Uterine serous carcinoma: a historic evaluation of therapy.

UNLABELLED: Summary OBJECTIVE: Uterine serous carcinoma (USC) is an aggressive, histological subtype of endometrial cancer with a poor prognosis. This study evaluates the additional effect of staging surgery above total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH+BSO) on the use of adjuvant therapy and subsequent survival outcomes in clinical early-stage USC patients. MATERIALS AND METHODS: This retrospective cohort study includes 75 women treated for clinical early-stage USC. RESULTS: In 33 (44%) clinical early-stage patients surgical staging was performed and 15 patients (45%) proved to have lymphatic or abdominal metastasis. Use of adjuvant therapy was similar in patients, both staged with no metastasis (n = 18) and patients who underwent TAH and BSO only (n = 42, p = 0.17). No significant survival difference was found between surgically staged and TAH+BSO patients. CONCLUSIONS: Surgical staging proved to be important to determine stage of disease and hence prognosis. Surgical staging did not lead to selective avoidance of adjuvant therapy in patients with no metastasis.

Sentinel nodes in vulvar cancer: Long-term follow-up of the GROningen INternational Study on Sentinel nodes in Vulvar cancer (GROINSS-V) I.

OBJECTIVE: In 2008 GROINSS-V-I, the largest validation trial on the sentinel node (SN) procedure in vulvar cancer, showed that application of the SN-procedure in patients with early-stage vulvar cancer is safe. The current study aimed to evaluate long-term follow-up of these patients regarding recurrences and survival. METHODS: From 2000 until 2006 GROINSS-V-I included 377 patients with unifocal squamous cell carcinoma of the vulva (T1, <4 cm), who underwent the SN-procedure. Only in case of SN metastases an inguinofemoral lymphadenectomy was performed. For the present study follow-up was completed until March 2015. RESULTS: Themedian follow-up was 105 months (range 0­179). The overall local recurrence ratewas 27.2% at 5 years and 39.5% at 10 years after primary treatment, while for SN-negative patients 24.6% and 36.4%, and for SN-positive patients 33.2% and 46.4% respectively (p = 0.03). In 39/253 SN-negative patients (15.4%) an inguinofemoral lymphadenectomy was performed, because of a local recurrence. Isolated groin recurrence rate was 2.5% for SN-negative patients and 8.0% for SN-positive patients at 5 years. Disease-specific 10-year survival was 91% for SN-negative patients compared to 65% for SN-positive patients (p b .0001). For all patients, 10-year disease-specific survival decreased from 90% for patients without to 69% for patients with a local recurrence (p b .0001).

Multimodal surgical guidance towards the sentinel node in vulvar cancer.

INTRODUCTION: Conventional sentinel node (SN) mapping is performed by injecting a radiocolloid followed by lymphoscintigraphy (and SPECT/CT imaging). An extra intraoperative injection with blue dye can then allow for optical identification of the SN. In order to improve the current clinical standard, the hybrid tracer indocyanine green (ICG)-(99m)Tc-nanocolloid was introduced, a tracer that is both radioactive and fluorescent. This feasibility study aimed to evaluate the value of a multimodal-based SN biopsy in vulvar cancer. MATERIALS AND METHODS: Fifteen patients with vulvar cancer (29 groins) scheduled for SN biopsy were peritumorally injected with ICG-(99m)Tc-nanocolloid followed by lymphoscintigraphy and SPECT/CT imaging to identify the SNs. In thirteen patients, shortly before the start of the operation, blue dye was intradermally injected around the lesion. SNs were harvested using a combination of radiotracing, fluorescence imaging, and optical blue dye detection. A portable gamma camera was used before and after SN excision to confirm excision of the preoperatively defined SNs. RESULTS: Preoperative lymphoscintigraphy and SPECT/CT imaging visualized drainage to 39 SNs in 28 groins. During the operation, 98% (ex vivo 100%) of the SNs were radioactive. With fluorescence imaging 96% of the SNs (ex vivo 100%) could be visualized. Only 65% of the SNs had stained blue at the time of excision. CONCLUSION: ICG-(99m)Tc-nanocolloid can be used for preoperative SN identification and enables multimodal (radioactive and fluorescent) surgical guidance in patients with vulvar cancer. The addition of fluorescence-based optical guidance offers more effective SN visualization compared to blue dye.

