Lymphadenectomy for high-grade endometrial cancer: Does it impact lymph node recurrence?

INTRODUCTION: The diagnostic role of lymph node (LN) assessment is established in endometrial cancer. Our study assesses whether surgical removal of metastatic LNs has oncologic benefit in high-grade endometrial cancer. MATERIALS AND METHODS: High-grade endometrial cancer cases (2000-2010) were collected from two tertiary cancer centres. In patients with at least one positive LN, recurrence free survival (RFS) was compared by the number of LNs removed. Factors predicting nodal recurrence (NR) were explored. Univariate statistical analyses by log rank test and multivariable cox proportional hazards model were performed using SAS version 9.4. RESULTS: Of 570 patients identified, 334 patients underwent staging lymphadenectomy, 74 (22.2%) patients had at least one positive LN. The median RFS with at least one positive lymph node was 87.1 months (95% CI ≥ 14.3) when greater than 15 LNs were removed, compared to 16.9 months (95% CI, 13.6-35.6) and 17.3 months (95% CI, 8.5-39.8) when 5-15 and less than 5 LNs were removed, respectively (p = 0.02). In the cohort of 570 patients, there were 167 disease recurrences with location described on imaging, 98 (58.7%) had a NR and 69 (41.3%) recurred at other sites. Multivariable modeling identified that only positive LNs at surgical staging predicted NR (HR 3.8, 95% CI 1.4-10.2). CONCLUSION: In high-grade endometrial cancer, positive LNs predict NR, and RFS is longer with a more extensive LN dissection in women with positive LNs. Future prospective studies should evaluate the oncologic benefit of surgical removal of metastatic LNs in high-grade endometrial cancer.

Polypoid or non-polypoid? A novel dichotomous approach to uterine carcinosarcoma.

OBJECTIVE: To examine the impact of the polypoid morphology of uterine carcinosarcoma on clinical outcome, as well as its relationship to well-established prognostic factors. METHODS: In a retrospective study of fifty eight patients with uterine carcinosarcoma treated with hysterectomy, we correlated the polypoid status of tumors with stage, lymphatic vascular invasion, myometrial invasion, size, carcinoma to sarcoma ratio, type of carcinomatous and sarcomatous components, disease free survival and overall survival. RESULTS: By multivariate analysis, the polypoid status had no impact on disease free survival (p=0.8958), but approached significance as a positive predictor for overall survival (p=0.0569); patients in the polypoid group lived on average 14.9 months longer than those with non-polypoid tumors. Polypoid neoplasms had a smaller average size and grew to a smaller maximum size than the non-polypoid tumors. While non-polypoid tumors were either carcinoma or sarcoma predominant, polypoid tumors were mostly sarcoma predominant (p=0.0348). Polypoid carcinosarcomas also demonstrated an appreciably lesser extent of myometrial invasion (p=0.0019), a markedly lower rate of lymphatic vascular invasion (p=0.0002), and tended to present as early stage tumors (p=0.0265). Carcinomatous component in polypoid tumors tended to have pure or nearly pure (>or=90%) endometrioid histology (p=0.1608). There was no relationship between polypoid status and type of sarcomatous component (p=0.5299). CONCLUSIONS: Polypoid carcinosarcomas differ from their non-polypoid counterparts in key histological parameters such as the carcinoma to sarcoma ratio, myometrial and lymphatic vascular invasion, stage and type of carcinomatous component. Patients with polypoid tumors may have a better survival outcome than those with non-polypoid tumors.

Lymph node assessment in cervical cancer: prognostic and therapeutic implications.

Lymph node status is not part of the staging system for cervical cancer, but provides important information for prognosis and treatment. This article reviews the incidence and patterns of lymph node metastasis, and the issues surrounding surgical assessment of lymph nodes. The preoperative assessment of lymph nodes by imaging, as well as the intraoperative assessment by sentinel nodes will be discussed. Finally, the prognostic and therapeutic implications of lymphadenectomy in cervical cancer will be reviewed.

Adjuvant hormonal therapy for stage I endometrial cancer.

QUESTION: What is the role of hormonal therapy as adjuvant therapy in patients with stage i endometrial cancer? PERSPECTIVES: There is little consensus on the role of adjuvant treatment for patients with stage i endometrial cancer. Although the use of hormonal therapy has been established in advanced disease, less agreement has emerged concerning the benefits of adjuvant hormonal therapy for patients with early-stage disease. The objective of the present evidence series was to review the existing literature on the role of hormonal therapy as adjuvant therapy in patients with stage i endometrial cancer. OUTCOMES: REPORTS WERE SOUGHT THAT INCLUDED AT LEAST ONE OF THE FOLLOWING OUTCOMES: overall survival, disease-free survival, recurrence (local, or distant, or both), adverse effects, and quality of life. Because of the potential for long-term adverse effects with adjuvant hormonal treatment in this patient population, especially with regard to thromboembolic or cardiovascular events, the rates of non-cancer-related death were also of interest. METHODOLOGY: The medline, embase, and Cochrane Library databases were systematically searched for randomized controlled trials, practice guidelines, systematic reviews, and meta-analyses. The resulting evidence informed the development of the clinical practice guideline. The systematic review with meta-analyses and practice guideline were approved by the Report Approval Panel of the Program in Evidence-Based Care, and by the Gynecology Cancer Disease Site Group (DSG). RESULTS: Nine randomized trials and one published meta-analysis comparing adjuvant hormonal therapy with no adjuvant therapy in women with stage i endometrial cancer constituted the evidence base. One trial reported a statistically significant survival benefit with adjuvant progestogen as compared with no further treatment (97% vs. 69%, p < 0.001). In that trial, the treatment group had a higher number of patients with less myometrial invasion, and a lower number of patients with advanced-stage disease. These differences in baseline characteristics between the randomized groups were considered to be clinically important. In addition, the results of that trial were not consistent with those of other trials, and the trial was a source of statistical heterogeneity when data were pooled across trials. In two of the nine randomized trials, statistically significant recurrence-free benefits were detected with adjuvant hormonal therapy as compared with no further therapy. In one trial, the difference between the rates of recurrence was 16%; however, the methodologic concerns related to that that trial limited its relevance. In the other trial, the difference between the rates of recurrence was 5%. In that trial, patients were at a high risk of recurrence. None of the remaining seven randomized trials reported any significant difference in recurrence rates between treatment groups. The meta-analysis identified in the literature detected no statistically significant recurrence-free or overall survival benefit associated with adjuvant hormonal therapy as compared with no adjuvant therapy [odds ratio (or): 1.05; 95% confidence interval (ci): 0.88 to 1.24). Those results are consistent with the results of the meta-analysis in the present report, which included an additional two trials (or: 1.10; 95% ci: 0.91 to 1.34). TARGET POPULATION: This clinical recommendation applies to women with newly diagnosed stage i endometrial cancer. RECOMMENDATION: The available evidence does not demonstrate any benefit for adjuvant hormonal therapy. The use of hormonal therapy is not recommended as adjuvant treatment for patients with stage i endometrial cancer.

