Ovarian Cancer, Version 1.2016, NCCN Clinical Practice Guidelines in Oncology.

This selection from the NCCN Guidelines for Ovarian Cancer focuses on the less common ovarian histopathologies (LCOHs), because new algorithms were added for LCOHs and current algorithms were revised for the 2016 update. The new LCOHs algorithms include clear cell carcinomas, mucinous carcinomas, and grade 1 (low-grade) serous carcinomas/endometrioid epithelial carcinomas. The LCOHs also include carcinosarcomas (malignant mixed Müllerian tumors of the ovary), borderline epithelial tumors (also known as low malignant potential tumors), malignant sex cord-stromal tumors, and malignant germ cell tumors.

Hypomagnesemia Is Prevalent in Patients Undergoing Gynecologic Surgery by a Gynecologic Oncologist.

OBJECTIVE: The aim of this study was to assess the incidence of and risk factors for hypomagnesemia in patients undergoing gynecologic surgery by a gynecologic oncologist. METHODS: A retrospective chart review was performed on all patients undergoing surgery for gynecologic pathology from July 2011 to July 2015 by a single surgeon. Demographic data, surgical indication, surgery performed, preoperative laboratory values, postoperative laboratory values, and medical history were examined. Hypomagnesemia was defined as less than 1.8 mg/dL. Hypermagnesemia was defined as greater than 2.5 mg/dL. RESULTS: Six hundred sixty-nine patients were identified for analysis. One hundred ninety-seven patients had hypomagnesemia (29.4%). Four hundred sixty-six patients had normal magnesium levels (69.5%), and 6 patients had hypermagnesemia (1%). Among patients with benign disease, 24.9% had preoperative hypomagnesemia compared with 32.7% of patients with a gynecologic malignancy. African American race (P = 0.041), diabetes mellitus (P < 0.001), and malignancy (P = 0.029) were all associated with preoperative hypomagnesemia. Diabetes and major surgery were associated with postoperative hypomagnesemia (P = 0.012 and P = 0.048, respectively). Hypomagnesemia was associated with increased preoperative and postoperative pain (P = 0.049 and P < 0.001, respectively) as well as postoperative hypokalemia (P = 0.001). Age, body mass index, hypertension, cancer type, hematocrit, surgical indication, and length of hospital stay were not associated with hypomagnesemia. CONCLUSIONS: Perioperative hypomagnesemia is prevalent in patients undergoing gynecologic surgery by a gynecologic oncology, especially in patients who have a gynecologic malignancy. We recommend routine preoperative and postoperative evaluation of serum magnesium in all patients undergoing gynecologic surgery by a gynecologic oncologist.

Incidence and contributing factors to termination of the patient-physician relationship.

PURPOSE: Identify the incidence and factors contributing to the termination of gynecologic patient-physician relationships. METHODS: All patients terminated from the practice between January 2008 and December 2012 were identified. Charts were reviewed for demographic information, termination reason, and cancer diagnosis. RESULTS: In the five year study period, 8851 new patients presented to the division of gynecologic oncology. Within this cohort, 123 patient-physician relationships were terminated. Among terminated patients, missed appointments (63.4%), noncompliance to treatment (23.6%), disruptive behavior (10.6%), and drug abuse behavior (2.4%) were the key reasons for termination. While no patients were terminated for financial reason, statistical differences were found for those with Medicaid insurance (OR = 5; 95% CI: 3.4-7.1). Terminated patients were more likely to be younger, African American/Black, and have a diagnosis of GTD or cancer, particularly cervical cancer, when compared against all retained patients. CONCLUSION: The prevalence of patient-physician relationship termination was low at 1.4% (123/8851). However, the finding that the 52% of terminated patients had a diagnosis of cancer is concerning; 73% of which had stage III or greater disease, or were unstaged. We hope that the identification and quantification of reasons for termination and those at risk for termination, as well as the introduction of patient-navigators, will lead to improved methods to ensure patient compliance and retention.

Colposcopic acetowhitening of vulvar lesion: a validity study.

