The Impact of Sociodemographic Factors and Emergency Admissions on the Place of Death of Gynecological Cancer Patients in England: An Analysis of a National Mortality-Hospital Episode Statistics-Linked Data Set.

OBJECTIVE: The aim of this study was to develop a predictive model for risk of death in hospital for gynecological cancer patients specifically examining the impact of sociodemographic factors and emergency admissions to inform patient choice in place of death. METHODS: The model was based on data from 71,269 women with gynecological cancer as underlying cause of death in England, January 1, 2000, to July 1, 2012, in a national Hospital Episode Statistics-Office for National Statistics database. Two thousand eight hundred eight deaths were used for validation of the model. Logistic regression identified independent predictors of a hospital death: adjusting for year of death, age group, income deprivation quintile, Strategic Health Authority, gynecological cancer site, and number of elective and emergency hospital admissions and respective total durations of stay. RESULTS: Forty-three percent of deaths from gynecological cancer occurred in hospital. The variables significantly predicting death in hospital were less recent year of death (odds ratio [OR], 0.93; P < 0.001), increasing age (OR, 1.17; P < 0.001), increasing deprivation (OR, 1.06; P < 0. 001), increasing frequency and length of elective and emergency admissions (P < 0.001). The model correctly identified 73% of hospital deaths with a sensitivity of 75% and a specificity of 72%. The areas under the receiver operating curve were 0.78 for the predictive model and 0.71 for the validation data set. Each subsequent emergency admission in the last month of life increased the odds of death in hospital by 2.4 times (OR, 2.38; P < 0.001). Hospital deaths were significantly lower in all other regions compared with London. The model predicted a 16% reduction of deaths in hospital if 50% of emergency hospital admissions in the last month of life could be avoided by better community care. CONCLUSIONS: Our findings could enable identification of patients at risk of dying in hospital to ensure greater patient choice for place of death.

Raman spectroscopy and multivariate analysis for the non invasive diagnosis of clinically inconclusive vulval lichen sclerosus.

Vulval lichen sclerosus (LS) is a common inflammatory condition associated with an increased risk of developing vulval carcinoma. Diagnosis is usually clinical although biopsy is necessary if the diagnosis is uncertain or if there is a failure to respond to adequate initial treatment. Raman spectroscopy has the potential to be applied in vivo for near real time objective non-invasive optical diagnosis, avoiding the need for invasive tissue biopsies. The aim of this study was to evaluate the diagnostic performance of Raman spectroscopy for differentiating LS from other vulval conditions in fresh vulval biopsies. Biopsies were analysed from 27 women with suspected LS in whom the attending gynaecologist could not establish the diagnosis on clinical presentation alone. Spectral variance was explored using principal component analysis and in conjunction with the histological diagnoses was used to develop and test a multivariate linear discriminant classification model. This model was validated with leave one sample out cross validation and the diagnostic performance of the technique assessed in comparison with the pathology gold standard. After cross validation the technique was able to correctly differentiate LS from other inflammatory vulval conditions with a sensitivity of 91% and specificity of 80%. This study demonstrates Raman spectroscopy has potential as a technique for in vivo non-invasive diagnosis of vulval skin conditions. Applied in the clinical setting this technique may reduce the need for invasive tissue biopsy. Further in vivo study is needed to assess the ability of Raman spectroscopy to diagnose other vulval conditions before clinical application.

Should grade 3 endometrioid endometrial carcinoma be considered a type 2 cancer-a clinical and pathological evaluation.

OBJECTIVE: Endometrial cancer is classified into: Type I estrogen-dependent endometrioid adenocarcinoma, with good prognosis and type 2 non-estrogen-dependent cancer with serous or clear cell histology and poor prognosis. Grade 3 endometrioid cancers (G3 EEC), share features of type 1 and type 2 cancer and have not been classified as either. This study compares immunohistochemistry and survival in G3 EEC and type 2 cancers. METHODS: Clinicopathological data compared with immunohistochemistry and survival in 156 consecutive patients with poor prognosis cancer-G3 EEC, uterine papillary serous (UPSC) and clear cell carcinoma (CC), sarcoma, carcinosarcoma and endometrial tumors of mixed histology. 131 (84%) datasets were complete, 25 tumors comprising sarcoma, carcinosarcoma or mixed histologies were excluded. Tissue microarray constructed and tested for estrogen receptor (ER), progesterone receptor (PR), p53 and human epidermal growth factor receptor-2 (Her-2). RESULTS: There was no significant difference in the mean age for G3 EEC (n=68) and USPC + CC (n=38), (68.01 and 67.08 respectively, p=0.697) or stage at diagnosis (p=0.384). For ER, PR, p53 and Her-2, there was no significant difference in marker positivity between G3 EEC and UPSC + CC (p=0.612, 0.132, 0.16 and 0.132 respectively). With a mean follow-up time 148 months Disease specific and recurrence-free survival between G3 EEC and USPC + CC was similar (p=0.842 and 0.863). CONCLUSION: G3 EEC and UPSC + CC share similar clinical, immunohistochemistry and poor survival. G3 EEC is better characterised as type 2 cancer and should be treated with similar adjuvant therapy to UPSC/CC.

Simple vaginal trachelectomy as a fertility-sparing treatment to manage high-grade dyskaryosis following multiple large loop excision of the transformation zone.

A 34-year-old nullipara, wishing to start a family, presented to colposcopy clinic. Her most recent cervical cytology result showed high-grade dyskaryosis. Having undergone four large loop excisions of the transformation zone during the past 6 years, this woman had no remaining vaginal cervix. In order to excise presumed high-grade cervical intraepithelial neoplasia while mitigating obstetric risk, she underwent a simple vaginal trachelectomy and isthmic cerclage. 6 months later, the patient had a negative test of cure. 7 months following surgery she became pregnant naturally. At 29 weeks she had antenatal sepsis of unknown cause, which was treated with intravenous antibiotics. She delivered by caesarean section at 37 weeks and now has a healthy child. This report will discuss the obstetric impact of colposcopic treatment, and simple vaginal trachelectomy as a fertility-sparing treatment option for women who have had multiple loop excision procedures to treat premalignant lesions.

Advances in the management of cervical cancer.

This review presents key advances in the management of cervical cancer. Traditionally, cervical cancer is staged clinically and has been treated either by radical hysterectomy or by radiotherapy. Improvements in imaging have led to more accurate therapeutic decision making and treatment planning. The evidence on fertility-preserving surgery for cervical cancer and chemoradiotherapy for locally advanced cancer is summarized here. An improved understanding of the viral aetiology of cervical cancer has led to the development of therapeutic vaccination, with limited success. There is increasing recognition of the psychosexual needs of women who have survived cervical cancer.

Influence of omental biopsy on adjuvant treatment field in clinical Stage I endometrial carcinoma.

In this study to assess the role of omental biopsy in the diagnosis of extrapelvic disease, data from 100 consecutive women with clinical Stage I endometrial cancer undergoing primary surgical treatment in our institution were analysed: 80 women had an omental biopsy, 20 did not, and six had adenocarcinoma in the omentum. No obvious morbidity attributable to this rapid and easily performed surgical procedure was recorded. We conclude that visual inspection and palpation of the omentum at the time of abdominal surgery for endometrial carcinoma is worthwhile and advisable. In addition, adopting a protocol of histological assessment upstaged a further two cases of this series. These data suggest that this technique might influence the prescription of adjuvant pelvic radiation in approximately one in 10 women currently considered for such therapy, as disease can be easily documented as having extended beyond the conventional radiotherapy field.