[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To describe the experience of laparoscopic staging of apparent early stage adnexal cancers. METHODS: Prospectively collected data on women who had laparoscopic staging for apparent early stage adnexal cancers from May 2008 to September 2012 was reviewed. All women had had a prior surgical procedure at which the diagnosis was made, without comprehensive staging. A systematic MEDLINE search from 1980 to 2012 for publications on laparoscopic staging was performed. RESULTS: Thirty-five women had laparoscopic staging. Median age was 45 years (range 21-73). Median operative time was 210 min (range 90-210). Four intra-operative and one post-operative complication occurred; overall complication rate 5/35 (14%). One vena cava and one transverse colon injury underwent laparotomies for repair. Laparotomy conversion rate 2/35 (6%). Following laparoscopic staging, the cancer was upstaged for eight (23%) women; microscopic omental involvement (four women), pelvic lymph node involvement (two women), para-aortic lymph node involvement (one woman) and contra-lateral ovarian involvement (one woman). After follow up for a median of 18 months (range 3-59) the disease free survival was 94% and overall survival was 100%. Nine studies were identified on laparoscopic staging of adnexal cancer, of which this is the largest single institution series. CONCLUSIONS: This study adds to the evidence that laparoscopic staging is at least as safe as staging by laparotomy with appropriate and similar oncological outcomes, but with the advantages of minimal access surgery. We therefore advocate the use of laparoscopy to achieve surgical staging for women with presumed early stage adnexal cancer.
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 05/2013; · 2.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We assessed ovarian cancer screening outcomes in women with a positive family history of ovarian cancer divided into a low-, moderate- or high-risk group for development of ovarian cancer.
545 women with a positive family history of ovarian cancer referred to the Ovarian Screening Service at the Royal Marsden Hospital, London from January 2000- December 2008 were included. They were stratified into three risk-groups according to family history (high-, moderate- and low-risk) of developing ovarian cancer and offered annual serum CA 125 and transvaginal ultrasound screening. The high-risk group was offered genetic testing.
The median age at entry was 44 years. The number of women in the high, moderate and low-risk groups was 397, 112, and 36, respectively. During 2266 women years of follow-up two ovarian cancer cases were found: one advanced stage at her fourth annual screening, and one early stage at prophylactic bilateral salpingo-oophorectomy (BSO). Prophylactic BSO was performed in 138 women (25.3%). Forty-three women had an abnormal CA125, resulting in 59 repeat tests. The re-call rate in the high, moderate and low-risk group was 14%, 3% and 6%. Equivocal transvaginal ultrasound results required 108 recalls in 71 women. The re-call rate in the high, moderate, and low-risk group was 25%, 6% and 17%.
No early stage ovarian cancer was picked up at annual screening and a significant number of re-calls for repeat screening tests was identified.
Hereditary Cancer in Clinical Practice 11/2011; 9(1):11. · 1.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the outcomes of surgical management of bowel obstruction in relapsed epithelial ovarian cancer (EOC) so as to define the criteria for patient selection for palliative surgery.
90 women with relapsed EOC underwent palliative surgery for bowel obstruction between 1992 and 2008.
Median age at time of surgery for bowel obstruction was 57 years (range, 26 to 85 years). All patients had received at least one line of platinum-based chemotherapy. Median time from diagnosis of primary disease to documented bowel obstruction requiring surgery was 19.5 months (range, 29 days-14 years). Median interval from date of completed course of chemotherapy preceding surgery for bowel obstruction was 3.8 months (range, 5 days-14 years). Ascites was present in 38/90(42%). 49/90(54%) underwent emergency surgery for bowel obstruction. The operative mortality and morbidity rates were 18% and 27%, respectively. Successful palliation, defined as adequate oral intake at least 60 days postoperative, was achieved in 59/90(66%). Only the absence of ascites was identified as a predictor for successful palliation (p=0.049). The median overall survival (OS) was 90.5 days (range, <1 day-6 years). Optimal debulking, treatment-free interval (TFI) and elective versus emergency surgery did not predict survival or successful palliation from surgery for bowel obstruction (p>0.05).
Surgery for bowel obstruction in relapsed EOC is associated with a high morbidity and mortality rate especially in emergency cases when compared to other gynaecological oncological procedures. Palliation can be achieved in almost two thirds of cases, is equally likely in elective and emergency cases but is less likely in those with ascites.
