Immunohistochemical expression of estrogen and progesterone receptors and outcomes in patients with newly diagnosed uterine leiomyosarcoma

Objective

We assessed the IHC expression of ER and PR and their prognostic significance in uterine leiomyosarcoma (LMS).

Methods

We identified 43 “high-grade” uterine LMS cases from 7/82-7/07 for whom ER/PR IHC analysis was performed at initial diagnosis at our institution.

Results

Disease was confined to the uterine body in 20/43 (47%). Eighteen (42%) of 43 were ER(+); 17/42 (41%) were PR(+). At last follow-up, 33 (77%) had recurred or progressed, and 23 (54%) had died. PR expression was associated with improved progression-free survival (PFS; P = 0.002) and overall survival (OS; P = 0.03) overall; ER expression was not. After adjusting for stage, ER expression was associated with PFS (P = 0.01), not OS (P = 0.3), and PR expression maintained a significant association with PFS (P = 0.002) and approached a significant association with OS (P = 0.05). Neither ER nor PR expression was associated with outcome in cases with disease outside the uterine body. In cases with confined disease, median PFS for ER(+) or PR(+) cases was not reached compared to 16.9 months for ER(−) cases (95% CI: 8.1-25.7; P = 0.03) and 13.5 months for PR(−) cases (95% CI: 5.9-21.1; P = 0.001). Only 1/10 PR(+) cases recurred and died; 9/10 PR(−) cases recurred, and 5 died. Two of 9 ER(+) cases recurred and died; 8/11 ER(−) cases recurred, and 4 died.

Conclusion

ER/PR expression is associated with survival outcomes in patients with high-grade uterine LMS confined to the uterine body. PR expression seems capable of identifying cases confined to the uterine body, which have better outcomes.     

BCL-2, in combination with MVP and IGF-1R expression, improves prediction of clinical outcome in complete response cervical carcinoma patients treated by radiochemotherapy

Objectives

To investigate whether BCL-2 expression would improve MVP/IGF-1R prediction of clinical outcome in cervix carcinoma patients treated by radiochemotherapy, and suggest possible mechanisms behind this effect.

Methods

Fifty consecutive patients, who achieved complete response to treatment, from a whole series of 60 cases suffering from non-metastatic localized cervical carcinoma, were prospectively included in this study from July 1999 to December 2003. Follow-up was closed in January 2011. All patients received pelvic radiation (45-64.80 Gy in 1.8-2 Gy fractions) with concomitant cisplatin at 40 mg/m2/week doses followed by brachytherapy. Oncoprotein expression was studied by immunohistochemistry in paraffin-embedded tumour tissue.

Results

No relation was found between BCL-2 and clinicopathological variables. High MVP/IGF-1R/BCL-2 tumour expression was strongly related to poor local and regional disease-free survival (P < 0.0001), distant disease-free survival (P = 0.010), disease-free survival (P < 0.0001), and cause-specific survival (P < 0.0001). NHEJ repair protein Ku70/80 expression was significantly repressed in tumours overexpressing all three oncoproteins (P = 0.047). No differences were observed in proliferation (Ki67 expression) or P53 alteration.

Conclusions

BCL-2, MVP, and IGF-1R overexpression were related to poorer clinical outcome in cervical cancer patients who achieved clinical complete response to radiochemotherapy. The NHEJ repair protein Ku70/80 expression could be involved in the regulation of these oncoproteins.     

A cost analysis of postoperative management in endometrial cancer patients treated by robotics versus laparoscopic approach

Objective

The purpose of this study is to compare postoperative pain management and costs in endometrial cancer patients who had a robotic-assisted or laparoscopic-assisted hysterectomy.

Methods

This is a retrospective cohort study of all endometrial cancer patients from 9/2005 to 6/2010 who had a completed robotic-assisted or laparoscopic-assisted hysterectomy. All surgeries were performed by gynecologic oncologists on the da Vinci S surgical system. Demographic data, patient-recorded pain scores, pain-management interventions, and postoperative pain medication costs were compared. Data was analyzed using Student's t-tests and Pearson's χ² tests in SPSS.

