Socioeconomic deprivation and survival in endometrial cancer: The effect of BMI.

OBJECTIVES: METHODS: This is a retrospective study of surgically managed endometrial cancer patients in the Royal Cornwall Hospital Truro between January 2006 and August 2017. Patient characteristics, overall survival, recurrence free survival and intra- and postoperative outcomes were evaluated across socioeconomic deprivation groups in which socioeconomic deprivation was measured with the English Indices of Multiple Deprivation (IMD). RESULTS: In total, we identified 831 women, of which 690 were included. The median age was 66 years with a median BMI of 31 and the majority of tumours were endometrioid tumours (80.1%). For type 1 (endometrioid) tumours, better survival was seen in the least deprived patients, however this was not significant in a multivariate analysis and only age, stage and BMI remained significant. For type 2 (all other) tumours, no association between survival and socioeconomic deprivation was found and only stage was significant. However, more affluent patients had significantly higher recurrence rates. In addition, we did not find evidence of an association between intra- or post-operative complication rates and socioeconomic deprivation. CONCLUSION: Socioeconomic deprivation is associated with survival in endometrial cancer patients, however after adjusting for confounders this association does not remain. Only age, stage and BMI are independent prognostic factors for survival. In addition, there is no evidence of association between socioeconomic deprivation and peri-operative outcomes in endometrial cancer patients.

Systematic review on socioeconomic deprivation and survival in endometrial cancer.

PURPOSE: The primary objectives in this review were to (1) assess the association between socioeconomic deprivation and survival in endometrial cancer patients (2) investigate if there is an association between socioeconomic deprivation and peri-operative morbidity in endometrial cancer patients. METHODS: We performed a systematic review using Medline (1946-2018), Embase (1980-2018), Cinahl (1981-2018) and the Cochrane Controlled Register of Trials to identify studies that reported on the association between socioeconomic deprivation and survival or peri-operative outcomes in endometrial cancer patients. Included were adult women (age ≥ 18 years) diagnosed with primary endometrial cancer. Two reviewers independently selected studies and assessed bias using the Newcastle-Ottawa assessment scale. Data extraction was completed using pre-determined forms, and summary tables of evidences from the included studies were created. RESULTS: Nine studies were included in this review with a total number of 369,900 patients. Eight studies investigated survival and socioeconomic deprivation, and the majority showed that socioeconomic deprivation is associated with poorer survival in endometrial cancer patients. One study assessed the association between deprivation and peri-operative morbidity and found no difference in 30-day postoperative mortality. CONCLUSIONS: Socioeconomic deprivation seems to be associated with worse survival in endometrial cancer patients, even after adjusting for stage at diagnosis. However, the impacts of important confounders such as BMI, smoking and comorbidities are unclear and should be assessed. The relationship between socioeconomic deprivation and peri-operative morbidity is unclear, and further research is needed to evaluate this aspect. A standardised measure for socioeconomic deprivation is needed in order to establish adequate comparison between studies.

Radiation-related toxicities and outcomes in endometrial cancer: are obese women at a disadvantage?

OBJECTIVE: To assess the impact of body mass index (BMI) on radiotherapy toxicities in endometrial cancer patients. METHODS: This was a retrospective cohort study of women diagnosed with endometrial cancer between January 2006 and December 2014 at the Royal Cornwall Hospital Trust. Women who received radiotherapy as part of their treatment, including external beam radiotherapy (EBRT) and/or vaginal brachytherapy were included. Radiation-related toxicities were graded according to the Radiation Therapy Oncology Group (RTOG) guidelines. Toxicity outcomes were compared across BMI groups-non-obese (BMI <30 kg/m2) and obese (BMI ≥30 kg/m2)-according to radiotherapy treatment received (EBRT, brachytherapy or a combination). RESULTS: Of a total of 159 women who received radiotherapy, 110 were eligible for inclusion in the study. Sixty-three women had a BMI <30 kg/m2 and 47 women were obese. Obese women had poorer Eastern Cooperative Oncology Group performance status (P = 0.021) and more comorbidities (P < 0.001) compared to the non-obese group. Total (any) toxicity rates were 60.3, 72.7 and 52.0% for EBRT and brachytherapy (N = 63), single-mode EBRT (N = 22) and brachytherapy (N = 25), respectively. BMI was not associated with the incidence of acute and late radiation toxicities in the different radiotherapy groups, and there were no differences in individual complications between the BMI groups. CONCLUSION: When comparing obese to non-obese women, obesity does not negatively impact the incidence of radiation toxicities in endometrial cancer. However, toxicities remain an important challenge as they are common and negatively influence the quality of life (QoL) of survivors. Future studies need to further explore the role of BMI and possible interventions to improve toxicities and QoL.

