A retrospective assessment of outcomes of chemotherapy-based versus radiation-only adjuvant treatment for completely resected stage I-IV uterine carcinosarcoma

PurposeTo determine the progression-free survival (PFS) and overall survival (OS) in a cohort of patients who received either platinum-based chemotherapy with or without radiation therapy (pelvic or WAI), or RT alone.MethodsMemorial Sloan-Kettering Cancer Center (MSKCC) electronic medical records from 8/1/1995 to 10/3/2007 were reviewed for patient age, diagnosis date, type of primary surgery, residual disease at the completion of primary surgery, FIGO stage, treatment details, dates of progression and death, and site(s) of first recurrence. PFS and OS by stage (I/II v III/IV) and by treatment type (chemotherapy with or without RT v RT alone) were determined using landmark analyses 8 weeks after surgery. Patients who received chemotherapy with or without RT (pelvic or abdominal) or RT alone (pelvic or abdominal) were included in the analysis. Both groups were allowed to have received intravaginal radiation therapy (IVRT).ResultsForty-nine patients met study criteria. Thirty-eight/49 patients received chemotherapy: 23/38 (60.5%) received paclitaxel-carboplatin; 7/38 (18.4%) received ifosfamide-platinum; 8/38 (21.0%) received other chemotherapy. FIGO stage was: I = 15 (31%); II = 5 (10%); III = 21 (43%); IV = 8 (16%). Three-year PFS for the entire cohort was 24%. Three-year OS for the entire cohort was 60%. Three-year median PFS time for the entire cohort was 15 months (95% CI: 11–25 months). Three-year median OS time for the entire cohort was 67 months (95% CI: 23–89 months). Three-year PFS for stages I–II was 43% v 14% for stages III–IV (HR = 1.98 [0.9–4.33]); P = 0.082. Three-year OS for stages I–II was 68% v 55% for stages III–IV (HR = 1.26 [0.47–3.41]); P = 0.648. Three-year PFS for chemotherapy with or without RT was 35% v 9% for RT alone (HR = 1.74 [0.79–3.85]); P = 0.164. Three-year OS for chemotherapy with or without RT was 66% v 34% for RT alone (HR = 2.02 [0.77–5.33]); P = 0.146.ConclusionsOur study corroborates GOG 150 results, and shows that paclitaxel-carboplatin appears to be an efficacious adjuvant chemotherapy regimen for completely resected uterine carcinosarcoma. The role of adjuvant RT in addition to chemotherapy warrants further investigation.     

Twenty-year review of radiotherapy for vaginal cancer: an institutional experience

ObjectiveTo evaluate clinical outcome, prognostic factors and chronic morbidity with radiotherapy for vaginal cancer treatment.Materials and methods68 patients with vaginal cancer treated by radical or adjuvant radiotherapy (RT) were selected. Five with rare subtypes of histopathology and 8 with adenocarcinoma were excluded from this study. 76.4% of the remainder had early-stage diseases (stage I: 14, II: 28, III: 9, and IV: 4). The patients in the years from which they were treated were almost evenly distributed (1st 5 years: 13, 2nd: 14, 3rd: 16, and 4th: 12). There were four treatment groups: external beam radiotherapy (EBRT) alone (n = 18), brachytherapy (BT) alone (n = 4), EBRT and BT (n = 30), and surgery plus RT (n = 3).ResultsMedian follow-up was 50.3 months ranging from 3 to 213 months. 5-year overall survival (OS) was 55.6%, disease-specific survival (DSS) was 77.3%, disease-free survival was 74.2%, and local control was 87.7%. Independent prognostic factors for DSS and OS were tumor stage, site and size (p < 0.05). Late radiation toxicity was minimal in the bladder (4.6%) and bowel (4.6%). Vaginal morbidity was observed in 35 patients (63.6%). It was lowest in the BT alone (0%), and highest in the EBRT and BT group (82.1%), especially for those received more than 70 Gy (p = 0.05, Odds ratio = 4.64, 95% confidence interval: 1.01–21.65).ConclusionThis retrospective review suggested that tumor stage, site, and size were important prognostic factors in patients with vaginal cancer. Higher radiation dose was associated with more frequent vaginal toxicity.     