Results

Two-hundred fifteen (101 robotic and 114 laparoscopic) patients met the inclusion criteria. There were no significant differences between the groups in age, BMI, clinical stage, comorbidities, lymph nodes retrieved, and the number of narcotic vs. non-narcotic drug interventions administered. Robotic patients had a lower number of initial drug interventions (21 vs. 52; P < .001) and total drug interventions (162 vs. 219; P < .001) than laparoscopic patients. Robotics had a lower initial pain score (2.1 vs. 3.0; P = .012). There was a 50% reduction in the pain medication cost on the day of surgery for robotic patients ($12.24 vs. $24.45; P < .01), and a 56% cost reduction for the rest of their length of stay ($3.63 vs. $8.17; P < .01).

Conclusion

Endometrial cancer patients who have robotic surgery experience less initial postoperative pain and have fewer drug interventions. The cost associated for their pain management represents a savings of greater than 50%. These factors demonstrate the value of robotic surgery in regard to postoperative pain management by delivering higher quality care at a lower cost.     

Activation of mTOR signaling pathway associated with adverse prognostic factors of epithelial ovarian cancer

Objective

Activation of the mammalian target of rapamycin (mTOR) pathway enhances cell survival and growth by regulating the efficiency of protein translation. This study was conducted to evaluate the association of activated mTOR signaling molecules with the clinicopathologic characteristics in epithelial ovarian cancer.

Methods

Immunohistochemical staining with antibodies against p-4EBP1, p-mTOR, and p-p70S6K were performed on specimens of 103 patients with ovarian cancer. Tumors were classified as chemoresistant in cases where time to recurrence after the end of chemotherapy was shorter than 6 months.

Results

Expressions of p-mTOR, p-4EBP1, and p-p70S6K were detected in 47.6%, 85.4%, and 64.1% of all patients, respectively. p-4EBP1 overexpression was associated with advanced stage (p = 0.04), histologic grade (p < 0.01), residual mass (p < 0.01), shorter disease-free survival rate (p = 0.01) and chemoresistance (p = 0.02). p-p70S6K was associated with residual mass with marginal significance (p = 0.06). p-4EBP1 expression was correlated with p-p70S6K expression (r = 0.42, p < 0.01), whereas p-mTOR was not associated with expression of its downstream effectors or prognostic factors.

Conclusions

Our findings suggest that p-4EBP1 expression was associated with poor prognostic factors of ovarian cancer and that p-4EBP1 overexpression may be a prognostic biomarker of ovarian cancer.     

Micropapillary pattern in serous borderline ovarian tumors: does it matter?

Objective

To evaluate the clinical and prognostic impact of micropapillary pattern in patients with serous borderline ovarian tumors (SBOT).

Methods

We retrospectively assessed 130 consecutive patients with typical (n = 97, 74.6%) or micropapillary (n = 33, 25.4%) SBOT. Clinicopathologic factors and outcomes were compared between these two groups.

Results

There were no significant between-group differences in age, menopausal status, parity, body mass index, cancer antigen 125 concentration, tumor size, tumor rupture, positive cytology, ovarian surface involvement, retrieved lymph nodes, use of laparoscopy, fertility-sparing and ovary-sparing procedures, complete staging and restaging, and adjuvant chemotherapy. However, the incidences of advanced stage (II-III) tumors (10.3% vs 36.4%, P = 0.001), microinvasion (2.1% vs 15.2%, P = 0.012), peritoneal implants (8.3% vs 33.4%, P < 0.001), and lymph node involvement (0% vs 21.2%, P < 0.001) were significantly higher in patients with micropapillary than with typical SBOT. Five patients with typical (5.2%) and three with micropapillary (9.1%) SBOT had recurrent disease (P = 0.418), and one patient (3%) in micropapillary SBOT group died due to the disease (P = 0.254). The 5-year disease-free survival (DFS) rates for patients with typical and micropapillary SBOT were 96% and 86%, respectively (P = 0.148). All three patients with micropapillary SBOT who had recurrence had peritoneal implants (one noninvasive and two invasive). Multivariate analysis showed that peritoneal implant was the only significant factor related to DFS (P = 0.002).

Conclusions

Because micropapillary SBOT was significantly associated with peritoneal implants, especially invasive implants, and lymph node involvement, complete staging procedures, including lymph node dissection, are recommended. However, micropapillary SBOT itself was not significantly associated with DFS. Peritoneal implant was the only factor independently associated with tumor recurrence.     

Clinical significance of pmTOR expression in endometrioid endometrial carcinoma

Objective

Endometrial adenocarcinoma has been proposed, due to frequent activation of the PI3K/AKT pathway, as a candidate neoplasm for treatment with mTOR inhibitors. However, data on the expression of mTOR in endometrial cancer are lacking.