Surgical morbidity and clinical outcomes in ovarian cancer - the role of obesity.

OBJECTIVE: To evaluate the effect of body mass index on the surgical outcomes in ovarian cancer patients. In addition, we performed a systematic review to compare our outcomes with the current literature. DESIGN: Retrospective cohort study and a systematic review of the literature. SETTING: Gynaecology department at the Royal Cornwall Hospital Trust. POPULATION: Surgically managed stage I-IV ovarian cancer patients between September 2006 and September 2014. METHODS: Primary and secondary outcome measures were evaluated across BMI categories; BMI <25 kg/m², BMI 25­29.9 kg/m², BMI ≥30 kg/m² and BMI ≥40 kg/m². A systematic review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. MAIN OUTCOME MEASURES: The primary outcome measure was surgical complications. Secondary outcome measures were other intra- and postoperative outcomes. RESULTS: Two hundred twenty-eight women were included in the study, of which 84 had a BMI <25 kg/m², 84 women had a BMI 25­29.9 kg/m², and 60 women were obese (BMI ≥30 kg/m²), 13 of whom were morbidly obese. Morbid obesity was associated with increased rates of wound complications. However, BMI did not show an association with other outcomes. In the review, an increasing BMI was associated with increased rates of wound complications and prolonged hospital stay, but did not impact other surgical outcomes. CONCLUSION: Obesity is associated with increased rates of wound complications and a prolonged hospital stay, but does not appear to affect other operative outcomes including cytoreduction status and 30-day mortality. Therefore, operative management and postoperative care require a multifactorial approach to minimise adverse outcomes.

High-grade vaginal intraepithelial neoplasia: can we be selective about who we treat?

OBJECTIVE: To determine the role of conservative management in high-grade vaginal intraepithelial neoplasia (HG VaIN). DESIGN: Retrospective observational study. SETTING: Northern Gynaecological Oncology Centre, Gateshead, UK. POPULATION: A total of 100 women with histologically-proven HG VaIN. METHODS: Review of patient records from 1995 to 2011. MAIN OUTCOME MEASURES: Rates of progression to cancer, treatment remission, and disease recurrence, particularly post-treatment when vaginoscopy is normal but cytology is abnormal. RESULTS: Of 100 women referred, 69 underwent initial treatment of whom 47 (68%) went into remission: of these, seven developed a recurrence after a median follow-up of 29 months (range 15-214 months). Of the 31 women managed conservatively with cytological and vaginoscopic surveillance, no cancers developed after a median follow-up of 35 months (range 2-230 months). Rate of overall progression to cancer was 3% and all were detected among the initial treatment group after a median of 59 months (range 8-249 months). Post-treatment, when normal vaginoscopy was accompanied by abnormal cytology, two categories existed. Of 24 cases with low-grade cytological abnormality, recurrence of HG VaIN occurred in seven (29%) after a median follow-up of 12 months (range 2-110 months). Of 19 cases with HG cytological abnormality, 15 (79%) developed recurrence at a median follow-up of 7 months (range 2-21 months), giving a hazard ratio 5.6 (95% confidence interval 2.0-15.5, P = 0.001). CONCLUSIONS: It is possible to select women with HG VaIN for conservative surveillance with excellent results. The majority of women undergoing initial treatment will enter remission. Post-treatment, if cytological abnormality develops in the presence of normal vaginoscopy, the majority of women will develop histological HG VaIN recurrence.