[Show abstract][Hide abstract] ABSTRACT: ObjectiveTo establish whether ADC and total choline were significantly different between cervical tumors with different histological characteristics (type, degree of differentiation, presence or absence of lymphovascular invasion, lymph-node involvement) in order to establish their role as predictive biomarkers.Methods62 patients with stage 1 cervical cancer were scanned at 1.5 T. T2-weighted imaging (TR/TE = 4500/80 ms), to identify tumor and normal cervix, was followed by diffusion-weighted imaging (TR/TE = 2500/69 ms; 5 b-values 0, 100, 300, 500 and 800 s/mm2) and MR spectroscopic imaging (15 mm slice, 7.5 mm in-plane resolution, TR = 888 ms). Regions of interest in normal cervix and tumor were drawn on apparent diffusion coefficient (ADC) maps by an expert observer with reference to the T2-weighted images. ADCs were calculated using a monoexponential fit of data from all b-values. MR spectra in voxels designated as tumor (> 30% tumor) or non-tumor were quantified using LCModel and referenced to tissue water.ResultsThere was a statistically significant difference between the ADC of tumor regions (1117 ± 183 × 10− 6 mm2/s) and of selected normal regions (1724 ± 198 × 10− 6 mm2/s; p < 0.001), and between tumors that were well/moderately differentiated (1196 ± 181 × 10− 6 mm2/s) compared with those that were poorly differentiated (1038 ± 153 × 10− 6 mm2/s; p = 0.016). There was no significant difference between the ADCs of the tumors when separated by other characteristics (tumor type, lymphovascular invasion, lymph-node metastases), or between measured total choline in any of the groups.ConclusionADCs are lower in cancer compared to normal cervical tissue, with degree of tumor differentiation contributing to this difference.
[Show abstract][Hide abstract] ABSTRACT: McBride and colleagues report that referral rates for patients with postmenopausal bleeding ranged from 66.4% in 55-64 year old patients to 40.1% in those over 85.1 We agree with Jiwa’s assertion that this overall referral rate …
[Show abstract][Hide abstract] ABSTRACT: To evaluate the use of inferior vena caval filters (IVCF) prior to surgery in women with gynaecological cancer and venous thromboembolism (VTE).
Retrospective review of medical notes and electronic records.
Gynaecological oncology cancer centre.
Women with gynaecological cancer and VTE requiring major surgery.
A retrospective analysis was performed on women treated for gynaecological malignancies who had had VTE, and an IVCF placed before major abdominal surgery were reviewed during the period 1996-2006.
Safety of IVCF placement and retrieval, peri-operative morbidity and incidence of further VTE.
The median age was 66 years (range 30-84 years). Of the 39 women, 35 (90%) women had a primary cancer diagnosis and 4 (10%) had recurrent disease. Twenty-two women had ovarian cancer, 2 had borderline ovarian tumours, 9 had uterine cancer, 5 had cervical cancer and 1 woman had concurrent ovarian and endometrial cancers. The recurrent cancers were two cervical, one ovarian and one uterine. The IVCF used were either of the permanent or retrievable type, the latter being more commonly used in younger women. All filters were placed without morbidity, and none of these women who then underwent major abdominal surgery had VTE complications. In 43.6% of women (n = 17), surgery was performed within 6 weeks of the diagnosis of VTE. All women received perioperative anticoagulation in the form of subcutaneous low-molecular-weight heparin. Three retrievable filters were uneventfully removed postoperatively. No filter-related problems occurred.
Surgery in women with gynaecological cancer and life-threatening VTE is feasible with preoperative IVCF placement. The use of IVCF was safe with no worsening of the VTE, and without surgical or filter-related problems. A short interval between the diagnosis of VTE and surgery was not associated with increased perioperative morbidity.
BJOG An International Journal of Obstetrics & Gynaecology 07/2008; 115(7):902-7. · 3.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To audit glove perforations at laparotomies for gynaecological cancers.
Gynaecological oncology unit, cancer centre, London.
Twenty-nine laparotomies for gynaecological cancers over 3 months.
Gloves used during laparotomies for gynaecological cancer were tested for perforations by the air inflation and water immersion technique. Parameters recorded were: type of procedure, localisation of perforation, type of gloves, seniority of surgeon, operation time and awareness of perforations.
Glove perforation rate.