OBJECTIVE: To evaluate the acetowhite changes of the vulva as a predictor for high grade vulvar intraepithelial neoplasia. METHODS: We performed retrospective analysis from 344 patients referred to our gynecology oncology clinic for genital dysplasia. All patients underwent vulvar colposcopy. Vulvar biopsies were performed for acetowhite changes and visible vulvar lesions such as ulceration, hyperpigmentation, and thickening of the vulvar tissue. High grade vulvar dysplasia was defined as vulvar intraepithelial neoplasia 2 or worse. Results of the vulvar pathology were collected and sensitivity, specificity, negative and positive predictive values. RESULTS: Of the 344 women who underwent vulvoscopy 241 patients had acetowhite lesions, of whom 89 had true high grade dysplasia. Using colposcopic acetowhite changes as a marker for high grade vulvar dysplasia, the test's sensitivity was 97 %, specificity was 40 %, negative predictive value was 98 %, and the positive predictive value was 37 %. CONCLUSION: Acetowhitening of the vulva has high sensitivity but low specificity as a predictor of high grade vulvar intraepithelial neoplasia. The absence of acetowhite lesion can reassure that high grade vulvar lesion is absent.

Multimodal pain control is associated with reduced hospital stay following open abdominal hysterectomy.

OBJECTIVE: To study the association of a multimodal pain protocol (MMPC) and reduced hospital stay after open abdominal hysterectomy. STUDY DESIGN: The study design was a comparison of a prospective cohort with a retrospective historical control. We enrolled endometrial cancer patients undergoing open abdominal hysterectomy with lymphadenectomy by the same surgeon. Control patients from 2008 to 2010 who received morphine PCA alone were compared with a similar demographic group of patients from 2011 to 2013 who received MMPC. MMPC consisted of gabapentin (900mg PO) and acetaminophen (1g IV) administered 45-60min preoperatively. The surgical site was injected with bupivacaine with 0.5% epinephrine prior to incision. The postoperative pain control regimen consisted of gabapentin (300mg PO every 6h), acetaminophen (1g IV every 8h for 24h postoperatively), ketorolac (15mg IV every 6h for 48h postoperatively), morphine PCA (2mg IV every 10min, no basal rate) and oxycodone/acetaminophen (10/325mg PO every 6h as needed). RESULTS: Length of hospital stay (LOH) of the study cohort (N=105 with MMPC) was compared with the historical with postoperative morphine alone (N=113 without MMPC). There were no differences in demographic, uterine cancer stage, or comorbidities between the two arms. The LOH was 1.6 days for patients receiving MMPC and 3.3 days for patients who received morphine alone (P<0.001). CONCLUSION: Multimodal pain control is associated with significantly reduced hospital stay after open abdominal hysterectomy.

The effect of ovarian imaging on the clinical interpretation of a multivariate index assay.

OBJECTIVE: The purpose of this study was to investigate the relationship between imaging and the multivariate index assay (MIA) in the prediction of the likelihood of ovarian malignancy before surgery. STUDY DESIGN: Subjects were recruited in 2 related prospective, multiinstitutional trials that involved 44 sites across the United States. Women had ovarian imaging, biomarker analysis, and surgery for an adnexal mass. Ovarian tumors were classified as high risk for solid or papillary morphologic condition on imaging study. Biomarker and imaging results were correlated with surgical findings. RESULTS: Of the 1110 women who were enrolled with an adnexal mass on imaging, 1024 cases were evaluable. There were 255 malignant and 769 benign tumors. High-risk findings were present in 46% of 1232 imaging tests and 61% of 1024 MIA tests. The risk of malignancy increased with rising MIA scores; similarly, the likelihood of malignancy was higher for high-risk, compared with low-risk, imaging. Sensitivity and specificity for the prediction of malignancy were 98% (95% CI, 92-99) and 31% (95% CI, 27-34) for ultrasound or MIA; 68% (95% CI, 58-77) and 75% (95% CI, 72-78) for ultrasound and MIA, respectively. For computed tomography scan or MIA, sensitivity was 97% (95% CI, 92-99) and specificity was 22% (95% CI, 16-28); the sensitivity and specificity for computed tomography scan and MIA were 71% (95% CI, 62-79) and 70% (95% CI, 63-76). Only 1.6% of ovarian tumors were malignant when both tests indicated low risk. A logistic regression model to predict risk of malignancy is presented. CONCLUSION: An understanding of how pelvic imaging influences the MIA score can help clinicians better interpret the malignant risk of an ovarian tumor.

