Laparoscopic surgery in endometriosis.

Endometriosis (the presence of endometrial glands and stroma outside of the uterine cavity) is a common gynecologic problem affecting 10% of women in the general population, 40% of women with infertility and 60% of women with chronic pelvic pain. Laparoscopy has revolutionized management of women with endometriosis. Diagnosis of endometriosis depends on visualization of endometriotic lesions and histologic confirmation. Endometriotic implants have a multitude of appearances: powder burns, red, blue-black, yellow, white, clear vesicular and peritoneal windows. Diagnostic laparoscopy is often combined with operative procedures to treat manifestations and symptoms of endometriosis. This often includes removal or laser vaporization of endometriotic implants, lysis of adhesions, restoration of normal anatomy and removal or fulguration of ovarian endometriomas (conservative surgery). Severe incapacitating endometriosis, recurrent endometriosis following conservative surgery and symptomatic endometriosis in women not desiring more children is often treated by laparoscopic unilateral or bilateral salpingo-oophorectomy or laparoscopically-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy (radical surgery). Endometriosis affecting the appendix, ureters, bladder wall and rectosigmoid colon could be treated with laparoscopic appendectomy, excision of endometriotic implants or laparoscopic colectomy and anastomosis, respectively. Hydrodis-section and use of CO2 super pulsed laser aid in removal of adherent endometriotic implants without damage to normal underlying structures. Robotic-assisted laparoscopic surgery promises to provide advantages in the management of women with severe endometriosis secondary to 3-dimensional visualization, decreasing surgeon's fatigue and hand tremors and improving surgical precision.

Recent advances in the management of women with ovarian cancer.

Ovarian cancer continues to be the leading cause of death secondary to gynecologic cancers among women in the western world. Current treatment of ovarian cancer entails a combination of surgery and chemotherapy. Currently, 1st-line chemotherapy consists of a combination of carboplatin and paclitaxel to which approximately 80% of women respond. Women who do not respond to chemotherapy or have a recurrence within 6 months of treatment have dismal prognoses. Women who respond to chemotherapy usually stay in remission for 1-3 years and then have tumor recurrence. Women with recurrent ovarian cancer can be treated with secondary cytoreduction followed by chemotherapy or by chemotherapy alone. Women with recurrent ovarian cancer usually succumb to their disease despite occasional good response to chemotherapy. Despite the fact that new chemotherapeutic drugs have been found effective among women with ovarian cancer, the prognosis of women with the disease continues to be poor. Advances in survival will depend on development of more accurate screening techniques and the development of new paradigms in treatment.

Tamoxifen and the female reproductive tract.

The use of tamoxifen among women with breast cancer or at high risk of the disease has greatly expanded over the past several decades. Tamoxifen has a complex effect on the female reproductive tract and several tamoxifen-associated changes have been described among tamoxifen users. These include endometrial thickening, cervical and endometrial polyps, endometrial hyperplasia, endometrial adenocarcinoma, uterine sarcoma, increase in the size of uterine leiomyomata, exacerbation of endometriosis and ovarian cysts. The most common uterine change associated with tamoxifen is endometrial polyps. The annual incidence of endometrial cancer among women on tamoxifen is 2 per 1000 and seems to be related to the cumulative tamoxifen dose. It is not clear whether endometrial cancer occurring among women on tamoxifen is of worse prognosis than endometrial cancer occurring among women not receiving tamoxifen. Tamoxifen is associated with several sonographic changes which make the use of ultrasound in surveillance of these patients difficult. There is no indication to implement routine screening for endometrial cancer among all women on tamoxifen. However, endometrial biopsy, preferably via hysteroscopy, should be considered in women with uterine bleeding.

Clinical features and risk of recurrence among patients with vaginal intraepithelial neoplasia.

