Pathology slide review is mandatory before planning treatment for referral patients with gynecologic cancer

Objective: To evaluate the impact of a pathology slide review on the management of gynecologic cancer patients. Materials and methods: The medical records of referral patients, with the original pathologic diagnosis of gynecologic cancer treated at Chiang Mai University Hospital between January 2002 and May 2003, were retrospectively reviewed. Results: During the study period, 402 cases were available for analysis. The slides reviewed were obtained from the following organs: cervix (305), ovary (33), endometrium (32), vulva (14), and others (17). In comparison between the diagnosis after slide review and the original referral diagnosis, the minor discrepancy rate was 41.5% (95% CI: 36.7–46.5%). The major discrepancy rate was 9.0% (95% CI: 6.3–12.2%) and the most common clinical consequence was the modification of planned surgery. There was no major diagnostic discrepancy in the vulvar specimens. Among patients with cervical neoplasia, there was a significantly lower rate of major discrepancy among patients with gross lesion than among those without (P < 0.001). Conclusion: Major diagnostic discrepancies were identified in 9% of referral patients with gynecologic cancer. A pathology slide review is strongly recommended before planning treatment to improve the quality of patient care.     

Treatment of gynecologic cancers in pregnancy

Gynecologic cancers are among the most common malignancies in reproductive-age women. Approximately 3% of women diagnosed with a malignancy of the reproductive tract will have a coexisting pregnancy. A pregnant woman with a gynecologic malignancy presents a significant challenge for the clinician for many reasons. Considerable diagnostic delay is common due to confusion of symptomatology with the physiologic changes associated with the pregnant state. The diagnostic options available for a patient suspected of having an invasive gynecologic malignancy may also be compromised by the pregnancy. In addition, difficult medical, ethical, and religious issues arise when the treatment of these malignancies is incompatible with continuation of the pregnancy. Unfortunately, a relatively limited experience with reproductive tract cancers in pregnancy has prevented the development of universally accepted management algorithms for many of the complex issues regarding their treatment. A literature review of diagnostic and treatment strategies for cervical, ovarian, endometrial, and vulvar carcinoma complicated by pregnancy is presented.     

Gynecologic malignancies in older women

The aging of the population is a social phenomenon that will present a challenge to clinical practice in the 21st century. Women constitute a majority of the elderly population as they outlive males by 5 to 7 years. Ovarian, endometrial, and vulvar cancers are diseases seen more commonly in postmenopausal and elderly women. Cervical cancer continues to be a significant problem in the elderly and is usually detected at a later stage in that population than in younger patients. Accordingly, primary care clinicians ought to possess a thorough knowledge of gynecologic malignancies and should refer women who present with these disorders to a gynecologic oncologist. Ovarian cancer patients treated by a gynecologic oncologist are more likely to undergo proper surgical staging, leading to optimal debulking surgery and improved survival. Age, by itself, should not alter the diagnostic and therapeutic approach to gynecologic malignancy. Elderly patients can safely undergo radical pelvic surgery. Multiagent chemotherapy is also possible in the elderly without excess morbidity, and without compromise of response rates. Radiation therapy for cervical cancer appears to be as effective and is generally well tolerated. The Papanicolaou (Pap) test continues to be the primary screening tool for cervical cancer. Although transvaginal ultrasound seems to be useful in detecting early-stage ovarian cancer, its cost effectiveness for screening the general population remains to be demonstrated. The main considerations in the treatment of ovarian, endometrial, cervical, and vulvar cancer are discussed.     