Pelvic insufficiency fractures in patients with cervical and endometrial cancer treated with postoperative pelvic radiation

ObjectiveThere is an increased awareness of pelvic insufficiency fractures (PIF) as a potential morbidity of pelvic radiotherapy (RT). The purpose of this study was to determine the incidence of PIF and assess prognostic factors, including intensity-modulated RT (IMRT), in gynecologic oncology patients treated with postoperative pelvic RT.MethodsWe performed a retrospective review of all patients with endometrial or cervical carcinoma who received postoperative pelvic RT at our institution during 2000–2008. Patients who received definitive or palliative RT were excluded.ResultsA total of 222 patients were identified, of whom 11 (5%) developed PIF at a median time of 11.5 months (range, 5.5–87.3 months) from RT completion. The 5-year actuarial rate was 5.1% (95% CI 3.3–6.9). In patients with osteoporosis, the 5-year rate was 15.6% compared with 2.9% for those without (P = 0.01). Similarly, patients who were on prior hormone-replacement therapy (HRT) had a higher rate (14.8% vs 4.1%, P = 0.009). The median body-mass index (BMI) for patients who developed PIF was significantly lower than those who didn't (25.9 vs 27.2, P = 0.016). The rate of PIF was 4.9% whether patients received IMRT or conventional RT.ConclusionsThe 5-year risk of PIF for postoperative pelvic RT in cervical and endometrial cancer is 5.1%. Women with history of osteoporosis, prior HRT, or low BMI need to be counseled about the risk of PIF. The use of IMRT did not decrease PIF, but further studies are needed to determine if a dose/volume relationship exists between RT and PIF.     

Health related quality of life and symptoms after pelvic lymphadenectomy or radiotherapy vs. no adjuvant regional treatment in early-stage endometrial carcinoma: A large population-based study

ObjectivesRoutine lymphadenectomy (LA) in early stage endometrial cancer does not improve survival. However, in the absence of lymph node metastasis, radiotherapy (RT) could be withheld and hence could result in less morbidity. Our aim was to evaluate health related quality of life (HRQL) in endometrial cancer survivors that received routine pelvic LA without RT compared to no LA, but RT in the presence of risk factors.MethodsStage I–II endometrial cancer survivors diagnosed between 1999 and 2007 were selected from the Eindhoven Cancer Registry. Survivors completed the SF-36 and the EORTC-QLQ-EN24. ANCOVA and multiple linear regression analyses were applied.Results742 (77%) of the endometrial cancer survivors returned a completed questionnaire. 377 (51%) had received no LA nor RT (LA?RT?), 198 (27%) had received LA+RT?, 153 (21%) LA?RT+ and 14 patients (2%) had received both. LA+ women reported as higher lymphedema symptom scores (25 vs. 20, p = 0.04). Women who were treated with RT reported higher gastrointestinal symptom scores vs. those who did not (23 vs. 16, p = 0.04). HRQL scales were comparable between all four treatment groups.ConclusionDespite distinct symptom patterns among women who received LA or RT, no clinically relevant differences in HRQL were observed when compared to women not receiving adjuvant therapy. Using LA to tailor adjuvant pelvic radiotherapy and prevent over-treatment in low-risk patients cannot be recommended.     

Postpartum compliance to oral glucose tolerance test

ObjectivesThe main objective of this study is to compare the rate of adherence to GTT done six weeks postpartum (early GTT) to the one performed three months or more after delivery (late GTT). The secondary objective is to determine factors associated to non-adherence to GTT.Materials and methodsThis is a retrospective study involving women with GDM who delivered in 1998 (late GTT; N = 229) and 2003 (early GTT; N = 244). We retrieved maternal, pregnancy, newborn and GDM parameters. Statistical analyses include the χ² test and logistic regression analysis.ResultsThe rate of adherence to early GTT (77.1%) was statistically higher than the one observed for late GTT (45.6%; P < 0.001). The factors identified as predictors of non-adherence were the year of delivery, parity ≥ 2, problem of adherence to GDM treatment, and no breastfeeding six weeks after delivery.ConclusionGTT performed six weeks after delivery increases the adherence to the test. The factors associated with non-adherence are more related to personal matters than to GDM.     