OBJECTIVE: The best treatment modality and factors affecting recurrence among women with vaginal intraepithelial neoplasia (VAIN) are yet to be determined. The aims of the current study were to describe the clinical features, results of treatment, and factors affecting recurrence among patients with VAIN. METHODS: We conducted a retrospective review of 121 women with VAIN after confirming the histologic diagnosis. Patient demographics, clinical features, and results of therapy were recorded. Factors affecting recurrence were assessed using the odds ratio and the 95% confidence intervals among patients who were followed up for 7 months or more and had at least one posttreatment Papanicolaou smear. Significant univariate odds ratios were assessed jointly in a multivariate model with a stratified analysis. RESULTS: The mean age of the patients was 35.0 (+/-17), 41% of the patients smoked, 39% had a history of human papillomavirus infection, 27% had history of sexually transmitted diseases, 22% had history of surgery for cervical intraepithelial neoplasia (CIN), and 23% had total hysterectomy. The upper third of the vagina was the most common site of VAIN and 61% of the lesions were multifocal. Associated cervical and vulvar intraepithelial neoplasia (VIN) were present in 65 and 10%, respectively. Recurrences of VAIN and progression to invasive vaginal cancer occurred in 33 and 2%, respectively. Recurrences following partial vaginectomy, laser, and 5-fluorouracil were 0, 38, and 59%, respectively (P = 0.0001). Multifocality and method of treatment were significant independent predictors of VAIN recurrences (odds ratio 3.3, 95% CI 1.2, 9.2, P = 0.02, and 22.4, 95% CI 1.3, 393.6, P = 0.001, respectively), with no interaction, based on a stratified analysis. CONCLUSIONS: VAIN occurs most often among women with CIN or VIN, commonly involves the upper third of the vagina, and is often multifocal. Partial vaginectomy provides the highest cure rate and multifocality is a risk factor for recurrence.

Metastatic serous borderline ovarian tumor in an internal mammary lymph node: a case report and review of the literature.

Background. Reports of supradiaphragmatic involvement of lymph nodes by serous borderline ovarian tumors are rare. Case. We describe the finding of metastatic tumor involving an internal mammary lymph node in a 74-year-old patient with serous borderline ovarian tumor. The positive lymph node was found incidentally during cardiac surgery 7 years after excision of the patient's serous borderline ovarian tumor. The incidence and significance of pelvic, paraaortic, and supradiaphragmatic lymph node involvement among women with borderline ovarian tumors is discussed. Conclusion. Supradiaphragmatic lymph node involvement can occur among women with serous borderline ovarian tumors. Borderline ovarian tumors should be included in the differential diagnosis of metastatic adenocarcinoma involving the supradiaphragmatic lymph nodes.

Intraoperative clinical evaluation of lymph nodes in women with gynecologic cancer.

OBJECTIVE: This study was undertaken to determine the accuracy of systematic intraoperative clinical evaluation of lymph nodes in women with gynecologic cancers and to examine the factors affecting such accuracy. STUDY DESIGN: The characteristics and overall intraoperative clinical impression of lymph node metastases were prospectively recorded for 178 consecutive women undergoing lymphadenectomy. The overall clinical impression and lymph node characteristics (enlargement, firmness, and adherence) were correlated with the final histopathologic diagnosis. RESULTS: The overall clinical impression showed excellent agreement with the final histopathologic diagnosis (kappa = 0.753) but had a high false-negative rate (25.8%). The combination of enlargement and firmness had the highest overall accuracy (93.3%). Accuracy of clinical evaluation varied significantly according to the type of cancer, node positivity, and the proportion of positive nodes with respect to the total number of nodes. CONCLUSION: Although systematic intraoperative clinical evaluation of lymph nodes by a trained surgeon has high overall accuracy and correlates well with the final histopathologic diagnosis, it has a high false-negative rate and cannot substitute for histopathologic examination.

Current treatment for ovarian cancer.

