Consideration for safe and effective gynaecological laparoscopy in the obese patient.

BACKGROUND: The number of obese and morbidly obese patients within the developed world is dramatically increasing within the last 20 years. Apart from demographical changes, obese patients are especially prone to have oestrogen-dependent morbidities and neoplasias, of which laparoscopic treatment should be the standard of care. The increasing number of patients with BMI >40 is concerning, making it necessary to summarise considerations for safe and effective Gynaecological Laparoscopic Surgery. CONSIDERATIONS: The sequel to successful laparoscopic surgery in obese patients comprises an interdisciplinary appreciation of laparoscopy. Preoperatively, anaesthetics and medical review are suggested to optimise treatment of comorbidities (i.e. infections and blood sugar levels). Positioning of the patient should consider anti-slip options and pannus fixation to ease laparoscopic access and decrease pressure to the chest. There is no standard port placement in obese patients and landmarks have to be the bony structures of the pelvis and ribs. Retraction of the bowel is essential and mobilisation of the sigmoid with fan retractors or endoloops can accomplish adequate vision. 30° scopes can be considered for vision "around the obstacle". An experienced assistant with anticipation of surgical steps is favourable for successful surgery completion. Intra-operatively, good surgical techniques are essential. Vessel sealing systems reduce the need for instrument changes and may be helpful in following visualised tissue planes. A transvaginal vault closure may be advantageous compared to laparoscopic closure and Endostiches may be preferred to close the fascia of large trocar sites under vision.

Feasibility RCT of definitive chemoradiotherapy or chemotherapy and surgery for oesophageal squamous cell cancer.

BACKGROUND: The optimal treatment for localised oesophageal squamous cell carcinoma (SCC) is uncertain. We assessed the feasibility of an RCT comparing neoadjuvant treatment and surgery with definitive chemoradiotherapy. METHODS: A feasibility RCT in three centres examined incident patients and reasons for ineligibility using multi-disciplinary team meeting records. Eligible patients were offered participation in the RCT with integrated qualitative research involving audio-recorded recruitment appointments and interviews with patients to inform recruitment training for staff. RESULTS: Of 375 patients with oesophageal SCC, 42 (11.2%) were eligible. Reasons for eligibility varied between centres, with significantly differing proportions of patients excluded because of total tumour length (P=0.002). Analyses of audio-recordings and patient interviews showed that recruiters had challenges articulating the trial design in simple terms, balancing treatment arms and explaining the need for randomisation. Before analyses of the qualitative data and recruiter training no patients were randomised. Following training in one centre 5 of 16 eligible patients were randomised. CONCLUSIONS: An RCT of surgical vs non-surgical treatment for SCC of the oesophagus is not feasible in the UK alone because of the low number of incident eligible patients. A trial comparing diverse treatment approaches may be possible with investment to support the recruitment process.

Production of Ascochyta rabiei lacking solanapyrone A toxin production.

Ascochyta rabiei, agent of Ascochyta blight of chickpea produces three toxins, Solanapyrones A, B and C of which solanapyrone A is the most toxic. All isolates of the fungus so far examined produce at least one of the Solanapyrone toxins, usually Solanapyrone A. The universality of solanapyrone production argues strongly for the importance of the toxins in virulence or pathogenicity. However, further evidence for this awaits the development of mutants lacking toxin production. Generation and isolation of fungal mutants defective in pathogenicity has been very useful for understanding the genetic and enzymatic processes responsible for infectivity in a number of pathosystems. Numerous tools have been used to transform plants and micro-organisms but the most widely micro-organism employed is Agrobacterium tumefaciens. In the present experiments, two strains of A. tumefaciens, AGL1 and LBA1126, harbouring two different plasmids, both encoding a gene for hygromycin resistance in the T-DNA region were used to transform isolate Tk21 of A. rabiei. The transformation of Ascochyta rabiei, gave rise to 498 colonies which grew on media supplemented with the selective agent; hygromycin B. The 30 sporulated transformants produced solanapyrone A on the specific medium at different rates. Solanapyrone A production, as demonstrated by the absorption of light at 327 nm, varied from 2.11 microg/ml to 4.32 microg/ml, representing a reduction of 74.11% to 46.99% in comparison with the wild type (8.15 microg/ml).

