Patterns of relapse in stage I–II uterine papillary serous carcinoma treated with adjuvant intravaginal radiation (IVRT) with or without chemotherapy

Objective

To evaluate patterns of relapse in early stage uterine papillary carcinoma (UPSC) patients receiving adjuvant intravaginal radiotherapy (IVRT) with or without chemotherapy.

Methods

From 1/1996 to 12/2010, 77 women with stage I–II UPSC underwent surgery followed by IVRT (median 21 Gy). Stage IA patients without residual disease at surgery were excluded. IVRT and chemotherapy (carboplatin/taxane) was given to 61 (79%) patients and IVRT alone to 16 (21%). The median follow-up was 62 months for surviving patients.

Results

Of the 77 patients, 11 (14%) relapsed as follows: vaginal 2 (3%), pelvic 5 (6%), para-aortic 5 (6%), peritoneal 6 (8%), and other distant sites 8 (10%). Of the 5 pelvic relapses, 2 were isolated and were salvaged. In those treated without chemotherapy, only 1/16 developed recurrence (mediastinal). The 5-year vaginal, pelvic, para-aortic, peritoneal, and distant recurrence rates were 2.7% (C.I. 0–6.2%), 5.8% (C.I. 0.6–11.0%), 5.4% (C.I. 0.6–10.1%), 5.3% (C.I. 0.5–10.1%) and 6.6% (C.I. 1.4–11.8%), respectively. The 5-year disease-free survival (DFS), and overall survival (OS) were 88% (C.I. 81–95%), and 91% (C.I. 84–97%), respectively. The only predictor of worse 5-year pelvic control was stage (96.2% stage IA vs 87.7% for stage IB-II, p = 0.043).

Conclusions

In stage I–II UPSC patients who predominantly receive adjuvant chemotherapy, IVRT as the sole form of adjuvant RT provides excellent locoregional control. The risk of isolated pelvic recurrence is too low to warrant routine use of external pelvic RT.     

Population-based treatment and outcomes of Stage I uterine serous carcinoma

Objective

Uterine serous carcinoma (USC) is a rare type of endometrial cancer that often recurs in patients with Stage I disease. Our objective was to evaluate treatment and outcomes in Stage I USC in the context of a population-based study.

Methods

This was a population-based retrospective cohort study of all patients with Stage I USC in British Columbia, Canada from 2004 to 2012. The British Columbia Cancer Agency (BCCA) recommends three cycles of paclitaxel and carboplatin chemotherapy followed by pelvic radiotherapy for all women with Stage I USC and any myometrial invasion (Stage IA MI −). If no myometrial invasion (Stage IA MI −), no postoperative treatment is given. Patient and disease characteristics, surgery, adjuvant therapy, recurrence rates and sites, and 5-year disease-free survival rates were evaluated.

Results

Of the 127 patients with Stage I USC, 41 were Stage IA MI −, 56 Stage IA MI +, and 30 Stage IB. Median follow-up was 25 months (2–98 months). Five year disease-free survival rates were 80.7%, 74.4%, and 48.5% for Stages IA MI −, IA MI +, and IB, respectively, and recurrence rates according to BCCA guidelines were 10%, 2.9% and 30%, respectively. Of the 18 with recurrences, 13 had a distant component (72.2%). There were no pelvic recurrences among those receiving adjuvant radiotherapy.

Conclusion

Our current protocol of observation alone postoperatively for Stage IA MI − and chemoradiotherapy for Stage IA MI + is associated with a low recurrence rate. In contrast, those with Stage IB USC have a higher recurrence rate despite chemoradiotherapy, and likely require alternate treatment strategies.     

Clinical outcomes following 3D image-guided brachytherapy for vaginal recurrence of endometrial cancer

Purpose

To evaluate clinical outcomes for women with recurrent endometrial cancer treated with 3D image-guided brachytherapy

Methods and materials

44 women, of whom 13 had received prior RT, received salvage RT for vaginal recurrence from 9/03 to 8/11. HDR or LDR interstitial brachytherapy was performed under MR or CT guidance in 35 patients (80%); 9 (20%) had CT-guided HDR cylinder brachytherapy. The median cumulative dose in EQD2 was 75.5 Gy. Actuarial estimates of local failure (LF), disease-free (DFS) and overall survival (OS) were calculated by Kaplan–Meier.