Ovarian cancer is the most lethal gynaecologic malignancy. Epithelial ovarian cancer (EOC) constitutes approximately 90% of cases of ovarian cancer and 70% of the patients with EOC present in advanced stage. Treatment of EOC usually consists of cytoreductive surgery which includes total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), omentectomy and lymphadenectomy followed by adjuvant chemotherapy. Current adjuvant chemotherapy includes paclitaxel and either cisplatin or carboplatin given every 3 weeks for six cycles. The combination paclitaxel and platinum chemotherapy achieves clinical response in approximately 80% of patients. However, most patients will have tumour recurrence within 3 years following treatment. Patients with platinum-sensitive tumours can be re-treated with platinum and/or paclitaxel. Those with platinum-resistant tumours have poor prognosis and treatment is palliative. Options of treatment in these patients include topotecan, doxil, gemcitabine, etoposide, or enrolment in clinical trials. Future research needs to focus on the role of cytoreductive surgery, second-look surgery, consolidation chemotherapy, development of new chemotherapeutic agents, chemoresistance modulators, as well as new approaches to the treatment of women with ovarian cancer.

Comparison of diaphragmatic wash and scrape specimens in staging of women with ovarian cancer.

OBJECTIVE: The best technique for obtaining cytologic specimens necessary for evaluation of diaphragmatic spread among women undergoing surgical staging for ovarian cancer has yet to be determined. The aim of the current study was to compare two methods for obtaining diaphragmatic cytology-wash and scrape-in accuracy, correlation to clinical findings, and smear quality. METHODS: We conducted a prospective study among women undergoing surgical staging for ovarian cancer. In each patient diaphragmatic scrape and wash specimens were obtained, then the undersurface of the diaphragm was inspected and palpated. The smears were examined for presence of cancer cells, correlated to clinical findings, and scored for quality (cellularity, preservation, and background). RESULTS: In 46 consecutive patients with stage I-III ovarian cancer, the diaphragm was clinically involved in 12 (26.1%). Malignant cells were demonstrated in 21 (45.7%) of wash and scrape specimens. There was perfect agreement between washes and scrapes and good agreement between clinical evaluation and scrapes or washes (kappa = 1.0 and 0.592, respectively). Wash specimens had significantly higher overall smear quality and cellularity scores (6.26 +/- 1.26 vs 6.11 +/- 1.06, P < 0.02, and 2.20 +/- 0.81 vs 1.85 +/- 0.76, P < 0.05, respectively). CONCLUSION: Although diaphragmatic wash specimens provide better-quality smears than scrape specimens, both techniques are equally diagnostic of diaphragmatic involvement in women undergoing surgical staging for ovarian cancer.

Epidemiologic differences between women with colorectal cancer and women with ovarian cancer.

BACKGROUND AND OBJECTIVES: The difference between the epidemiologic features of women with colorectal cancer and those with ovarian cancer has not been thoroughly studied. The aim of this study is to review the epidemiologic features of women with colorectal cancer and compare them with those of women with ovarian cancer. METHODS: The epidemiologic features of 705 women with colorectal cancer were compared with those of 503 women with primary epithelial ovarian cancer. Both groups included all women with the confirmed respective histologic diagnoses admitted to Roswell Park Cancer Institute between 1982 and 1996 who returned a voluntary self-administered epidemiologic questionnaire. RESULTS: Women with ovarian cancer were significantly younger, had higher education and income, had fewer children, and were more likely to have never been married and nulligravid than those with colorectal cancer. There was a significant difference in the contraceptive history between both groups among women > or = 45 years of age. More women with ovarian cancer had a family history of ovarian cancer and more women with colorectal cancer had a family history of colorectal cancer. CONCLUSIONS: The epidemiologic features of women with colorectal cancer are different from those with ovarian cancer. The difference between both groups might indicate difference in the environmental or genetic etiology of both cancers.

What are the physical characteristics associated with a normal metabolic profile despite a high level of obesity in postmenopausal women?

