The yield of endometrial aspiration in women with various risk factors and bleeding abnormalities.

BACKGROUND: Even in the face of a substantial increase in the numbers of endometrial cancer cases and in the numbers of women who have risk factors, there is no clear agreement about the indications for assessing the endometria of women with abnormal bleeding or about the tools to use in that assessment. This study sought to determine in a group of high risk women with abnormal uterine bleeding, the probability that an outpatient endometrial aspiration would identify significant pathology. METHODS: Retrospective cohort study of the histology from endometrial aspirations performed from 2001 to 2008 for abnormal uterine bleeding at Harbor-UCLA Medical Center and its satellite public health clinics. Medical records were reviewed in detail to assess risk factors, descriptions of bleeding abnormalities and histologic results. RESULTS: The charts of 1601 women who underwent 1636 endometrial biopsies for a wide variety of abnormal uterine bleeding patterns yielded 73 (4.6 %) cases of endometrial carcinoma, 43 cases of atypical endometrial hyperplasia (2.7 %), for an overall yield of significant pathology of 7.2 %. Hyperplasia without atypia was found in another 83 cases (5.2 %). Obesity, diabetes and postmenopausal age are associated with an increased risk of significant pathology. Bleeding patterns were so poorly documented that analysis of yield by this factor should be viewed with caution. CONCLUSIONS: The probability of detecting significant uterine pathology is greatest among obese, diabetic postmenopausal women with diabetes (26.3 %). Conversely, the probability of identifying significant pathology in younger women without risk factors is less than 2 %. For women who perceive their individualized risk estimate to be too small to justify an endometrial biopsy, it may be possible to offer oral higher dose progestin therapy on the condition that persistent abnormal bleeding will require more intensive evaluation. These estimates of absolute risk of being diagnosed with significant pathology on endometrial biopsy may be helpful to patients as they consider giving informed consent for the procedure.

Rethinking the use of radiation and chemotherapy after radical hysterectomy: a clinical-pathologic analysis of a Gynecologic Oncology Group/Southwest Oncology Group/Radiation Therapy Oncology Group trial.

OBJECTIVE: To retrospectively analyze data from a previously reported randomized trial of either pelvic radiation (RT) or RT + chemotherapy (CT) in patients undergoing radical hysterectomy and pelvic lymphadenectomy with positive pelvic lymph nodes, parametrial involvement, or surgical margins; to explore associations between RT + CT; and to investigate histopathologic and clinical factors which might be predictive of recurrence. METHODS: Histopathologic sections from biopsies and hysterectomies and clinical data were reviewed from patients with stage IA2, IB, or IIA cervical cancer treated with RT or RT + CT (cisplatin 70 mg/m2 plus fluorouracil 1000 mg/m2 every 3 weeks for four cycles). A univariate analysis was performed because the relatively small sample size limited the interpretation of a multivariate analysis. RESULTS: Of the 268 enrolled women, 243 (RT = 116; RT + CT = 127) were evaluable. The beneficial effect of adjuvant CT was not strongly associated with patient age, histological type, or tumor grade. The prognostic significance of histological type, tumor size, number of positive nodes, and parametrial extension in the RT group was less apparent when CT was added. The absolute improvement in 5-year survival for adjuvant CT in patients with tumors < or =2 cm was only 5% (77% versus 82%), while for those with tumors >2 cm it was 19% (58% versus 77%). Similarly, the absolute 5-year survival benefit was less evident among patients with one nodal metastasis (79% versus 83%) than when at least two nodes were positive (55% versus 75%). CONCLUSIONS: In this exploratory, hypothesis-generating analysis, adding CT to RT after radical hysterectomy, appears to provide a smaller absolute benefit when only one node is positive or when the tumor size is < 2 cm. Further study of the role of CT after radical hysterectomy in patients with a low risk of recurrence may be warranted.

Validation of referral guidelines for women with pelvic masses.