Computed tomography adnexal mass score to estimate risk for ovarian cancer.

OBJECTIVE: We wish to develop a CT scan-based scoring system which estimates the probability of adnexal mass malignancy. METHODS: Patients (324) undergoing adnexal mass surgery were recruited into the study from June 1, 2002, to January 1, 2009. All study patients had a preoperative CT scan and serum CA-125 test. CT scan abnormalities included any solid tumor components, ascites, and pelvic or abdominal lymphadenopathy and omental caking. RESULTS: There were 225 (70%) benign and 99 (30%) malignant ovarian masses. Using logistic regression with the area under the curve of the receiver operating curve of 82%, the cancer probability was determined by the equation. e(-3.6372+0.0306*(A)+0.001*(C)+1.551*(D)+1.7377*(E)+2.76*(F)) / 1+e(-3.6372+0.0306*(A)+0.001*(B)+0.876*(C)+1.551*(D)+1.7377*(E)+2.76*(F)) where A = age, B = CA-125, C = solid adnexal mass is 1 and cystic is 0, D = ascites is 1, E = omental caking is 1 and absence is 0, F = node size ≥1 cm is 1 and <1 cm is 0 value. The natural logarithm e is a constant [2.718281828]. For example, for a woman of age 60, CA-125 = 50 U/mL, with solid adnexal mass, ascites, omental caking, and lymphadenopathy, the probability is 0.994. Hence, this woman has a 99.4% probability of having cancer. CONCLUSION: The computed tomography adnexal mass score combines CT scan findings, CA-125, and patient age into an equation to predict the malignant probability of an adnexal mass.

Ovarian cancer, version 2.2013.

These NCCN Guidelines Insights focus on the major updates to the 2013 NCCN Guidelines for Ovarian Cancer. Four updates were selected based on recent important updates in the guidelines and on debate among panel members about recent clinical trials. The topics include 1) intraperitoneal chemotherapy, 2) CA-125 monitoring for ovarian cancer recurrence, 3) surveillance recommendations for less common ovarian histopathologies, and 4) recent changes in therapy for recurrent epithelial ovarian cancer. These NCCN Guidelines Insights also discuss why some recommendations were not made.

Risk factors for anal intraepithelial neoplasia in women with genital dysplasia.

OBJECTIVE: To identify risk factors associated with anal intraepithelial neoplasia and develop a model for predicting the likelihood of anal intraepithelial neoplasia in heterosexual women. METHODS: A prospective cohort of 327 patients from 2006 to 2011 with a biopsy-confirmed diagnosis of genital intraepithelial neoplasia (vulvar, vaginal, or cervical) underwent both anal cytology and anoscopy. Variables significant between those with and without anal intraepithelial neoplasia were identified using logistic regression. A forward stepwise regression analysis was carried out to identify a combination of variables that effectively predicted anal intraepithelial neoplasia. RESULTS: In the cohort of analyzed patients, 64 (46.7%) women with anal intraepithelial neoplasia were identified, yielding a prevalence of 19.6%. Immunosuppression, vulvar dysplasia, multiple sexual partners (more than four), smoking history, and history of anal sex were positively associated with anal intraepithelial neoplasia (P<.05). These variables were analyzed using forward stepwise logistic regression. The final model used the presence of any two of three risk factors (vulvar intraepithelial neoplasia [VIN], immunosuppression, and history of anal sex) to predict 38.8% of anal intraepithelial neoplasia in our population. Area under the receiver operating characteristic curve for two of three of the factors was 0.708 (P<.05). This model has a negative predictive value of 88.2% (95% confidence interval [CI] 0.83-0.92) and positive predictive value of 43.1% (95% CI 0.31-0.56). CONCLUSION: A simple predictive model based on the presence or absence of two of three risk factors (VIN, immunosuppression, and history of anal sex) can be used by the clinician to quantify anal intraepithelial neoplasia risk in women with genital dysplasia. LEVEL OF EVIDENCE: II.

