MRI measurement of residual cervical length after radical trachelectomy for cervical cancer and the risk of adverse pregnancy outcomes: a blinded imaging analysis.

OBJECTIVE: To determine the association between the residual cervix measured on postoperative MRI after radical vaginal trachelectomy (RVT) and adverse obstetrical outcomes. DESIGN: Observational study. SETTING: Referral Cancer centre. POPULATION: Women who conceived after RVT for cervical cancer at the Royal Marsden Hospital, London, between 1995 and 2015. METHODS: Postoperative MRI scans were analysed by three researchers. The agreement between researchers was assessed by Pearson's correlation coefficient and Bland-Altman plot. Patients were divided into two groups (<10 and ≥10 mm residual cervix) for the analysis of adverse obstetrical outcomes. MAIN OUTCOME MEASURES: Late miscarriage, premature delivery, premature rupture of membranes (PROM) and chorioamnionitis. RESULTS: Thirty-one MRI scans were available; 29 of these women had a pregnancy that progressed beyond the first trimester. There was a strong reproducibility of the measurement of residual cervix (P < 0.001). Nineteen women (65.5%) had <10 mm residual cervix and 10 (34.5%) had ≥10 mm. Among women with <10 mm residual cervix, seven (36.8%) experienced PROM and ten (66.7%) had a preterm birth; No women with ≥10 mm residual cervix had PROM and two (22.2%) had a preterm birth (P = 0.028 and P = 0.035, respectively). Overall, there were nine (16.7%) first-trimester miscarriages, six (11.1%) late fetal losses, 12 (31.6%) preterm births and 36 (66.7%) live births. After a mean follow up of 78.1 months, 36 women were disease-free and one woman had died. CONCLUSIONS: MRI measurements of the residual cervix are reproducible between observers. The incidence of PROM and premature delivery is higher when the residual cervix after RVT is <10 mm. TWEETABLE ABSTRACT: The risk of prematurity after RVT can be predicted from measurements of residual cervical length on postoperative MRI scan.

Radical vaginal trachelectomy at 16 weeks' gestation: A case report.

•A young woman diagnosed with early-stage cervical cancer whilst pregnant is a clinical dilemma.•The maternal risks need to be balanced against the risks to the foetus.•Radical vaginal trachelectomy has a potential role as treatment with a favourable outcome for mother and baby.

Influencing surgical management in patients with carcinoma of the cervix using a T2- and ZOOM-diffusion-weighted endovaginal MRI technique.

BACKGROUND: Endovaginal MRI (evMRI) at 3.0-T with T2-weighted (T2-W) and ZOnal Oblique Multislice (ZOOM)-diffusion-weighted imaging (DWI) potentially improves the detection of stage Ia/Ib1 cervical cancer. We aimed to determine its sensitivity/specificity, document tumour-to-stromal contrast and establish the effect of imaging on surgical management. METHODS: Following ethical approval and written informed consent, 57 consecutive patients with suspected stage Ia/Ib1 cervical cancer underwent evMRI at 3.0-T using T2-W and ZOOM-DWI. Sensitivity/specificity were calculated against histopathology for two independent observers. Tumour-to-stromal contrast was determined on T2-W, and diffusion-weighted (b=800 s mm(-2)) images and apparent diffusion coefficients (ADCs) were recorded. In patients due for radical vaginal trachelectomy (RVT), change of surgical management based on imaging findings was documented. RESULTS: Sensitivity/specificity for detecting tumour was the following: reporting read 88.0/81.8%, anonymised read 92.0/81.8% (observer 1); 84.0/72.7% (observer2; median tumour volume=1.7 cm(3)). Intraobserver agreement was excellent (kappa=0.89) and the interobserver agreement was good (kappa=0.65). Tumour-to-stromal contrast was greater on ZOOM-DWI compared with T2-W images (3.35±2.36 vs 1.39±0.95; P<0.0004). Tumour and stromal ADCs were significantly different (P<0.00001). In 31 patients due for RVT, evMRI altered surgical management in 12 (38.7%) cases (10 cone-biopsy, 2 chemoradiotherapy). CONCLUSION: T2-W+ZOOM-DWI evMRI has high sensitivity/specificity for detecting stage Ia/Ib1 cervical tumours; in patients due for RVT, the surgical management was altered in ∼39%.

