Routine ureteric stenting before cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy in managing peritoneal carcinomatosis from gynecologic malignancies: a single-center experience.

BACKGROUND: Iatrogenic ureteric injury is a rare, yet serious operative complication in gynecologic procedures and associated with substantial morbidities such as prolonged hospitalization, additional financial-based ureter-related repairing procedures, impaired renal function, and compromised quality of life. Direct visual identification of ureters can be very challenging in managing patients with primary advanced or recurrent disseminated intraperitoneal gynecologic malignancies, who are referred to complex procedures such as cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). AIMS: To report our single-center experience (feasibility and morbidity) with prophylactic ureteric stents as a routine practice before CRS+HIPEC procedure in managing peritoneal carcinomatosis (PC) from gynecologic malignancies. METHODS: From June-2010 to March-2014, all patients with gynecologic-related PC, managed with CRS+HIPEC, and underwent prophylactic ureteric stents. The data were retrospectively abstracted and analyzed. RESULTS: Fifty-three patients were identified. Almost all PC cases were secondary/recurrence presentations (90.6 %) and originated from ovarian cancer (84.9 %). Optimal cytoreduction microscopic residual disease) was achieved in 35 patients (60 %). Average insertion time of ureteric stents was 8.9 ± 3.3 min. Fifty-two patients (98.1 %) received bilateral ureteric stents. Forty-nine patients (92.5 %) had their ureteric stents removed by the end of procedure. No patient experienced major peri-operative urinary tract-related complications. CONCLUSIONS: Prophylactic ureteric stents appeared to be feasible, potentially safe, and could reduce the risk of iatrogenic ureteric injuries without incurring an increase in urinary tract-related complications. Prophylactic ureteric stenting does not eliminate the necessity for competent anatomical knowledge, meticulous retroperitoneal dissection and direct intra-operative visualization of ureters.

Clinical practice guidelines on the screening and treatment of precancerous lesions for cervical cancer prevention in Saudi Arabia

BACKGROUND: Cervical cancer is the third most common gynecological malignancy in Saudi women with an estimated incidence rate of 1.9 cases per 100 000 women-years. More than 40% of cervical cancer cases are diagnosed at advanced stages due to lack of a routine screening program in Saudi Arabia. Thus, national guidelines for routine screening and treatment of precancerous cervical lesions are needed. METHODS: The Saudi Centre for Evidence-Based Healthcare invited a panel of local experts and partnered them with a team from McMaster University in Canada for methodological support, to develop national clinical practice guidelines on the screening and treatment of precancerous lesions for cervical cancer. After the panel identified key clinical questions, the McMaster University working group updated existing systematic reviews that had been used for the 2013 WHO Guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. Recommendations were based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. Those recommendations took into account the available evidence, patient values and preferences, and resource use in the Saudi context. The panel provided recommendations on two major issues: screening for precancerous lesions (cervical intraepithelial neoplasia 2 & 3) and treatment of those lesions to prevent cervical cancer in women who tested positive after screening. CONCLUSIONS: The Saudi expert panel recommends using the HPV DNA test followed by colposcopy or cytology (Pap test) followed by colposcopy to screen for CIN2+ in women at risk of cervical cancer. The panel recommends cryotherapy or loop excision electrosurgery procedure (LEEP) over cold knife cone biopsy to treat women at risk of cervical cancer that tests positive for CIN2+. Universal screening for precancerous cervical dysplasia in women in Saudi Arabia is recommended using HPV testing and or cytology. Either cryotherapy or LEEP are preferred for treatment. CONCLUSIONS: National studies on cervical cancer screening modalities and treatment of precancerous cervical lesions, including HPV prevalence and its association with cervical cancer, are scarce.

Sociodemographic characteristics and sexual behavior as risk factors for human papillomavirus infection in Saudi Arabia.