Combined chemotherapy and radiation improves survival for node-positive endometrial cancer

ObjectiveTo evaluate the clinical outcomes for women with node-positive endometrioid adenocarcinoma of the uterusMethodsRecords were reviewed for 66 patients with Stage IIIC endometrioid adenocarcinoma diagnosed between 1/1995 and 12/2009. Study inclusion required TAH, BSO and negative chest imaging. Papillary serous and clear cell histologies were excluded. Adjuvant treatment was external beam radiation (RT) alone in 18 patients (27%), combined chemotherapy and RT in 44 (67%), chemotherapy alone in 1 (2%), and no adjuvant therapy in 3 (5%). The median follow-up was 48 months.ResultsOf 66 patients, 56 (85%) had positive pelvic nodes only, 5 (8%) had positive para-aortic nodes only, and 5 (8%) had both. Of the 62 patients who received adjuvant RT, only 4 (6%) had an in-field recurrence, including 2 with residual disease after surgery. Disease-free (DFS) and overall (OS) survival rates at 5 years were 71% and 81%, respectively. By adjuvant treatment modality, 5-year DFS and OS rates were 63% and 67% for RT alone and 79% and 90% for combined modality therapy (p = 0.15 and p < 0.01). On multivariate analysis, combined modality therapy significantly improved DFS (HR 0.12, 95% CI 0.03–0.49, p < 0.01) and OS (HR 0.20, 95% CI 0.05–0.75, p = 0.02) compared to adjuvant RT alone.ConclusionsCompared to RT alone, combined modality therapy decreased recurrence and improved survival in patients with node-positive endometrioid adenocarcinoma of the uterus. In addition, external beam RT resulted in excellent local and regional control. Future studies are needed to define the optimal chemotherapy regimen, sequencing, and radiation fields.     

Prediction of suboptimal primary cytoreduction in primary ovarian cancer with combined positron emission tomography/computed tomography--a prospective study

ObjectiveThe treatment of FIGO stage IB2 cervical cancer is controversial. Our aim was to assess treatment patterns, outcomes, and complications in patients with stage IB2 cervical cancer.MethodsA retrospective study of patients with stage IB2 cervical carcinoma at a single institution between January 1982 and September 2006 was performed. To adequately control treatment variables, we only included patients who underwent their entire treatment at our institution. Toxicity was assessed using NCI Common Toxicity Criteria (CTC).ResultsWe identified 82 patients, of whom 47 met the strict inclusion criteria. Of these, 27 patients (57%) underwent primary radical hysterectomy (RH) and 20 (43%) were treated with definitive radiation/chemoradiation therapy (RT/CRT). Patients selected for RT/CRT had a higher American Society of Anesthesiologist (ASA) score than those selected for surgery (P = 0.037). The 3-year progression free survival rate was 52% for the RH group and 55% for the RT/CRT group (P = 0.977). The 3-year overall survival rates were 72% and 55%, respectively (P = 0.161). Overall, 52% of patients in the RH group received postoperative radiation therapy as part of their adjuvant treatment. CTC grade 3, 4, and 5 complications affected 5 patients (19%) in the RH group and 3 (15%) in the RT/CRT group.ConclusionBoth RH and definitive RT/CRT are adequate management strategies for patients with FIGO stage IB2 cervical cancer. However, there was a subset of patients in whom RH as monotherapy was appropriate. Further studies are needed to evaluate the role of new preoperative models that will accurately identify these patients.     