Results

Histologic subtypes were endometrioid (EAC, 33), papillary serous/clear cell (UPSC/CC, 5) and carcinosarcoma (CS, 6). The 2-year DFS/OS rates were 75%/89% for EAC and 11%/24% for UPSC/CC/CS (both p < 0.01). On MVA, high tumor grade was associated with recurrence (HR 3.2 for grade 2, 9.6 for grade 3, p < 0.01). The LF rate at 2 years was 4% for patients without versus 39% for those with prior RT (p = 0.1). Patients who had prior RT received lower cumulative doses at recurrence (66.5 Gy vs. 74.4 Gy, p < 0.01). The 2-year DFS/OS rates with and without prior RT were 26%/55% and 72%/80% (both p = 0.1). Four patients (9%) experienced grade 3 late toxicity, including 3 of 13 (23%) in the re-irradiation setting and 1 of 31 (3%) with no prior radiotherapy.

Discussion

3D image-guided brachytherapy results in excellent local control for women with recurrent endometrial cancer, particularly with cumulative EQD2 doses greater than 70 Gy. Successful salvage of vaginal recurrence is related to tumor grade and histologic subtype.     

Five-year outcomes of adjuvant carboplatin/paclitaxel chemotherapy and intravaginal radiation for stage I-II papillary serous endometrial cancer

Objective

The purpose of this study is to report our single-institution experience with concurrent adjuvant intravaginal radiation (IVRT) and carboplatin/paclitaxel chemotherapy for early stage uterine papillary serous carcinoma (UPSC).

Methods

From 10/2000 to 12/2009, 41 women with stage I-II UPSC underwent surgery followed by IVRT (median dose of 21 Gy in 3 fractions) and concurrent carboplatin (AUC = 5-6) and paclitaxel (175 mg/m²) for six planned cycles. IVRT was administered on non-chemotherapy weeks. The Kaplan-Meier method was used to estimate survival, and the log-rank test was used for comparisons.

Results

Median patient age was 67 years (51-80 years). Surgery included hysterectomy, bilateral salpingo-oophorectomy, peritoneal washings, omental biopsy, and pelvic and paraaortic lymph node sampling. FIGO 2009 stage was IA in 73%, IB in 10%, and II in 17%. Histology was pure serous in 71% of cases. Thirty-five patients (85%) completed all planned treatment. With a median follow-up time of 58 months, the 5-year disease-free (DFS) and overall survival (OS) rates were 85% (95%CI, 73-96%) and 90% (95%CI, 80-100%). The 5-year pelvic, para-aortic, and distant recurrence rates were 9%, 5%, and 10%, respectively. There were no vaginal recurrences. Of the 4 pelvic recurrences, 2 were isolated and were successfully salvaged. Patients with stage II disease had lower DFS (71% vs. 88%; p = 0.017) and OS (71% vs. 93%; p = 0.001) than patients with stage I disease.

Conclusions

Concurrent adjuvant carboplatin/paclitaxel chemotherapy and IVRT provide excellent outcomes for early stage UPSC. Whether this regimen is superior to pelvic radiation will require confirmation from the ongoing randomized trial.     

Clinical predictors of long-term survival for stage IVB uterine papillary serous carcinoma confined to the abdomen

Objective

To identify clinical predictors of long-term survival in women with FIGO Stage IVB uterine papillary serous carcinoma (UPSC) confined to the abdomen

Methods

Records were reviewed for 48 patients with Stage IVB UPSC diagnosed from 1/1980 to 12/2011. Study inclusion required hysterectomy, salpingo-oophorectomy and negative chest imaging. Disease-free (DFS) and overall (OS) survival rates were calculated using the Kaplan–Meier method. Multivariate analysis (MVA) was performed using Cox proportional hazards.