Antifungal activity of rhizospheric bacteria.

Fluorescent Pseudomonad spp. were isolated from the rhizosphere of potato plants (Algeria) by serial dilutions of rhizosphere soils on Kings B medium and were tested for their antifungal activity. The antifungal activity of the Pseudomonas isolated from Potatoes rhizosphere was tested against Pythium ultimum, Rhizoctonia solani and Fusarium oxysporum in dual culture with bacteria on PDA. The Petri dish was divided into tow, on one the bacteria was spread and on the opposite side fungal plugs were inoculated and incubated for one week. Fourteen bacteria were isolated; only one isolate inhibited the growth of Pythium ultimum, Rhizoctonia solani, Fusarium solani; Fusarium oxysporum f.sp. albedinis and Fusarium oxysporum f. sp. Lycopersici with inhibition zones of 39.9, 33.7, 30.8, 19.9 and 22.5 mm respectively.

The effect of essential oil of Ammoides pusilla (brot.) breistr on the growth and the production of solanapyrone a by Ascochyta rabiei.

Biological control such as the use of plant extracts has emerged as promising option to the phenomena of fungi resistance to chemical. Several constituent of essential oil have been studied for their biological activity including antibacterial and antifungal activity. In this study the effect of Ammoides pusilla essential oil with different concentrations was test against the growth of Ascochyta rabiei and the production of solanapyrone A by the fungus. After 14 days the mycelium was collected and the dry weight measured. A. rabiei did not grow at a final concentration of 6 and 3 mg/ml, at 1.5 mg/ml and 0.625ml there was little growth of the fungus with a dry weight of 55 mg and 99 mg respectively compared to the control with 519 mg dry weight, but there was no solanapyrone A produced. However a new compound appeared at the HPLC at 10 min. 30 sec. compared with the solanapyrone A which elutes at nearly 14 minutes.

Gastrointestinal cancer: developing an information booklet for patients.

AIM: To ascertain from patients and their relatives the advice they would like to receive on dealing with the post-operative symptoms associated with oesophagectomy and gastrectomy. The findings would be used by the Oesophageal Patients Association to update its information booklet. METHOD: A literature review was undertaken to investigate what information is available. Qualitative methodology using focus groups with patients and healthcare professionals informed the study. The focus group proceedings were tape recorded and transcribed. Inductive thematic analysis was used, with words being grouped into categories to explore recurrent themes and overlapping concepts. Themes were labelled and the transcripts re-explored for items relevant to each theme. FINDINGS: The literature search produced 604 articles. Many were irrelevant to upper gastrointestinal (GI) cancer but useful information was obtained from others, leading to a first draft of the updated booklet. The focus groups' data were crucial in developing the booklet. CONCLUSION: The updated booklet will assist patients who have had surgery for upper GI cancer to manage their nutrition.

Analysis of clinical decision-making in multi-disciplinary cancer teams.

Management decisions for patients with cancer are frequently taken within the context of a multi-disciplinary team (MDT). There is little known, however, about decision-making at team meetings and whether MDT decisions are all implemented. This study evaluated team decision-making in upper gastrointestinal cancer. Consecutive MDT treatment decisions were recorded for patients with oesophageal, gastric, pancreatic and peri-ampullary tumours. Implementation of MDT decisions was investigated by examining hospital records. Where decisions were implemented it was recorded as concordant and discordant if the decision changed. Reasons for changes in MDT decisions were identified. 273 decisions were studied and 41 (15.1%) were discordant (not implemented), (95% confidence interval 11.1-20.0%). Looking at the reasons for discordance, 18 (43.9%) were due to co-morbid health issues, 14 (34.2%) related to patient choice and 8 (19.5%) decisions changed when more clinical information was available. For one discordant decision, the reason was not apparent. Discordant decisions were more frequent for patients with pancreatic or gastric carcinoma as compared to oesophageal cancer (P = 0.001). Results show that monitoring concordance between MDT decisions and final treatment implementation is useful to inform team decision-making. For upper gastrointestinal cancer, MDTs require more information about co morbid disease and patient choice to truly optimize the implementation of multi-disciplinary expertise.

