British Gynaecological Cancer Society recommendations and guidance on patient-initiated follow-up (PIFU).

The National Cancer Survivorship Initiative through the National Health Service (NHS) improvement in the UK started the implementation of stratified pathways of patient-initiated follow-up (PIFU) across various tumor types. Now the initiative is continued through the Living With and Beyond Cancer program by NHS England. Evidence from non-randomized studies and systematic reviews does not demonstrate a survival advantage to the long-established practice of hospital-based follow-up regimens, traditionally over 5 years. Evidence shows that patient needs are inadequately met under the traditional follow-up programs and there is therefore an urgent need to adapt pathways to the needs of patients. The assumption that hospital-based follow-up is able to detect cancer recurrences early and hence improve patient prognosis has not been validated. A recent survey demonstrates that follow-up practice across the UK varies widely, with telephone follow-up clinics, nurse-led clinics and PIFU becoming increasingly common. There are currently no completed randomized controlled trials in PIFU in gynecological malignancies, although there is a drive towards implementing PIFU. PIFU aims to individualize patient care, based on risk of recurrence and holistic needs, and optimizing resources. The British Gynaecological Cancer Society wishes to provide the gynecological oncology community with guidance and a recommendations statement regarding the value, indications, and limitations of PIFU in endometrial, cervical, ovarian, and vulvar cancers in an effort to standardize practice and improve patient care.

Patient satisfaction with robotic surgery.

This study is a service evaluation of the robotic-assisted surgery service within the Gynaecology Oncology department at Sheffield Teaching Hospitals. The aim is not only to evaluate and improve this new service within the department, but also to add to the available literature that reviews patient satisfaction with robotic-assisted surgery. An anonymous questionnaire was developed with questions taken from the NHS User Experience Survey Question Bank and additional questions in the same format specific to robotic-assisted surgery. This was posted to the first 140 patients to have undergone robotic-assisted surgery within Gynae Oncology at STH. One hundred completed questionnaires were returned. Over 90% of patients were pleased with the care that they received pre-operatively and felt that they have enough input into the decisions made about treatment. Half of patients (51%) reported having pain post-procedure, with a quarter of these patients experiencing severe pain. The majority of patients (72%) felt that their length of stay in hospital was of the right duration. Almost all patients (99%) were pleased with the overall care that they received and 91% would recommend robotic-assisted surgery as a modality. Patients are very satisfied with the care that they receive when undergoing robotic-assisted surgery within Gynae Oncology at our center and the majority of patients would recommend robotic-assisted surgery as a modality.

Juvenile granulosa cell tumour of the ovary presenting with hyperprolactinaemic amenorrhoea and galactorrhoea.

UNLABELLED: Secondary amenorrhoea and galactorrhoea represent a common endocrine presentation. We report a case of an oestrogen-producing juvenile granulosa cell tumour (JGCT) of the ovary in a 16-year-old post-pubertal woman with hyperprolactinaemia amenorrhoea and galactorrhoea which resolved following surgical resection of the tumour. This patient presented with a 9-month history of secondary amenorrhoea and a 2-month history of galactorrhoea. Elevated serum prolactin at 7081 mIU/l and suppressed gonadotropins (LH <0.1 U/l; FSH <0.1 U/l) were detected. Serum oestradiol was significantly elevated at 7442 pmol/l with undetectable ß-human chorionic gonadotropin. MRI showed a bulky pituitary with no visible adenoma. MRI of the abdomen showed a 4.8 cm mass arising from the right ovary with no evidence of metastatic disease. Serum inhibin B was elevated at 2735 ng/l. A right salpingo-oophorectomy was performed, and histology confirmed the diagnosis of a JGCT, stage International Federation of Gynaecology and Obstetrics 1A. Immunohistochemical staining for prolactin was negative. Post-operatively, oestrogen and prolactin levels were normalised, and she subsequently had a successful pregnancy. In summary, we present a case of an oestrogen-secreting JGCT with hyperprolactinaemia manifesting clinically with galactorrhoea and secondary amenorrhoea. We postulate that observed hyperprolactinaemia was caused by oestrogenic stimulation of pituitary lactotroph cells, a biochemical state analogous to pregnancy. To the best of our knowledge, this is the first report of hyperprolactinaemia as a result of excessive oestrogen production in the context of a JGCT. LEARNING POINTS: Hyperprolactinaemia with bilateral galactorrhoea and secondary amenorrhoea has a wide differential diagnosis and is not always caused by a prolactin secreting pituitary adenoma.Significantly elevated serum oestradiol levels in the range seen in this case, in the absence of pregnancy, are indicative of an oestrogen-secreting tumour.JGCTs are rare hormonally active ovarian neoplasms mostly secreting steroid hormones.Serum inhibin can be used as a granulosa cell-specific tumour marker.JGCTs have an excellent prognosis in the early stages of the disease.

Laparoscopy versus laparotomy for the management of early stage endometrial cancer.