Impact of routine expert breast pathology consultation and factors predicting discordant diagnosis

BackgroundThis study aimed to evaluate the impact of expert breast pathology consultation on operative management and predictive factors of discordant diagnosis.MethodsA retrospective review of patients referred with breast biopsies and subsequent expert pathology consultation from 2014 to 2019. Discordance in diagnosis and documented changes in therapy were recorded. Univariate and multivariable analyses were performed.ResultsNinety-one (91/263, 35%) patients had discordant findings after expert pathology consultation. No benign or in situ diagnoses were upgraded to invasive cancer. Tumor subtype changed in 10% while change in invasive cancer grade was most common (45%). Clinical management was altered in 3/263 (1%) with one change in surgical plan. Benign lesions without atypia (7.5% vs. 1.1%, p = 0.03) and excisional biopsies (8.7% vs. 2.2%, p = 0.04) were more often associated with non-discordant pathology. No independent predictors of discordance were observed.ConclusionsDiscordant diagnoses after expert pathology consultation are common despite few changes in operative management. Excisional biopsy and benign lesions without atypia may be associated with less pathologic discordance after expert review.     

Estimation of an optimal radiotherapy utilization rate for gynecologic carcinoma: part I--malignancies of the cervix, ovary, vagina and vulva

BACKGROUND: Radiotherapy usage rates exhibit wide variations both within and between countries. Current estimates of the proportion of cancer patients who should optimally receive radiotherapy are based either on expert opinion or on the measurement of actual usage rates rather than on the best available scientific evidence. METHODS: With the goal of developing an evidence-based benchmark for radiotherapy use in the treatment of malignancies of the cervix, vagina, vulva, and ovary (endometrial malignancies are covered in a separate article), the authors reviewed international evidence-based treatment guidelines. Optimal radiotherapy usage trees were constructed, and proportions of patients with clinical indications for radiotherapy were obtained from epidemiologic data. These ideal usage rates were compared with actual radiotherapy utilization rates recorded in Australia and elsewhere. RESULTS: According to the best available evidence, radiotherapy is indicated at least once for 58% of patients with cervical carcinoma, 4% of patients with ovarian carcinoma, 100% of patients with vaginal carcinoma, and 34% of patients with vulvar carcinoma. A review of the limited data available suggests that actual radiotherapy usage rates for patients with gynecologic malignancies are comparable to optimal usage rates. CONCLUSIONS: Actual practice appears to approximate the authors' model of optimal radiotherapy use. This finding reflects the high level of agreement among treatment guidelines as well as the existence of high-quality evidence related to the management of gynecologic malignancies, and it may also be indicative of the fact that a large proportion of patients are treated in specialist units. The management of gynecologic malignancies may serve as a good example in the development of management strategies for other types of cancer.     

Radiotherapy for gynecologic malignancies.

This review highlights the curative potential of radiation in gynecologic malignancies. The controversies concerning the role of surgery in the management of bulky cervical cancer is discussed. Prognostic factors associated with improved pelvic control with radiation alone are described, particularly the bulk of pelvic disease, which is not accounted for in the current International Federation of Gynecology and Obstetrics staging system. The potential for integration of radiation and chemotherapy into the management of vulvar cancer to improve cosmesis and function as well as to reduce the risk of locoregional recurrence is described. The role of whole abdominal radiation in the management of advanced endometrial and ovarian cancers as well as the role of hyperfractionation to reduce acute morbidity of large abdominal fields is reviewed. Prognostic factors associated with locoregional and distant failure for endometrial cancer are outlined and the new pathologic staging system is critically analyzed. Finally, the treatment of vaginal cancer with radiation alone (external beam plus interstitial-intracavitary radiation) or surgery is reviewed and the prognostic importance of the present modifications to the vaginal staging system are emphasized.     

Surgery for gynecologic malignancies.

The surgical management of invasive and preinvasive gynecologic malignancies continues to evolve at a brisk pace. Several good techniques are available for the treatment of preinvasive cervical disease, including cryotherapy, loop electrocautery excision, laser therapy, and standard knife conization. The use of radical surgery for early invasive cervical cancer has been extended to older women, and complications have been minimized. There has been a significant trend toward more conservative surgery in the management of invasive vulvar cancer. The new surgical staging system for endometrial cancer has generated much controversy. The importance of thorough surgical staging for ovarian cancer is clear, and our understanding of the role of cytoreduction has increased. The role of new techniques, including operative laparoscopy, is being defined in the management of gynecologic cancers.     