Association between quality of life scores and short-term outcome after surgery for cancer of the oesophagus or gastric cardia.

BACKGROUND: Evidence suggests that baseline quality of life (QOL) scores are independently prognostic for survival in patients with cancer, but the role of QOL data in predicting short-term outcome after surgery is uncertain. This study assessed the association between QOL scores and short-term outcomes after surgery for oesophageal and gastric cancer. METHODS: Consecutive patients selected for oesophagectomy or total gastrectomy between November 2000 and May 2003 completed the European Organization for Research and Treatment of Cancer's quality of life questionnaire, QLQ-C30. Multivariable regression models, adjusting for known clinical risk factors, were used to investigate relationships between QOL scores, major morbidity, hospital stay and survival status at 6 months. RESULTS: Of 130 patients, 121 completed the questionnaire (response rate 93.1 per cent). There were 29 major complications (24.0 per cent) and 22 patients (18.2 per cent) died within 6 months of operation. QOL scores were not associated with major morbidity but were significantly related to survival status at 6 months after adjusting for known clinical risk factors. A worse fatigue score of 10 points (scale 0-100) corresponded to an increase in the odds of death within 6 months of surgery of 37.4 (95 per cent confidence interval (c.i.) 12.4 to 67.8) per cent (P = 0.002). Pretreatment social function scores were moderately associated with hospital stay (P = 0.021); a reduction in social function by 10 points corresponded to an increase in hospital stay of 0.93 (95 per cent c.i. 0.12 to 1.74) days. CONCLUSION: QOL scores supplement standard staging procedures for oesophageal and gastric cancer by providing prognostic information, but they do not contribute to perioperative risk assessment.

Early-stage vaginal carcinoma--an analysis of 70 patients.

OBJECTIVES: The aims of this study were to assess outcomes and define prognostic factors for early-stage vaginal carcinoma. METHODS: A retrospective analysis was performed of women with FIGO stages I and II vaginal carcinoma identified from the database of the Queensland Centre for Gynaecological Cancer between January 1982 and December 1998. RESULTS: Seventy women were identified. The 5-year survivals for stages I and II carcinomas were 71 and 48%, respectively (P < 0.05). Sixty-one patients (87%) had squamous cell carcinomas with a 5-year survival of 68% versus 22% for adenocarcinomas (P < 0.01). Those women with grade 3 tumors had a 5-year survival of 40% versus 69% for grades 1 and 2 (P < 0.05). Tumor size and site were not significant prognostic factors. Patients treated by surgery alone or with combined surgery and radiotherapy had a significantly improved survival compared to the radiation alone group (P < 0.01). Eighty-five percent of recurrences were locoregional. The median time to relapse was 12 months after initiation of therapy. CONCLUSION: Tumor morphology, grade, and stage are important prognostic indicators. Measures aimed at improving local control of the disease, including surgery, are necessary.

Anemia before and during concurrent chemoradiotherapy in patients with cervical carcinoma: Effect on progression-free survival.

To determine the impact of anemia before and during chemoradiation in patients with cervical cancer, we collected data on hemoglobin (Hb) levels before and during treatment from 60 unselected patients with cervical carcinoma. All patients had FIGO stage IB to IVA disease and were treated with concurrent chemoradiation for the aim of cure. Patients with an Hb value below or equal to the lower 25th quartile were considered anemic. Progression-free survival (PFS) was evaluated by univariate and multivariate analyses. After a median follow-up of 26.3 months, 20 patients developed disease progression. The lowest Hb during chemoradiation (nadir Hb), the stage of disease, and parametrial involvement were correlated significantly with PFS. On multivariate analysis, the nadir Hb (relative risk [RR] 0.29) and tumor stage (RR 3.4) remained the only prognostically relevant factors predicting PFS. At 60 months the PFS was 39.1% for anemic patients and 48.0% for nonanemic patients (P < 0.0002). In patients undergoing chemoradiation for cervical carcinoma, a low nadir Hb is highly predictive of shortened PFS, whereas the Hb before treatment is prognostically not significant.