Optimal pain management in total abdominal hysterectomy.

UNLABELLED: Effective postoperative pain management provides improved patient comfort and satisfaction, earlier mobilization, fewer pulmonary and cardiac complications, reduced risk of deep vein thrombosis, faster recovery, and reduced cost of care. Although many therapeutic modalities are available for pain management, the optimal combination in managing postoperative pain in total abdominal hysterectomy is controversial. The objective of this study was to review the literature to formulate optimal, evidence-based preoperative, intraoperative, and postoperative pain management for women undergoing total abdominal hysterectomy. Using the OVID platform, we searched in MEDLINE and PubMed using MeSH terms postoperative pain and total abdominal hysterectomy for published articles from 1960 to the present; we found 545 studies. We screened and included only randomized clinical trials, publications in English, human studies, and abdominal hysterectomy for noncancerous indications. We excluded 456 studies that reported on animal studies; laparoscopic, vaginal, supracervical, or robotic hysterectomy; pharmacokinetic studies; primary outcome other than pain management; and chronic pain management. Studies with inadequate power, poor methodology, or inconclusive results were further excluded from this review. Thus, 89 studies constituted the cohort for our article. Pain control remains complex given variables such as age, anxiety, and extent of surgery. In general, regimens should be tailored to the needs of the individual patient, taking into account medical, psychological, and physical condition. A multimodality approach is better than conventional, single-agent narcotic in achieving optimal pain management. After reading this article, the reader should be able to understand various modalities that can be considered for preoperative, intraoperative, and postoperative pain management in total abdominal hysterectomy. TARGET AUDIENCE: Obstetricians and gynecologists, family physicians Learning Objectives: After completing this CME activity, physicians should be better able to understand various modalities that can be considered for preoperative, intraoperative, and postoperative pain management in total abdominal hysterectomy.

Prevalence of and factors contributing to missing lymph tissue in uterine cancer staging surgery.

OBJECTIVE: We wished to investigate the prevalence of missing lymph nodes (MLN), factors contributing to MLN, and the effect of MLN on progression free survival (PFS). METHODS: Patients with uterine cancer undergoing abdominal hysterectomy and lymphadenectomy were recruited. All surgeries adhered to the Gynecologic Oncology Group protocol in collecting all the lymph node tissues in paraaortic, common iliac, obturator fossa, and external and internal iliac bilaterally. Data regarding race, age, body mass index (BMI), lymph node counts, staging, location of missing lymph nodes, length of surgery, and estimated blood loss were collected and analyzed in reference to missing lymph nodes. The definition of missing lymph node was an incomplete nodal specimen obtained without actual lymph node tissue. RESULTS: Between April 2003 and January 2010, 235 consecutive patients were enrolled prospectively; 108 patients had missing lymph nodes post-operatively (46%), and 127 patients had complete lymph nodes. We found no correlation between MLN relative to race (P = 0.97), age (P = 0.25), BMI (P = 0.09), estimated blood loss (P = 0.38), American Society of Anaesthesiologist physical status classification system (P = 0.18), surgery time (P = 0.22), hospital stay (P = 0.05), nodes without cancer (P =0.12), nodes with cancer (P = 0.99), stage (P = 0.90), grade (P = 0.17), or PFS (P = 0.29). CONCLUSION: In our study, although prevalence of missing lymph nodes seems relatively high, none of the perioperative variables studied appeared to contribute to missing lymph nodes. Finally, missing lymph nodes did not affect progression free survival.

A cross-sectional analysis of lower genital tract intraepithelial neoplasia in immune-compromised women with an abnormal Pap.