Land and sea connection: the east coast fishery closure, unemployment and health.

The closure of the east coast fishery in Canada in 1992 has affected the lives of individuals and communities both directly and indirectly, causing massive unemployment. Previous research indicates that unemployment negatively affects people's health and other aspects of family functioning. This study assesses the perceived effects of unemployment on the individuals' health, and compares the psychological well-being of the employed and that of the unemployed individuals in the same communities affected by the cod moratorium. The sample consisted of 681 individuals, 16 years of age and older from randomly selected households. They were individually interviewed using structured questionnaires. The GHQ-28 with a high test-retest coefficient (0.90) and split-half reliability (0.92) was used to measure the psychological well-being. The unemployed reported more stress, boredom, high level of uncertainty, less satisfaction with themselves, their life, their educational level, income and health. Implications for health promotion, policy formulation and future research are put forward.

An evaluation of the expression, subcellular localization, and function of rab4 in the exocrine pancreas.

The small GTP-binding protein, rab4, is involved in recycling of transferrin receptors and translocation of GLUT4. Recent studies suggest that rab4 controls regulated exocytosis in the exocrine pancreas. We conducted the present study to further investigate the role of rab4 in the exocrine pancreas. We found that the exocrine pancreas expresses two rab4 immunoanalogs, one of approximately 28 kDa identified previously in neonatal glands, and one of approximately 24 kDa which is similar to rab4 characterized in other systems. The latter species was mostly membrane-anchored and localized to endosome-like structures in a supranuclear region that was immunopositive for the transferrin receptor. The approximately 24-kDa rab4 form also localized to the apical plasmamembrane, and this immunofluorescence increased greatly in tissue challenged with a secretagogue. We propose that the approximately 24-kDa rab4 species is involved in compensatory membrane retrieval following regulated exocytosis, and that rab4-positive endocytic vesicles move through a supranuclear recycling compartment.

Adapting the CAUSN accreditation process for emerging models of nursing education in Canada.

This paper highlights the accreditation issues raised by new and emerging models of baccalaureate nursing education and program delivery in Canada. It suggests ways of adapting the accreditation process to address recent changes. Nursing degree programs now offered by universities include programs at several sites, collaborative programs with partner institutions at multiple sites, and programs offered primarily through distance education. The accreditation program developed by the Canadian Association of University Schools of Nursing (CAUSN) provides a mechanism for monitoring the quality of a nursing education program and promoting the growth of the school that offers the program. Since the decision to undergo accreditation signifies a major commitment on the part of a nursing program, it is essential that the accreditation process be adaptable to meet the needs of evolving nursing education and program delivery models, and that it be fair, equitable, and credible.

Chinese elders speak out: implications for caregivers.

The purpose of the study was to describe the experience of some Chinese elders who are living with, and dependent on, their adult children. A second purpose was to explore the potential physical and mental health outcomes associated with being dependent on their adult children for psychological, financial, social, and, in some cases, physical care and support. The sample consisted of 10 first-generation Chinese elderly. Taped interviews were carried out with the assistance of an interpreter using semistructured and open-ended questions developed by the researcher. The data analysis used the constant comparative method, and four major themes emerged: loneliness and isolation, reduced resources with which to reciprocate in the care-receiving relationship, an expressed need for meaningful relationships and roles within the family, and the desire for greater independence. Implications for providing culturally sensitive care are discussed, as well as implications for client education and further research.

The impact of HIV-positive diagnosis on the individual, Part 1: Stigma, rejection, and loneliness.

The growing incidence of HIV infection and AIDS has generated panic, fear, anxiety, and negative attitudes among the general public. As an illness, HIV infection and AIDS have become the new sources of stigma. This article explores the stigma, rejection, and loneliness of 25 individuals with known HIV-infection/AIDS, who were interviewed using a set of open-ended questions. The results indicated that the HIV-positive diagnosis had a profound impact on the individual's psychosocial aspects of life, particularly interactions with others. Most of those infected by the virus were lonely, had to cope with stigmatization, and suffered disruption of family and peer relationships. They were confronted with prolonged uncertainty about their lives and experienced intense, constant fear of disclosure of their illness and of being rejected by society, yet they were not always able to discuss these fears and anxieties openly with friends or family.