Study design

We used immunohistochemistry to evaluate the expression of pmTOR in 62 endometrial cancer surgical specimens.

Results

The pmTOR protein was diffusely expressed in the cytoplasm of neoplastic epithelial cells, showing variable intensity. According to the chosen cutoff value, 34 (54.8%) out of 62 patients were scored as pmTOR-positive. pmTOR expression was significantly decreased in carcinomas with deep infiltration into the myometrium (P = .009), though it was not correlated with disease stage or lymph node metastasis. Univariate analysis showed that increased expression of pmTOR was significantly associated with better disease-free survival (P = .021).

Conclusions

We show for the first time an association between pmTOR and better survival in patients with endometrial cancer. Future studies to stratify endometrial tumors by pmTOR status are needed.     

Is older age a poor prognostic factor in stage I and II endometrioid endometrial adenocarcinoma?

Objective

Prior studies have shown that age ≥ 70 years is associated with more aggressive non-endometrioid histology and worse survival in endometrial cancer. The purpose of this study is to assess if age is an independent poor prognostic factor in endometrioid histologies.

Methods

Under an IRB-approved protocol, we identified patients with surgical stage I to II endometrioid endometrial adenocarcinoma from 1995 to 2008 at two institutions. Patients were divided into two groups based on age at diagnosis: Group A (age 50-69 years) and Group B (age ≥ 70 years). All patients underwent hysterectomy, bilateral salpingoophorectomy, +/−pelvic/aortic lymphadenectomy and adjuvant therapy. Prognostic factors were evaluated by univariate and multivariate analyses.

Results

We identified 338 patients with stage IA to IIB endometrioid endometrial adenocarcinoma. The median age in Group A was 59 years (range 50-69) and Group B was 75 years (range 70-92). Patients in Group B were more likely to have hypertension (51% vs. 68%, p = 0.006) and coronary artery disease (9% vs. 18%, p = 0.03). There were no differences in progression-free or disease-specific survival, however, Group B had a worse overall survival (OS) (50.1 vs. 62.6 months, p = 0.03). On univariate analysis, age (p = 0.04), grade (p = 0.006), and coronary artery disease (p = 0.01) were associated with worse OS. After adjusting for grade and coronary artery disease, age was no longer a significant variable for OS (p = 0.17).

Conclusions

After adjusting for other poor prognostic factors, age ≥ 70 years alone may not be a significant variable affecting overall survival in patients with early stage endometrioid endometrial adenocarcinoma.     

Post fellowship training in "new-to-them" surgical techniques: assessment of learning curve characteristics

Objective

To evaluate surgically related quality outcomes during the learning curve for board-certified or board-eligible gynecologic oncologists developing “new-to-them” surgical techniques.

Methods

The study design was a retrospective review of patients with endometrial cancer clinically limited to the uterus and/or cervix undergoing TLH-BSO or TAH-BSO, aortic and pelvic lymphadenectomy(APLNDx), peritoneal washings with/without omentectomy from May 1996 to April /2006. A “senior” surgeon taught three board-certified or board-eligible gynecologic oncologists a “new-to-them” technique to perform both TLH-BSO and TAH-BSO with APLNDx using argon beam coagulation and endoscopic staplers in patients with early-stage endometrial cancer. The main outcome measures were: a) length of surgery; b) surgical measures, e.g. lymph node count; and c) peri-operative morbidity. A comparison of outcomes with the “senior” surgeon was undertaken. The learning curve characteristics were analyzed by ANOVA and curve estimate analysis.

Results

The mean operative times associated with learning a new technique to perform TLH-BSO with APLNDx and TAH-BSO with APLNDx were 155.39 +/− 26.32 and 102.28 +/− 34.22 min, respectively, with significant improvement after 20 cases (150.27 +/− 26.68 vs. 172.30 +/− 22.28, p = 0.030) and 30 cases (93.30 +/− 24.97 vs. 124.63 +/− 29.73, p = 0.030), respectively. Intra- and peri-operative morbidity and lymph node count were unaffected by experience.

Conclusion

While mean operative times decreased, outcome measures of surgical quality were not adversely affected during the learning curve for post-fellowship training while acquiring “new-to-them” surgical techniques. This study emphasizes the need for “senior” surgical supervision during the initial training period. The results of this study are likely transferable to fellowship-trained gynecologic oncologists learning other “new-to-them” surgical techniques and procedures.     