OBJECTIVES: To determine the prevalence and the sociodemographic characteristics and sexual behavior risk factors for human papillomavirus (HPV) infection in a hospital-based cohort of women in Saudi Arabia. METHODS: Cervical specimens and questionnaire data were collected from women attending clinics in Riyadh, Saudi Arabia. Cervical specimens were examined for abnormal cytology using a standard Pap test and for the presence of HPV-DNA using PCR and reverse line blot hybridization tests. RESULTS: Approximately 73% of the 400 women tested were Saudi nationals. Nearly 50% were under 40 years old (range 22-80 years, mean±standard deviation 41.20±10.43 years). Approximately 17% of the women were HPV-positive. The most commonly detected HPV types were HPV-18 (34%) and HPV-16 (19%), with multiple infections detected in 10% of positive specimens. Multivariate analyses revealed that smoking and multiple partners were significant risk factors for HPV infection (p<0.01). CONCLUSIONS: Because of societal challenges and an unsubstantiated assumption of low HPV prevalence, few studies have examined sociodemographic characteristics or sexual behaviors associated with HPV in Saudi women. However, a high prevalence of HPV infection was found, with smoking and multiple partners as significant risk factors, in this hospital-based cohort of predominantly Saudi women.

Radiotherapy dose escalation with concurrent chemotherapy in locally advanced cervix cancer is feasible.

BACKGROUND: To test the feasibility of radiotherapy dose escalation using volumetric arc therapy (VMAT) and image-guided radiotherapy (IGRT) with concurrent chemotherapy in locally advanced cervix cancer (LACC) and compare this with whole-pelvis three-dimensional conformal radiation therapy (CRT) in terms of clinical toxicity. METHODS: Database was reviewed for all LACC patients treated during 2011 and 2012. Twenty patients who were treated with escalated dose of radiotherapy using VMAT were selected for analysis. A matched cohort of 40 patients who had 3DCRT between 2005 and 2008 was selected as control. Mean basal hemoglobin, average weekly hemoglobin, and maximal drop in hemoglobin were measured for both 3DCRT and VMAT groups and treatment toxicity scored according to RTOG criteria. Charts were also reviewed for other acute and late toxicities including the rate of compliance with prescribed treatment. RESULTS: Mean age was 46 (30-63) and 47 years (33-67), mean tumor size was 5.5 and 5 cm and blood transfusion rate was 55 and 45 % in CRT and VMAT groups, respectively. Hemoglobin toxicity (Grade I-II) was encountered in 97.5 and 90 % (p 0.0.3) while Grade I-III Leukopenia was 90 and 70 % (p 0.02), respectively. There was no Grade 3 or 4 GI or GU toxicity. CONCLUSION: VMAT/IGRT with dose escalation is feasible in LACC without excessive toxicity as compared to CRT "Box". We propose a randomized control trial of this novel approach of higher radiation dose and volume against the standard prescription based on CRT.

Gestational trophoblastic neoplasia: treatment outcomes from a single institutional experience.

PURPOSE: To report the outcomes of gestational trophoblastic neoplasia (GTN) at a single institution and to determine the factors affecting response to chemotherapy and survival. METHODS/PATIENTS: From 1979-2010, we retrospectively reviewed the data of 221 patients treated at our center. GTN Patients were assigned to low-risk (score ≤6) or high-risk (score ≥7) based on the WHO risk factor scoring system. Overall survival (OS) probabilities were estimated using Kaplan-Meier method. Logistic regression was applied to study the impact of different factors on the response to initial therapy. RESULTS: Patients' OS rate was 97 %. Median age at diagnosis was 37 year. 131 (59 %) patients had low-risk and 88 (40 %) cases had high-risk GTN. Complete remission rates to initial chemotherapy in low-risk group were 53 % and 87 % for single-agent methotrexate or dactinomycin, respectively. In high-risk group, 94 % achieved complete remission to initial chemotherapy with etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine (EMA-CO). Etoposide, cisplatin, and dactinomycin as primary therapy in high-risk patients was successful in 70 %, while bleomycin, etoposide, and cisplatin (BEP) was successful in 53 % of cases. Salvage chemotherapy, surgical intervention or radiation therapy resulted in overall complete remission of 90 % in low-risk and 73 % in high-risk groups. Factors associated with resistance to initial chemotherapy were advanced-stage III/IV (p = 0.005), metastatic site other than lung or vagina (p = 0.005) and high-risk prognostic score (p = 0.05). OS was significantly influenced by the type of antecedent pregnancy (molar 98 % vs. others 93 %; p = 0.04), FIGO stage (I, II 100 % vs. III, IV 94 %; p = 0.02), score (low-risk 100 % vs. high-risk 92 %; p = 0.01), and site of metastasis (lung/vagina 98 % vs. others 85 %; p = 0.002). CONCLUSIONS: GTNs have excellent prognosis if properly treated at experienced centers. Single-agent dactinomycin seems more effective for low-risk GTN. EMA-CO remains the preferred primary treatment regimen for high-risk group. The excellent outcome reflects the success of salvage therapy.