Management of lymph nodes in the treatment of vulvar cancer

The management of vulvar cancer has changed in the past two decades. Modern treatment of vulvar cancer must be individualized, and less radical surgery is now being performed if possible, in consideration of the quality of life (QOL) of patients. Even though the treatment now tends to be conservative, lymph nodes in all patients should be appropriately treated, with the only exception being microinvasive cancer with less than 1-mm stromal invasion. Here we review the up-to-date management of lymph nodes in patients with vulvar cancer.     

Cyclosporin A reverses chemoresistance in patients with gynecologic malignancies

Multidrug resistance is a major obstacle in successful systemic therapy of gynecologic malignancies. The objectives of this study are to evaluate the activity of cyclosporin A used to overcome drug resistance in a variety of gynecologic malignancies. Forty women (29 with ovarian cancer, 7 with uterine cancer, 3 with cervical cancer, and 1 with choriocarcinoma) were treated with cyclosporin A, 4 mg/kg intravenously, 6 hours before and 18 hours after the specific chemotherapeutic agent, to which the tumor had developed drug resistance. All patients had shown resistance to the chemotherapy agent used in combination with cyclosporin A. All patients had been heavily pretreated (mean, 2.8 previous chemotherapy regimens). Overall, among 38 available patients with gynecologic malignancies, a 29% objective response rate was observed. Twenty-six (65%) of all patients received three or more cycles of cyclosporin A. There was a 25% response rate for patients with ovarian cancer patients and 50% for those with uterine cancer. There were no responses among the three patients with cervical cancer, and the patient with choriocarcinoma had a complete response. All patients were evaluable for toxicity. Leukopenia and nausea were the most common toxic reactions, but in most cases they were transient, and only three patients required a treatment delay. The most common grade 3 or 4 toxicity was thrombocytopenia, which was observed in 22% of the patients. Cyclosporin A is well tolerated and has significant potential for reversal of chemoresistance in heavily pretreated patients with ovarian and uterine malignancies.     

Impact of second opinion pathology in the definitive management of patients with bladder carcinoma

BACKGROUND: The accurate diagnosis, staging, and grading of bladder neoplasms depend heavily on the interpretation of biopsies and transurethral resection (TUR) specimens. Although many centers require review of outside pathologic material before definitive treatment such as radical cystectomy, the authors are unaware of data supporting the utility of this approach in urothelial (transitional cell) carcinoma. The authors therefore examined the clinical and cost impact of pathologic review on patients referred to an academic urology department for treatment of bladder neoplasia. METHODS: The pathologic material from 97 patients referred to an academic center for evaluation of urothelial carcinoma of the bladder from July 1996 to July 1999 was reviewed. This material was received from 30 community hospitals and 4 academic centers. The 97 patients had undergone 131 (mean, 1.35; range, 1-10) biopsies or TUR procedures before referral. Surgical pathologists at the authors' institution reviewed all outside patient material, and discordant cases were rereviewed by one of the authors (S.E.M), an experienced genitourinary pathologist. Follow-up chart review was performed in discordant cases to determine clinical and pathologic outcomes. RESULTS: Upon review at the authors' institution, 24 of 131 (18%) specimens with a referring diagnosis of urothelial carcinoma exhibited significant discrepancies with regard to the diagnosis, stage, grade, or tumor histologic type made at the outside institution. Four tumors (3%) were found to be nonurothelial neoplasms. Five specimens (4%) were judged inadequate for staging because they contained no muscularis propria. Three patients were upstaged, including two patients shown to have muscle invasive disease. Eight patients were downstaged, including two patients referred with purported muscle invasive disease who were determined to have only superficial disease on pathology review. Two patients initially thought to have carcinoma in situ (tumor in situ [Tis]) showed no evidence of Tis on pathology review. One patient with purported muscle invasive disease was shown to have only metaplasia, and one patient had a highly significant change in tumor grade. As a result of the pathology review, five radical cystectomies were avoided, whereas five repeat TUR procedures were recommended for inadequate staging. One patient shown to have muscle invasion on pathology review proceeded directly to cystectomy, avoiding a planned repeat TUR. A cystectomy also was recommended to a second patient who was shown to have invasive disease by the pathology review. Pathology review of 131 specimens resulted in net savings of $86,176 or $658 per TUR reviewed. CONCLUSIONS: The review of bladder pathologic materials before definitive therapy can impact clinical decisions significantly and can reduce overall expenditures for the management of this cohort of bladder carcinoma patients.     