Effectiveness of an instructional DVD on third- and fourth-degree laceration repair for obstetrics and gynecology postgraduate trainees

Objective

To assess the effectiveness of an instructional DVD on the anatomy and repair of anal sphincter lacerations to improve postgraduate trainees’ understanding.

Methods

A total of 71 obstetrics and gynecology trainees completed a pretest of third- and fourth-degree lacerations to assess baseline knowledge and perceptions. Question categories included anatomy, antibiotics, anesthesia, repair methods, complications, postoperative care, and risk factors. After 1 year of clinical experience, 67 trainees (94%) were randomly assigned into DVD (intervention) and non-DVD (control) groups. A post-test was administered 4 weeks later.

Results

In the DVD group (n = 34), mean scores on the pretest versus the post-test were 65% vs 74% for postgraduate year (PGY)-1 (P = 0.09); 72% vs 83% for PGY-2 (P = 0.06); 67% vs 83% for PGY-3 (P = 0.01); and 75% vs 87% for PGY-4 (P < 0.001). In the non-DVD group (n = 33), mean scores did not change significantly for any year level. The increase in score from pretest to post-test was significantly different between the 2 groups, independent of year (P < 0.001). DVD group scores improved significantly over non-DVD group scores in anatomy (P = 0.005) and repair methods (P = 0.042) subscales.

Conclusion

An educational video is an effective tool for improving understanding of third- and fourth-degree lacerations for physicians-in-training.     

Oral micronized progesterone for prevention of preterm birth

Objective

To evaluate oral micronized progesterone (OMP) to prevent preterm birth (PTB).

Methods

A randomized, double-blind, placebo-controlled trial of 150 women with at least one PTB who received 100 mg of OMP or placebo twice a day from recruitment (18-24 weeks) until 36 weeks or delivery.

Results

PTB occurred in 29 (39.2%) women in the OMP group (n = 74) compared with 44 (59.5%) in the control group (n = 74, P = 0.002). Mean gestational age at delivery was higher in the OMP group (36.1 vs 34.0 weeks, P < 0.001). Fewer preterm births occurred between 28 and 31 weeks plus 6 days in the OMP group (RR 0.20; 95% CI, 0.05-0.73, P < 0.001). Neonatal age at delivery (34 vs 32 weeks, P < 0.001), birth weight (2400 vs 1890 g, P < 0.001), NICU stay (> 24 h, P < 0.001), and Apgar scores (P < 0.001) were more favorable in the OMP group, and fewer neonatal deaths occurred (3 vs 7, P = 0.190).

Conclusion

OMP reduced the risk of PTB between 28 and 31 weeks plus 6 days, NICU admissions, and neonatal morbidity and mortality in high risk patients.     

The significance of preoperative leukocytosis in endometrial carcinoma

Objective

To evaluate the impact of preoperative leukocytosis among patients with endometrial carcinoma.

Methods

The medical records of all patients that underwent surgical treatment for endometrial carcinoma between January 2005 and December 2010 were retrospectively reviewed. Patients were separated into two groups based on the presence or absence of preoperative leukocytosis (WBC ≥ 10,000 cells per μl). The groups were then compared with respect to pathologic findings, progression-free survival and overall survival.

Results

1144 patients were identified, 156 (13.6%) with preoperative leukocytosis and 988 (86.4%) without leukocytosis. The leukocytosis group had a greater percentage of patients with stage 3 (15.4% vs. 9.8%, crude p = 0.02) and 4 (7.1% vs. 3.0%, crude p = 0.007) disease. Leukocytosis was associated with a greater mean tumor size (4.4 vs. 3.4 cm, p = 0.0002) and a greater percentage of patients with cervical stromal involvement (14.8% vs. 8.7%, crude p = 0.02), adnexal involvement (14.1% vs. 7.5%, crude p = 0.007) and lymphvascular space invasion (24% vs. 16.3%, crude p = 0.02). On multivariate analysis, mean tumor size (OR, 95% CI; 1.10, 1.02-1.18) remained significantly associated with preoperative leukocytosis. There was no difference between groups, with respect to time to recurrence. However, leukocytosis was independently associated with an increased risk of death (HR, 95% CI; 1.69, 1.07-2.68).

Conclusions

Preoperative leukocytosis, among endometrial cancer patients, was independently associated with increasing tumor size and independently imposed an increased risk of death.     