Diagnostic accuracy of preoperative tests for lymph node status in endometrial cancer: a systematic review.

BACKGROUND: Approximately 72% of endometrial cancers are FIGO stage I at diagnosis and about 10% have lymph node metastases. An ideal diagnostic test for nodal disease would be able to prevent both overtreatment (i.e. unnecessary lymphadenectomy) and undertreatment (i.e. withholding lymphadenectomy or adjuvant postoperative treatment to patients with lymph node metastases). OBJECTIVES: In this review we compare the accuracy of preoperative tests (computed tomography, magnetic resonance imaging, positron emission tomography-computed tomography, CA-125 serum levels, and ultrasonography) for the detection of lymph node metastases in endometrial cancers with the final histopathologic diagnosis after complete pelvic and para-aortic lymphadenectomy as the gold standard. METHOD: A systematic search in MEDLINE (using PubMed), Embase and The Cochrane Library was performed up to 23 July 2012. RESULTS: We found one article that met our inclusion criteria for computed tomography, none for magnetic resonance imaging, 2 for positron emission tomography/computed tomography), 2 for CA-125 and none for ultrasonography. CONCLUSIONS: Due to the lack of high-quality articles on a preoperative test for lymph node status in endometrial cancer, no proper comparison between these modalities can be made.

[The practice guideline 'Vaginal discharge' (first revision) from the Dutch College of General Practitioners; a response from the perspective of gynaecology]. / De standaard 'Fluor vaginalis' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de gynaecologie.

The Dutch College of General Practitioners (NHG) revised their practice guideline on vaginal discharge. From a gynaecological point of view, relocation of cervix problems from this guideline to the NHG guideline 'The STD consultation' is not practical. Moreover, the role of simple, but effective diagnosis with a microscope in the primary-care setting cannot be overemphasized. The reluctance to oral treatment is rather inopportune, because once-only ingestion has the advantage of promoting compliance. As physical examination is not always necessary in a recurrent Candida infection, treatment performed by the patient with imidazole compounds is a possibility that does not always result in abuse or increased resistance.

Transrectal ultrasonography in male subfertility patients: an intra- and interobserver study.

The purpose of this paper was to examine whether ultrasound abnormalities of the prostate and seminal vesicles, which may be related to male accessory gland infection, are reproducible. Forty-seven men attending an infertility clinic were studied. Imaging findings of transrectal ultrasonography were recorded. Kappa (kappa)-values to determine the intra- and inter-observer variation were assessed. Calcifications have good intra-observer (kappa = 0.77; 95% CI: 0.59-0.96) and good inter-observer reproducibility (kappa = 0.73; 95% CI: 0.54-0.93). Dilatation of the peri-prostatic plexus had moderate intra-observer (kappa = 0.57; 95% CI: 0.33-0.80) and good inter-observer reproducibility (kappa = 0.74; 95% CI: 0.55-0.94). Other ultrasound abnormalities of the prostate were not reproducible. None of the ultrasound abnormalities of the seminal vesicles were reproducible. In our study the prevalence of ultrasound abnormalities which may be related to male accessory gland infection was as high as 96%. However, only calcifications and dilatation of the venous plexus had good reproducibility. Other observed ultrasound abnormalities of the prostate and seminal vesicles were poorly reproducible and are therefore of no use in the diagnosis of male accessory gland infection.

Accurate detection of male subclinical genital tract infection via cervical culture and DNA hybridization assay of the female partner.

The accuracy of the PACE2 DNA hybridization assay of the cervix and cervical culture in female partners for the diagnosis of male subclinical genital tract infection were assessed in a male infertility population. A total of 184 men were screened for the presence of Chlamydia trachomatis, Ureaplasma urealyticum and Mycoplasma hominis. Seventy-one men were identified with a positive test for one or more of the above mentioned micro-organisms. The overall prevalence of bacterial infection was 39%. Female partners of all men were tested with the PACE2 DNA hybridization assay to detect a C. trachomatis infection. Sensitivity was 100% and specificity was 100%. In 67 female partners (94%) of men who tested positive for U. urealyticum and/or M. hominis, a cervical swab culture was performed. The sensitivity of the cervical swab culture was 100%. In view of the high prevalence of U. urealyticum and M. hominis in the male genital tract and the role these sexually transmitted pathogens may play in infertility, one might question whether all couples should be screened for the presence of these pathogens. Transurethral swab culture after digital prostatic massage is disincentive to men. The cervical culture in their female partner, performed as part of the routine fertility work-up, is a suitable alternative to detect the presence of these micro-organisms in the male genital tract.