OBJECTIVES: Persistent human papillomavirus (HPV) infections can cause intraepithelial neoplasia of the lower genital tract. Immune-compromised women have higher rates for all lower genital tract intraepithelial neoplasia. We wish to study the distribution of genital intraepithelial neoplasia in women with and without an immune system. METHODS: The study consisted of 343 women with an abnormal genital lesion or cervical cytology who were referred to a gynecologic oncologist. All patients underwent vulva, vaginal, cervical and anal colposcopy. Any lesion detected was biopsied. Demographic and medical data were collected. The Chi-square test was used to determine the relationship between immunosuppression status and various variables, including sites of intraepithelial neoplasia. RESULTS: Immune-compromised women (N = 33) are more likely than immune-competent women (N = 310) to have intraepithelial neoplasia of the vulva (p < 0.05) and vagina (p < 0.05), but not more likely to have intraepithelial neoplasia of the anus or cervix. Immune-compromised women are more likely than immune-competent women to have multifocal intraepithelial neoplasia (p < 0.001). In addition, immune-compromised women are more likely to have higher grade disease of the vulva and vagina (p < 0.05), and no more likely to have higher grade disease on the cervix or anus than immune-competent women. CONCLUSION: Women with conditions suppressing the immune system are at higher risk for HPV-related disease outside of the cervix and for worse HPV-related diseases than immune-competent women. This study highlights the need for vigilant evaluation of the complete lower genital tract in women with immune-compromised systems.

Ovarian cancer, version 3.2012.

These NCCN Guidelines Insights focus on the major updates for the 2012 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Ovarian Cancer by describing how and why the new recommendations were made. The 6 update topics were selected based on recent important updates in the guidelines and on debate among panel members about recent clinical trials, and include: 1) screening, 2) diagnostic tests for assessing pelvic masses, 3) primary treatment using neoadjuvant chemotherapy, 4) primary adjuvant treatment using bevacizumab in combination with chemotherapy, 5) therapy for recurrent disease, and 6) management of drug/hypersensitivity reactions. These NCCN Guidelines Insights also discuss why some recommendations were not made (eg, panel members did not feel the new data warranted changing the guideline). See "Updates" in the NCCN Guidelines for Ovarian Cancer for a complete list of all the recent revisions.

Smoking cessation counseling in women with genital intraepithelial neoplasia.

OBJECTIVE: Cigarette smoking is a risk factor for cervical, vaginal, vulvar, and anal dysplasia. We will study the prevalence of cigarette smoking in patients with genital dysplasia and effect of counseling on smoking cessation. METHODS: All patients with genital dysplasia were screened for smoking history. One clinician provided smoking cessation counseling using the US Department of Health 5 A's technique: ask patients about their smoking status, advise smokers to quit, assess their readiness to quit, assist with their smoking cessation effort, and arrange for follow-up visits. Patients were informed on how smoking may cause worsening of genital dysplasia and increased risk of progression to cancer. Each patient received 2 counseling sessions, but no pharmacological or psychological interventions. Smoking cessation was evaluated by patient self-report via phone or during clinic visits. RESULTS: From January 2007 to December 2010, 344 patients were referred to our gynecologic oncology clinic for evaluation of genital dysplasia. Patients who were smokers (n=125, 36%) were counseled to cease smoking in 2 counseling sessions, with 100% compliance for attendance. At study analysis (July 2011), 83 patients still smoke and 40 patients quit smoking (smoking cessation rate of 32%). Caucasian patients (P=.0013) and patients with vulvar dyplasia (P=.411) seemed to smoke more than other races and patients with cervical/vaginal dysplasia respectively. CONCLUSION: Smoking cessation counseling for the genital dysplasia patients who smoked was associated with smoking cessation in 32% of the patients.

RhoB mediates antitumor synergy of combined ixabepilone and sunitinib in human ovarian serous cancer.

