Assessment of endometrial sampling as a predictor of final surgical pathology in endometrial cancer.

BACKGROUND: The histology and grade of endometrial cancer are important predictors of disease outcome and of the likelihood of nodal involvement. In most centres, however, surgical staging decisions are based on a preoperative biopsy. The objective of this study was to assess the concordance between the preoperative histology and that of the hysterectomy specimen in endometrial cancer. METHODS: Patients treated for endometrial cancer during a 10-year period at a tertiary cancer centre were identified from a prospectively collected pathological database. All pathology reports were reviewed to confirm centralised reporting of the original sampling or biopsy specimens; patients whose biopsies were not reviewed by a dedicated gynaecological pathologist at the treating centre were excluded. Surgical pathology data including histology, grade, depth of myometrial invasion, cervical stromal involvement and lymphovascular space invasion (LVSI) as well as preoperative histology and grade were collected. Preoperative and final tumour cell type and grade were compared and the distribution of other high-risk features was analysed. RESULTS: A total of 1329 consecutive patients were identified; 653 patients had a centrally reviewed epithelial endometrial cancer on their original biopsy, and are included in this study. Of 255 patients whose biopsies were read as grade 1 (G1) adenocarcinoma, 45 (18%) were upgraded to grade 2 (G2) on final pathology, 6 (2%) were upgraded to grade 3 (G3) and 5 (2%) were read as a non-endometrioid high-grade histology. Overall, of 255 tumours classified as G1 endometrioid cancers on biopsy, 74 (29%) were either found to be low-grade (G1-2) tumours with deep myometrial invasion, or were reclassified as high-grade cancers (G3 or non-endometrioid histologies) on final surgical pathology. Despite these shifts, we calculate that omitting surgical staging in preoperatively diagnosed G1 endometrioid cancers without deep myometrial invasion would result in missing nodal involvement in only 1% of cases. CONCLUSIONS: Preoperative endometrial sampling is only a modest predictor of surgical pathology features in endometrial cancer and may underestimate the risk of disease spread and recurrence. In spite of frequent shifts in postoperative vs preoperative histological assessment, the predicted rate of missed nodal metastases with a selective staging policy remains low.

Intraoperative margin assessment of the radical trachelectomy specimen.

OBJECTIVE: To summarize our experience in the frozen section (FS) assessment of the trachelectomy surgical margin. METHODS: All surgeries from 1994 to 2007 were performed by one surgeon. The FS examination was consistently carried out by a group of gynecologic pathologists according to the protocol described in details in this article. Cases were retrieved from the pathology files and the slides were reviewed by two pathologists. RESULTS: 132 patients were identified with complete pathology records. They ranged from 17 to 46 years old (median 31). Surgeries were performed for clinical Stages 1A (n=39) and 1B (n=93) tumors (63 adenocarcinoma, 59 squamous cell carcinoma, 7 adenosquamous and 3 others). In 78 cases, no residual tumor was seen in the trachelectomy specimens as it was resected by the preceding LEEP or cone. The margin was reported as negative in 123, suspicious in 3 and positive in 6 cases. It was revised in 16 cases (6 positive, 2 suspicious and 8 negative but <5 mm). Final margin assessment agreed with the FS diagnosis in 130 (98.5%) and showed interpretational overcall in 2 cases (1.5%); only one of which resulted in a revised margin. No false negative intraoperative assessment was found. CONCLUSIONS: We describe our FS protocol and summarize our data. This protocol is reliable since none of the patients was under-treated.

Immunohistochemical assessment of proliferation markers and altered gene expression in archival specimens of ovarian epithelial tumors.

Recently reported morphologic and molecular genetic evidence suggests that some ovarian carcinomas arise from their benign and low malignant potential (LMP) counterparts. In order to help reach a better understanding of ovarian tumorigenesis, we studied a wide range of gene products involved in cellular growth regulation in archival material obtained from three groups of tumors with graduated malignant potential. Immunohistochemical staining was performed for Ki-67, proliferating cell nuclear antigen (PCNA), epidermal growth factor receptor (EGFR), HER-2/neu-encoded receptor protein, p53 gene product, and multidrug resistance gene product (P-glycoprotein). The expression of EGFR, HER-2/neu-encoded receptor protein, and mutant p53 product was significantly lower in LMP tumors than in carcinomas (p < 0.05). HER-2/neu immunopositivity was more prevalent in adenocarcinomas than in LMP tumors, and the proportion of HER-2/neu-positive adenocarcinomas increased with the progression of the disease. The staining differences between LMP tumors and adenocarcinomas with antibodies against Ki-67, PCNA, and P-glycoprotein were not statistically significant. Immunohistochemical detection of EGFR, HER-2/neu, and p53 in ovarian epithelial tumor is relevant to ovarian tumorigenesis. It could serve as a powerful tool for the pursuit of retrospective studies focused on these important biologic markers.

The impact of socioeconomic setting and program effort on contraceptive prevalence in the Egyptian governorates.