Feasibility of quality of life assessment in patients with upper gastrointestinal tract cancer.

Quality of life (QOL) is an important outcome after treatment for upper gastrointestinal tract cancer but few studies report good accrual and subsequent attrition is usually high. This study investigated the feasibility of a nurse-led service to obtain longitudinal QOL assessments and explored how clinical and sociodemographic factors influence patients' need for help to complete questionnaires. Fully informed patients were invited into the study. Baseline hospital assessments were scheduled by telephone and thereafter by post unless patients' health indicated the need for a home visit. In all, 128 out of 140 (91%) baseline QOL assessments were performed. Follow-up questionnaire completion was good, with 114 patients (89%) completing all but one of the expected assessments. At baseline, 41 (32%) patients required a lot of help to complete questionnaires. Patients requiring help were more likely to be undergoing palliative treatment than treatment aimed at cure (68 vs 33%; odds ratio 3.48, P<0.01). Patients' with advanced stage cancer of the upper gastrointestinal tract receiving palliative treatment require dedicated staff to ensure good compliance with longitudinal QOL data collection. It is essential to budget for this in clinical trails.

Safety and efficacy of low anterior en bloc resection as part of cytoreductive surgery for patients with ovarian cancer.

OBJECTIVE: To examine the feasibility and safety of a low anterior resection of the rectosigmoid plus adjacent pelvic tumour as part of primary cytoreduction for ovarian cancer. METHODS: This study included 65 consecutive patients with primary ovarian cancer who had debulking surgery from 1996 through 2000. All patients underwent an en bloc resection of ovarian cancer and a rectosigmoid resection followed by an end-to-end anastomosis. Parameters for safety and efficacy were considered as primary statistical endpoints for the aim of this analysis. RESULTS: Postoperative residual tumour was nil, <1 cm, and >1 cm in 14, 34, and 14 patients, respectively. The median postoperative hospital stay was 11 days (range, 6 to 50 days). Intraoperative complications included an injury to the urinary bladder in one patient. Postoperative complications included wound complications (n = 14, 21.5%), septicemia (n = 9, 13.8%), cardiac complications (n = 7, 10.8%), thromboembolic complications (n = 5, 7.7%), ileus (n = 2, 3.1%), anastomotic leak (n = 2, 3.1%), and fistula (n = 1, 1.5%). Reasons for a reoperation during the same admission included repair of an anastomotic leak (n = 1), postoperative hemorrhage (n = 1), and wound debridement (n = 1). Wound complications, septicemia, and anastomotic leak formation were more frequent in patients who had a serum albumin level of < or =30 g/L preoperatively. There was one surgically related mortality in a patient who died from a cerebral vascular accident 2 days postoperatively. CONCLUSIONS: An en bloc resection as part of primary cytoreductive surgery for ovarian cancer is effective and its morbidity is acceptably low.

The significance of psammoma bodies on cervical cytology smears.

OBJECTIVE: The association between psammoma bodies on cervical smear (PBCS) and the presence of gynecological malignancy has been documented previously. The aim of this study was to determine the incidence of malignancy where psammoma bodies were detected on smear, to identify features that may be predictive of associated malignancy, and to make recommendations about management. METHODS: The databases of two large private pathology laboratories were accessed to obtain details of all patients reported to have PBCS between April 1992 and May 2000. A retrospective review was then undertaken to determine if any patients were found to have gynecological malignancies. The appearances of the background cells on the cervical smear and details of clinical management were recorded and evaluated. RESULTS: Twenty-two patients were found to have PBCS. Five patients were found to have a gynecological malignancy. These five patients were significantly older than the remaining patients. When these results were combined with all cases reported in the world literature, it became apparent that patients with coexisting malignancy were statistically significantly older than those not found to have malignancy (P < 0.0001). The cytological appearance of cells on the background smear was highly predictive of the presence or absence of malignancy. CONCLUSIONS: There is an association between PBCS and genital tract malignancy. This association is much stronger for postmenopausal women. The background cytology is highly predictive of the presence of associated malignancy. There is a strong argument that all women with psammoma bodies on cervical smear should undergo smear review, pelvic ultrasonography, hysteroscopy and biopsy, and laparoscopy to exclude the presence of a gynecological malignancy. For younger reproductive-aged women, a negative workup is reassuring.