A cohort study evaluating robotic versus laparotomy surgical outcomes of obese women with endometrial carcinoma

Objective

Minimally invasive surgery offers advantages for management of obese patients, but technical difficulty often deters its utilization. Compared to laparotomy, robotic surgery should allow comparable staging and improved surgical outcomes. Therefore, we evaluated outcomes in robotic and laparotomy cohorts of obese women with endometrial cancer at our institution.

Methods

Retrospective robotic and laparotomy cohorts of obese women (BMI ≥ 30 kg/m²) undergoing surgical management of primary endometrial cancer from March 2006 to March 2009 were formulated utilizing a computerized database. Patient demographics, operative statistics, peri-operative complications, and pathologic details were collected in an intent to treat analysis. Chi-square or Fisher's exact test and t-test were used for statistical analysis.

Results

73 women underwent robotic surgical management, 11% converted to laparotomy. Mean BMI (39.8 vs. 41.9, p = 0.152), number of co-morbidities (2.49 vs. 2.62, p = 0.690), number of previous surgeries (0.97 vs. 0.94, p = 0.841), and lymphadenectomies performed (65.8% vs. 56.7%, p = 0.227) were similar between cohorts. Total lymph nodes obtained were not statistically different between cohorts (8.01 vs. 7.24, p = 0.505). Total operative time and room time was significantly longer for robotic surgery; however, estimated blood loss, the percentage of patients receiving transfusion, hospital length of stay, wound complications (4.1% vs. 20.2%, p = 0.002) and other complications (9.6% vs. 29.8%, p = 0.001) were improved for the robotic cohort.

Conclusions

Robotic management of obese women with endometrial cancer yields acceptable staging results and improved surgical outcomes. Although operating time is longer, hospital time is shorter. Robotic surgery may be an ideal approach for these patients.     

“Top hat” versus conventional loop electrosurgical excision procedure in women with a type 3 transformation zone

Objective

To compare the “top-hat” and conventional loop electrosurgical excision procedures (LEEP) performed in women with a type 3 transformation zone to assess the rate of endocervical margin involvement.

Methods

Women with a type 3 transformation zone randomly allocated into the conventional (n = 94) and top-hat LEEP (n = 86) groups were analyzed.

Results

The rate of endocervical margin involvement in the top-hat group was lower than that in the conventional group (32.6% vs 53.2%; RR 0.36; 95% CI, 0.19-0.68; P = 0.003). Among women with positive endocervical margins, women undergoing top-hat LEEP were less likely to have residual lesions compared with those in the conventional group (52.2% vs 84.1%, respectively, P = 0.04). There was no significant difference in the complication rate between the top-hat and conventional groups (7.0% vs 10.6%, respectively, P = 0.39).

Conclusion

Top-hat LEEP performed in women with a type 3 transformation zone reduces the risks of endocervical margin involvement and residual diseases compared with conventional LEEP, with no significant difference in perioperative complications.     

Comparison between 155 cases of robotic vs. 150 cases of open surgical staging for endometrial cancer

Objective

To compare the outcomes of 155 cases of endometrial cancer who had robot-assisted surgical staging to 150 open cases.

Methods

Retrospective chart review of cases of endometrial cancer that underwent staging two different ways by two surgeons at an academic institution.

Results

Mean age was 62.4 years in the robotic arm and 65 (P = 0.04) in the open arm. Mean body mass index was 34.5 Kg/m² in the robotic arm and 33 Kg/m² in the open arm (P = 0.2). Pelvic and para-aortic lymph node dissection were performed in 94.8% and 67.7% of the robotic cases versus 95.3% and 74% of the open cases, respectively. Mean operative time was 127 min in the robotic arm, and 141 min in the open arm (P = 0.0001). Mean lymph node count was 20.3 in the robotic arm, and 20 in the open arm (P = 0.567). Mean estimated blood loss was 119 ml in the robotic arm and 185 in the open arm (P = 0.015). Mean hospital stay was 1.5 days in the robotic arm, and 4 days in the open arm (P = 0.0001). The incidence of postoperative ileus (0.6% vs. 10.7%, P = 0.0001), infections (5.2% vs. 24%, P = 0.0001), anemia/transfusion (1.3% vs. 7.7%, P = 0.005), and cardiopulmonary complications (3.2% vs.14.7%, P = 0.003) was significantly lower in the robotic arm vs. the open arm. There was one death in the robotic arm attributed to pre-existing cardiac condition.