Results

Median age at diagnosis was 70 years (range, 53–87). Optimal cytoreduction (Opt) to < 1 cm residual disease was performed in 36 patients (75%). With a median follow-up of 21 months for all patients and 99 months for survivors, 36 (75%) experienced disease progression or relapse, most commonly intraperitoneal (16, 44%). At 5 years, DFS and OS rates were 12% and 19%, respectively. Five patients (10%) were long-term survivors without relapse at a median of 124 months. All 5 had Opt and carboplatin/paclitaxel chemotherapy, and 4 received radiotherapy (2 pelvic, 1 whole-abdominal, 1 brachytherapy). On MVA in the chemotherapy-treated population, Opt (HR 0.09, 95% CI 0.02–0.35) and radiotherapy (HR 0.36, 0.15–0.80) were associated with decreased rates of recurrence or progression. Opt (HR 0.09, 0.02–0.38) was prognostic for OS when adjusted for age.

Conclusions

Clinical predictors of long-term survival for Stage IVB UPSC confined to the abdomen include optimal cytoreduction and adjuvant platinum and paclitaxel chemotherapy. Radiotherapy may decrease rates of recurrence or progression. Despite intra-abdominal involvement, disease remission and long-term survival may be achieved in some patients.     

Relationship between minimally invasive hysterectomy,pelvic cytology,and lymph vascular space invasion: A single institution study of 458 patients

Objective

The aim of this study is to determine whether a minimally invasive approach to hysterectomy is associated with an increased rate of lymph vascular space invasion (LVSI) and/or malignant pelvic peritoneal cytology in endometrial cancer.

Methods

We performed a single institution analysis of 458 women with endometrial cancer who underwent either total abdominal hysterectomy (TAH) or minimally invasive hysterectomy (MIH) with use of a disposable uterine manipulator. All patients had endometrial cancer diagnosed by endometrial biopsy at a single academic institution between 2002 and 2012. Exclusion criteria were pre-operative D&C and/or hysteroscopy, uterine perforation or morcellation, and conversion to laparotomy. Multivariate logistic regression models to determine if type of hysterectomy predicts either LVSI or presence of abnormal cytology were controlled for grade, stage, depth of invasion, tumor size, cervical and adnexal involvement.

Results

LVSI was identified in 39/214 (18%) MIH and 44/242 (18%) TAH (p = 0.99). Pelvic washings were malignant in 14/203 (7%) MIH and 16/241 (7%) TAH (p = 1.0). Washings were atypical or inconclusive in 16/203 (8%) MIH and 6/241 (2.5%) TAH (p = 0.014). In multivariate analyses, type of hysterectomy was not a significant predictor of either LVSI (p = 0.29) or presence of malignant washings (p = 0.66), but was a predictor of atypical or inconclusive washings (p = 0.03).

Conclusion

Minimally invasive hysterectomy with use of a uterine manipulator for endometrial cancer is not associated with LVSI or malignant cytology. Algorithms that better determine the etiology and implications of inconclusive or atypical pelvic cytology are needed to inform the possible additional risk associated with a minimally invasive approach to endometrial cancer.     

Adjuvant treatment and analysis of failures in patients with high-risk FIGO Stage Ib–II endometrial cancer: An Italian multicenter retrospective study (CTF study)

Objectives

The purpose of this retrospective study was to assess the clinical outcome of patients with high-risk, early-stage endometrioid endometrial cancer (stage Ib or II with myometrial invasion > 50%, grade 2–3).

Methods

We assessed 192 patients who underwent hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy, had histologically negative pelvic nodes, and had negative CT findings for aortic node involvement.

Results

Tumor relapsed in 36 patients after a median time of 21.2 months. The recurrence was vaginal in 7 (19.4%), distant in 16 (44.4%), aortic in 8 (22.2%), and involved multiple sites in 5 (13.9%). There was a trend to a lower vaginal recurrence rate in the 143 patients who received adjuvant radiotherapy (+ chemotherapy) compared with the 46 who did not (2.1% versus 8.7%). Distant or aortic recurrences were lower in the 37 patients who received adjuvant chemotherapy (+ radiotherapy) than in the 152 who did not (2.7% versus 18.4%, p = 0.02). Of the 29 patients who received sequential adjuvant chemotherapy and radiotherapy, none developed local recurrence and only one had distant recurrence. There was a trend for a better 5-year progression-free survival and overall survival for the patients who received chemotherapy (+ radiotherapy) compared with those who did not (86.0% versus 71.3%, and 92.3% versus 75.6%, respectively).