BACKGROUND: Traditionally, surgery for endometrial cancer (hysterectomy with removal of both fallopian tubes and ovaries) is performed through laparotomy. It has been suggested that the laparoscopic approach is associated with a reduction in operative morbidity. Over the last 10 to 15 years there has been a steady increase of laparoscopy for endometrial cancer. This review investigates the evidence of benefits and harms of laparoscopic surgery compared with laparotomy for presumed early stage endometrial cancer. OBJECTIVES: To compare the overall survival (OS) and disease-free survival (DFS) for laparoscopic surgery versus laparotomy in women with presumed early stage endometrial cancer. SEARCH METHODS: We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2012, MEDLINE, EMBASE and CINAHL up to April 2012. We also searched registers of clinical trials, abstracts of scientific meetings, and reference lists of included studies. Trial registers we searched included NHMRC Clinical Trials Register, UKCCCR Register of Cancer Trials, Meta-Register and Physician Data Query Protocol, as well as abstracts of scientific meetings. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing laparoscopy and laparotomy for early stage endometrial cancer. DATA COLLECTION AND ANALYSIS: We independently abstracted data and assessed risk of bias. Hazard ratios (HRs) were used for OS and recurrence-free survival (RFS), risk ratios (RR) for severe adverse events and the mean difference (MD) method was used for continuous outcomes in women who received laparoscopy or laparotomy and these were then pooled in random-effects meta-analyses. MAIN RESULTS: Eight RCTs comparing laparoscopy with laparotomy for the surgical management of early stage endometrial cancer were identified.All eight trials met the inclusion criteria, 3644 women were assessed at the end of the trials. Three trials assessing 359 participants with early stage endometrial cancer, found no statistically significant difference in the risk of death and disease or recurrence between women who underwent laparoscopy and those who underwent laparotomy (HR = 1.14, 95% confidence interval (CI): 0.62 to 2.10) and HR = 1.13, 95% CI: 0.90 to 1.42 for OS and RFS respectively). There was no statistically significant difference in the rate of peri-operative death, women requiring a blood transfusion, and bladder, ureteric, bowel and vascular injury. However, a meta-analysis of two trials found that women in the laparoscopy group lost significantly less blood than those in the laparotomy group (MD = -106.82 mL, 95% CI: -141.59 to -72.06). A further meta-analysis of two trials, which assessed 2923 women and included one very large trial of over 2500 participants, found that the rate of severe post-operative adverse events was significantly lower in the laparoscopy group compared with the laparotomy group (RR = 0.58, 95% CI: 0.37 to 0.91). The large trial did not give a breakdown of these severe post-operative adverse events into different adverse event categories. Most trials were at moderate risk of bias. Hospital stay was reported in all of the trials and results show that on average, laparoscopy was associated with a significantly shorter hospital stay. AUTHORS' CONCLUSIONS: This review has found evidence to support the role of laparoscopy for the management of early endometrial cancer.For presumed early stage primary endometrioid adenocarcinoma of the endometrium, laparoscopy is associated with similar overall and disease-free survival. Laparoscopy is associated with reduced operative morbidity and hospital stay. There is no significant difference in severe post-operative morbidity between the two modalities.

Ectopic gestational trophoblastic disease: a case series review.

OBJECTIVE: To highlight the clinical presentation, treatment, histological review and outcome of patients referred to the Sheffield Centre with possible ectopic gestational trophoblastic disease (GTD). STUDY DESIGN: A retrospective case note review of patients with possible ectopic GTD referred to the Sheffield Centre between 1997 and 2010 was performed. RESULTS: During the 13 years of this retrospective study 6,708 patients were registered at the Centre with GTD, of whom 42 had possible ectopic GTD. Most patients presented with abdominal pain and/or vaginal bleeding (67%). Ectopic pregnancy was diagnosed by ultrasound scan in 19%. Laparoscopic removal of ectopic pregnancy was carried out in 50% of cases; the rest underwent laparotomy for removal of ectopic conceptus. Histological review of slides was performed in 19 cases for whom there was clinical concern. This resulted in 12 confirmed cases of ectopic GTD: 4 choriocarcinomas, 5 partial moles and 3 complete moles. No evidence of metastasis was recorded in any of the cases. Three patients diagnosed with ectopic choriocarcinoma needed chemotherapy. Two responded to methotrexate and 1 needed second-line chemotherapy. All patients are alive and free of disease. CONCLUSION: Ectopic GTD is rare and still overdiagnosed. Presentation is the same as for conventional ectopic pregnancy. Central review of the histology should be undertaken, especially in cases where there is clinical, hCG level or histopathologic concern. Conventional chemotherapy for gestational trophoblastic neoplasia is effective. Prognosis remains excellent.

Evaluation of follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment.