Laparoscopic staging for apparent early stage ovarian or fallopian tube cancer. First case series from a UK cancer centre and systematic literature review.

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.

Outcomes of surgical management of bowel obstruction in relapsed epithelial ovarian cancer (EOC).

OBJECTIVE: 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. METHODS: 90 women with relapsed EOC underwent palliative surgery for bowel obstruction between 1992 and 2008. RESULTS: 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). CONCLUSION: 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.

Ovarian recurrence from a Stage 1b1 cervical adenocarcinoma previously treated with radical vaginal trachelectomy: A case report.

► Post cervical cancer treatment new pelvic abnormality must be regarded as recurrence. ► Benign MRI features does not exclude recurrence from previous cervical adenocarcinoma.

Obstetric management following fertility-sparing radical vaginal trachelectomy for cervical cancer.

Radical vaginal trachelectomy now affords a fertility-sparing procedure for the treatment of early-stage cervical cancer in young women. Subsequent obstetric management within this group of women remains a challenge to the obstetrician, with risks of premature labour a continuing probability throughout pregnancy. Here we describe four cases of successful pregnancy following radical vaginal trachelectomy within our unit. The merits of early antenatal intervention, regular lower uterine segment length monitoring and use of daily progesterone pessaries are discussed, alongside the current supportive evidence. We conclude with a discussion of proposed recommendations for obstetric management of pregnancy in women post-radical vaginal trachelectomy.

Isolated groin recurrence in vulval squamous cell cancer (VSCC). The importance of node count.

OBJECTIVE: To determine whether there is a node count which can define an adequate inguinofemoral lymphadenectomy (IFL) in primary VSCC. METHODS: A retrospective and prospective review of patients with node negative VSCC who had a full staging IFL. Detection of isolated groin recurrences (IGR) would allow groins with higher risk of groin recurrence to be identified. RESULTS: The median node count of 228 IFLs in 139 patients was eight (0-24). There were six IGR (4.3%). Increased rate of IGR was present in patients with increased age, tumour diameter and depth of invasion, lymphovascular space invasion, unilateral IFL, and moderate/poor tumour grade. In the 138 groins with node counts of eight or greater there were no IGRs compared to six in the patients with either undissected groins or groin node counts less than eight (p = 0.030) Interval to IGR was significantly shorter than other sites of recurrence. Both disease-specific and overall survival were significantly reduced in IGR. CONCLUSIONS: An inadequate IFL is a nodal count of less than eight per groin; both these groins and undissected groins are at increased risk of IGR and should have close surveillance.

Conservative surgery for carcinoma of the cervix.

Cancer of the cervix is the second most common female cancer, with more than half a million cases worldwide occurring annually. Although screening programmes have significantly reduced the incidence and death rates in the western world, social pressures have led to the delay in childbearing, increasing numbers of cervix cancer present early in reproductive life and at an early stage. These women are often anxious to retain their fertility potential, if at all possible. Standard treatment is either radical hysterectomy or radiotherapy to the pelvis, both of which will inevitably compromise fertility, rendering future childbearing impossible. This has led to a questioning of the rationale for extensive surgery in all cases of early stage cervical cancer. The experience of reducing the radicality of surgery while not compromising its efficacy has been learnt from the current management of breast cancer. Such that this may be applied to cervical cancer. Accurate staging and measurement using magnetic resonance imaging can indicate the site and location of the tumour, allowing a radical wide local excision of early stage tumours to be carried out. This allows conservation of the corpus uteri with a potential for fertility preservation. An isthmic vaginal anastomosis maintains continuity of the vaginal canal after insertion of an isthmic cerclage. Laparoscopic pelvic lymphadenectomy completes the procedure. This technique combines aspects of the traditional radical vaginal hysterectomy plus the use of minimal access surgery to carry out the pelvic node dissection. A more invasive abdominal approach has also been described. Over 900 cases have been carried out and published, with 790 carried out vaginally (radical vaginal trachelectomy) and 116 abdominally. There have been over 300 pregnancies with 195 live births. Premature rupture of the membranes is a risk, with 10% of babies being significantly premature. Delivery is by classical caesarean section. Fertility rates are good with a low recurrence rate of 4%. Overall, radical vaginal trachelectomy seems to be a safe procedure in well-selected cases when carried out in centres with appropriate experience of radical vaginal surgery, and laparoscopic techniques. Obstetric management in high-risk feto-maternal units is necessary in view of the high risk of prematurity. This new approach preserves fertility in previously impossible situations and questions traditional management and teaching.