Defining the Optimal Treatment Strategy in Patients With Uterine Serous Carcinoma.

AIMS: Uterine serous carcinoma (USC) is an aggressive subtype of endometrial cancer with high rates of relapse and death. As adjuvant therapy might be beneficial in early-stage disease, the impact of standard complete surgical staging is questioned. Therefore, we wanted to explore the optimal treatment strategy for women diagnosed with USC. MATERIALS AND METHODS: A retrospective multicentre study of women diagnosed with primary USC in the UK and the Netherlands. Treatment strategy in relation to overall survival and progression-free survival was recorded and evaluated with Kaplan-Meier and Cox regression analysis. Furthermore, primary surgical staging and/or adjuvant treatment in relation to patterns of recurrence were evaluated. RESULTS: In total, 272 women with a median age of 70 years were included. Most patients presented with International Federation of Gynecology and Obstetrics (FIGO) stage I disease (44%). Overall, 48% of patients developed recurrent disease, most (58%) with a distant component. Women treated with chemotherapy showed significantly better overall survival (hazard ratio 0.50, 95% confidence interval 0.31-0.81; P = 0.005) and progression-free survival (hazard ratio 0.48, 95% confidence interval 0.28-0.80; P = 0.04) in multivariable analysis. Furthermore, even in surgically staged women with FIGO stage IA disease, a high recurrence rate of 42% was seen. CONCLUSION: Women with USC who received adjuvant chemotherapy showed better survival rates compared with those who received other or no adjuvant treatment. The benefit of adjuvant chemotherapy was observed across all tumour stages, including surgically staged FIGO stage IA. These data question the role of surgical staging in the absence of macroscopic disease in USC.

Cervical cancer incidence in young women: a historical and geographic controlled UK regional population study.

BACKGROUND: The commencing age of cervical screening in England was raised from 20 to 25 years in 2004. Cervical cancer incidence in young women of England is increasing. It is not clear if this is due to either greater exposure to population risk factors or reduced cervical screening. METHODS: We measured if the relative risk of cervical cancer in younger women (20-29 years) of the north-east of England (NE) differed to that of women aged 30yrs and above since 2004. We also measured average annual percentage change (AAPC) in the 3 yr moving average incidence for all age-groups. Regional screening coverage rate and population risk factors were reviewed. Comparisons were made with Wales where screening continues to commence from the age of 20yrs. RESULTS: Cervical cancer incidence in women aged 20-29 increased annually by an average of 10.3% between 2000 and 2009. The rise in women aged 30-39 was less steep (3.5%/year) but no significant rise was observed in women aged 40-49. Socioeconomic factors remained stable or improved during the time period except for the incidence of chlamydia, herpes simplex and in particular, genital warts, which increased significantly in young women. Data from Wales show similar results. CONCLUSION: The incidence of cervical cancers in young women of the NE is increasing. The rise in incidence is unrelated to the change in screening policy in 2004. Close monitoring of incidence in young women and a greater attempt to reverse the current decline in screening coverage of women aged 25-29 years are recommended.

Tumour-free distance from serosa is a better prognostic indicator than depth of invasion and percentage myometrial invasion in endometrioid endometrial cancer.