Pelvic node removal and disease-free survival in cervical cancer patients treated with radical hysterectomy and pelvic lymphadenectomy

ObjectiveTo examine the relationship between the number of pelvic nodes removed and 5-year disease-free survival in early-stage cervical cancer patients who underwent radical hysterectomy and pelvic lymphadenectomy (RHPL).MethodsThe medical records of 826 cervical cancer patients who underwent RHPL and who had at least 11 pelvic nodes removed at Chiang Mai University Hospital between January 2002 and December 2008 were reviewed. The patients were divided into 4 groups according to the number of nodes removed: 11–20 nodes (n = 243); 21–30 nodes (n = 344); 31–40 nodes (n = 171); and ≥ 41 nodes (n = 68). The 5-year disease-free survival of patients in each group was compared. The clinicopathological factors were analyzed using Cox regression to identify independent prognostic factors.ResultFive-year disease-free survival was not significantly different among the 4 groups. When patients with and without nodal involvement were considered separately, the 5-year disease-free survival in all groups was not significantly different. At multivariate analysis, the number of pelvic nodes removed was not an independent prognostic factor.ConclusionThe number of pelvic nodes removed was not associated with 5-year disease-free survival or number of positive pelvic nodes.     

An analysis of risk factors for postoperative pelvic cellulitis after laparoscopic-assisted vaginal hysterectomy

ObjectiveTo assess risk factors for postoperative pelvic cellulitis in women undergoing laparoscopic-assisted vaginal hysterectomy (LAVH).Materials and MethodsA total of 195 patients who underwent LAVH for benign gynecological diseases during the period 2007–2008 were enrolled. Among them, 11 patients developed pelvic cellulitis (group 1, cases) and 184 did not (group 2, controls).ResultsThe proportion of patients in American Society of Anesthesiologists physical status scale (ASA) class II was significantly higher in group 1 (p = 0.017). The grade of pelvic adhesion was significantly more severe in group 1 (p = 0.044). The mean length of hospital stay in group 1 was significantly longer than in group 2. Logistic regression analysis revealed that patients in ASA class II were six times more likely to develop postoperative pelvic cellulitis than patients in ASA class I. In addition, the analysis showed that there was a twofold increase in risk for pelvic cellulitis with each single-grade increase in the degree of pelvic adhesion. Women with postoperative pelvic cellulitis also had a significantly increased length of hospital stay.ConclusionUnderstanding the risk factors for postoperative pelvic infection, such as systemic disease, pelvic adhesion, and prolonged hospital stay, comprehensive care of patients, and correction of modifiable risk factors will help reduce the rate of postoperative pelvic cellulitis in women undergoing LAVH.     

The effect of maximal surgical cytoreduction on sensitivity to platinum-taxane chemotherapy and subsequent survival in patients with advanced ovarian cancer

ObjectivesLimited information exist about the frequency of micrometastases, their topographic distribution and prognostic impact in patients with cervical carcinoma (CX).MethodsLymph nodes of patients with surgically treated CX, FIGO IB to IIB, with pelvic lymph node involvement, were re-examined regarding the size of metastatic deposits, their topographic distribution within the pelvis. Lymph node status (pN0 vs. pN1mic = metastasis < 0.2 cm vs. pN1 = metastasis > 0.2 cm) was correlated to recurrence free (RFS) and overall survival (OS).Results31.4% of all patients (281/894) represented pelvic lymph node involvement. 22.2.% of the node positive ones showed micrometastases (pN1mic). Most commonly, obturator and internal nodes were affected by pN1mic, without any side differences. Patients with macrometastases (pN1) and micrometastases (pN1mic) represented significant reduced RFS-rate at 5-years (62% [95% CI: 54.2 to 69.8] for pN1 and 68.9% [95% CI: 55.5 to 82.4] for pN1mic) when compared to patients without metastatic disease (91.4% [95% CI: 89.0 to 93.8]; p < 0.001) The 5-years OS-rate was decreased in patients with metastatic disease (pN0: 86.6% [95% CI: 83.7 to 89.5], pN1mic: 63.8% [95% CI: 50.9 to 76.7], pN1: 48.2% [95% CI: 40.4 to 56.0]; p < 0.0001). These differences persisted in detailed analysis within these subgroups. In multivariate analysis, tumor stage, pelvic lymph node involvement and micrometastases were independent prognostic factors.ConclusionsA remarkable number of patients with CX show micrometastases within pelvic nodes. Micrometastatic disease represents an independent prognostic factor. So, all patients with pelvic lymph node involvement, including micrometastatic deposits, might be candidates for adjuvant treatment.     