Klotho在宫颈癌及卵巢癌中的研究进展

宫颈癌、卵巢癌为常见的妇科恶性肿瘤,在全球范围内是导致女性死亡的常见原因,然而其发病机制尚未完全明确。近十年来许多文献报道Klotho基因及其蛋白与宫颈癌、卵巢癌的发生发展及预后有明显联系。因此,本文就最近有关研究文献作一综述,旨在为妇科肿瘤的基因诊断及靶向治疗提供理论依据。     

Results of registration of gynecologic malignant neoplasms in Shizuoka Prefecture--evaluation for one and a half years

To eliminate death by cancer, it would be necessary for us to register newly developed cancer in certain districts. We have registered all gynecologic malignant neoplasms in Shizuoka Prefecture, Japan, since October 1982 using a microcomputer. Analysis for one and a half years was performed as follows. Gynecologic malignancies are as detailed below: cervical cancer 304 cases, corpus cancer 58 cases, ovarian cancer 51 cases, vaginal cancer 4 cases, vulvar cancer 5 cases. A study of the correlation between detected malignancies and gynecologic examinations, particularly concerning cytologic check-up, revealed the importance of cytology in early cancer detection.     

Some surgical aspects of gynecologic cancer.

The most important developments in gynecologic oncology in recent years have been the advent of supervoltage irradiation that allows the delivery of better and safer therapy; the diligent search for new cancerostatic drugs and hormones and their clinical application, singly and in combination; and studies suggesting the possibility of immunotherapy. Conversely, few noteworthy developments have emerged in the operative management of gynecologic malignancy, even though refinements of surgical technique, improved preoperative and postoperative care, and better control of infectious problems gradually have decreased the operative morbidity and mortality rates and have improved the survival rates significantly. Surgery continues to be the dominant therapy. Irradiation, chemotherapy, and hormones are therapeutic adjuvants in the management of ovarian, endometrial, cervical, vulvar, and other genital malignancies. As a result of earlier diagnosis, with the greatly diminished incidence of far-advanced carcinoma of the cervix, primary surgery is having a larger role in the management of the early stages of this lesion. Aggressive surgical removal of advanced, dissemenated ovarian carcinoma is worthwhile; diminishing the volume of the lesion significantly improves the response of residual tumor to adjuvant therapy.     

Sentinel node evaluation in gynecologic cancer

The sentinel node evaluation has revolutionized the modern surgical management of cutaneous melanoma and breast cancer. In gynecologic oncology, sentinel node mapping has been mainly studied in vulvar and cervical cancer. In vulvar cancer, data from 12 studies including 353 cases indicate that the sentinel node detection rate is 92% and the negative-predictive value is 99%. Three groin recurrences have been documented so far (< 1%). The technique has more recently been studied in cervical cancer. Data from 12 studies including 323 cases indicate a lower sentinel node detection rate of 80% to 86% and a negative-predictive value of 99%. Three false-negative cases have been reported so far (< 1%). Review of the literature suggests that the combined approach with blue dye and lymphoscintigraphy is superior to the blue dye alone for sentinel node detection. It also suggests that the sentinel node mapping technique is feasible in vulvar and cervical cancer and that it may become a valuable alternative to the traditional groin and pelvic lymphadenectomy. However, results have not been duplicated in large multi-institutional trials, and the technique should still be performed in the context of clinical trials. Complications of the sentinel node mapping technique are rare and usually benign but physicians should be aware of the serious risk of anaphylactic reaction to the blue dye (1% to 2%). Before this technique becomes a standard approach in the management of gynecologic malignancies, more data will be needed to clarify some of the related controversies.     