OBJECTIVE: To evaluate the prognostic performance of tumour-free distance (TFD) compared with depth of invasion (DOI) and percentage of myometrial invasion (MI). DESIGN: Retrospective cohort study. SETTING: Regional gynaecological oncology centre. POPULATION: All women identified with stage I-III endometrioid endometrial carcinoma from January 2000 to December 2007, who had surgery at the Northern Gynaecological Oncology Centre (NGOC). METHODS: Surgicopathological, follow-up and survival data were collected. Univariate and multivariate analyses were performed comparing TFD, DOI and MI with known prognostic factors. The prognostic accuracy of TFD was assessed by receiver operating characteristic (ROC) curve analyses, and an optimum cut-off was proposed. MAIN OUTCOME MEASURES: Death from disease, recurrence and pelvic lymph node involvement. RESULTS: A total of 288 women were identified. The median follow-up time was 67 months, with 40 recurrences and 32 disease-related deaths. When TFD, DOI and MI were separately examined in multivariate analyses with other covariates, TFD was an independent predictor of death from disease (HR 1.22; 95% CI 1.00-1.48; P = 0.05). In multivariate analyses including all three measures together (TFD, DOI and MI), TFD was an independent predictor of death from disease (HR 1.49; 95% CI 1.03-2.16; P = 0.04) and recurrence (HR 1.39; 95% CI 1.01-1.91; P = 0.05). TFD was also an independent predictor of lymph node involvement when examined separately (OR 0.74; 95% CI 0.56-0.96; P = 0.03), and together with DOI and MI (OR 0.67; 95% CI 0.49-0.92; P = 0.01), in women who had pelvic lymphadenectomy (n = 86). A TFD cut-off of 1.75 mm showed good prognostic performance. CONCLUSIONS: The TFD measure may be a more accurate method of representing myometrial invasion in the staging for endometrial cancer.

Intra-operative frozen section analysis for suspected early-stage ovarian cancer: 11 years of Gateshead Cancer Centre experience.

OBJECTIVE: In centres in which intra-operative frozen section (FS) analysis is not performed, 'apparent' early-stage ovarian cancer diagnosed after surgery on paraffin section may require further restaging laparotomy or adjuvant chemotherapy. Previous studies on FS analysis have reported high sensitivity, specificity and overall accuracy. The objective of this article is to present the largest published dataset on the accuracy of FS analysis over an 11-year period from a single institution. DESIGN: Diagnostic test accuracy. SETTING: Northern Gynaecological Oncology Centre and Department of Cellular Pathology, Gateshead, UK. POPULATION: 1439 intra-operative FS analyses performed between January 2000 and December 2010 for suspected ovarian cancer. METHODS: Prospectively collected data on FS analysis were compared with gold standard paraffin section. MAIN OUTCOME MEASURES: Sensitivity, specificity, likelihood ratios and post-test probability. RESULTS: The overall sensitivity and specificity of FS analysis were 91.2% and 98.6%, respectively. Positive and negative likelihood ratios were 64.7% and 0.09%, respectively. The pre-test probability of an ovarian tumour being borderline or malignant was 45.8%. When FS analysis was reported to be positive, the post-test probability increased to 98% (confidence interval, 97-99%). Conversely, when FS analysis was reported to be negative, the post-test probability decreased to 7% (confidence interval, 6-9%). The majority of false test results were either borderline tumours or of mucinous differentiation. CONCLUSIONS: Intra-operative FS analysis has excellent diagnostic test accuracy and assists gynaecological oncologists to perform the appropriate surgery in 95% of cases, thereby preventing the morbidity of surgical staging in benign cases and the morbidity of restaging procedures or chemotherapy in early-stage malignant tumours.

Borderline nuclear change, high-grade dyskaryosis not excluded: current concepts and impact on clinical practice.

OBJECTIVE: Borderline nuclear change, high-grade dyskaryosis not excluded (B/HG) is a subcategory of the borderline category recommended by the British Society for Clinical Cytology as warranting direct referral to colposcopy. This subcategory is equivalent to the Bethesda category of atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H). The purpose of this study was to determine the validity and accuracy of using B/HG to identify potential cervical intraepithelial neoplasia (CIN) grade 2 or worse (CIN2+). METHODS: Data were collected from the hospital pathology database for borderline, B/HG and high-grade cytology (moderate dyskaryosis and above), and their respective histological and colposcopic outcomes. SPSS was used for data analysis. RESULTS: Of the 84,799 total cytology samples screened between July 2006 and December 2009, 5225 (6.1%) were reported as borderline, 309 (0.4%) as B/HG and 1222 (1.4%) as high-grade cytology. Thus, B/HG comprised 5.9% of the overall borderline category, in keeping with national guidelines (<10%). CIN2+ was confirmed in 86.6% of high-grade, 40.8% of B/HG and 3.0% of borderline cytology. Of 309 women reported with B/HG cytology, 239 had colposcopy. Colposcopic appearances showed a positive predictive value (PPV) of 71.8% for detecting CIN2+ and a negative predictive value of 60.7%. CONCLUSIONS: The B/HG category was associated with a significantly higher incidence of CIN2+ compared with borderline cytology as a whole. This refining performance justifies its existence. Colposcopic appearances had a high PPV for detecting CIN2+. Therefore, colposcopy is recommended in patients with B/HG cytology and treatment should be offered if high-grade colposcopic changes are seen.

Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme.

OBJECTIVE: An analysis of surgical experience in gastrointestinal procedures within a UK-based gynaecological oncology centre to which subspecialty fellows within the subject are exposed. DESIGN: Retrospective study. SETTING: Northern Gynaecological Oncology Centre, Gateshead, UK. POPULATION: All women undergoing bowel surgery over a six-year period, 1 January 2000 to 31 December 2005. METHODS: Cases were analysed by specialty and grade of surgeon performing the procedure. MAIN OUTCOME MEASURE: Proportion of cases to which subspecialty fellows were exposed. RESULTS: Two hundred and sixty-two women (11.5%) underwent bowel surgery out of 2280 women undergoing major surgery for gynaecological cancer. This included ovarian/primary peritoneal cancer in 186 women (71%). Of these 262 cases, 238 operations (91%) were performed by a gynaecological oncologist, 20 (7.5%) were performed jointly with the gastrointestinal surgeons and four (1.5%) were performed solely by the gastrointestinal surgeons. A gynaecological oncology subspecialty fellow performed 21 (8%) and assisted in an additional 204 operations (78%). Perioperative morbidity and mortality statistics in addition to overall survival outcomes were comparable to the published literature. CONCLUSIONS: A significant proportion of major surgical operations performed within a gynaecological oncology centre require gastrointestinal procedures. The majority of these procedures can be performed by gynaecological oncologists with an acceptable perioperative morbidity and mortality rate. Subspecialty training has the potential to allow trainees significant exposure to these procedures. An accredited post-Fellowship Training Programme can provide the opportunity for hands-on experience to allow gynaecological oncologists the confidence and credibility to perform these procedures independently.

Patients' views of follow-up after treatment for gynaecological cancer.

This project set out to quantify women's views of routine follow-up. Women attending for routine follow-up after gynaecological cancer completed a questionnaire. A total of 54% (48/89) reported increased anxiety prior to their appointment, and 10% (9/90) still felt more anxious afterwards. Most women (82/92, 89%) preferred to see a hospital doctor, and preferred this to a review by a specialist nurse or general practitioner (p<0.001). Women thought the examination was the most important part of the visit (p<0.0001). Women viewed the specialist nurse's role as listening to concerns and taking blood, rather than detecting recurrence (p<0.0001). Women ranked detection of recurrence as the most important reason for attending for follow-up (p<0.0001). Overall, women think that detection of recurrence is the primary rationale for routine follow-up. Their views need to be taken into consideration when considering changes in the provision of follow-up care.

Interventions for reducing anxiety in women undergoing colposcopy.