Comparison of laparoscopy and laparotomy for endometrial cancer

ObjectiveTo compare the safety and efficacy of laparoscopy and laparotomy on clinical outcomes among patients with endometrial cancer.MethodsEligible randomized controlled trials (RCTs) conducted between 1966 and June 2010 were analyzed by meta-analysis.ResultsEight RCTs were included, with 3599 patients in total. No significant difference was observed between laparoscopy and laparotomy in overall (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.50–1.82; P = 0.892), disease-free (OR, 0.96; 95% CI, 0.50–1.82; P = 0.892), or cancer-related (OR, 0.90; 95% CI, 0.27–3.08; P = 0.871) survival. More intraoperative complications (OR, 1.33; 95% CI, 1.03–1.73; P = 0.030), fewer postoperative complications (OR, 0.59; 95% CI, 0.46–0.75; P < 0.001), longer operative time (standardized mean difference [SMD], 0.80; 95% CI, 0.46–1.15; P < 0.001), lower blood loss (SMD, –2.29; 95% CI, –3.67 to ? 0.91; P = 0.001), and shorter hospital stay (SMD, –2.60; 95% CI, –3.47 to ? 1.72; P < 0.001) were associated with laparoscopy. There was no significant difference between the groups in pelvic (SMD, 0.22; 95% CI, –0.03 to 0.48; P = 0.086) or para-aortic (SMD, 0.54; 95% CI, –0.04 to 1.11; P = 0.067) lymph node yield.ConclusionLaparoscopy has short-term advantages and seemingly equivalent long-term outcomes and, in experienced hands, might be a feasible alternative to laparotomy for endometrial cancer.     

Delivery in lateral position. Comparative study in low risk pregnancy between lateral and dorsal position for the delivery in eutocic vaginal birth

ObjectiveFor several years in French labour wards, delivery in the lateral decubitus position (LP) has raised great interest. We wanted to assess perineal outcomes and neonatal morbidity following delivery in the lateral LP compared to the dorsal decubitus position (DP).Patients and methodsTwo teams of midwives, in a private and in a public hospital, performed a total of 6800 deliveries in the area of Tours following a training session on the techniques of delivery in the lateral decubitus position. The design was a retrospective case-control study including patients with low obstetrical risks and normal vaginal delivery. We included 645 patients who gave birth from May 1st to September 30th, 2007.ResultsWe showed a significant difference in perineum outcomes, with a lower episiotomy rate (56.7% in LP/40.7% in DP, P = 0.0001), a higher rate of intact perineum (56.7% in LP/40.7% in DP, P = 0.0001) and no differences with respect to perineal laceration. These differences were significant in primiparous (intact perineum: 46.8% in LP/20.2% in DP, P = 0.004; episiotomy: 17% en DL/44.7% en DD, P = 0.006) and secondiparous patients (episiotomy: 8.6% in LP/30.7% in DP, P = 0.0001). We showed significant differences in fetal heart abnormalities during labour in favour of the lateral decubitus position (no anomaly, P = 0.00004; separated decrease, P = 0.04; bradycardia, P = 0.0009; early decrease, P = 0.04).Discussion and conclusionThe neonatal mortality and morbidity did not differ between delivery positions. The lateral position seems to be protective for the perineum without affecting neonatal outcome. Incorporating lateral decubitus deliver into daily practice is possible in large groups of midwives after appropriate training.     