Glove perforations during open surgery for gynaecological malignancies.

OBJECTIVE: To audit glove perforations at laparotomies for gynaecological cancers. SETTING: Gynaecological oncology unit, cancer centre, London. DESIGN: Prospective audit. SAMPLE: Twenty-nine laparotomies for gynaecological cancers over 3 months. METHODS: 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. MAIN OUTCOME MEASURE: Glove perforation rate. RESULTS: 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. CONCLUSIONS: 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.

The use of inferior vena caval filters prior to major surgery in women with gynaecological cancer.

OBJECTIVE: To evaluate the use of inferior vena caval filters (IVCF) prior to surgery in women with gynaecological cancer and venous thromboembolism (VTE). DESIGN: Retrospective review of medical notes and electronic records. SETTING: Gynaecological oncology cancer centre. POPULATION: Women with gynaecological cancer and VTE requiring major surgery. METHODS: 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. MAIN OUTCOME MEASURES: Safety of IVCF placement and retrieval, peri-operative morbidity and incidence of further VTE. RESULTS: 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. CONCLUSIONS: 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.

Pre-treatment white blood cell subtypes as prognostic indicators in ovarian cancer.

OBJECTIVE: Inflammatory cells can both suppress and stimulate tumour growth and their influence on clinical outcome in cancer patients has been studied in various cancer types. Here we have investigated their influence on outcome in primary epithelial ovarian cancer. STUDY DESIGN: Serum white blood cell numbers according to subtype were recorded prior to treatment in 136 patients with primary epithelial ovarian cancer. Their correlation with overall survival and disease-free survival was analysed using both univariate and multivariate analysis adjusting for the known prognostic factors (age, stage and debulking status). RESULTS: Multivariate analysis demonstrated that a lower lymphocyte fraction of total white blood cells was significantly associated with mortality (p<0.01). On univariate analysis (p=0.0027, HR=1.15), and multivariate analysis of those patients who were optimally debulked (p=0.036, HR=1.17), a higher monocyte count was significantly associated with recurrence. On multivariate analysis amongst those who were suboptimally debulked, a higher eosinophil count was predictive of both recurrence (p=0.0037, HR=1.77) and mortality (p=0.033, HR=1.73). CONCLUSION: High monocyte counts amongst those who were optimally debulked independently predict adverse outcome in primary epithelial ovarian cancer.

Alveolar soft part sarcoma of the uterine cervix.

A 19-year-old woman presented with 1-year history of heavy irregular vaginal bleeding and iron deficiency anemia. Pelvic examination revealed a 3-4 cm size cervical lesion distorting the cervical canal but with no obvious parametrial involvement. Histology and immunohistochemistry on a wedge biopsy had features consistent with alveolar soft part sarcoma (ASPS). Preoperative imaging excluded metastasis. She subsequently underwent radical hysterectomy, left salpingo-oophorectomy, right salpingectomy, and pelvic lymph node sampling--preserving the right ovary. The histology showed negative margins and no involvement of the lymph nodes. Postoperative adjuvant radiotherapy was administered. At 18 months posttreatment, there is no sign of recurrence. We review literature on diagnosis and treatment of genital ASPS.

Primary non-Hodgkin's lymphoma of the ovaries: imaging findings.

Primary ovarian lymphoma is very rare. We report a case of primary ovarian Burkitt-type non-Hodgkin's lymphoma, describing the imaging appearance on ultrasound, CT and MRI, and review the literature.

Assessment of an in vitro model for laparoscopic pelvic lymphadenectomy.