OBJECTIVE: Guidelines for referring women with pelvic masses suspicious for ovarian cancers to gynecologic oncologists have been published jointly by Society of Gynecologic Oncologists (SGO) and the American College of Obstetricians and Gynecologists (ACOG). They are based on patient age, CA 125 level, physical findings, imaging study results, and family history. Although the guidelines are evidence-based, their predictive value in distinguishing cancers from benign masses is unknown. METHODS: Chart review for factors included in the guidelines of surgically evaluated women with pelvic masses at 7 tertiary care centers during a 12-month interval was performed. This information was used to estimate the predictive values of the SGO and ACOG guidelines in identifying patients with malignant pelvic masses. RESULTS: A total of 1,035 patients were identified, including 318 (30.7%) with primary malignancies of the ovary, fallopian tube, or peritoneum. Seventy-seven were younger than 50 years old (premenopausal group), and 240 were 50 years old or older (postmenopausal group). Fifty additional patients (4.8%) had cancers metastatic to the ovaries, and the remaining 667 (64.4%) had benign masses. The referral guidelines captured 70% of the ovarian cancers in the premenopausal group and 94% of the ovarian cancers in the postmenopausal group. The positive predictive value was 33.8% for the premenopausal group and 59.5% for the postmenopausal group, whereas the negative predictive values were more than 90% for both groups. Elevated CA 125 level was the single best predictor of malignancy in both groups. CONCLUSION: The SGO and ACOG referral guidelines effectively separate women with pelvic masses into 2 risk categories for malignancy. This distinction permits a rational approach for referring high-risk patients to a gynecologic oncologist for management.

Urinary diversion following radical pelvic surgery.

PURPOSE OF REVIEW: To describe the reconstructive techniques in urinary diversion utilized by the gynecologist after radical pelvic surgery. The radical resection of pelvic malignancies remains an important part of the armamentarium of the gynecological oncologist. Techniques in continent urinary diversion should be used to restore these women to an acceptable quality of life. Reconstruction is the surgical challenge of this and future generations of pelvic surgeons. It is imperative that pelvic surgeons begin to consider the quality of life and the functional reintegration into society of the patients we are able to salvage with these radical surgical efforts. RECENT FINDINGS: The advent of continent urostomies has significantly improved the quality of life of patients who undergo radical tumor resection involving the bladder. Such techniques prevent the need for urostomy bags, and thus all the physical and psychological ramifications associated with them. We will review recent literature associated with the complications and the management of these complications. SUMMARY: Familiarity with techniques in continent urinary diversion by the gynecologist is an important part of the management of patients with gynecological malignancies and permanent bladder atony.

Early stage cervical cancers containing human papillomavirus type 18 DNA have more nodal metastasis and deeper stromal invasion.

PURPOSE: To investigate the clinical and pathological factors which might explain the poor prognosis associated with early stage cervical cancers containing human papillomavirus (HPV) type 18 DNA. EXPERIMENTAL DESIGN: A clinical and pathological review of 144 patients with stage IB cervical cancer treated with radical hysterectomy and bilateral pelvic lymph node dissection was done. HPV genotyping was determined from fresh tumor specimens through PCR. Clinical-pathological information, sites of recurrence, use of adjuvant radiation, and survival data were analyzed. RESULTS: Thirty-three (23%) tumors contained HPV 18 DNA. These tumors did not differ from those which contained non-HPV 18 DNA with respect to tumor grade or size. However, HPV 18-containing cancers were more likely to be adenocarcinomas. A higher incidence of pelvic lymph node metastasis was noted among the HPV 18 group (48%) as compared with the non-HPV 18 group (28%), and deeper stromal invasion was more common in HPV 18-associated tumors. Although a slightly higher proportion of patients with HPV 18-containing tumors received adjuvant radiation (67%) than those with non-HPV 18 cancers (49%), recurrences were more common among HPV 18 patients. Eleven (33%) of HPV 18-containing cancers relapsed compared with 18 (16%) of non-HPV18-containing tumors. CONCLUSIONS: The explanation for the worse prognosis associated with stage IB cervical cancers containing HPV 18 DNA treated with radical hysterectomy and bilateral pelvic lymph node dissection appears to be related to deeper cervical stromal invasion and more nodal metastases. Despite an increased use of adjuvant radiation therapy, these cancers are still more likely to relapse.

New developments in the treatment of invasive cervical cancer.

Cervical cancer is a preventable disease that is curable when it is detected early. For advanced-stage cancer, the prognosis is worse. Over the years, much progress has been made in radiation therapy and in chemotherapy, but it took three decades for the arrival of concurrent chemoradiation therapy, which significantly improved the survival among women with advanced cervical cancer. This fact underscores the need and the importance for continuing efforts in clinical research. While current standards of therapy are being fine-tuned as more information is being gathered, great strides are being made in the areas of molecular and cancer biology. Novel treatments for cervical cancer appear to be imminent in the near future.