A multi-institutional cohort study of adjuvant therapy in stage I-II uterine carcinosarcoma

ObjectiveTo evaluate the impact of adjuvant post-operative therapy in women with early stage uterine carcinosarcoma.MethodsAfter IRB approval was obtained at all sites, a multi-center retrospective study of women with FIGO stage I–II uterine carcinosarcoma diagnosed from 1997 to 2007 was conducted. Post-operative treatment included observation (OBS), radiation (RT), chemotherapy (CT) alone or with RT (CT + RT). Data analyzed included demographic and pathologic factors, adjuvant therapy outcomes, and time-to-event information. The Kaplan–Meier method was used to estimate time-to-event functions. Cox regression modeling was used to examine the impact of selected covariates on progression free survival (PFS), and overall survival (OS).Results111 women were identified: 94 (85%) had stage I and 17 (15%) had stage II uterine carcinosarcoma. Forty-four women (40%) did not receive adjuvant therapy (OBS), 29 (26%) women had adjuvant CT, 23 (20%) women underwent RT and 15 (14%) women underwent RT + CT. Seventy-three patients were alive without disease and 38 had progressed or died at the close of data collection. In multivariate analysis, CT (p = 0.003), LVSI (p < 0.0001) and a pre-existing cancer (p = 0.004) were most predictive of PFS. LVSI was predictive of shortened OS (p = 0.01).ConclusionsIn women with FIGO stage I–II uterine carcinosarcoma, adjuvant chemotherapy is associated with improved PFS compared to radiation or observation alone. Ongoing clinical trials will clarify the role of chemotherapy in women with this disease.     

Validation of the female sexual function index in women with chronic pelvic pain

IntroductionChronic pelvic pain (CPP) is a common gynecological problem that is also associated with sexual dysfunction.AimThe purpose of this research was to investigate the validity and reliability of Female Sexual Function Index (FSFI) in women with CPP.MethodOne hundred women with CPP and 100 age-matched subjects without CPP were compared in the study.Main Outcome MeasuresSexual function was assessed by FSFI.ResultsInternal consistency (Cronbach's alpha values = 0.91–0.97) was high for all scales. There were significant differences between women with and without CPP for each of the FSFI domain and total scores with very large effect sizes (1.29–2.56) (P < 0.0001, for all). Interdomain correlations of FSFI in the CPP group corresponded well to each other (P < 0.0001, for all). Moreover, test–retest reliability (r = 0.79–0.90) was also within acceptable ranges for this population.ConclusionWe concluded that the FSFI showed good ability to discriminate between women with and without sexual dysfunctions in the CPP population. Verit FF, and Verit A. Validation of the Female Sexual Function Index in women with chronic pelvic pain.     

Oncologic outcome of fertility-sparing radical trachelectomy versus radical hysterectomy for stage IB1 cervical carcinoma

ObjectiveTo compare the oncologic outcomes of women who underwent a fertility-sparing radical trachelectomy (RT) to those who underwent a radical hysterectomy (RH) for stage IB1 cervical carcinoma.MethodsWe performed a case–control study of all patients with stage IB1 cervical carcinoma who underwent a vaginal or abdominal RT between 11/01 and 6/07. The control group consisted of patients with stage IB1 disease who underwent an RH between 11/91 and 6/07 and who would be considered candidates for fertility-sparing surgery. Information was extracted from a prospectively acquired database. Recurrence-free and disease-specific survival (RFS and DSS) were estimated using Kaplan–Meier estimates and compared with the log-rank test where indicated. Multivariate analysis was performed using the Cox regression method.ResultsForty stage IB1 patients underwent an RT and 110 patients underwent an RH. There were no statistical differences between the two groups for the following prognostic variables: histology, median number of lymph nodes removed, node positive rate, lymph-vascular space involvement (LVSI), or deep stromal invasion (DSI). The median follow-up for the entire group was 44 months. The 5-year RFS rate was 96% (for the RT group compared to 86% for the RH group (P = NS). On multivariate analysis in this group of stage IB1 lesions, tumor size < 2 cm was not an independent predictor of outcome, but both LVSI and DSI retained independent predictive value (P = 0.033 and 0.005, respectively).ConclusionFor selected patients with stage IB1 cervical cancer, fertility-sparing radical trachelectomy appears to have a similar oncologic outcome to radical hysterectomy. LVSI and DSI appear to be more valuable predictors of outcome than tumor diameter in this subgroup of patients.     