Conclusions

Our data appear to suggest that adjuvant chemotherapy reduces the risk of distant or aortic recurrences and that sequential adjuvant chemotherapy and radiotherapy achieve an excellent local and distant control of disease in these clinical settings.     

Quality of life in patients with endometrial cancer treated with or without systematic lymphadenectomy

Objective

To compare the quality of life (QoL) of women affected by endometrial cancer treated with surgery with or without systematic lymphadenectomy.

Study design

Consecutive patients affected by stages I and II endometrial cancer and treated with surgery between 2008 and 2011 were selected. Eligible subjects were divided into two groups: Group A consisted of 36 patients who had hysterectomy plus bilateral salpingo-oophorectomy without lymphadenectomy; Group B consisted of 40 patients who had hysterectomy plus salpingo-oophorectomy plus pelvic and aortic lymphadenectomy. The EORTC Quality of Life Questionnaire-Cancer Module (QLQ-C30) and Quality of Life Questionnaire-Endometrial Cancer Module (QLQ-EN24) were administered to selected patients. All data were recorded and then analyzed using the scoring manual of the EORTC Quality of Life Group.

Results

Among symptom scales, only lymphedema gave a statistically significant difference among two groups, with a score of 10.64 ± 17.43 in Group A and 21.66 ± 24.51 in Group B (p = 0.0285). The p value obtained comparing the “Global Health Status” (items 29 and 30) in Group A and in Group B was not statistically significant.

Conclusion

Lymphadenectomy did not influence negatively global health status, but lymphadenectomy maintained its importance in determining a patient's prognosis and in tailoring adjuvant therapies. We therefore support its practice as part of the surgical procedure in patients affected by high risk endometrial cancer.     

Adjuvant radiation in early stage,unfavorable histology endometrial carcinoma is associated with improved local control and survival

Objective

Unfavorable histology endometrial carcinomas confer worse prognosis. We determined the association of adjuvant radiation on local recurrence and survival for unfavorable, early stage endometrial cancer.

Methods

We retrospectively identified 125 patients who had a hysterectomy for early stage (FIGO IA), unfavorable histology (clear cell, papillary serous or grade 3 endometrioid), endometrial carcinoma treated between 1992 and 2011. Patients were restaged according to current FIGO 2009 guidelines. Primary endpoint was local control and secondary endpoints were distant recurrence and overall survival.

Results

The median age of the cohort was 67 years old with a mean follow up 152 months. Adjuvant radiation was delivered in 60 patients (48%). There were a total of 24 recurrences; 5 had local–regional recurrences, 4 local and distant recurrence, 12 distant only recurrences, and 3 had unspecified recurrences. The 5-year local–regional control was 97.8% in patients who received radiation and 80.1% in patients who did not receive radiation (p = 0.018). The 5-year overall survival rate was 68.1% if patients did not receive radiation and 84.9% if they did receive radiation (p = 0.0062). On univariate analysis, only radiation (HR 0.12, 95% CI: 0.03 to 0.49, p-value = 0.018) was associated with a significant increase in local relapse free survival.

Conclusions

Adjuvant radiation therapy was significantly associated with an improvement in local–regional control and overall survival in patients with unfavorable histology, early stage endometrial cancer.     

Radiotherapy with concurrent cisplatin-based doublet or weekly cisplatin for cervical cancer: A systematic review and meta-analysis

Background

Treatment with weekly cisplatin (CDDP) plus radiotherapy (RT) is the standard regimen for stage IB to stage IVA cervical carcinoma (CC). We performed a systematic review and meta-analysis of published studies to evaluate whether CDDP-based doublet therapy improves survival compared to weekly CDDP plus RT in patients with CC.