Peritoneal washing cytology is unnecessary in gynecologic surgery for benign diseases.

BACKGROUND: The presence of tumor cells in peritoneal washing cytology specimens taken during surgery affects the staging of many gynecologic malignancies. Peritoneal washings are often collected routinely, even in cases of presumed benign disease. This study was designed to address whether evaluation of these specimens is justified. METHODS: We reviewed diagnostic reports from all peritoneal washings and the corresponding surgical pathology specimens from patients undergoing gynecologic surgery during a 1-year period in one institution and a 20-month period in the other. Cases were divided into benign and malignant categories based on the surgical pathology diagnosis. RESULTS: Three hundred forty-six patients had peritoneal washings collected during the study period. The proportion of cases with malignancy was 30% in one institution and 49% in the other. Of these, 119 had an endometrial or ovarian malignancy, including 16 ovarian tumors of low malignant potential. Malignant cells were detected in 19 cases. In 10 of these 19, grossly apparent peritoneal tumor implants were present at the time of surgery. The remaining 227 were found to have benign disease, and the peritoneal washing cytology diagnosis was negative in all cases. Potential savings of $13,000 to $17,000 based on current insurance reimbursement could have been realized for these 227 patients without compromising patient care. CONCLUSIONS: These data suggest that peritoneal washing cytology specimens collected at the time of gynecologic surgery for presumed benign disease can be held and processed later if an unsuspected malignancy is discovered. This practice can result in cost savings without compromising patient care. Cancer (Cancer Cytopathol) Copyright 1999 American Cancer Society.     

Prognostic factors of vulvar cancer

While vulvar cancer is rare in Japan, the management of this disease has changed dramatically over the past 20 years. The radical vulvectomy that was previously believed to be the only effective treatment for vulvar cancer has now been replaced by more individualized treatments, from the standpoint of QOL. Because the lesion diameter and groin node status (laterality and number positive) are the most important prognostic factors of vulvar cancer, numerous refinements have been made in the management. The refinements include conservative surgery for patients with isolated lesions, omission of groin lymph node dissection in T 1 A tumors with stromal invasion <1 mm, and omission of contralateral groin lymph node dissection in T 1 tumor with negative ipsilateral node metastasis. In addition to these changes, elimination of groin dissection using sentinel lymph node procedure and preoperative chemoradiation for patients with advanced disease are currently under investigation. In this review, we discuss these issues along with the evidence upon which these therapies are based.     

Advances in the chemotherapy of gynecologic malignancies.

Chemotherapy is playing an ever increasing role in the treatment of patients with the common gynecologic malignancies, including ovarian, cervical cancer, and endometrial cancer. Chemotherapy has its most defined role in the treatment of patients with ovarian cancer where virtually all patients will receive cytotoxic chemotherapy. There are four major areas of research in chemotherapy in gynecologic malignancies. In retrospective studies it has been demonstrated that dose intensity is an important factor in maximizing response rates. Clinical studies are now prospectively evaluating the importance of dose intensity, particularly with the new platinum analogue carboplatin. In addition, it has been demonstrated in endometrial cancer and cervical cancer that patients with poor prognostic features such as high grade tumours and large volume disease have a low probability of cure by standard modalities such as surgery and radiation. In this group of patients combined modality approaches are being evaluated. In addition, regional therapy, either in the form of intra-arterial therapy for patients with cervical cancer or intraperitoneal therapy for patients with ovarian cancer, is being investigated. The primary factor limiting the effectiveness of chemotherapy in gynecologic malignancies is the development of drug resistance. It has recently been demonstrated that several drugs such as taxol, ifosfamide, and hexamethylmelamine have activity in patients who have had previous treatment with platinum-based compounds. In addition, the mechanism associated with the development of drug resistance in ovarian cancer have recently been identified. Clinical trials have been initiated with compounds such as buthionine sulfoximine in an attempt to specifically reverse resistance associated with alkylating agents and platinum compounds.     