Impact of hemoglobin levels before and during concurrent chemoradiotherapy on the response of treatment in patients with cervical carcinoma: preliminary results.

BACKGROUND: In patients undergoing radiation for cervical carcinoma, there is evidence that anemia is associated with an impaired outcome. For patients undergoing chemoradiation, there are no data available. The objective of this retrospective study was to examine the impact of anemia before and during chemoradiation in patients with cervical carcinoma. METHODS: The authors collected data on hemoglobin (Hb) levels before and during treatment from 57 patients with cervical carcinoma. The stage of disease ranged between Stage IB and Stage IVA. All patients were treated with concurrent chemoradiation. Response to chemoradiation was evaluated by univariate and multivariate analyses. RESULTS: The mean Hb level at the time of presentation was 12.9 +/- 1.6 g/dL in patients with a complete clinical response (CCR) and 12.1 +/- 1.4 g/dL in those with persistent disease (P = 0.126). In patients with a CCR, the mean nadir Hb level was 11.1 +/- 1.3 g/dL, and in patients with treatment failure, it was 9.8 +/- 1.8 g/dL (P = 0.008). A univariate logistic regression model demonstrated that the nadir Hb level was the most predictive factor for treatment failure (relative risk, 1.92; P = 0.015) followed by disease stage (relative risk, 0.51; P = 0.074). In a multivariate model, the nadir Hb level remained the only prognostically relevant factor predicting the response to chemoradiation. Only patients with nadir Hb values > 11 g/dL throughout chemoradiation had a more than 90% chance of achieving a CCR. CONCLUSIONS: In patients undergoing chemoradiation for cervical carcinoma, the nadir Hb level is highly predictive of response to treatment, whereas the Hb level at the time of presentation is prognostically not significant.

Accuracy of frozen section for the operative management of endometrial cancer.

OBJECTIVE: To assess the accuracy of intra-operative frozen section reports at identifying the features of high risk uterine disease compared with final histopathology. DESIGN: Retrospective study. METHODS: The records of 460 patients with uterine cancer registered with the Queensland Centre for Gynaecological Cancer between January 1, 1996 and December 31, 1998 were reviewed. Intra-operative frozen section was undertaken in 260 patients with endometrial adenocarcinoma. Frozen section pathology was compared with the final histopathology reports. Inter-observer reliability was assessed using percentage agreement and kappa statistics. Clinical notes were also reviewed to determine if errors resulted in sub-optimal patient care. RESULTS: Respectively, tumour grade and depth of myometrial invasion were accurately reported in 88.6% of cases (expected 61.5%, Kappa 0.70) and 94.7% (expected 53.8%, Kappa 0.89). Errors were predominantly attributable to difficulties with respect to the interpretation of tumour grade. The error resulted in the patient receiving sub-optimal surgical management in only 11 cases (5.3%) CONCLUSION: Frozen section is accurate at identifying the features of high risk uterine disease in the setting of endometrial cancer and can play an important role in directing primary operative management.

Human kallikrein 4 (KLK4) is highly expressed in serous ovarian carcinomas.

