Exploration of Preliminary Objective Triage by Menopause Score and CA 125 Result Prior to Accelerating Fast-Track Booking for Suspected Ovarian Cancer-A Role for the Pathway Navigator?

The 28-days-to-diagnosis pathway is the current expected standard of care for women with symptoms of ovarian cancer in the UK. However, the anticipated conversion rate of symptoms to cancer is only 3%, and use of the pathway is increasing. A rapid triage at the moment of receipt of the referral might allow resources to be allocated more appropriately. In secondary care, multidisciplinary teams (MDTs) use the risk of malignancy index (RMI) score, (multiply menopausal status pre = 1 or post = 3 × ultrasound score = 0 - 3 × the CA 125 level), using a score of >200, to triage urgency and management in possible ovarian cancer cases. The most powerful determinant of the RMI score variables is CA 125 level, an objective number. Could a simple modification of the RMI score retain a high sensitivity for cancer whilst improving specificity and, consequently, decrease the morbidity of false-positive classification? To test this hypothesis, a retrospective evaluation of an ovarian two-week-wait telephone clinic of one consultant gynaecological oncologist was undertaken. Enquiry re menopause status was scored as one for pre- and three for postmenopausal or uncertain. CA 125 levels of >67 u/mL for premenopausal and >23 u/mL for postmenopausal women were used to precipitate urgent cross-sectional imaging requests and MDT opinions. These CA 125 cut thresholds were calculated using an assumption that the RMI imaging score, regardless of whether the result was available, could be three. We contemplate that women who did not exceed a provisional RMI score of >200 might be informed they are extremely unlikely to have cancer, removed from the malignancy tracker and appropriate follow-up arranged. One hundred and forty consecutive cases were analysed; 43% were deemed premenopausal and 57% postmenopausal. Twenty of the women had cancer, eighteen (90%) of whom had an RMI > 200. One hundred and twenty were benign, and only twenty-three (19%) classified as urgent cases in need of accelerated referral to imaging. In contrast, CA 125 > 35 u/mL, whilst retaining the sensitivity of 90%, misclassified 36 (30%) of the benign cases. It is possible that a telephone triage via a questionnaire determining menopausal status and the CA 125 result could offer a sensitivity for cancer of 90% and urgent expert review of under 20% of benign cases. This rapid initial telephone assessment could be presented by a trained pathway navigator, physician associate or nurse specialist. Substantial savings in NHS cancer services resources, anxieties all around and reduced patient morbidity may occur as a result.

Implementation of a robotic surgical program in gynaecological oncology and comparison with prior laparoscopic series.

BACKGROUND: Robotic surgery in gynaecological oncology is a rapidly developing field as it offers several technical advantages over conventional laparoscopy. An audit was performed on the outcome of robotic surgery during our learning curve and compared with recent well-established laparoscopic procedure data. METHOD: Following acquisition of the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, California, USA), we prospectively analysed all cases performed over the first six months by one experienced gynaecologist who had been appropriately trained and mentored. Data on age, BMI, pathology, surgery type, blood loss, morbidity, return to theatre, hospital stay, and readmission rate were collected and compared with a consecutive series over the preceding 6 months performed laparoscopically by the same team. RESULTS: A comparison of two consecutive series was made. The mean age was somewhat different, 55 years in the robotic versus 69 years in the laparoscopic group, but obesity was a feature of both groups with a mean of BMI 29.3 versus 28.06, respectively. This difference was not statistically significant (P = 0.54). Three subgroups of minimal access surgical procedures were performed: total hysterectomy and bilateral salpingooophorectomy (TH + BSO), total hysterectomy and bilateral salpingooophorectomy plus bilateral pelvic lymphadenectomy (TH + BSO + BPLND), and radical hysterectomy plus bilateral pelvic lymphadenectomy (RH + BPLND). The mean time taken to perform surgery for TH + BSO was longer in the robotic group, 151.2 min compared to 126.3 min in the laparoscopic group. TH + BSO + BPLND surgical time was similar to 178.3 min in robotic group and 176.5 min in laparoscopic group. RH + BPLND surgical time was similar, 263.6 min (robotic arm) and 264.0 min (laparoscopic arm). However, the numbers in this initial analysis were small especially in the last two subgroups and do not allow for statistical analysis. The rate of complications necessitating intervention (Clavien-Dindo classification grade 2/3) was higher in the robotic arm (22.7%) compared to the laparoscopic approach (4.5%). The readmission rate was higher in the robotic group (18.2%) compared to the laparoscopic group (4.5%). The return to theatre in the robotic group was 18.2% and 4.5% in laparoscopic group. Uncomplicated robotic surgery hospital stay appeared to be shorter, 1.3 days compared to the uncomplicated laparoscopic group, 2.5 days. There was no conversion to the open procedure in either arm. Estimated blood loss in all cases was less than 100 mL in both groups. CONCLUSION: Robotic surgery is comparable to laparoscopic surgery in blood loss; however, the hospital stay in uncomplicated cases appears to be longer in the laparoscopic arm. Surgical robotic time is equivalent to laparoscopic in complex cases but may be longer in cases not requiring lymph node dissection. The robotic surgery team learning curve may be associated with higher rate of morbidity. Further research on the benefits to the surgeon is needed to clarify the whole picture of this versatile novel surgical approach.

Experience in the management of patients older than 80 years with vulval cancer.