Quality of life in women with gynecologic cancer in Turkey

Aim: The management of gynecological cancer patients mainly aims at prolonging survival but modern therapy focuses on good survival combined with a good quality of life (QoL). The aim of this study was to evaluate QoL and identify its associated factors in Turkish women with gynecologic cancer. Method: The study included 119 women diagnosed with endometrial, cervical, ovarian or vulvar cancer and treated at the Gynecologic Oncology Department of Celal Bayar University Faculty of Medicine. The data were collected between January and June 2011. QoL was measured with EORTC QLQ-C30 version 3.0. Relationships between clinical and socio-demographic characteristics and QoL scores were analyzed using the Mann-Whitney U, Kruskal Wallis and t-tests. Result: Global health status, physical and role function scores were found higher in women under the age of 60 years. Role function scores were found lower, and emotional and social scores were found to be higher in single women than in married women. Physical scores were found higher in women who had graduated from secondary school or above. Women with ovarian cancer had the highest while women with cervical cancer had the lowest global health score (65.3 ±24.7 and 43.0±24.1, respectively). Women with endometrial cancer were found to have better role function, and social well being than those with vulvar, cervical or ovarian cancer. Global, physical, role function, cognitive and social scores were found higher in women who had been treated with surgery. Conclusion: Gynecological cancer and treatment processes cause significant problems that have negative effects on physical, emotional, social and role function aspects of QoL. Health care providers play a key role in the identification and treatment of the complications of cancer therapy. Minimizing the effect of the symptoms of gynecologic cancer may positively impact on patient QoL.     

宫颈癌患病危险因素及一级预防

宫颈癌是常见的妇科恶性肿瘤之一,其危险因素包括生物学、行为学、社会经济学、遗传易感性等方面.随着宫颈癌诊断和筛查技术的发展,宫颈癌和癌前病变得以早期发现和治疗,使得宫颈癌的发病率和死亡率明显下降.但要进一步降低宫颈癌的发病率还需要做好一级预防.本文就宫颈癌危险因素以及一级预防等方面进行综述.     

Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board

BACKGROUND: The treatment of breast cancer requires a multidisciplinary approach, and patients are often referred to a multidisciplinary cancer clinic. The purpose of the current study was to evaluate the impact of this approach on the surgical management of breast cancer. METHODS: The medical records of 149 consecutive patients referred to a multidisciplinary breast cancer clinic over a 1-year period with a diagnosis of breast cancer were reviewed retrospectively for alterations in radiologic, pathologic, surgical, and medical interpretations and the effect that these alterations had on recommendations for surgical management. RESULTS: A review of the imaging studies resulted in changes in interpretations in 67 of the 149 patients studied (45%). This resulted in a change in surgical management in 11% of patients. Review of the pathology resulted in changes in the interpretation for 43 of the 149 patients (29%). Thirteen patients (9%) had surgical management changes made solely as a result of pathologic reinterpretation. In 51 patients (34%), a change in surgical management was recommended after discussion with the surgeons, medical oncologists, and radiation oncologists that was not based on reinterpretation of the radiologic or pathologic findings. Overall, a second evaluation of patients referred to a multidisciplinary tumor board led to changes in the recommendations for surgical management in 77 of 149 of those patients studied (52%). CONCLUSIONS: The changes in management stemmed from differences in mammographic interpretation, pathologic interpretation, and evaluation by medical and radiation oncologists and surgical breast specialists. Multidisciplinary review can provide patients with useful additional information when making difficult treatment decisions.