OBJECTIVE: The aim was to evaluate antitumor activity of the combination of ixabepilone and sunitinib in pre-clinical models of chemotherapy naïve and refractory epithelial ovarian tumors, and to investigate the mechanism of synergy of such drug combination. METHODS: HOVTAX2 cell line was derived from a metastatic serous papillary epithelial ovarian tumor (EOC) and a paclitaxel-resistant derivative was established. Dose response curves for ixabepilone and sunitinib were generated and synergy was determined using combination indexes. The molecular mechanism of antitumor synergy was examined using shRNA silencing. RESULTS: The combination of ixabepilone and sunitinib demonstrated robust antitumor synergy in naïve and paclitaxel-resistant HOVTAX2 cell lines due to increased apoptosis. The GTPase, RhoB, was synergistically upregulated in cells treated with ixabepilone and sunitinib. Using shRNA, RhoB was demonstrated to mediate antitumor synergy. These results were validated in two other EOC cell lines. CONCLUSIONS: Ixabepilone plus sunitinib demonstrated antitumor synergy via RhoB in naïve and paclitaxel-resistant cells resulting in apoptosis. This study demonstrates a novel mechanism of action leading to antitumor synergy and provides 'proof-of-principle' for combining molecular targeted agents with cytotoxic chemotherapy to improve antitumor efficacy. RhoB could be envisioned as an early biomarker of response to therapy in a planned Phase II clinical trial to assess the efficacy of ixabepilone combined with a receptor tyrosine kinase inhibitor such as sunitinib. To the best of our knowledge, this is the first demonstration of antitumor synergy between these two classes of drugs in EOC and the pivotal role of RhoB in this synergy.

Keratosis reduces sensitivity of anal cytology in detecting anal intraepithelial neoplasia.

OBJECTIVE: To identify factors that may contribute to poor sensitivity of anal cytology in contrast to the sensitivity of anoscopy in heterosexual women. METHODS: We analyzed 324 patients with biopsy confirmed diagnosis of genital intraepithelial neoplasia (either vulva, vaginal, or cervical) from 2006 to 2011 who underwent both anal cytology and anoscopy. Cytology, anoscopy, and biopsy results were recorded. Biopsy specimens underwent independent analysis for quality of specimen. Also, biopsy specimens were analyzed for characteristics that may contribute to correlation, or lack thereof, between anal cytology and anoscopic directed biopsy. RESULTS: 133 (41%) patients had abnormal anoscopy and underwent directed biopsy. 120 patients with normal anal cytology had anoscopy directed biopsies, resulting in 58 cases of AIN (sensitivity 9.4%; 0.039-0.199). This cohort was noted to have extensive keratosis covering the entire dysplastic anal lesion. 18 patients yielded abnormal anal cytology. Of these patients, 13 had anoscopic directed biopsies revealing 6 with AIN and absent keratosis (specificity 88.6%; 0.78-0.95). The κ statistic for anal cytology and anoscopy was -0.0213 (95% CI=-0.128-0.086). CONCLUSION: Keratosis reduces the sensitivity of anal cytology. Furthermore, anal cytology poorly correlates with anoscopy in the detection of AIN (κ statistic=-0.0213).

Obesity and perioperative outcomes in endometrial cancer surgery.

OBJECTIVE: Obesity is a significant risk factor in developing endometrial cancer. As obesity is becoming more endemic, we wish to evaluate the impact of obesity on perioperative outcomes in patients undergoing uterine cancer surgery. METHODS: We analyzed our prospective database on patients with endometrial cancer who underwent abdominal hysterectomy and pelvic/aortic lymphadenectomy by one gynecologic oncologist. Information regarding race, age, body mass index (BMI), lymph node counts, staging, and estimated blood loss were analyzed against patient's weight category. Weight category was divided as follows: Normal weight (BMI < 25), overweight (BMI 25 to <30), obese (BMI 30 to <35) and morbid obesity (BMI ≥ 35). RESULTS: Between April 2003 and December 2009, 233 patients were recruited prospectively. This study found no difference in the number of lymph nodes harvested patient (P = 0.0539) or length of hospital stay (P = 0.4234) in patients with a normal BMI versus that of an overweight, obese, or morbidly obese. However, estimated blood loss (P = 0.01) and operative time (P = 0.0015) were greater as BMI increased. African American patients were more morbidly obese than Caucasian patients. Furthermore, younger patients tend to be more obese across all races. Finally, obesity did not affect perioperative complications (P = 0.78). CONCLUSION: Obesity increases surgical blood loss and operative time. However, obesity does not affect length of hospital stay, number of lymph nodes harvested, or perioperative complications in uterine cancer staging surgery.

Endometrial cancer in a 15-year-old girl: A complication of Cowden Syndrome.