Although obesity is often associated with insulin resistance and a cluster of metabolic disturbances, the existence of a subgroup of healthy but obese individuals has been postulated. It is unclear why some obese individuals fail to show traditional risk factors associated with the insulin resistance syndrome despite having a very high accumulation of body fat. To address this issue, we identified and studied a subgroup of metabolically normal but obese (MNO) postmenopausal women to gain insight into potential physiological factors that may protect them against the development of obesity-related comorbidities. We carefully examined the metabolic characteristics of 43 obese, sedentary postmenopausal women (mean +/- SD, 58.0 +/- 6.0 yr). Subjects were classified as MNO or as metabolically abnormal obese (MAO) based on an accepted cut-point for insulin sensitivity (measured by the hyperinsulinemic/euglycemic clamp technique). Thereafter, we determined 1) body composition (fat mass and lean body mass), 2) body fat distribution (abdominal visceral and sc adipose tissue areas, midthigh sc adipose tissue and muscle attenuation), 3) plasma lipid-lipoprotein levels, 4) plasma glucose and insulin concentrations, 5) resting blood pressure, 6) peak oxygen consumption, 7) physical activity energy expenditure, and 8) age-related onset of obesity with a questionnaire as potential modulators of differences in the risk profile. We identified 17 MNO subjects who displayed high insulin sensitivity (11.2 +/- 2.6 mg/min.kg lean body mass) and 26 MAO subjects with lower insulin sensitivity (5.7 +/- 1.1 mg/min.kg lean body mass). Despite comparable total body fatness between groups (45.2 +/- 5.3% vs. 44.8 +/- 6.6%; P: = NS), MNO individuals had 49% less visceral adipose tissue than MAO subjects (141 +/- 53 vs. 211 +/- 85 cm(2); P: < 0.01). No difference was noted between groups for abdominal sc adipose tissue (453 +/- 126 vs. 442 +/- 144 cm(2); P: = NS), total fat mass (38.1 +/- 10.6 vs. 40.0 +/- 11.8 kg), muscle attenuation (42.2 +/- 2.6 vs. 43.6 +/- 4.8 Houndsfield units), and physical activity energy expenditure (1060 +/- 323 vs. 1045 +/- 331 Cal/day). MNO subjects had lower fasting plasma glucose and insulin concentrations and lower insulin levels during the oral glucose tolerance test (P: values ranging between 0.01-0.001). No difference was observed between groups for 2-h glucose levels and glucose area during the oral glucose tolerance test. MNO subjects showed lower plasma triglycerides and higher high density lipoprotein cholesterol concentrations than MAO individuals (P: < 0.01 in both cases). Results from the questionnaire indicated that 48% of the MNO women presented an early onset of obesity (<20 yr old) compared with 29% of the MAO subjects (P: = 0.09). Stepwise regression analysis showed that visceral adipose tissue and the age-related onset of obesity explained 22% and 13%, respectively, of the variance observed in insulin sensitivity (total r(2) = 0.35; P: < 0.05 in both cases). Our results support the existence of a subgroup of obese but metabolically normal postmenopausal women who display high levels of insulin sensitivity despite having a high accumulation of body fat. This metabolically normal profile is associated with a lower accumulation of visceral adipose tissue and an earlier age-related onset of obesity.

Laparoscopy as the primary modality for the treatment of women with endometrial carcinoma.