PIP: The authors measured the impact of the socioeconomic setting (SES) and the family planning program effort upon variations in the contraceptive prevalence rate (CPR) at the governorate level during 1992. Indexes are developed to measure the SES and the family planning program effort at the governorate level. The study was also conducted to measure the extent to which the SES and the program effort affect CPRs at the governorate level and to measure the impact of the SES on the program effort. The following indicators were chosen to use in building the SES index: population literacy rate, primary and secondary school enrollment ratios, life expectancy at birth, infant mortality rate, per capita income, percent of the population working in agriculture, and the percent of the population living in urban areas. The number of governorate population council meetings; the number of women per family planning center; the number of women per pharmacy; the percent of women who have family planning services in their localities; the number of information, education, and communication hours per 1000 women/year; the number of home visits per woman; record keeping and statistical reporting; social marketing; and the private sector were chosen as indicators in building the family planning program effort index.^ieng

Determinants of birth intervals in Sudan.

Using individual birth history data from the Sudan Fertility Survey, 1979, parity-related differences in fertility are demonstrated, as well as differences between socioeconomic groups. Rural women, women with no education and those married to uneducated husbands show rapid parity progression and its cumulative effects on fertility which are consistent over all birth intervals. Urban women, women with some education and those married to educated husbands, however, go rapidly through their second and third birth intervals and then more slowly at higher parities. A limitation of the study was the inability to control fully for the effects of breast-feeding and contraception. There is evidence for a reduction in high parity births, starting in the 1970s.

Attitudes of urban Sudanese men toward family planning.

Using data from the Male Attitude Survey of 1985, this paper shows that Sudanese men play a major role in family planning decision-making. Attitudes regarding family planning issues are presented for 1,500 men aged 18 years and over, living in urban areas of Khartoum, the capital of Sudan. The decision not to practice family planning is found to be male-dominated, and husbands are responsible for providing contraceptives when family planning is practiced. Widespread misconceptions about vasectomy, along with a very low acceptance rate, exist among the men in the sample. It is concluded that the involvement of men in family planning programs will give these programs a better chance of success in the future.

PIP: The 1985 Male Attitude Survey, developed by the Sudan Fertility Control Association and Family Health International, is the 3rd knowledge, attitude, and practice survey done in the urban areas of Khartoum Province. The others were done in 1978 and 1982. Large families are desired in this area, and the fertility rate in the northern Sudan is 6.9. The sample for this study included 1500 Sudanese Moslem males over 18 from 835 households. 87% had some education; 7% were illiterate. 1/4 of the men were laborers or farmers, and the average monthly income was $38.00 (US). The average number of children ever born was 2.54. 96% of the respondents knew of at least 1 method of contraception, but only 18.7% had ever practiced it. Among the 636 ever-married men, 30.6% were ever-users. 59.5% of the men approved of family planning, or at least felt that it was not against Islamic law. Of the 90% of men who had any opinion about an ideal family size, the mean selected was 4.8. 40.2% of the men wanted more children, and 75% said that Islam encourages large families. Among ever-married men who expressed an opinion, 44.7% said that family planning decisions should be made jointly by husband and wife; 34.1% felt they were the husband's responsibility. Of the 475 ever-married men who had never practiced family planning, the decision had been made by the husband in 37% of the cases. Of the 258 men currently practicing contraception, the husband had made the decision in 13.9% of families; the decision was made jointly in 69.6% of families. In 61.3% of cases the contraceptives were obtained by the husband. 72.3% of families obtained contraceptives from private sources; only 6% went to a family planning clinic for contraceptives, and only 7.9% of those who had questions about family planning said that they would seek advice at a family planning clinic. 14.8% of families that stopped using contraceptives even though they wanted no more children, stopped contracepting because of the negative sociocultural associations of contraception. 30.6% of the men approved of tubal ligation for their wives, if circumstances warranted, but only 8.5% said they would accept vasectomy. 34% of the men thought of it as castration, 26% thought it reduces sexual potency, and 20% thought that it affects the ability to do manual labor. Since male attitudes toward family planning are bound to affect the success of a family planning program in urban Khartoum, it is suggested that future programs involve men as much as possible.

Age pattern of fertility in the Sudan.

PIP: Birth registration in the Sudan as in many other developing countries is incomplete and far from accurate. Estimates are based on census or sample survey data. Methods of analysis are applied which are suitable to the kind and quality of the collected information, and data provided by the World Fertility Survey is used. The number of children everborn tabulated by the duration of marriage is used to derive an estimate of the age pattern of fertility. These observed average parities are here used for the estimation of the age specific fertility schedule. The advantages of applying this method to the Sudanese data are mainly due to the greater confidence in the reports of the duration of marriage than in reports of age. It is believed that sociocultural factors in the Sudan help to sustain a high level of fertility. A few of these factors are the high infant mortality rate, the high economic and psychological value of children, and the large preferred family size. In spite of the evidence of some contraceptive use, the effectiveness of such use in reducing fertility is low. Yet the present analysis shows that the level of marital fertility is only 78% of the natural model schedule, a level which is lower than expected. A possible explanation may lie in the high level of maternal morbidity, poor nutritional and hygienic conditions in general and the substantial amount of pregnancy wastage and number of stillbirths, especially for young wives. Adequate antenatal care is lacking or even absent in some areas. These factors may have a negative effect on fecundity. However, the crude birth rate is high. This may be due to the prevalence of the traditional pattern of 1st marriage characterized by early and almost universal marriage of females. The calculated crude birth rate is consistent with the rate calculated by other methods using different data.^ieng