► The youngest case of endometrial carcinoma in the English literature ► Endometrial cancer is diagnosed in approximately 13-19% of women with Cowden Syndrome. ► Screening guidelines should follow that of Lynch Syndrome.

The University of Tennessee Obstetrics & Gynecology resident physician work efficiency.

OBJECTIVE: Physicians in training are commonly evaluated on their medical knowledge and clinical skills but rarely in work efficiency. We developed a Resident Efficiency Score (RES) to study the clinical productivity and efficiency of residents. METHODS: Physician Post Graduate Year (PGY) 1, 2, 3 and 4 trainees rotating on the gynecologic oncology service recorded their clinical work (using the Relative Value Units (RVU) and Medicare 1997 Evaluation and Management guideline) and their working hours. RES was calculated using total RVU per work hour logged (RES=RVU/hour). RESULTS: From July 1, 2007 to June 31, 2008, 36 residents rotated thru the gynecologic oncology service and were included in the study The residency included 23 female and 13 male residents, consisting of 23 Caucasians, nine African Americans, two East Indians, one Hispanic and one Iranian. These residents, under the supervision of three gynecologic oncology faculty members, evaluated 1,168 new, 7,011 clinic and 1,568 hospital patients during the study period. Residents' average weekly hours were similar: PGY 1 (55), PGY 2 (53.5), PGY 3 (60.5), PGY 4 (53.4) (p= 0.88). Overall resident work efficiency increased from PGY 1 (RES 4.4) to PGY 2 (RES 5.6) to PGY 3 (RES 6.2), and regressed in PGY 4 (RES 5.2) (p=0.04). Work efficiency was similar among all PGY years in the operating room (p=0.5) and on the weekend (p=0.18). CONCLUSION: In this study, resident physicians worked more productively up to the third year and then regressed. RES may be a useful tool in helping resident to evaluate their clinical work efficiency.

Anal intraepithelial neoplasia in women with genital intraepithelial neoplasia.

OBJECTIVE: To estimate the prevalence of anal intraepithelial neoplasia in heterosexual women with genital intraepithelial neoplasia, and to compare anal cytology with colposcopy for their effectiveness in anal intraepithelial neoplasia screening. METHODS: Women with confirmed intraepithelial neoplasia on the cervix, vagina, or vulva were referred for gynecologic oncology care. All patients underwent anal cytology and high-resolution anoscopy. Any lesion detected on anoscopy was biopsied. Wilson score method was used to estimate 95% confidence interval for prevalence. McNemar's test compared the two screening methods. RESULTS: Women with average age of 39.6 years (range 14 to 83 years) underwent anal cytology and anoscopy (N=205). Of the 205 patients with genital intraepithelial neoplasia, 25 patients (12.2%) had biopsy-proven anal intraepithelial neoplasia. Twelve patients (5.9%) had abnormal anal cytology (nine with atypical squamous cells of undetermined significance [ASC-US], three with low-grade squamous intraepithelial lesions [LSIL]). None of the nine patients with anal ASC-US had biopsy-proven anal intraepithelial neoplasia. Of the three patients with anal LSIL, two had anal intraepithelial neoplasia II and one had condyloma on biopsy. However, 78 patients (38%) had abnormal anoscopy findings that resulted in 25 biopsy-proven anal intraepithelial neoplasias (8 anal intraepithelial neoplasia I, 5 anal intraepithelial neoplasia II, 12 anal intraepithelial neoplasia III)), condylomas (n=11), and hyperkeratosis (n=8). Anoscopy identified 32% (25 patients) with anal intraepithelial neoplasia out of 78 abnormal anoscopic examinations. In diagnosing anal intraepithelial neoplasia, anoscopy has 100% sensitivity and 71% specificity; anal cytology has 8% sensitivity and 94% specificity. CONCLUSION: Patients with cervical, vulvar, and vaginal intraepithelial neoplasia have 12.2% prevalence of anal intraepithelial neoplasia and should be screened with high-resolution anoscopy. In anal intraepithelial neoplasia screening, anoscopy is more sensitive but less specific than anal cytology.