BACKGROUND: The current study was conducted to assess the feasibility of laparoscopy in the treatment of women with early stage endometrial carcinoma and to compare the surgical outcome, cost, and quality of life among these patients with those treated with laparotomy. METHODS: A prospective study was conducted over 2 years in which all women with early stage endometrial carcinoma who could tolerate laparoscopic surgery were treated with laparoscopically assisted vaginal hysterectomy (LAVH), bilateral salpingo-oophorectomy (BSO), and lymphadenectomy. Women with a similar disease stage who underwent similar surgical procedures through laparotomy in the previous 2 years were used as the control group. Both groups were compared with regard to their characteristics, surgical outcome, and cost and were interviewed regarding their quality of life. RESULTS: Eighty-six of 90 women with endometrial carcinoma underwent LAVH. The procedure was converted to laparotomy in 5 patients (5.8%). Laparoscopic surgery thus was successful in 90% of the women. There were no significant differences noted between those women who underwent LAVH and those who underwent total abdominal hysterectomy (TAH) (n = 57) with regard to patient characteristics, type of surgical procedure, preoperative and postoperative hematocrit, complications, patient recall of postoperative pain, and tumor recurrence. LAVH patients had significantly smaller body mass indices, a longer surgical time, more pelvic lymph nodes, a smaller decrease in postoperative hematocrit, received less pain medication, had a shorter hospital stay, an earlier return to full activity and work, and a higher level of satisfaction with their treatment, although their procedures had a higher cost compared with TAH patients. CONCLUSIONS: The majority of women with early stage endometrial carcinoma can be treated with laparoscopy with an excellent surgical outcome, shorter hospitalization, earlier recovery, and improved quality of life, but with a higher financial cost.

Familial ovarian cancer and early ovarian cancer: biologic, pathologic, and clinical features.

Women with ovarian cancer have poor overall survival rates, largely because the disease is so often diagnosed at an advanced, less curable stage. Because women with early ovarian cancer experience good survival rates, there is great interest in the study and detection of early disease. Familial ovarian cancer has been relevant to the study of early ovarian cancer in two different ways. First, women from ovarian cancer families often undergo prophylactic oophorectomy to prevent development of this disease. These ovaries have been studied for pathologic or molecular features that might represent early preinvasive disease. Second, screening tests to detect presymptomatic ovarian cancer have selectively targeted this population because of the increased positive predictive value of these tests in this population. A review of the clinical, pathologic, epidemiologic, and molecular biologic aspects of familial ovarian cancer provides a background to facilitate understanding these issues.

Cavernous hemangioma of the cervix in association with focal nodular hyperplasia of the liver. A case report.

BACKGROUND: Hemangioma of the cervix and focal nodular hyperplasia of the liver are both thought to be congenital vascular anomalies that could be associated with exogenous hormone use. CASE: A 34-year-old woman taking oral contraceptives developed hemangioma of the cervix and focal nodular hyperplasia of the liver. CONCLUSION: Cervical hemangioma can occur with focal nodular hyperplasia, and both could be related to oral contraceptives.

c-erbB-2 Immunohistochemistry in Paraffin Tumors.

Immunohistochemistry is the study of the intracellular distribution of antigens based on the formation of an immune complex. The concept is based on the application of a specific antibody to the antigen to be detected and visualization of the antigen-antibody reaction with a staining procedure. Immunohistochemical staining allows direct observation of antigenic expression at the cellular level.

Significance of atypical squamous cells of undetermined significance on ThinPrep papanicolaou smears.

OBJECTIVE: The aim of this study was to assess the prevalence and risk factors predictive of dysplasia among women seen in a gynecologic oncology service with the cytologic diagnosis of atypical squamous cells of undetermined significance (ASCUS) on Papanicolaou smears obtained by the ThinPrep method. METHODS: Patients with ASCUS ThinPrep Papanicolaou smears seen at the Division of Gynecologic Oncology, University of Vermont, between 1997 and 1999 were identified. The cytologic smears were reviewed and subtyped into reactive or suggestive of squamous intraepithelial lesion (SIL). The charts of these patients were reviewed and the following information was abstracted: age, gravidity, parity, menopausal status, use of hormonal replacement therapy, smoking, history of pelvic cancer, history of radiation therapy, history of abnormal Papanicolaou smear and its treatment, history of human papillomavirus (HPV) infection, and follow-up information including results of repeat Papanicolaou smears, colposcopy, and biopsies. The prevalence of dysplasia was calculated. The demographic features of women with ASCUS, reactive, were compared with those with ASCUS, SIL, using a two-sample t test, chi(2), and Fisher's exact test. Risk factors predictive of dysplasia were calculated using the odds ratio and the 95% confidence interval. P < 0.05 was considered significant. RESULTS: One hundred twenty-six patients with ASCUS on ThinPrep Papanicolaou smear were identified; 63 patients had ASCUS, reactive, and 63 patients had ASCUS, SIL. The demographic features of both groups were similar. The overall prevalence of dysplasia was 15.9% and was significantly higher among women with ASCUS, SIL, than among women with ASCUS, reactive (25.4% versus 6.4%, P = 0.003). The type of ASCUS cytology (reactive versus SIL), smoking, and history of HPV were significant risk factors for dysplasia (P = 0.003, 0.037, and 0. 042, respectively). CONCLUSIONS: The prevalence of dysplasia among women seen in a gynecologic oncology service with ASCUS cytology on ThinPrep Papanicolaou smears is 15.9%. Women with ASCUS favor SIL, those who smoke, and those with a history of HPV are at higher risk for dysplasia and should be offered colposcopy.