Materials and methods

We conducted a systematic search for randomized and nonrandomized studies in PubMed, EMBASE, Web of Science, Scopus, and the Cochrane Register of Controlled Trials. We then carried out a meta-analysis by using the fixed- or random-effects models. The primary endpoints were overall survival (OS) and progression-free survival (PFS), reported as odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Four randomized trials and 4 retrospective studies that included a total of 1500 patients matched our selection criteria. Meta-analysis showed that for locally advanced CC, concurrent RT and with CDDP-based doublet chemotherapy significantly improved the OS (OR, 0.65; 95% CI, 0.51–0.81; p = 0.0002), PFS (OR, 0.71; 95% CI, 0.55–0.91; p = 0.006), and rate of locoregional relapse (OR, 0.64; 95% CI, 0.47–0.89; p = 0.008), compared to RT with concurrent weekly CDDP alone.

Conclusions

In patients with CC, platinum-based doublet chemotherapy plus concurrent RT was associated with improvements in the OS and PFS of 35% and 30% patients, respectively, compared to RT plus weekly CDDP. Therefore, platinum-based combination therapy plus RT should be the preferred treatment over weekly CDDP plus RT for stage IB–IVA CC.     

Realism and construct validity of novel pelvic models of common gynecologic conditions

Objective

To test a novel set of pelvic trainers for realism and construct validity.

Methods

Seven models of the female pelvis were studied. Participants performed speculum and bimanual examinations, documented their findings, and recorded opinions of the models in a structured questionnaire. Results were analyzed by participant grade (inexperienced and experienced).

Results

Twenty-six inexperienced and 24 experienced gynecologists participated. Experienced doctors were more likely to correctly identify the uterus corresponding to 16 weeks of gestation (P < 0.001), the large fibroid uterus (P = 0.01), and uterine anteversion (P = 0.04). Identification of the uterus containing a small fibroid, the uterus corresponding to 10 weeks of gestation, and an adnexal cyst was low overall (< 35%) and not significantly different between the groups. Correct identification of cervical findings (ectropion and polyp) was high in both groups (65%–88%). Experienced doctors were more consistent—with 17 (71%) reporting the same correct finding on a repeated model, compared with 8 (31%) inexperienced doctors. Forty-nine (98%) doctors completed the structured questionnaire, 36 (73%) of whom felt the models were realistic.

Conclusion

The models were found to be realistic and have construct validity. Senior participants were consistent at correctly identifying most abnormalities. The models may be useful for pelvic examination training; further testing is required regarding their ability to aid learning of clinical and communication skills.     

Non-radical surgery for small early-stage cervical cancer. Is it time?

Objectives

Non-radical surgery has been proposed in women with early-stage cervical cancer to reduce morbidity. Our objective was to evaluate the outcomes of women with early-stage cervical cancer treated with non-radical surgery.

Methods

Between March 1991 and July 2013, 51 women with early-stage cervical cancer underwent simple hysterectomy or cone biopsy. All patients had assessment of pelvic lymph nodes. Patient demographics, stage, perioperative complications, pathology findings and disease-free interval were collected prospectively.

Results

Twenty-six women had squamous cell carcinoma (SCC), 22 adenocarcinoma (AC) and 3 adenosquamous (AS) carcinoma. Thirty women were FIGO stage 1A1, 8 women IA2, and 13 women 1B1. Twenty-two (43%) and 29 (57%) women underwent simple hysterectomy and cone biopsy respectively. Median measurable tumor size was 10 mm (range 2–11), and median depth of invasion was 2.0 mm (range 0.1–12 mm). Lymphovascular space invasion (LVSI) was present in 18 women (35%). Surgical margins were negative in all women. Two women received adjuvant chemoradiation (one had deep stromal invasion with LVSI, and one had two micrometastases to pelvic nodes). Forty-nine women (96%) had their Foley catheter removed on the day of surgery or post-operative day 1. No intraoperative or postoperative complications occurred and the median blood loss was 100 ml. Median follow-up was 21 months (range 1–112). None of the 51 women developed a recurrence during follow-up (95% CI: 0–6%).

Conclusion

Non-radical surgery in appropriately selected early-stage cervical cancer patients results in a low complication rate and excellent oncologic outcomes. This approach seems to be a reasonable option in well-selected patients.     

Performance and cost analysis of Siriraj liquid-based cytology: A direct-to-vial study

Objective

To compare the cytological diagnoses, specimen adequacy, and cost of the Siriraj liquid-based cytology (LBC) with those of the conventional smear technique.

