Should All Cases of High-Grade Serous Ovarian, Tubal, and Primary Peritoneal Carcinomas Be Reclassified as Tubo-Ovarian Serous Carcinoma?

INTRODUCTION: The dualistic theory of ovarian carcinogenesis proposes that epithelial "ovarian" cancer is not one entity with several histological subtypes but a collection of different diseases arising from cells of different origin, some of which may not originate in the ovarian surface epithelium. METHODS: All cases referred to the Pan-Birmingham Gynaecological Cancer Centre with an ovarian, tubal, or primary peritoneal cancer between April 2006 and April 2012 were identified from the West Midlands Cancer Registry. Tumors were classified into type I (low-grade endometrioid, clear cell, mucinous, and low-grade serous) and type II (high-grade serous, high-grade endometrioid, carcinosarcoma, and undifferentiated) cancers. RESULTS: Ovarian (83.5%), tubal (4.3%), or primary peritoneal carcinoma (12.2%) were diagnosed in a total of 583 woman. The ovarian tumors were type I in 134 cases (27.5%), type II in 325 cases (66.7%), and contained elements of both type I and type II tumors in 28 cases (5.7%). Most tubal and primary peritoneal cases, however, were type II tumors: 24 (96.0%) and 64 (90.1%), respectively. Only 16 (5.8%) of the ovarian high-grade serous carcinomas were stage I at diagnosis, whereas 240 (86.6%) were stage III+. Overall survival varied between the subtypes when matched for stage. Stage III low-grade serous and high-grade serous carcinomas had a significantly better survival compared to clear cell and mucinous cases, P = 0.0134. There was no significant difference in overall survival between the high-grade serous ovarian, tubal, or peritoneal carcinomas when matched for stage (stage III, P = 0.3758; stage IV, P = 0.4820). CONCLUSIONS: Type II tumors are more common than type I and account for most tubal and peritoneal cancers. High-grade serous carcinomas, whether classified as ovarian/tubal/peritoneal, seem to behave as one disease entity with no significant difference in survival outcomes, therefore supporting the proposition of a separate classification of "tubo-ovarian serous carcinoma".

Surgical and oncological outcome of total laparoscopic radical hysterectomy in obese women with early-stage cervical cancer.

OBJECTIVE: To evaluate the clinical experience of the total laparoscopic radical hysterectomy (TLRH) for the surgical management of cervical cancer in obese (body mass index [BMI] >30 kg/m) and nonobese (BMI <30 kg/m) women. METHODS: Data were collected prospectively on intraoperative and postoperative parameters and complications for all women undergoing a TLRH for cervical cancer. Patients were classified as obese, BMI >30 kg/m, or nonobese, BMI <30 kg/m. Assessment of surgical radicality was made by comparing the excision specimens in the 2 groups with a cohort of open radical hysterectomy cases performed before the introduction of the TLRH. RESULTS: A total of 58 women underwent a TLRH; 15 (25.9%) were obese and 43 (74.1%) were in the nonobese group. There was no significant difference in intraoperative blood loss or median duration of surgery between the obese and nonobese groups. The median hospital stay in both groups was 3 days (range, 2-13 days). Four cases were converted to laparotomy (7%); all were in the nonobese group. Postoperatively, 3 patients developed ischemic ureterovaginal fistulae (5%) between days 5 and 7 after surgery; all were in the nonobese group. There was no significant difference in the parametrial length, maximum vaginal cuff length, and number of lymph nodes excised between the 2 groups. To date, there has been one recurrence during the median follow-up period of 19 months (range, 3-42 months). She belonged to the nonobese group. CONCLUSIONS: The TLRH is a surgically safe procedure for early-stage cervical cancer. Obesity did not adversely affect the performance of TLRH or the radicality of the excision. In obese women, TLRH should be the favored route of surgery for all women who require a radical hysterectomy owing to its favorable perioperative outcome and short hospital stay.

Is gynaecological surgical training a cause for concern?: a questionnaire survey of trainees and trainers.

BACKGROUND: Concerns have been raised as to whether the current postgraduate training programme for gynaecological surgery is being detrimentally affected by changes in working practices, in particular the European Working Time Directive (EWTD). The purpose of this study was to investigate the surgical activity of obstetrics and gynaecology trainees and to explore trainees' and trainers' opinions on the current barriers and potential solutions to surgical training. METHODS: Two questionnaire surveys were conducted, one to obstetrics and gynaecology trainees working within the West Midlands Deanery and a second to consultant gynaecologists in the West Midlands region. RESULTS: One hundred and four trainees (64.3%) and 66 consultant gynaecologists (55.0%) responded. Sixty-six trainees (66.7%) reported attending up to one operating list per week. However, 28.1% reported attending up to one list every two weeks or less and 5 trainees stated that they had not attended a list at all over the preceding 8 weeks. Trainees working in a unit with less than 3999 deliveries attended significantly more theatre sessions compared to trainees in units with over 4000 deliveries (p = 0.007), as did senior trainees (p = 0.032) and trainees attached to consultants performing major gynaecological surgery (p = 0.022). In the previous 8 weeks, only 6 trainees reported performing a total abdominal hysterectomy independently, all were senior trainees (ST6 and above). In the trainers' survey, only two respondents (3.0%) agreed that the current program produces doctors competent in general gynaecological surgery by the end of training, compared to 48 (73.8%) respondents who disagreed. CONCLUSIONS: Trainees' concerns over a lack of surgical training appear to be justified. The main barriers to training are perceived to be a lack of team structure and a lack of theatre time.