Hysterectomy for obese women with endometrial cancer: laparoscopy or laparotomy?

OBJECTIVE: The aim of this study was to investigate the feasibility and safety of laparoscopic management of obese women with early stage endometrial cancer and to compare the surgical outcome, cost, hospital stay, recall of postoperative pain control, time to return to full activity and to work, and overall satisfaction among these women and those managed by laparotomy. METHODS: We conducted a prospective study over 2 years applying laparoscopic surgery to all women with clinical stage I endometrial cancer and body mass indices (BMIs) between 28.0 and 60.0 who can tolerate such surgery. As a control, we used women with clinical stage I endometrial cancer and similar BMIs who underwent laparotomy in the previous 2 years. Both groups were compared in their characteristics, surgical outcome, cost, and hospital stay, and interviewed regarding time to recovery, recall of postoperative pain control, and overall satisfaction with their management. RESULTS: Forty of 42 obese women who presented with clinical stage I endometrial cancer during the study period were offered laparoscopic surgery. The procedure was converted to laparotomy in 3 (7.5%) patients. Laparoscopic surgery was thus successful in 88.1% of all obese women. There was no significant difference between women who underwent laparoscopy and those who underwent laparotomy in patient characteristics, proportion of women who underwent lymphadenectomy, complications, total cost, patients' recall of postoperative pain, and patients' satisfaction with management. Women who underwent laparoscopy had a significantly longer operative time, more pelvic lymph nodes removed, a smaller drop in postoperative hematocrit, less pain medication, and a shorter hospital stay (194.8 versus 137.7 min, P <0.001; 11.3 versus 5.3, P < 0.001; 3.9 versus 5.4, P = 0.029; 32.3 versus 124.1 mg, P < 0.001; and 2.5 versus 5.6 days, P < 0.001, respectively). There was a trend toward earlier resumption of full activity and return to work among women who underwent laparoscopy (23.2 versus 45.0 days, P = 0.073, and 35.3 versus 67.0 days, P = 0.055, respectively). CONCLUSIONS: Most obese women with early stage endometrial cancer can be safely managed through laparoscopy with excellent surgical outcome, shorter hospitalization, and less postoperative pain than those managed through laparotomy.

Significance of atypical glandular cells of undetermined significance on ThinPrep Papanicolaou smears.