BACKGROUND: Before cervical cancer develops the cells of the cervix become abnormal. Following an abnormal cervical smear colposcopy is performed. Colposcopy is the visualisation of the cervix using a binocular microscope. Women experience high levels of anxiety and negative emotional responses at all stages of cervical screening. High levels of anxiety before and during colposcopy can have adverse consequences, including pain and discomfort during the procedure and high loss to follow-up rates. This review evaluates interventions designed to reduce anxiety levels during colposcopic examination. OBJECTIVES: To compare the efficacy of various interventions aimed at reducing anxiety during colposcopic examination in women. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (CENTRAL), (Cochrane Library, Issue 1, 2006) MEDLINE (1951-2006), EMBASE (1980-2006), CINAHL (1982-2006), Psych Lit and CancerLit, NHMRC Clinical Trials Register, UKCCCR Register of Cancer Trials, Meta-Register and Physician Data Query Protocols. SELECTION CRITERIA: Randomised and quasi randomised controlled trials of interventions to reduce anxiety during colposcopic examination. DATA COLLECTION AND ANALYSIS: One author searched the citations and reference lists. Studies that appeared to meet inclusion criteria were retrieved and assessed independently by the remaining three authors. The methodological quality of included studies was assessed using the Cochrane Collaboration Back Review Group's methodological quality criteria (van Tulder 2003). MAIN RESULTS: Eleven trials were included, these trials used various interventions to reduce anxiety. These examined 1441 women's anxiety levels after different types of intervention. These included: Information leaflets - (proved not to be associated with anxiety reduction). Counselling: pre-colposcopic counselling was not associated with anxiety reduction. Information leaflets and information video and pre-colposcopy counselling was not associated with a reduction in anxiety levels. Listening to music during colposcopy: this intervention was associated with reduction in anxiety levels (p < 0.002). Video colposcopy was associated with reduction in anxiety levels, and the reduction in anxiety was significant (p < 0.0002). Information using graphs and verbal information and information video versus information only when sought: There was no significant reduction in the level of anxiety in the intervention group. Information leaflets and information video versus information leaflets only: There was a reduction in anxiety levels in the intervention group compared to the control group (p < 0.00001). AUTHORS' CONCLUSIONS: Anxiety appears to be reduced by playing music during colposcopy, showing information videos prior to colposcopy and viewing video colposcopy during the procedure. Although information leaflets did not reduce anxiety levels, they did increase knowledge levels and so are useful in obtaining clinical consent to the colposcopic procedure.

A randomized controlled study of peritoneal closure at cesarean section.

OBJECTIVE: To assess the benefits or problems that may be associated with peritoneal closure at cesarean section. METHODS: A randomized-controlled study of women undergoing cesarean section in Sultan Qaboos University Hospital Maternity Unit. After the decision is taken for cesarean section, women were randomized to either repair of peritoneum using standard technique or non-repair of peritoneum. Duration of operation, maternal morbidity, blood loss assessed by post-operative hemoglobin change and requirement of transfusion, post operative infection, thromboembolic disease, and length of hospital stay were analyzed in 2 groups of patients. Sixty women were randomized into the study, 30 group A, had peritoneal closure and 30, group B, and had non-closure. RESULTS: The average duration of operation for group A was 61.9+/-12.734, and for group B was 53.56 +/-11.209 (p< 0.01 statistically significant). There was no statistically significant difference in the length of stay, estimated blood loss, the mean drop in hemoglobin, postoperative pyrexia, and wound infection rate between the 2 groups. CONCLUSIONS: Our study has confirmed the previous study findings, and has shown that there are no advantages in suturing of the peritoneum in terms of blood loss, blood transfusion, operation duration, postoperative pyrexia and wound infection. In fact non-suturing of the peritoneum was associated with shorter operation duration (p< 0.01 significant), and reduced cost.

Urinary tract fistulas in radical surgery for cervical cancer: the importance of early diagnosis.

BACKGROUND: Urinary fistulas are a well-recognised complication of radical gynaecological oncology surgery for cervical cancer. Reported incidence varies between 0.6 and 5.1%. METHODS: A retrospective case-note review of vesical and ureteric fistulas diagnosed in cases that underwent radical surgery for the new diagnosis of early stage cervical cancer between January 2000 and June 2010. RESULTS: A total of 323 radical procedures for cervical cancer were performed during the study period. There were nine urinary tract fistulas found in eight women undergoing radical surgery for stage 1b1 cervical cancer, giving an incidence of 2.7%. Haemorrhage was the commonest associated factor and the commonest presenting symptom for fistula was leaking of urine per vagina. The fistulas were managed conservatively or surgically depending on their nature and severity. The longer the delay in confirming the diagnosis and initiating treatment the more severe were the long-term symptoms and morbidity. CONCLUSION: Identification of predisposing factors, high index of suspicion, early investigations and multidisciplinary team management of urinary tract fistula are necessary to reduce post-operative morbidity and minimise renal loss.

Evaluation of prognostic factors and treatment outcomes in uterine carcinosarcoma.