Differentiated-type vulval intraepithelial neoplasia has a high-risk association with vulval squamous cell carcinoma.

OBJECTIVE: To assess the potential malignant risk of vulval premalignant conditions, in particular, to investigate whether there is a difference in the cancer risk between women with the 2 types of vulval intraepithelial neoplasia (VIN). METHODS: All vulval biopsy specimens taken for any reason in a single center for a 5-year period were identified. The histologic reports of 1309 biopsy specimens from 802 women were reviewed, and all pathologic conditions present were recorded for each woman. Reports of patients with biopsy specimens containing usual-type VIN, differentiated-type VIN, lichen sclerosus, and squamous hyperplasia were selected and analyzed for the presence of metachronous or subsequent carcinoma to give a proportional risk for each condition. RESULTS: Five hundred eighty women were identified with premalignant vulval conditions: 171 had usual-type VIN, 70 had differentiated-type VIN, 191 had lichen sclerosus, 145 had squamous hyperplasia, and 3 had other conditions not included in this analysis. Within these groups, the numbers of women with prior, synchronous, or subsequent vulval squamous cell carcinoma were 44 (25.7%), 60 (85.7%), 53 (27.7%), and 53 (31.7%), respectively (P = 0.000). CONCLUSIONS: Differentiated-type VIN is significantly more associated with vulval squamous cell carcinoma than usual-type VIN.

Vulval squamous cell carcinoma occurring on a background of differentiated vulval intraepithelial neoplasia is more likely to recur: a review of 154 cases.

OBJECTIVE: To assess the frequency of recurrence of vulval carcinoma, arising from the background of usual-type vulval intraepithelial neoplasia (uVIN), differentiated VIN (dVIN, and nonneoplastic epithelial disorders (NNEDs). STUDY DESIGN: A retrospective review was conducted of 200 pathology specimens of vulval squamous cell carcinoma (VSCC) from 154 women over a 5-year period. The pathologic findings were reviewed where information of the adjacent pathology and number of recurrences of carcinoma for each woman were recorded. The number of recurrences was then correlated with the adjacent pathology using logistical regression analysis. RESULTS: The overall recurrence rate for vulval carcinoma was 22.6%. A single recurrence occurred in 12.9% of patients, whereas 5.8% had 2 recurrences and 3.9% has 3 recurrences of vulval carcinoma. The odds ratio (OR) of having a recurrence of VSCC associated with dVIN alone is 3.85 (95% CI 0.52, 28.24) and 4.3 when associated with dVIN in combination with NNEDs (95% CI 0.84, 21.92), whereas with VSCC associated with uVIN the OR is 1.35 (95% CI 0.20, 9.01). CONCLUSION: Vulval cancers arising on a background of dVIN appear more likely to recur than cancers arising from undifferentiated VIN; this is compounded by the concurrent presence of NNEDs.

Neuroendocrine Carcinoma of the Cervix: Review of a Series of Cases and Correlation With Outcome.

Introduction Neuroendocrine carcinoma (NEC) of the cervix is associated with a poor prognosis despite multimodal treatment. The correct diagnosis of this tumor type is imperative to provide clinicians and patients with prognostic information and ensure that appropriate treatment is provided. Methods A clinicopathological study was undertaken on all cervical tumors registered as NEC with the West Midlands Cancer Intelligence Unit between January 1, 1998 and December 31, 2009. Of the 45 cases diagnosed during the study period, the tumor samples of 41 cases were traced, anonymized, and then independently reviewed by 2 gynecological pathologists. Results The review confirmed 31/41 (78%) cases to be NEC, which overall, represented 1.3% of all the cervical cancers registered in the West Midlands over the period of the study. In the correct histological context, synaptophysin was the most sensitive and specific positive immunohistochemical marker of NEC differentiation. The cases that on review were confirmed as NEC had a significantly worse outcome than the non-NEC cases: median survival for NEC cases was 33.3 months versus 315.0 months for the non-NEC cases, P = .013. Conclusions Histological review of a series of NECs has shown significantly reduced survival in those patients with confirmed NEC in comparison with those patients where a diagnosis of NEC was not confirmed. We propose morphological and immunohistochemical criteria for the diagnosis of cervical NEC; and discourage unqualified use of the term "small cell carcinoma" as this does not accurately convey the diagnosis of SCNEC. We urge pathologists to use the 2014 World Health Organization classification when reporting these tumors.