OBJECTIVE: The aim of this study was to assess the incidence and risk factors predictive of significant histopathologic findings among women with atypical glandular cells of undetermined significance (AGCUS) on ThinPrep Papanicolaou smears. METHODS: ThinPrep smears with AGCUS obtained between 1997 and 1999 were reviewed. Patients' charts were reviewed and patients' characteristics, follow-up information, and colposcopy and biopsy results were recorded. Pathologic slides were reviewed. The demographic features of women with favor reactive smears were compared with those with favor neoplasia and risk factors predictive of significant histopathologic findings (high-grade squamous intraepithelial lesion, endometrial hyperplasia, and cervical or endometrial cancers) were calculated. RESULTS: The rate of diagnosis of AGCUS was 0.65%. Eighty-four patients with follow-up information were identified. The demographic features of women with smears favor neoplasia (n = 43) were similar to those with smears favor reactive (n = 41). The rates of incidence of any dysplasia or cancer and significant histopathologic findings were 32.1 and 22.6%, respectively, and were higher among women with smears favor neoplasia than among women with smears favor reactive (41.9% versus 22.0%, P = 0.051, and 34.9% versus 9.8%, P = 0.006, respectively). The subtype of cytology was the only factor that predicted significant histopathologic findings (odds ratio = 5.0, 95% confidence interval 1.6, 15.6, P < 0.010). CONCLUSIONS: In women with AGCUS on ThinPrep smears, significant histopathologic findings were found in 34.9% versus 9.8%, depending on the subtype of the smear (favor neoplasia vs reactive). Further studies are needed to validate the cytologic criteria for subtyping AGCUS smears and base management of women with AGCUS cytology on the subtype of the smear.

Effect of menopausal status on insulin-stimulated glucose disposal: comparison of middle-aged premenopausal and early postmenopausal women.

OBJECTIVE: Studies in animal models suggest that ovarian hormone deficiency is associated with the development of insulin resistance. In women, ovarian hormone levels are dramatically reduced after the menopause transition. However, the effect of the menopause transition on insulin sensitivity is unclear. Thus, we examined the effect of menopausal status on insulin sensitivity. RESEARCH DESIGN AND METHODS: Insulin-stimulated glucose disposal was measured in 43 middle-aged premenopausal women (47 +/- 3 years of age) during the luteal phase of the menstrual cycle and 40 early postmenopausal women (51 +/- 4 years; time since menopause, 21 +/- 13 months) using the hyperinsulinemic-euglycemic clamp technique. Body composition was measured by dual-energy X-ray absorptiometry and abdominal fat distribution by computed tomography RESULTS: No difference in fat-free mass (FFM) was found between groups. Total body (P < 0.01), subcutaneous abdominal (P < 0.05), and intra-abdominal (P < 0.01) adiposity were greater in postmenopausal women compared with premenopausal women. No differences in insulin-stimulated glucose disposal were found between premenopausal and postmenopausal women on an absolute basis (pre, 436 +/- 130 vs. post, 446 +/- 120 mg/min), when expressed relative to FFM (pre, 10.7 +/- 3.0 vs. post, 11.5 +/- 3.6 mg x kg(-1) FFM x min(-1)) or when statistically adjusted for FFM (pre, 436 +/- 125 vs. post, 445 +/- 126 mg/min). CONCLUSIONS: These results suggest that menopausal status does not affect insulin sensitivity, as measured by the hyperinsulinemic-euglycemic clamp technique.

Effect of surgeon's experience on the surgical outcome of laparoscopic surgery for women with endometrial cancer.

OBJECTIVE: The purpose of this study was to assess the effect of increasing surgeon's experience in the laparoscopic management of women with endometrial cancer on the surgical outcome of these patients. METHODS: Seventy-five consecutive women with clinical stage I endometrial cancer who underwent laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node sampling by the same surgeon using the same technique and instruments over a period of 2 years were divided into three equal groups based on the date of surgery. The three groups were compared in patient characteristics and surgical outcome using one-way analysis of variance and Pearson chi(2) tests. RESULTS: The three groups were similar in patient characteristics. There was no significant difference in estimated amount of blood loss, rate of conversion to laparotomy, complications, and length of hospital stay among the three groups. There was a significant decrease in operating time (means: 231.0 min for group 1, 175.0 min for group 2, and 167.7 min for group 3, P < 0.001) and a significant increase in the number of pelvic lymph nodes harvested (7.8 for group 1, 10.6 for group 2, and 11.9 for group 3, P < 0.05) with increasing surgeon's experience. CONCLUSIONS: A learning curve is demonstrated in the laparoscopic management of women with endometrial cancer. With increasing surgeon's experience, there is significant decrease in operating time and increase in the number of pelvic lymph nodes removed.