaginal tape (TVT) procedure on procedural knowledge and skill. METHODS: Twenty-five gynecology residents participated in a teaching module about the TVT procedure and urinary incontinence, which included a simulated insertion on a training model. Questionnaires using 10-point scales for self-rated competence and knowledge and a written examination were administered before and after the module. A simulated TVT insertion was evaluated at an examination at 7 weeks and at 7 months. RESULTS: A significant median improvement of 44% on the written examination and at least one point on each of the self-rated competence and knowledge scales were observed after the teaching module. Residents performed the insertion well at both examinations (89% and 90%), regardless of surgical experience. More than 94% agreed the module was useful and improved their understanding of the procedure. CONCLUSION: A short teaching module and simulation session can effectively teach residents and improve their perceived competence with the TVT procedure.

A review of therapeutic abortions and related areas of concern in Canada.

OBJECTIVE: To review the legal status of abortion and its prevalence, safety, and accessibility in Canada and to highlight related areas of concern. METHODS: We conducted a review of research literature, published reports, websites, and articles in order to describe abortion services and associated issues such as access, availability, and safety in Canada. RESULTS: Therapeutic abortion is often the result of unintended pregnancy. Even so, emergency contraception may not be accessible for all Canadian women, and effective contraception is underutilized. In Canada, abortion has been decriminalized and is generally safe, but current reports of prevalence and complication rates are inconsistent. Abortion rates appear to be decreasing. Medical or surgical termination of pregnancy is available and often publicly funded. However, barriers related to time, cost, travel, and regional disparities hamper unrestricted access to therapeutic abortion in this country, and although the place of abortion in medical education remains controversial, current curriculum content appears to be inadequate. CONCLUSIONS: The Society of Obstetricians and Gynaecologists of Canada states that comprehensive family planning services, including therapeutic abortion, should be freely available to all. The Canadian Medical Association affirms that induced abortion should be uniformly available to all women. In Canada, the issues related to therapeutic abortion access, availability, and safety must be addressed.