BACKGROUND: Ovarian cancer is the sixth most common cancer and seventh cause of cancer death in women worldwide. Traditionally, many patients who have been treated for cancer undergo long-term follow up in secondary care. Recently however it has been suggested that the use of routine review may not be effective in improving survival, quality of life (QoL), and relieving anxiety. In addition, it may not be cost effective. OBJECTIVES: To compare the potential benefits of different strategies of follow up in women with epithelial ovarian cancer following completion of primary treatment. SEARCH STRATEGY: We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, Issue 4), MEDLINE and EMBASE (to November 2010). We also searched CINAHL, PsycLIT, registers of clinical trials, abstracts of scientific meetings, reference lists of review articles, and contacted experts in the field. SELECTION CRITERIA: All relevant randomised controlled trials (RCTs) that evaluated follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment. DATA COLLECTION AND ANALYSIS: Two review authors independently abstracted data and assessed risk of bias. MAIN RESULTS: We found only one RCT (Rustin 2010) that met our inclusion criteria. This trial included 529 women and reported data on immediate treatment versus delayed treatment in women with confirmation of remission and with normal CA125 concentration and no radiological evidence of disease after surgery and first-line chemotherapy.Overall survival showed no significant difference between the immediate and delayed arms after a median follow up of 56.9 months (unadjusted hazard ratio (HR) = 0·98, 95% confidence interval (CI) 0·80 to 1·20; P = 0·85). Time from randomisation to first deterioration in global health score or death was significantly shorter in the early group compared with the delayed group (HR 0·71, 95% CI 0·58 to 0·88; P < 0·01). The trial was at low risk of bias. AUTHORS' CONCLUSIONS: There is a lack of randomised studies on most aspects of follow-up care after treatment for epithelial ovarian cancers. Limited evidence from a single trial suggests that routine surveillance with CA125 in asymptomatic patients, with treatment at CA125 relapse, does not seem to offer survival advantage when compared to treatment at symptomatic relapse. Randomised controlled trials are needed to compare different types of follow up on the outcomes of survival, quality of Life, cost and psychological effects.

Interventions for psychosexual dysfunction in women treated for gynaecological malignancy.

BACKGROUND: Psychosexual dysfunction (sexual difficulties not directly due to physical factors) is known to be a common complication of treatment for gynaecological cancer. It has a considerable impact on quality of life (QoL) for the increasing number of women who are survivors of gynaecological cancer. OBJECTIVES: To determine the effectiveness of interventions for psychosexual dysfunction in women who have been treated for gynaecological malignancy (cancer of uterine cervix, uterine corpus, ovary, vulva). SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, up to October 2008), MEDLINE (1950 to October 2008), EMBASE (1982 to October 2008), CINAHL (1980 to October 2008) and PsycINFO (1806 to October 2008). We hand searched reference lists from eligible trials. SELECTION CRITERIA: We selected all randomized controlled trials (RCTs) of a medical or psychological intervention to prevent or treat psychosexual dysfunction in adult women previously treated for gynaecological cancer. DATA COLLECTION AND ANALYSIS: We selected five studies for inclusion in this review and analysed any outcome data relating to resumption of sexual intercourse, DSM-IV diagnoses or validated scales of sexual functioning. Sensitivity analysis was performed where possible. MAIN RESULTS: The review included data from 5 studies, comprising a total of 413 patients, examining 5 different interventions. One trial suggested a short-term benefit for the use of vaginal Dienoestrol in women after pelvic radiotherapy (NNT = 4). Another trial suggested a short-term benefit for one regime of low dose-rate brachytherapy over another but this modality is not in widespread use. Studies of a Clinical Nurse Specialist intervention, Psychoeducational Group Therapy and a Couple-Coping intervention, did not show any significant benefit. All the studies were of poor methodological quality. AUTHORS' CONCLUSIONS: There is no convincing evidence to support the use of any interventions for psychosexual dysfunction in women treated for gynaecological cancer. There is a need for more studies of high methodological quality.

Providing a quality service: direct referral from the cytology laboratory to the colposcopy clinic.

OBJECTIVES: To compare the time taken for the referral process and the accuracy of referrals before and after a process review and the introduction of a system of direct referral from the cytology laboratory to the colposcopy clinic. SETTING: The colposcopy service in a large teaching hospital in Teesside. METHODS: Data on time points within the referral process and smear histories were collected. Data on time points were obtained retrospectively from the case-notes from before the new system of referral ('pre' group) and from an electronic database after the changes ('post' group). Smear histories were retrieved from the cytology database. RESULTS: The overall time that patients waited from the time the smear was taken until the time they were seen in the colposcopy clinic was significantly reduced. The median time between smear and colposcopy decreased from 92.5 days (range 35-254 days) in the 'pre' group to 33 days (range 13-43 days) in the 'post' group (P=0.0001). The median time taken from the smear report being issued until the report arrived in the colposcopy clinic was 14 days (range 4-123 days) in the 'pre' group, compared with two days (range 0-17 days) in the 'post' group (P=0.0001). There was a significant reduction in the number of inaccurate referrals in the 'post' group compared with the 'pre' group (P=0.02). CONCLUSIONS: Direct referral significantly reduces the time patients wait for colposcopy appointments and improves the accuracy of referrals.