OBJECTIVE: The aims of this study were to determine the prognostic factors, survival outcomes and response to adjuvant therapy in women with uterine carcinosarcoma treated in a single institution. STUDY DESIGN: This is a cohort study of women diagnosed with carcinosarcoma and treated at the Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead, UK. The medical records of all patients diagnosed with carcinosarcoma between January 1960 and July 2002 were reviewed. RESULTS: A total of 93 women were identified during this period. The median age was 67 years. The most common presentation was abnormal vaginal bleeding, occurring in 85%, followed by pelvic mass in 45%, and abdominal pain in 38%. At surgery there was extra-uterine spread in 54% of women. The median follow-up was 33 months (range 4-146 months). Adjuvant therapy was not associated with survival advantage. Recurrence was diagnosed in 55 patients (59%) and the overall 5-year survival for all stages was 33%. On multivariate analysis depth of myometrial invasion, stage and pelvic nodes metastasis were associated with poor survival. CONCLUSION: The poor outcome for these patients may reflect the aggressive nature of carcinosarcoma and that at the time of presentation more than 50% have extra-uterine disease, which was associated with significant poorer survival. Systemic adjuvant therapy has not been associated with significant improvement in the outcome. More studies are needed to better define the appropriate treatment for this rare cancer.

Primary endometrial squamous cell carcinoma.

Primary squamous cell carcinoma of the endometrium (PESCC) is rare and its pathogenesis is unclear. Identification of PESCC and its differentiation from endometrial involvement by squamous cell carcinoma is essential for correct patient management and is based on strict pathological criteria. We present a case of a 71-year-old patient satisfying the proposed diagnostic criteria for PESCC together with a review of the literature.

Professionals' and patients' views of routine follow-up: a questionnaire survey.

Traditionally, women who have been treated for a gynecological cancer have undergone long-term follow-up by hospital doctors. Recently, there has been interest in alternative models of follow-up, including nurse-based review. The project compares patients' and professionals' views of follow-up. A questionnaire was completed by 96 women attending routine follow-up clinics and by 32 professionals involved in delivering follow-up. A large majority of women (82/96, 92%) and professionals (25/34, 73%) thought that follow-up should be provided by a hospital doctor. However, professionals were more likely to think that specialist nurses and general practitioners should be involved in the provision of follow-up (P < 0.01). Professionals thought that the most important part of the follow-up visit was the consultation, whereas women thought it was the examination (P < 0.001). Women thought that detection of recurrence was the most important reason for continuing surveillance, whereas professionals regarded addressing patients' concerns as the primary reason for follow-up (P < 0.001). We conclude that the views of women undergoing follow-up after gynecological cancer differ significantly from the professionals providing follow-up care. These views must be considered when developing alternative follow-up strategies.

The feasibility of storing ovarian tumor cells on databasing paper: establishing a library of ovarian cancer DNA.

The purpose of this study was to assess the feasibility of establishing a library of ovarian cancer nucleic acids using paper matrix by: 1) confirming the stability of DNA stored on paper matrix over a prolonged period of time, 2) determining the amount of genetic material required for storage, and 3) establishing the stability of RNA. Tumor tissue from 66 patients with ovarian cancer was collected intraoperatively, frozen, and dissociated with collagenase and trypsin. A cell suspension was then prepared and spotted onto the paper. The numbers of cells that were stored on the paper were counted using a hemocytometer. The cell suspension was serially diluted and spotted on the paper matrix until the minimum cell number that can be stored and produce a PCR product was determined. PCR, STR genotyping and direct sequencing were performed on tissue stored on the paper matrix. FTA paper was used as RNA template, and RT PCR converted the RNA to cDNA. Ten to 50 mg of ovarian cancer tissue was stored on FTA paper. We stored 7 x 10(4) cells on ISOcode paper and 18 x 10(4) cells on FTA and obtained extractable DNA. PCR analysis on cards with DNA stored 18 months ago enabled us to establish the stability of DNA after storage. RNA was stable for 6 months when stored on FTA cards. Since genetic material is extractable from the paper matrices after passage of time, it could be a suitable medium for the storage of genetic material in cancer tissue banks.