Study design

An observational study with historical comparison was conducted in a tertiary university hospital. Cytological reports of 23,676 Siriraj-LBC specimens obtained in 2006 were compared with those of 25,510 conventional smears obtained in 2004.

Results

Overall prevalence of abnormal cervical cytology detected by conventional smear was 1.76% and by Siriraj-LBC was 3.70%. Compared with the conventional method, the Siriraj-LBC yielded a significantly higher overall detection rate of abnormal cervical cytology, with a 110.23% increase in the detection rate (P < 0.001), mainly due to the increase in diagnosis of squamous intraepithelial lesions (SIL), both low and high grade, together with atypical squamous cells of undetermined significance, “atypical squamous cells cannot exclude HSIL”, and malignancies, but not atypical glandular cells. The Siriraj-LBC had a smaller proportion of unsatisfactory slides (4.94% vs. 18.60%, P < 0.001) and a higher negative predictive value (96.33% vs. 92.74%, P = 0.001), but no difference in positive predictive value (83.03% vs. 86.83%, P = 0.285). The cost of Siriraj-LBC was approximately 67% higher than that of the conventional cytology used in Siriraj Hospital and 50–70% lower than that of the commercially available LBC techniques in Thailand.

Conclusion

The Siriraj-LBC increases the detection rate of abnormal cytology, improves specimen adequacy, and enhances the negative predictive value without compromising the positive predictive value. For centers where conventional Pap smear does not perform well, the introduction of a low cost Siriraj-LBC might help to improve performance and it may be an economical alternative to the commercially available liquid-based cytology.     

Phase II trial of adjuvant pelvic radiation "sandwiched" between combination paclitaxel and carboplatin in women with uterine papillary serous carcinoma

Objective

To evaluate the safety and survival in women treated with adjuvant pelvic radiation “sandwiched” between six cycles of paclitaxel and carboplatin chemotherapy with completely resected UPSC.

Methods

Surgically staged women with UPSC (FIGO stage 1-4) and no visible residual disease were enrolled. Treatment involved paclitaxel (175 mg/m²) and carboplatin (AUC = 6.0-7.5) every 21 days for 3 doses, followed by radiation therapy (RT), followed by an additional 3 cycles of paclitaxel and carboplatin (AUC = 5-6). Survival analysis, using Kaplan-Meier methods, was performed on patients who completed at least 3 cycles of chemotherapy and RT.

Results

A total of 81 patients were enrolled, of which 72 patients completed the first 3 cycles of chemotherapy followed by prescribed RT. Median age was 67 years (range: 43-82 years). 59/72 (82%) had disease confined to the uterus and 13/72 (18%) had completely resected extra-uterine disease (stage 3 and 4). 65 (83%) completed the protocol. Overall PFS and OS for combined stage 1 and 2 patients was 65.5 ± 3.6 months and 76.5 ± 4.3 months, respectively. PFS and OS for combined stage 3 and 4 patients was 25.8 ± 3.0 and 35.9 ± 5.3 months, respectively. Three-year % survival probability for stage 1 and 2 patients was 84% and for stage 3 and 4 patients was 50%. Of the 435 chemotherapy cycles administered, there were 11(2.5%) G3/G4 non-hematologic toxicities. 26(6.0%) cycles had dose reductions and 37(8.5%) had dose delays.

Conclusions

Compared to prior studies of single modality adjuvant therapy, RT “sandwiched” between paclitaxel and carboplatin chemotherapy is well-tolerated and highly efficacious in women with completely resected UPSC.     

Endometrial polyp size and polyp hyperplasia

Objective

To assess the correlation between the size of endometrial polyps and the histopathologic diagnosis of hyperplasia or cancer.

Methods

A retrospective study was conducted using databases of the outpatient clinic at Antonio Pedro University Hospital in Niterói, Brazil, and of a private hysteroscopy service. The analysis included 1136 asymptomatic patients with an endometrial polyp identified on hysteroscopy, with pathologic examination, during the period 1999–2012. The polyp size, the patients’ age, the indication for hysteroscopic examination, and the use of hormone medication were compared with the finding of hyperplasia in the pathologic examination.