Previous studies indicated that a new member of the human kallikrein (KLK) gene family, KLK4, was expressed in prostate, breast, and endometrial carcinoma cell lines and may have potential as a tumor marker. The aim of this study was to examine the expression of KLK4 in the normal ovary and ovarian tumors of different histology, stage, and differentiation and to determine its association with ovarian tumor progression. Using reverse transcription-PCR, Southern blot, and densitometry analyses, we found the level of KLK4 expression was higher in late stage serous (SER) epithelial-derived ovarian carcinomas than in normal ovaries, mucinous epithelial tumors, and granulosa cell tumors. KLK4 was highly expressed in all of the SER ovarian carcinoma cell lines (eight of eight), SER epithelial carcinomas (11 of 11), and two adenomas, whereas it was expressed at a lower level (or not at all) in normal ovaries (four of six), mucinous epithelial tumors (three of four), endometrioid carcinomas (four of five), clear cell carcinomas (two of three), or granulosa cell tumors (three of six). Of particular interest, KLK4 mRNA variants were detected in SER ovarian carcinoma cell lines and primary cultured ovarian tumor cells, but they were not present in normal ovaries. In situ hybridization analysis showed that KLK4 mRNA transcripts are localized to adenocarcinoma cells of ovarian tumor tissues. Similarly, immunohistochemical staining of ovarian carcinoma sections showed immunoreactivity to KLK4 protein product (hK4) antipeptide antibodies. In addition, intracellular hK4 levels, as detected on Western blot analysis, were induced by 100 nM estrogen treatment of the estrogen receptor positive ovarian carcinoma cell line OVCAR-3, >8-24 h. Our results show that the level of KLK4 expression and expression of KLK4 mRNA variants are associated with progression of ovarian cancer, particularly late stage SER adenocarcinomas. Moreover, hK4 may be a candidate marker for the diagnosis and/or monitoring of ovarian epithelial carcinomas.

Postoperative vaginal vault brachytherapy for node-negative Stage II (occult) endometrial carcinoma.

OBJECTIVE: The aim of this study is to look at the efficacy of extended surgical staging and postoperative vaginal vault brachytherapy in patients with Stage II (occult) endometrial carcinoma. METHODS: Between January 1989 and December 1997, there were 30 patients with Stage II (occult) endometrial carcinoma who received postoperative vaginal vault brachytherapy as the only adjuvant treatment. The study group consisted of 15 of these patients who had extended surgical staging (including lymphadenectomy). RESULTS: At a median follow-up of 36 months (range 17 to 113 months), there has been no recurrence. There were no major complications from surgery. Only 1 patient had mild rectal bleeding following vaginal vault brachytherapy and there were no grade 3 or 4 bowel toxicities. CONCLUSIONS: Extended surgical staging and postoperative vaginal vault brachytherapy for Stage II (occult) endometrial carcinoma is associated with minimal morbidity and excellent survival.

Primary Bartholin gland carcinoma: a report of seven cases.

This study reviews our experience with 7 patients with primary Bartholin gland cancer (BGC) treated at the Queensland Gynaecological Cancer Centre (QCGC) and compares this with previously published data. A retrospective clinicopathologic review of all patients with primary BGC treated at QCGC from 1988 to 2000 was performed. Of the 7 patients treated, all underwent primary surgery and 5 of the 7 patients received radiotherapy postoperatively. All patients presented with a local swelling or a lump. Two had associated discharge and 2 had associated pain. Of the 7 patients, 2, 3 and 2 respectively were classified as having Stage IB, II or III disease. Five of the 7 patients had squamous cell carcinoma (SCC), one had adenoid-cystic carcinoma and 1 had a small-cell neuroendocrine cancer of the Bartholin gland. None of the patients with SCC developed recurrent disease. The patient with adenoid-cystic carcinoma experienced local recurrences at 4 years and again at 5 years and 3 months. Nine years after primary treatment she was diagnosed with pulmonary metastases. The patient with small-cell neuroendocrine cancer of the Bartholin gland was considered tumour-free after operation. Thorough imaging, including a CT scan of her chest, abdomen and pelvis showed no evidence of disease. She died 1 year and three months after diagnosis from disseminated pulmonary disease. We present the first report of small cell neuroendocrine cancer of the Bartholin gland. Therapeutic principles in the management of vulval cancer at other sites appear to be appropriate for management of BGC.