Conclusion

Robotic-assisted staging reaps the benefits of minimally invasive surgery without compromising the adequacy of the procedure. Dedication to the technique shortens the operative time.     

Effect of bariatric surgery on pregnancy outcome

Objective

To compare the perinatal outcomes of women who delivered before with women who delivered after bariatric surgery.

Methods

A retrospective study was undertaken to compare perinatal outcomes of women who delivered before with women who delivered after bariatric surgery in a tertiary medical center between 1988 and 2006. A multivariate logistic regression model was constructed to control for confounders.

Results

During the study period, 301 deliveries preceded bariatric surgery and 507 followed surgery. A significant reduction in rates of diabetes mellitus (17.3% vs 11.0; P = 0.009), hypertensive disorders (23.6% vs 11.2%; P < 0.001), and fetal macrosomia (7.6% vs 3.2%; P = 0.004) were noted after bariatric surgery. Bariatric surgery was found to be independently associated with a reduction in diabetes mellitus (OR 0.42, 95% CI 0.26-0.67; P < 0.001), hypertensive disorders (OR 0.38, 95% CI 0.25-0.59; P < 0.001), and fetal macrosomia (OR 0.45, 95% CI 0.21-0.94; P = 0.033).

Conclusion

A decrease in maternal complications, such as diabetes mellitus and hypertensive disorders, as well as a decrease in the rate of fetal macrosomia is achieved following bariatric surgery.     

Comparison of clinical outcomes of patients with clear cell and endometrioid ovarian cancer associated with endometriosis to papillary serous carcinoma of the ovary

Objective

The aim of this investigation was to compare outcomes of patients with clear cell carcinoma (CCC) and endometrioid carcinoma (EC) of the ovary associated with endometriosis to patients with ovarian papillary serous carcinoma (PSC).

Methods

Patients with CCC and EC of the ovary associated with endometriosis were identified and matched by age and stage to PSC controls. Student's t test and chi square test were used to analyze continuous and categorical data. The Kaplan–Meier method was used for survival analysis.

Results

67 cases associated with endometriosis were identified, of which 45 were arising in endometriosis. Cases were matched to 134 PSC controls. 27 patients with tumors associated with endometriosis presented at stage I (40.3%), 27 at stage II (40.3%), ten at stage III (14.9%) and three at stage IV (4.5%). There was no difference in rate of optimal cytoreduction or response to chemotherapy in cases vs. PSC controls. There was a significant increase in synchronous endometrial cancer in tumors associated with endometriosis compared to PSC (25.4% vs. 3.7%; P < 0.001). 18 cases (26.9%) had recurrent disease vs. 55 (41%) controls (P = 0.03). The 5-year disease-free survival (DFS) and overall survival (OS) of patients with tumors associated with endometriosis compared to PSC controls were 75% vs. 55% (P = 0.03) and 85% vs. 77% (P = 0.2), respectively.

Conclusions

Patients with tumors associated with endometriosis had a higher rate of synchronous endometrial cancer. Cases also demonstrated a lower rate of recurrence and improved 5 year DFS; however, this did not translate into a difference in OS.     

Effect of intra-abdominal instillation of lidocaine during minor laparoscopic procedures

Objective

To assess the effect of intraperitoneal instillation of lidocaine on postoperative pain after minor gynecological laparoscopic surgery.

Method

A prospective, double-blind, placebo-controlled clinical trial of 75 patients undergoing gynecological laparoscopy randomized to receive intraperitoneal instillation of either 120 mg of lidocaine (n = 60) or normal saline (n = 15) at the end of surgery. Postoperative pain was evaluated by Wong-Baker Faces Pain Rating Scale (WBFS) score at 15 minutes and at 1, 2, 4, 12, and 24 hours postoperatively.

Results

The WBFS score was lower for the lidocaine group than for the control group at 1, 2, and 4 hours after surgery (P = 0.023). There was no difference in WBFS scores between the 2 groups at 15 minutes (P = 0.46), 12 hours (P = 0.13), and 24 hours (P = 0.07) after surgery.

Conclusion

Intraperitoneal instillation of lidocaine was effective in reducing postoperative pain after minor gynecological laparoscopic procedures.     