Results

Only polyp size showed statistical significance among the variables analyzed (P < 0.05). Endometrial polyps greater than 15 mm showed a hyperplasia rate of 14.8%, compared with 7.7% in the group with smaller polyps (P < 0.05).

Conclusion

Endometrial polyps measuring more than 15 mm were associated with hyperplasia.     

The importance of adjuvant chemotherapy and pelvic radiotherapy in high-risk early stage endometrial carcinoma

Objective

To determine the impact of a policy change in which women with high-risk early stage endometrioid endometrial cancer (EEC) received adjuvant chemoradiotherapy.

Methods

This is a population-based retrospective cohort study of British Columbia Cancer Registry patients diagnosed from 2008 to 2012 with high-risk early stage EEC, who received adjuvant chemoradiotherapy after primary surgery. High-risk early stage was defined as the presence of two or more high-risk uterine factors: grade 3 tumor, more than 50% myometrial invasion, and/or cervical stromal involvement. Adjuvant therapy consisted of 3 or 4 cycles of carboplatin and paclitaxel chemotherapy, followed by pelvic radiotherapy. Sites and rate of recurrence were compared to a historical cohort diagnosed from 2005 to 2008 in which none of the patients received adjuvant chemoradiotherapy. Five-year progression-free and overall survival rates were calculated.

Results

The study includes 55 patients. All patients except for 2 received at least 3 cycles of chemotherapy. All patients received pelvic radiotherapy except for 2 who received brachytherapy only. Median follow-up was 27 months (7–56 months). Four patients (7.3%) recurred, including three with distant recurrence only and one with both a pelvic and paraaortic nodal recurrence. The historical cohort had a 29.4% recurrence rate, and therefore the hazard ratio for recurrence was 0.27 (95% CI 0.02–4.11). Five-year progression-free and overall survival rates were 88.6% and 97.3%, respectively.

Conclusion

Patients with high-risk early stage endometrial carcinoma treated with adjuvant chemoradiotherapy have a low rate of recurrence compared to those not receiving such therapy.     

Peritoneal cytology: A risk factor of recurrence for non-endometrioid endometrial cancer

Objective

We compared the impact of positive peritoneal cytology on prognosis between patients with endometrioid and non-endometrioid endometrial carcinoma.

Methods

We retrospectively reviewed the medical records of 490 patients diagnosed with endometrial cancer between 2000 and 2012. These patients were divided into two groups: endometrioid and non-endometrioid histologies. We compared the patients' baseline characteristics, tumor recurrence patterns, and survival to determine the prognostic factors and how they differed between the two groups.

Results

Of the included patients, 448 had endometrioid histology and 42 had non-endometrioid histology. A total of 27 patients experienced tumor recurrence: 17 with endometrioid histology (4.0%) and 10 with non-endometrioid histology (23.8%). Compared to endometrioid type, non-endometrioid type exhibited higher rates of recurrence (p < 0.01). Recurrence sites of the non-endometrioid group were mainly peritoneal seeding (p < 0.01) and distant organ metastasis (p = 0.02). Risk factors for tumor recurrence included patient age, stage of disease, and adjuvant treatment for endometrioid type. On the other hand, in cases of non-endometrioid endometrial cancer, positive peritoneal cytology was an independent prognostic factor regardless of tumor stage (HR, 15.34; 95% CI, 3.55–66.25; p < 0.01). Among cases with non-endometrioid histology, median recurrence-free survival significantly differed between the negative peritoneal cytology group and the positive peritoneal cytology group (120 months versus 22 months, respectively; p < 0.01).

Conclusions

Positive peritoneal cytology is an independent prognostic factor for patients with non-endometrioid endometrial cancer.     

Outcome of unexpected adnexal neoplasia discovered during risk reduction salpingo-oophorectomy in women with germ-line BRCA1 or BRCA2 mutations

Objective

This study computed the risk of clinically silent adnexal neoplasia in women with germ-line BRCA1 or BRCA2 mutations (BRCA^m +) and determined recurrence risk.

Methods

We analyzed risk reduction salpingo-oophorectomies (RRSOs) from 349 BRCA^m + women processed by the SEE-FIM protocol and addressed recurrence rates for 29 neoplasms from three institutions.