Value of detecting leukocytospermia in the diagnosis of genital tract infection in subfertile men.

OBJECTIVES: To evaluate whether detection of leukocytospermia in a routine semen analysis is of diagnostic value in selecting men with an "actual" microbial infection and to assess the association between leukocytospermia and a history of bacterial and viral infections. DESIGN: Prospective clinical study. SETTING: Infertility clinic at the Center for Reproductive Medicine, Academic Medical Center, Amsterdam, the Netherlands. PATIENT(S): One hundred eighty-four men among subfertile couples attending our infertility clinic. INTERVENTION(S): The number of leukocytes was assessed in three semen samples. Serologic tests were performed, as was transurethral culture after digital prostatic massage. MAIN OUTCOME MEASURE(S): Diagnosis of actual bacterial and viral infections in relation to seminal leukocyte concentrations. The association of a history of sexually transmitted diseases with seminal leukocyte concentration. RESULT(S): An actual bacterial infection was present in 39% of men, and 11% of men had an actual viral infection. The area under the receiver operating curve, which was used to determine whether detection of leukocytospermia was of diagnostic value in identifying men with actual bacterial or viral infections, was 0.55 and 0.56 for bacterial and viral infection, respectively. A past infection with N. gonorrhoeae was associated with the presence of leukocytospermia. A past viral infection was not associated with leukocytospermia. CONCLUSION(S): Detection of leukocytospermia appears to be of no diagnostic value for selection of men with actual microbial infections, but leukocytospermia is associated with a history of gonorrhea.

The value of palpation, varicoscreen contact thermography and colour Doppler ultrasound in the diagnosis of varicocele.

Three non-invasive methods for the detection of a varicocele were evaluated in 63 men presenting with infertility. Physical examination, varicoscreen contact thermography and colour Doppler ultrasound were compared with spermatic venography as reference strategy. Physical examination had a sensitivity of 71%. Whether the non-palpable varicoceles are all subclinical is questionable since the specificity of physical examination was 69%. Varicoscreen proved be quick, easy and cheap but of no clinical value (sensitivity 97%, specificity 9%). Colour Doppler ultrasound using strict criteria was a good diagnostic tool (sensitivity 97%, specificity 94%). No imaging difference was seen with colour Doppler ultrasound among clinical and subclinical varicoceles. Since the debate on treating all degrees of varicocoeles is ongoing, we suggest that Doppler sonography should be a routine examination in infertile men.

[Periampullary carcinoma as a second primary tumor following a previously treated adenocarcinoma of the colon]. / Peri-ampullair carcinoom als tweede primaire tumor na een eerder behandeld adenocarcinoom van het colon.

Three patients are presented who developed periampullary carcinoma after colectomy for adenocarcinoma. The combination of colonic carcinoma and periampullary carcinoma is rare, although wellknown in patients with colonic polyposis or Gardner's syndrome. Perhaps genetic research might help select patients with a high risk of developing multiple carcinomas in the gastrointestinal tract. The five-year survival rate for periampullary carcinoma after subtotal colectomy is higher than for pancreatic carcinoma.

Long-term follow-up after colectomy and ileorectal anastomosis in familial adenomatous polyposis coli. Is there still a place for the procedure?

Forty-four patients with familial adenomatous polyposis coli treated with colectomy and ileorectal anastomosis were studied. Mean age at operation was 27 years. The mean follow-up period was 10 years (median 8 years). Three patients (7%) developed rectal cancer 1, 4, and 24 years after the initial operation, respectively. Proctectomy with ileostomy was performed in one patient, and 7 patients underwent a conversion to an ileoanal procedure for an increasing number of rectal polyps in the rectum stump. Although frequent bowel actions and episodes of diarrhea were common findings in patients after colectomy and ileorectal anastomosis, almost all patients (96%) were more or less satisfied with their quality of life after the procedure. On the basis of our results and the results reported in the literature, colectomy with ileorectal anastomosis is still the operation of choice in selected patients with familial adenomatous polyposis coli. An initial ileal pouch - anal anastomosis, or a conversion to such a procedure after colectomy and ileorectal anastomosis is indicated, depending on the number and size of rectal polyps.