Perforations were found in gloves from 27/29 (93%) laparotomies. The perforation rate was 61/462 (13%) per glove. The perforation rate was three times higher when the duration of surgery was more than 5 hours. The perforation rate was 63% for primary surgeons, 54.5% for first assistant, 4.7% for second assistant and 40.5% for scrub nurses. Clinical fellows were at highest risk of injury (94%). Two-thirds of perforations were on the index finger or thumb. The glove on the nondominant hand had perforations in 54% of cases. In 50% of cases, the participants were not aware of the perforations. There were less inner glove perforations in double gloves compared with single gloves (5/139 versus 26/154; P = 0.0004, OR = 5.4, 95% CI 1.9-16.7). The indicator glove system failed to identify holes in 44% of cases.
Glove perforations were found in most (93%) laparotomies for gynaecological malignancies. They are most common among clinical fellows, are often unnoticed and often not detected by the indicator glove system.
BJOG An International Journal of Obstetrics & Gynaecology 06/2008; 115(8):1015-9. · 3.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The 2002 RCOG survey of training reported that the percentage of obstetric and gynaecology trainees who class their operative training as good or very good has declined from 45% in 1995, to 39% in 2002; reduction in years of training and number of working hours may have further impact on the surgical experience. In this study, we have attempted to assess the level of surgical confidence reported by senior and recently accredited trainees in obstetrics and gynaecology in the UK via an anonymised postal questionnaire. A total of 103 replies were received from 202 questionnaires. Some 99% of the respondents said they felt competent to carry out a simple total abdominal hysterectomy; 61.2% could confidently dissect the ureter and 55.3% could repair major damage to the bladder. However, when managing major obstetric haemorrhage, only 44.6% of respondents felt confident to perform a caesarean hysterectomy; 27.1% could dissect the ureter and 41.7% could apply a B-Lynch suture to the uterus. The level of competence increased with seniority and also with additional time spent in research, subspecialty training or other specialties. There appears to be an appropriate level of confidence in carrying out gynaecological surgical procedures by senior trainees and new consultants. However, surprisingly few respondents were confident in performing any surgical procedure necessary in the management of major obstetric haemorrhage. This may have serious implications in the provision of out of hours senior cover for maternity units in the future.
Journal of Obstetrics and Gynaecology 06/2006; 26(4):297-301. · 0.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background and Aims: Lymph node metastases (LNM) are the most important prognostic factor in VSCC, traditional management involves removal of the primary tumour and regional inguinal lymph nodes for patients with more than 1mm depth of invasion (DOI). Lymphadenectomy often results in significant morbidity and a review of the frequency of LNMwas therefore conducted in two cancer centres according to standard clinicopathological criteria. Methods: Retrospective case note and pathology review. Results: 338 patients were reviewed; mean age at diagnosis was 66 years (15-103). data was available for 183 patients who had lymph node surgery: 126 Radical vulvectomy/wide local excision (RV/ WLE) and bilateral lymphadenctomy; 31 RV/WLE and unilateral lymphadenctomy; 26 lymph node biopsy, fine needle aspirate, or debulking of enlarged nodes. 33.8% of patients had LNM. (see table) Conclusions: Patients are at increased risk of lymph node metastasis with increasing depth of invasion and tumour size, presence of vessel or perineural invasion, and worsening differentiation of VSCC. The omission of lymphadenectomy in patients with less than 1mm depth of invasion appears to be safe, however even patients with small, well differentiated tumours with no LVSI/VI/PNI are at risk of LNM and therefore require lymph node assessment.
[Show abstract][Hide abstract] ABSTRACT: We set out to study whether computerized tomography (CT) scanning of the vulva and the groin and groin ultrasound scanning (USS) alone or with fine needle aspiration cytology (FNAC) (USS/FNAC) influenced or could influence the surgical management of primary squamous cell carcinoma of the vulva (SCCaV). Forty-four patients underwent surgery for primary SCCaV following radiologic imaging by one or more modalities. Patient details included the clinical assessment of the carcinoma, radiologic findings, the operation performed, and whether the decision regarding the type and extent of surgery for the vulval carcinoma and, in particular, for the groin node dissection was or could be influenced by the radiologic findings. The age range was 38-87 years, with a median of 74 years. A total of 75 groin dissections were performed. Twenty-five of the 44 patients (56.8%) did not have groin node metastasis, 14 had unilateral metastasis (31.8%), and 5 (11.4%) had bilateral metastasis. All cases with histologically proven nodal status were analyzed to compare the preoperative imaging status with the histology. The calculated sensitivity, specificity, negative predictive value, and positive predictive value for CT were 58%, 75%, 75%, and 58%, for USS alone-87%, 69%, 94%, and 48%, and for USS-guided FNAC-80%, 100%, 93%, and 100%, respectively. There was no patient in whom surgical planning for the vulval carcinoma or the groin nodes was or could be altered by the CT findings. The data do not support the routine use of CT scanning in patients with primary SCCaV, either in assessment of the primary vulval carcinoma or in detecting groin nodal metastases. For the groin nodes, USS/FNAC is superior to CT in assessing disease status. In contrast to CT, USS/FNAC may have a useful clinical role in the management of the groin nodes in vulval carcinoma.