Results

Nineteen neoplasms (5.4%) were identified at one institution, 9.2% of BRCA1 and 3.4% of BRCA2 mutation-positive women. Fourteen had a high-grade tubal intraepithelial neoplasm (HGTIN, 74%). Mean age (54.4) was higher than the BRCA^m + cohort without neoplasia (47.8) and frequency increased with age (p < 0.001). Twenty-nine BRCA^m + patients with neoplasia from three institutions were followed for a median of 5 years (1–8 years.). One of 11 with HGTIN alone (9%) recurred at 4 years, in contrast to 3 of 18 with invasion or involvement of other sites (16.7%). All but two are currently alive. Among the 29 patients in the three institution cohort, mean ages for HGTIN and advanced disease were 49.2 and 57.7 (p = 0.027).

Conclusions

Adnexal neoplasia is present in 5–6% of RRSOs, is more common in women with BRCA1 mutations, and recurs in 9% of women with HGTIN alone. The lag in time from diagnosis of the HGTIN to pelvic recurrence (4 years) and differences in mean age between HGTIN and advanced disease (8.5 years) suggest an interval of several years from the onset of HGTIN until pelvic cancer develops. However, some neoplasms occur in the absence of HGTIN.     

Assessment of female sexual function among women with pelvic organ prolapse or urinary incontinence via an Arabic validated short-form sexual questionnaire

Objective

To assess female sexual function among women with pelvic organ prolapse or urinary incontinence via an Arabic, validated, short-form sexual questionnaire (PISQ-12).

Methods

The present study was conducted among women attending Suez Canal University Hospital, Ismailia, Egypt, between September 2009 and August 2011. In the pilot study, 42 women completed the final version of the Arabic PISQ-12 at recruitment and then 2 weeks later, and the data were compared to evaluate reliability and internal consistency. The formal comparative study included 154 premenopausal sexually active women: 80 control women, and 74 women with some degree of pelvic prolapse with or without stress incontinence. All participants had a vaginal examination and completed the questionnaire. The main outcome measures were the mean questionnaire scores within its 3 domains (behavioral, physical, and partner-related).

Results

The test–retest reliability and internal consistency of the Arabic PISQ-12 were excellent. Validity was approved by an expert panel. The case group had a significantly lower mean total questionnaire score (31.07 ± 4.2 vs 34.7 ± 6.2; P < 0.05) but a higher partner-related score (9.0 ± 2.4 vs 8.4 ± 2.5; P < 0.05).

Conclusion

The Arabic version of PISQ-12 was shown to be an effective and objective method of evaluating sexual function among patients with pelvic organ prolapse.     

Advantages of recombinant follicle-stimulating hormone over human menopausal gonadotropin for ovarian stimulation in intrauterine insemination: a randomized clinical trial in unexplained infertility

Objective

To compare two different gonadotropin preparations, human menopausal gonadotropin (hMG) and recombinant follicle-stimulating hormone (rFSH), combined with clomiphene citrate (CC) in women with unexplained infertility undergoing intrauterine insemination (IUI).

Study design

In this prospective clinical trial, couples prepared for IUI cycles were randomly allocated to two groups either to receive CC and hMG (group A, n = 127) or CC and rFSH (group B, n = 132) for ovarian stimulation. Outcomes including rates of clinical pregnancy, miscarriage, OHSS, multiple pregnancy, cancelation, and live birth were compared between groups.

Results

Duration of gonadotropin therapy was significantly shorter in group B (5.1 ± 0.84 vs. 4.7 ± 0.8 days, CI = 95%, P < 0.001). The total dose of administered gonadotropin was also significantly lower in group B (386.9 ± 68.2 vs. 348.2 ± 56.3 IU, CI = 95%, P < 0.001). Dominant follicle number (>17 mm), mean follicular diameter, and endometrial thickness on the day of hCG injection were similar. Clinical pregnancy, multiple pregnancies, abortion, live birth, ovarian hyperstimulation syndrome (OHSS), and cancelation rates were not statistically different between the groups.

Conclusion

IUI cycles in which rFSH had been administered may require shorter duration and a lower total gonadotropin dose.