An in vitro model was developed for laparoscopic pelvic lymphadenectomy. A construct validity study was performed comparing experienced laparoscopic surgeons with inexperienced trainees. Outcome measures included global and task-orientated scoring and data from electromagnetic motion analysis of hands. Marking was performed by three independent surgeons using video playback. A significant difference was found in the time taken, number of movements made and total distance travelled between the groups. Both scoring systems discriminated between the expert and inexperienced group, demonstrating the model's construct validity.

Evaluation of endometrial carcinoma on magnetic resonance imaging.

Our aims were to assess diagnostic performance of T2-weighted (T2W) and dynamic gadolinium-enhanced T1-weighted (T1W) magnetic resonance imaging (MRI) in the preoperative assessment of myometrial and cervical invasion by endometrial carcinoma and to identify imaging features that predict nodal metastases. Two radiologists retrospectively reviewed MR images of 96 patients with endometrial carcinoma. Tumor size, depth of myometrial and cervical invasion, and nodal enlargement were recorded and then correlated with histology. The sensitivity, specificity, positive and negative predictive values (PPV and NPV) for the identification of any myometrial invasion (superficial or deep) were 0.94, 0.50, 0.93, 0.55 on T2W and 0.92, 0.50, 0.92, 0.50 on dynamic T1W, and for deep myometrial invasion were 0.84, 0.78, 0.65, 0.91 on T2W and 0.72, 0.88, 0.72, 0.88 on dynamic T1W. The sensitivity, specificity, PPV and NPV for any cervical invasion (endocervical or stromal) were 0.65, 0.87, 0.57, 0.90 on T2W and 0.50, 0.90, 0.46, 0.92 on dynamic T1W, and for cervical stromal involvement were 0.69, 0.95, 0.69, 0.95 on T2W and 0.50, 0.96, 0.57, 0.95 on dynamic T1W. Leiomyoma or adenomyosis were seen in 73% of misdiagnosed cases. Sensitivity and specificity for the detection of nodal metastases was 66% and 73%, respectively. Fifty percent of patients with cervical invasion on MRI had nodal metastases. In conclusion, MRI has a high sensitivity for detecting myometrial invasion and a high NPV for deep invasion. MRI has a high specificity and NPV for detecting cervical invasion. Dynamic enhancement did not improve diagnostic performance. MRI may allow accurate categorization of cases into low- or high-risk groups ensuring suitable extent of surgery and adjuvant therapy.

The performance of magnetic resonance imaging in early cervical carcinoma: a long-term experience.

We report our long-term experience of performance of magnetic resonance imaging (MRI) in localizing cervical tumor, assessing tumor size, staging, and lymph node infiltration in patients with early cervical cancer. MRI of 150 patients with early carcinoma between 1995-2005 was retrospectively reviewed. Tumor location, size, tumor distance from internal os, parametrial invasion, myometrial invasion, lymph node size, and location were documented. All patients underwent surgery, pelvic lymphadenectomy, and histological correlation of MRI findings. For staging, MRI and histopathology had kappa value of 0.89. For parametrial invasion, MRI had specificity, negative predictive value (NPV) of 97% and 100%, respectively. For tumor size, MRI and histology had mean difference of -0.9 mm with 95% limits of agreement between -12.6 to +13 mm. In tumors greater than 10 mm, mean difference was 0.3 mm and limits of agreement were -7.5 to +7.9 mm. For internal os involvement sensitivity, specificity, positive predictive value (PPV) and NPV were 90%, 98%, 86%, 98%. respectively. For myometrial invasion sensitivity, specificity, NPV, and PPV were 100%, 99%, 88%, 100%, respectively. Incidence of nodal metastases was 2.9%. On a per-patient basis, sensitivity, specificity for nodal involvement was 37% and 92% and on node-by-node basis, sensitivity and specificity of MRI was 27% and 99%, respectively. Our study confirms MRI is highly accurate in localizing cervical tumor, excluding parametrial invasion, confirming myometrial and internal os invasion. MRI is therefore useful in selecting patients for surgery and mandatory in patients for fertility-preserving surgery. Using accepted size criteria for nodal involvement, MRI is insensitive and currently will not avoid need for pelvic lymphadenectomy.