Clinical and pathologic features of young endometrial cancer patients with loss of mismatch repair expression

Objective

This study examines premenopausal and early menopause patients in a unique population with endometrial cancer and loss of mismatch repair (MMR) gene expression. The purpose is to compare clinical and pathologic differences in patients with loss of expression (LOE) to those with normal expression (NE).

Methods

Endometrial cancer patients under age 60 in-between 1998 and 2008 were identified from a single tumor registry. Clinical and pathologic data were abstracted from records. Staining for expression of MSH6, MSH2, MLH1, and PMS2 were performed on archived tissue blocks. Statistical analysis was performed.

Results

158 patients were analyzed; 58% Asian, 34% Pacific Islander, and 8% Caucasian. 31 demonstrated LOE of at least one MMR gene; 127 retained NE. 50% Caucasian, 21.9% Asian, and 12.5% Pacific Island populations had LOE of one or more MMR genes. LOE was found to have a higher incidence of Grade III (p = 0.0013) and stage 3-4 tumors (p = 0.0079), mean depth of myometrial invasion (p = 0.0019), lymphovascular space invasion (p = 0.0020), nodal metastases (p = 0.0157), and a lower incidence of Grade I (p = 0.0020) and stage 1A tumors (p = 0.0085). LOE had a significantly lower mean BMI (p = 0.0001). 35% of patients in the NE vs zero in the LOE group had a BMI greater than 40.

Conclusion

Younger patients with LOE endometrial cancer appear to represent a clinically significant subgroup of patients without features characteristically found in classic type 1 endometrial cancer generally demonstrating lower BMI and tumors associated with poor prognostic characteristics. It is unclear if the distinctive ethnicity found in Hawaii has a significant impact on outcome. Further investigation is necessary to identify appropriate treatment strategies.     

Oral misoprostol reduces vaginal bleeding following surgical evacuation for first trimester spontaneous abortion

Objective

To assess the effectiveness and tolerability of misoprostol to reduce the amount and duration of vaginal bleeding following surgical evacuation for first trimester spontaneous abortion.

Methods

A total of 160 patients who underwent surgical evacuation for first trimester spontaneous abortion between 8 and 12 weeks of pregnancy were randomized into 2 groups to receive either 200 µg of oral misoprostol immediately after evacuation followed every 6 hours for 48 hours or no misoprostol. Pain scores, duration and amount of bleeding, and endometrial thickness were assessed over 10 days.

Results

Women who received misoprostol had significantly fewer bleeding days after evacuation (4.11 ± 2.69 vs 5.89 ± 3.06; P < 0.001), fewer patients reported vaginal bleeding lasting 10 days or more (3.8% vs 15.0%; P = 0.014), and endometrial thickness 10 days after evacuation was less (6.25 ± 2.38 vs 7.23 ± 1.94; P = 0.05). Pain scores were comparable in both groups (1.54 ± 0.65 vs 1.63 ± 0.83; P = 0.40) after 10 days.

Conclusion

Oral misoprostol is effective in reducing the prevalence and amount of vaginal bleeding after surgical evacuation for first trimester spontaneous abortion.     

Knowledge of Lynch syndrome among obstetrician/gynecologists and general surgeons

Objective

To determine comfort and knowledge among obstetrician/gynecologists and general surgeons regarding recommendations for cancer screening for women with Lynch syndrome.

Methods

A questionnaire on Lynch syndrome was administered to all obstetrician/gynecologists and general surgeons at a hospital in New York, USA.

Results

Fifty obstetrician/gynecologists and 62 general surgeons completed the survey (67% response rate). Physicians were more comfortable counseling on colon cancer than endometrial cancer screening (51% vs 28%; P < 0.001). Obstetrician/gynecologists were more comfortable than general surgeons counseling patients on endometrial cancer screening (36% vs 21%; P = 0.090) but less comfortable counseling patients on colon cancer screening (36% vs 63%; P = 0.008). There was no significant difference between the specialties in the number of knowledge-based questions answered correctly. Furthermore, there was no correlation between a physician’s perceived knowledge and number of correct answers.

Conclusion

Most physicians did not report being comfortable counseling about recommendations for endometrial cancer screening. While obstetrician/gynecologists reported greater comfort than general surgeons, we found no significant difference in disease knowledge between the groups. Because appropriate cancer screening can improve the outcomes of patients with Lynch syndrome, physicians must be knowledgeable and comfortable with screening recommendations for both endometrial and colon cancer, regardless of clinical specialty.