Laparoscopic hysterectomy versus abdominal hysterectomy for severe pelvic endometriosis

ObjectiveTo compare the surgical outcomes of laparoscopic hysterectomy (LH) versus abdominal hysterectomy (AH) in patients with severe pelvic endometriosis.MethodsA retrospective review of patients undergoing hysterectomy for endometriosis was conducted between January 2002 and December 2007. A total of 503 patients had severe pelvic endometriosis; of these, 115 patients underwent LH and 388 patients underwent AH. Surgical outcomes—including operative time, blood loss, length of hospital stay, and need for blood transfusion—were analyzed and compared between the 2 treatment groups.ResultsOperative time was significantly longer for LH than for AH (185.1 ± 48.7 minutes and 139.9 ± 52.4 minutes, respectively; P < 0.001). However, estimated volume of blood loss, length of hospital stay, and complication rates were significantly less for patients in the LH group than for those in the AH group (302.6 ± 255.1 mL versus 760.9 ± 633.2 mL [P < 0.001]; 3.5 ± 1.1 days versus 6.4 ± 3.0 days [P < 0.001]; and 18.3% versus 49.0% [P < 0.001], respectively).ConclusionCompared with AH, LH was associated with fewer complications. LH should, therefore, be the preferred surgical option for women with severe pelvic endometriosis who require a hysterectomy.     

Sentinel lymph node biopsy in early-stage cervical cancer: utility of intraoperative versus postoperative assessment

ObjectiveTo determine the diagnostic accuracy of sentinel lymph node (SLN) detection using lymphoscintigraphy, intraoperative blue dye, and radiocolloid in patients with early-stage cervical cancer.MethodsIntra-cervical injection of technetium-99 sulfur colloid and lymphoscintigraphy were performed preoperatively. Isosulfan blue was injected intra-cervically immediately prior to surgery. SLNs were excised and examined intraoperatively (imprint cytology and frozen section) and postoperatively (H and E histology and immunohistochemistry (IHC) for cytokeratin).ResultsThirty eight patients were evaluable. Laparoscopy and laparotomy were performed in 28.9% and 71.1%, respectively. Subjects had squamous cell carcinoma (n = 26), adenocarcinoma (n = 10) or adenosquamous (n = 2) histologies. 55.3% had cervical tumors < 2 cm. The overall SLN detection rate was 92.1%. The external iliac region just distal to the common iliac bifurcation was the most common SLN location. A mean of 2.1 SLNs were detected per patient with bilateral SLNs observed in 47.4%. On final pathology, metastatic nodal disease was identified in 15.7% of patients. Of these, 83.3% were detected in the SLNs. Sensitivity of SLN detection of metastasis was 100% for patients with cervical tumors < 2 cm. However intraoperative evaluation by imprint cytology and frozen section correctly identified lymph node metastasis in only 33.3%.ConclusionsSLN detection is feasible and accurately reflects pelvic nodal basin status when performed in early-stage cervical cancer patients. However, while current intraoperative pathology techniques for assessing nodal metastases reliably detect metastases larger than 2 mm, they lack sufficient sensitivity to detect micrometastasis and isolated tumor cells.     

Quality of life and emotional distress in early stage and locally advanced cervical cancer patients: a prospective, longitudinal study

ObjectivesThis prospective, longitudinal study investigates QoL issues and emotional distress in early stage cervical cancer (ECC) patients undergoing radical surgery (RS) and in locally advanced cervical cancer (LACC) patients triaged to chemoradiation (CT/RT) followed by RS.MethodsThe Global Health Status scale of EORTC QLQ-C30 (GHS), the EORTC QLQ-CX24 (CX24) and the Hospital Anxiety and Depression Scale (HADS) questionnaire were administered at baseline, and after 3, 6, and 12 months from surgery. For LACC patients QoL assessment was also performed after CT/RT. Statistical analysis was performed by the ANOVA for repeated measures and the Between Subject test.ResultsIn ECC and LACC patients, the GHS scores improved over time (5.5% difference in mean scores compared to baseline in ECC, and 7.0% difference in mean score compared to baseline in LACC patients). An early worsening of lymphedema scores was documented in ECC cases (14.6% difference in mean values compared to baseline, p value = 0.001), and in LACC patients (difference up to 28.3% of mean values, value = 0.0001). Menopausal symptoms persistently worsened over time reaching > 15% difference of mean values compared to baseline in both groups. Sexual activity scores markedly improved both in ECC and LACC patients (difference of mean score values compared to baseline was 16.5% in ECC, and 6.7% in LACC patients). Both ECC and LACC patients experienced an improvement of anxiety scores.ConclusionsLymphedema and menopausal symptoms were the most disabling treatment-related sequelae; the amount of QoL issues and their multifaceted aspects require the cooperation of multidisciplinary teams.     