Postoperative chemotherapy in advanced ovarian granulosa cell tumors.

The objective of this research is to assess the use of first-line postoperative chemotherapy in patients with advanced ovarian granulosa cell tumor (GCT). A retrospective population-based case series identified 60 women with stage IC or greater ovarian GCT over a 25-year period. Five patients were excluded because of incomplete information. None of the patients had received chemotherapy or radiotherapy prior to the diagnosis of advanced GCT. All patients had, at a minimum, a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Pathology was centrally reviewed and the diagnosis confirmed. Of the 55 eligible patients, the 21 women with stage III and IV disease were the main focus of the study. Clinical outcomes and survival were compared between 13 women who received combination chemotherapy and eight who did not. Univariate analysis was conducted to assess the impact of age at diagnosis, size of residual disease, and adjuvant use of radiation therapy on prognosis. For the 55 patients, median age at diagnosis was 54 years (range 22-79). Median length of follow-up was 4.4 years (range 0.3-23.3). Median time to progression was 2.3 years (range 0.3-5.3). Sixty percent of those with no macroscopic disease after primary surgery recurred within 4.5 years of diagnosis. All patients with gross residual disease (>2 cm) were dead within 4 years of diagnosis. Overall 5 years survival rate was 61.6% (95% CI (49.3-76.9)). Among stage III and IV patients, there were no differences with respect to age at diagnosis and use of radiation therapy between those who did and did not receive chemotherapy. The only statistically significant difference was the presence of macroscopic residual disease (82% vs. 22%). Although there was no statistical significant difference in overall survival, there was a trend toward a poorer outcome in the group that received chemotherapy. Survival of patients with macroscopic residual disease was not influenced by use of chemotherapy (P = 0.976). We conclude that the presence of macroscopic residual disease after primary surgery was the most important prognostic factor. Although these patients were more likely to receive postoperative chemotherapy, there was no evidence to document a beneficial effect of systemic therapy in this group of women.

Diagnostic laparoscopy in infertile women with normal hysterosalpingograms.

OBJECTIVE: To assess the value of laparoscopy in infertile women with normal hysterosalpingograms, with and without risk factors suggesting pelvic disease. STUDY DESIGN: We retrospectively reviewed 1,022 consecutive charts from a tertiary infertility practice. In 265 women, laparoscopies were performed after normal hysterosalpingograms. RESULTS: Laparoscopies were normal in 136 (51%) women, whereas 129 (49%) had one or more abnormal laparoscopic findings, including minimal or mild endometriosis (n = 85), moderate or severe endometriosis (n = 11), adnexal adhesions (n = 27), subserosal myomas (n = 17), ovarian neoplasms (n = 5), distal phimosis (n = 1) and salpingitis isthmica nodosa (n = 1). Only 7% of cases had findings that might require standard operative laparoscopy or laparotomy, although not all were causally related to infertility. A history of dysmenorrhea or dyspareunia increased the likelihood of detecting endometriosis from 41% to 64% and 69%, respectively. The presence of both symptoms increased the likelihood to 83%. CONCLUSION: In the presence of a normal hysterosalpingogram, laparoscopy identified other pelvic disease in about half of patients. Because most abnormalities were mild, this knowledge can be used to plan a micro-laparoscopic approach for many women, reserving traditional or operative laparoscopy for women with an abnormal hysterosalpingogram or extensive disease following micro-laparoscopy. Alternately, knowledge of the nature and severity of the expected laparoscopic findings might lead to bypassing laparoscopy in favor of assisted reproduction when the perceived benefit of surgical intervention is small.