INTRODUCTION: Vulval cancer is a disease of an increasing elderly population and consequently comorbidities are common. These conditions may preclude the application of standard therapy. OBJECTIVE: To review the outcome of women with vulval cancer older than 80 years comparing those who received recommended treatment (protocol-adherent) with those who did not (protocol-violated). METHODS: A retrospective chart review of a consecutive series of patients discussed over a 6-year period at our Multidisciplinary Team meeting. Treatment was deemed protocol-adherent if the Royal College of Obstetricians and Gynaecologists guidelines were followed and protocol-violated if not. Outcome data were retrieved from case notes, primary care input, cancer registry database, and reviewed in terms of survival and recurrence. RESULTS: Twenty-three cases of squamous cell carcinoma of the vulva were identified between 1999 and 2005 at Portsmouth Oncology Centre. Eight women were protocol-adherent and 15 women were not. Treatment decisions were made after individual discussion in conjunction with performance status. Protocol adherence was associated with a 25% recurrence rate and violation with a 53% recurrence rate. Median survival was shorter in the protocol-violated group compared with the adherent group (18 months vs 43.5 months respectively). CONCLUSION: These data imply that this issue arises not infrequently, perhaps every 3 to 4 months at each gynecological oncology Multidisciplinary Team meeting in the UK. The higher recurrence rate and shorter median survival among the protocol-violated group supports the validity of the current Royal College of Obstetricians and Gynaecologists treatment guidelines in this elderly age group. A prospective scoring system should be evolved to ensure a more objective approach to such patients with considerable co-morbidities.

Cytological follow-up of women older than 50 years with high-grade cervical smear treated by large loop excision.

OBJECTIVE: To evaluate cytological surveillance for women older than 50 years, to detect recurrent or residual disease after treatment of cervical intraepithelial neoplasia by loop excision. MATERIALS AND METHODS: Women undergoing a large loop excision for high-grade squamous intraepithelial lesion or glandular cytological abnormalities during a period of 4 years (2000-2003) were identified from the colposcopy database. Women younger than 50 years or with a history of previous loop excision were excluded. Clinical data, histology, and follow-up cytology results for up to 2 years after treatment were collected. RESULTS: Eighty-nine patients were identified. Age of the women ranged from 51 to 66 years, with a median of 51.5 years. Thirty-two (36%) had severe dyskaryosis, 53 (60%) had moderate dyskaryosis, and 4 (4%) had glandular abnormalities on cervical cytology before the loop biopsy. Cervical intraepithelial neoplasia (CIN) 2,3 and glandular abnormalities, CIN 1, and no abnormalities were found in 50 (56%), 18 (20%), and 19 (22%) loop specimens, respectively. Invasive disease was found in 2 (2%) cases. They were excluded from further analysis. The lesion was completely excised in 58 (65%) and incompletely excised in 23 (26%) patients. It was not possible to comment on the margin status in 8 (9%) cases. These were excluded from further analysis. Of the 23 women who had margins involved, 8 (35%) had ectocervical, 12 (52%) had endocervical, and 3 (13%) had both margins involved. All women had follow-up cervical smears at the cytology clinic. At 6-month follow-up, 3 patients had persistent CIN and 4 had borderline changes on cervical smears. At 2 years follow-up, 3 patients had high-grade squamous intraepithelial lesion abnormalities, 2 of whom had clear margins at their loop biopsy earlier.Twenty percent of the women with positive endocervical margins on loop excision needed further treatment for residual or persistent disease on follow-up. Overall, 4 (5%) of the 79 patients who had a loop biopsy went on to have cytological abnormalities suggestive of persistent/residual disease needing further treatment. CONCLUSION: Cytological surveillance for post-loop biopsy follow-up seems to be a good option for detecting residual disease in this high-risk group of patients.

Why do women still develop cancer of the cervix despite the existence of a national screening programme?

The study looked at why women developed invasive cervical cancer during a 10-year period. It reviewed the hospital records of 66 patients with cervical cancer with an age range of 21-81 years. Screening non-attenders accounted for a disproportionate number of cases. The proportion of women who had never been screened did not vary during the study period. Attention needs to focus on reasons why these women do not attend.

A molecular genetic and statistical approach for the diagnosis of dual-site cancers.

BACKGROUND: Concurrent tumors can be synchronous, independently derived, non-metastatic tumors or metastatic tumors. The prognosis and clinical management of patients with these different concurrent tumor types are different. METHODS: DNA from normal and tumor tissues of 62 patients with synchronous endometrial and ovarian, bilateral ovarian, or endometrial and bilateral ovarian tumors was analyzed for loss of heterozygosity and microsatellite instability using eight polymorphic microsatellite markers at loci frequently deleted in ovarian and/or endometrial cancers. A statistical algorithm was designed to assess the clonal relationship between the tumors. RESULTS: The original histopathology reports classified 26 (42%) case patients with single primary tumors and related metastatic lesions and 21 (34%) with independent primary tumors; 15 (24%) were unclassified. Genetic data identified 35 (56%) case patients with single primary tumors and related metastatic lesions, 18 (29%) with independent primary tumors, and nine (15%) that could not be typed. Excluding case patients with histopathology reports for which a clonal relationship was uncertain or was not reported, there was 53% concordance between genetic and histopathology diagnoses. Increasing the stringency of the statistical analysis increased the number of uncertain diagnoses but did not affect the proportion of discordant genetic and histologic diagnoses. CONCLUSIONS: We have developed a rapid and robust combined genetic and statistical method to establish whether multiple tumors from the same patient represent distinct primary tumors or whether they are clonally related and therefore metastatic. For the majority of case patients, histopathology reports and genetic analyses were in agreement and diagnostic confidence was improved. Importantly, in approximately one-fourth of all case patients, genetic and histopathologic analyses suggested alternative diagnoses. The results suggest that genetic analysis has implications for clinical management and can be performed rapidly as a diagnostic test with paraffin-embedded tissues.