International Journal of Gynecological Cancer 01/2006; 16(1):312-7. · 1.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Integrin beta1 is both overexpressed and in an 'active' conformation in vulval squamous cell carcinomas (VSCCs) compared to matched normal skin. To investigate the significance of integrin beta1 deregulation we stably knocked-down integrin beta1 expression in the VSCC cell line A431. In vitro analysis revealed that integrin beta1 is required for cell adhesion, cell spreading and invasion. However, integrin beta1 is not required for cell growth or activation of FAK and ERK signalling in vitro or in vivo. Strikingly, while control tumours were able to invade the dermis, integrin beta1 knockdown tumours were significantly more encapsulated and less invasive.
British Journal of Cancer 02/2005; 92(1):102-12. · 5.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Tamoxifen is the standard adjuvant treatment for women with breast carcinoma, decreasing the incidence of contralateral disease. However, the risk of endometrial cancer is increased. To establish current gynaecological management of women receiving tamoxifen in the United Kingdom we conducted a postal questionnaire of consultant gynaecologists, enquiring about frequency of, and methods used to investigate women on tamoxifen. Ninety-five per cent investigate women on tamoxifen only if they are symptomatic. Pelvic ultrasound and endometrial sampling are used for first-line investigation by 68.7%. Interpreting ultrasound findings, endometrial thickness is the parameter regarded as most important. An endometrial thickness of greater than 5 mm is regarded abnormal by 47.8% of respondents and of 4 mm by 23.6%. As there is no consensus of opinion regarding normal values for endometrial thickness, further data are required to ensure consistency when interpreting ultrasound reports of women on tamoxifen.
Journal of Obstetrics and Gynaecology 10/2004; 24(6):675-9. · 0.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Invasive mucinous carcinoma of the ovary (mucinous epithelial ovarian cancer [mEOC]) is a histologic subgroup of epithelial ovarian cancer (EOC). Chemotherapy for mEOC is chosen according to guidelines established for EOC. The purpose of this study is to determine whether this is appropriate.
Women with advanced mEOC (International Federation of Gynecology and Obstetrics stage III or IV) who underwent first-line platinum-based chemotherapy were compared with women with other histologic subtypes of EOC in a case-controlled study.
Eighty-one patients (27 cases, 54 controls) treated with platinum-based regimens were analyzed. The response rates for cases and controls were 26.3% (95% CI, 9.2% to 51.2%) and 64.9% (95% CI, 47.5% to 79.8%), respectively (P=.01). The odds ratio for complete or partial response to chemotherapy for mEOC was 0.19 (95% CI, 0.06 to 0.66; P=.009) compared with other histologic subtypes of EOC. Median progression-free survival was 5.7 months (95% CI, 1.9 to 9.6 months) versus 14.1 months (95% CI, 12.0 to 16.2 months; P<.001) and overall survival was 12.0 months (95% CI, 8.0 to 15.6 months) versus 36.7 months (95% CI, 25.2 to 48.2 months; P<.001) for cases and controls, respectively. The hazard ratio for progression and death was 2.94 (95% CI, 1.71 to 5.07; P<.001) and 3.08 (95% CI, 1.69 to 5.6; P<.001), respectively, for mEOC patients as compared with controls.
Patients with advanced mEOC have a poorer response to platinum-based first-line chemotherapy compared with patients with other histologic subtypes of EOC, and their survival is worse. Specific alternative therapeutic approaches should be sought for this group of patients, perhaps involving fluorouracil-based chemotherapy.
Journal of Clinical Oncology 04/2004; 22(6):1040-4. · 18.04 Impact Factor