The effect of bladder fullness on evaluation of pelvic organ prolapse

ObjectiveTo investigate the effect of bladder fullness on pelvic organ prolapse (POP) staging via the Pelvic Organ Prolapse Quantification System (POP-Q).MethodsSixty women with advanced POP underwent pelvic examination with maximal Valsalva straining via POP-Q with an empty bladder and after transcatheter bladder filling to maximum cystometric capacity, with simultaneous intra-abdominal and intravesical pressure recordings. Main outcome measures included POP-Q values and staging with full versus empty bladder.ResultsAn empty bladder was associated with a significantly higher POP-Q staging (median, 3 vs 2; P < 0.0001); and a lower location of points Ba (4.51 vs 1.37; P < 0.0001), Aa (2.58 vs 0.62; P < 0.0001), Bp (? 0.68 vs ? 1.10; P = 0.01), Ap (0.83 vs ? 1.27; P = 0.002), C (1.57 vs ? 1.07; P < 0.0001), and D (0.14 vs ? 2.77; P < 0.0001) compared with a full bladder. However, genital hiatus, perineal body, and total vaginal length values were not significantly affected by bladder fullness. No differences in intra-abdominal or detrusor pressures were noted between empty and full bladder states.ConclusionPOP-Q assessment with a full bladder is associated with underestimation of POP severity. Therefore, bladder emptying should be a standard requirement for POP-Q staging and reporting.     

Robotic versus open radical hysterectomy: a comparative study at a single institution

ObjectiveTo compare the short-term surgical outcome of patients undergoing robotic radical hysterectomy (RRH) versus open radical hysterectomy (ORH) for the treatment of early stage cervical cancer.MethodsIRB approval was obtained for a retrospective chart review of all radical hysterectomies (RHs) for Stage I and II cervical cancer performed at Brigham and Women's Hospital between August 1, 2004 and August 1, 2007. Prior to August 1, 2006 all procedures were ORHs. After this date, all procedures were RRHs. Demographic data, operative data and short-term outcomes were compared. Statistical analysis using t-tests and Fisher's Exact test were performed with SAS software.ResultsA total of 48 RHs were identified, including 16 RRHs and 32 ORHs. The groups did not differ significantly in age, body mass index, stage, or histology. Mean operative time was significantly longer for RRH than ORH (4:50 vs 3:39 h, p = 0.0002). The mean estimated blood loss was significantly less for RRH than ORH (81.9 vs 665.6 mL, p < 0.0001). The mean number of lymph nodes resected did not differ between RRHs and ORHs (15.6 vs 17.1, p = 0.532). There were no intra-operative complications in the RRH group and one ureteral transection in the ORH group. Three RRH patients (18.8%) suffered post-operative complications which included a vaginal cuff infected hematoma, a transient ureterovaginal fistula, and a pelvic lymphocele, in comparison to seven in the ORH group (21.9%) which included 3 wound infections, two patients with pulmonary emboli, a partial small bowel obstruction with a mesenteric abscess, and a post-operative ileus (p = 0.999). Mean length of stay was significantly shorter for the RRH group (1.7 vs. 4.9 days, p < 0.0001).ConclusionRRH results in lower blood loss and shorter length of stay, compared to ORH. Intra-operative and post-operative complication rates are comparable. RRH is a promising new surgical technique that deserves further study.