Inability of preoperative computed tomography scans to accurately predict the extent of myometrial invasion and extracorporal spread in endometrial cancer

OBJECTIVE: The purpose of this study was to assess the value of computed tomography (CT) scans in predicting preoperatively the depth of invasion and extrauterine spread in patients with endometrial cancer. METHODS: The records of 54 patients with endometrial cancer who underwent a preoperative CT scan and surgical treatment (36 of whom had complete surgical staging) were reviewed. Final pathological findings were compared with those of the CT scan. The ability of the CT scan to detect the depth of invasion of the tumor into the myometrium and extrauterine spread was assessed. RESULTS: The sensitivity of CT scans at predicting the depth of myometrial invasion (none, inner half, outer half) and cervical and parametrial spread was 10, 9, and 17%, respectively, and sensitivity in predicting any degree of myometrial invasion, lymph node metastasis, adnexal involvement, and the presence of malignant cells in peritoneal cytology was 61, 50, 60 and 57%, respectively. CONCLUSION: CT scan has limited usefulness in determining the depth of myometrial invasion or extent of tumor spread in patients with endometrial cancer. Its routine preoperative use is difficult to justify.     

Detection of recurrent cervical cancer by whole-body FDG PET scan in asymptomatic and symptomatic women

OBJECTIVE: To determine the ability of whole-body [(18)F]fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) scan to detect recurrent cervical carcinoma in both symptomatic and asymptomatic women. MATERIALS AND METHODS: We retrospectively reviewed the records of 44 women previously treated for cervical cancer who underwent 47 posttreatment whole-body FDG PET scans in an attempt to detect recurrent disease. Twenty-six scans were performed in asymptomatic women, whereas 21 scans were performed in women with symptoms suggestive of recurrence. RESULTS: About 30.8% of asymptomatic women had recurrent disease detected by PET scan compared to 66.7% of women in the symptomatic group. The sensitivity of PET scan for recurrent disease in asymptomatic women was 80.0%, specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 88.9%. For symptomatic women, the sensitivity of PET was 100%, specificity of 85.7%, a positive predictive value of 93.3%, and a negative predictive value of 100%. CONCLUSIONS: The whole-body FDG PET scan is a sensitive imaging modality for the detection of recurrent cervical carcinoma in both symptomatic and asymptomatic women.     

Post treatment surveillance of type II endometrial cancer patients

Objective

There are few studies analyzing surveillance for Type II endometrial cancer recurrence. Our objective was to determine the types of post treatment surveillance tests performed in our institution and the efficacy of these tests in detecting recurrence in type II endometrial cancer patients.

Methods

One hundred and thirty six cases of type II endometrial cancers at Cedars-Sinai Medical Center from January of 2000 to August of 2011 were identified and 106 patients met inclusion criteria. Medical charts were reviewed for surveillance methods and number of follow up visits. For patients who underwent a recurrence of disease, the surveillance method utilized for detection was documented.

Results

Forty-seven of the 106 (44%) patients developed recurrence with a mean progression free interval of 11 months. All patients had a history and physical at each surveillance visit, 78% had Pap testing, 57% had CA-125 levels drawn, 59% had CT (computed tomography) scans done, 6% had PET (positron emission tomography) scans done for surveillance. In our cohort, recurrence was detected by symptoms in 16, by CA-125 in 11, by physical exam in 7, by CT scan in 12, and by PET scan in one patient. No patients had recurrence detected by vaginal cytology.

Conclusions

Although performed in the majority of patients, Pap testing did not detect any recurrences within this cohort. History and physical exam detected the most recurrences. These findings suggest that educating patients about relevant symptoms and performing thorough follow-up exams may be the most important aspects of detecting type II endometrial cancer recurrence.     

Whole-body [18F]fluoro-2-deoxyglucose positron emission tomography scan staging prior to planned radical hysterectomy and pelvic lymphadenectomy

The aim of the study was to determine the effectiveness of whole-body [18F]fluoro-2-deoxyglucose positron emission tomography (FDG PET) imaging in properly selecting candidates for radical hysterectomy who are at low risk for subsequent chemoradiation. Retrospective study of 14 women undergoing planned radical hysterectomy and pelvic lymphadenectomy with clinically localized cervical cancer and either negative or inconclusive metastatic nodal disease by PET scan was performed. Pelvic lymph nodes were clearly negative by FDG PET scan in 12 of the 14 women. Two women had focal FDG uptake suspicious, although not definitive, for nodal metastasis, and pelvic nodes were positive at surgery in both. Computed tomography (CT) scan failed to detect nodal disease in either woman. Neither PET nor CT was effective at detecting parametrial disease, and both also failed to detect the primary tumor in some cases. Women with FDG PET scans that are clearly negative for nodal disease are good candidates for radical hysterectomy and are at low risk for subsequent chemoradiation.     

2-[Fluorine-18]-fluoro-2-deoxy-d-glucose positron emission tomography in the diagnosis of recurrent ovarian cancer

OBJECTIVE: The aim of the study was to investigate the role of 2-[fluorine-18]-fluoro-2-deoxy-d-glucose positron emission tomography (FDG PET) in the diagnosis of recurrent ovarian cancer. METHODS: One hundred six FDG PET scans performed in 54 patients in the follow-up after cytoreductive surgery and chemotherapy of ovarian cancer were reevaluated. Fifty-eight scans were performed in patients with suspected recurrence and 48 scans in patients who were clinically disease free. Thirty-seven PET scans were validated by histology and 66 studies by a median follow-up of 22 months in disease-free patients or 12 months in patients with recurrent disease. Three scans were validated by concordant positive findings of tumor marker CA125, computed tomography, and FDG PET. RESULTS: FDG PET correctly identified recurrent disease in 73/88 cases. PET ruled out recurrent disease in 15/18 cases. The sensitivity and specificity for PET were 83 and 83%, respectively. In patients with suspected disease, sensitivity was 94% compared to 65% in patients judged clinically disease free. The sensitivity of PET was 96% if suspicion of recurrence was based on a rise of CA125 alone. PET preceded the conventional diagnosis by a median of 6 months in patients judged clinically free of disease. The median relapse-free interval after a negative PET scan was 20 months. CONCLUSION: FDG PET provides the chance to detect recurrent ovarian cancer at an earlier stage during follow-up. Patients with a negative PET scan have a longer relapse-free interval than patients with a positive PET scan.     

Clinical impact of FDG-PET imaging in post-therapy surveillance of uterine cervical cancer: from diagnosis to prognosis

OBJECTIVES: To evaluate the ability of whole-body 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) scan to detect recurrent cervical cancer in women during follow-up after definitive treatment. METHODS: We retrospectively reviewed the whole-body FDG-PET scan of the women who had reached complete response after primary treatment for detection of recurrent cervical cancer between September 1, 2001 and October 31, 2004. RESULTS: One hundred twenty-one consecutive patients were registered for the current study and seventy-six women were diagnosed as recurrence, twenty of which were asymptomatic. The FDG-PET scan detected 73 (96.1%) patients among 76 patients with recurrent disease and discriminated 38 (84.4%) patients among 45 patients without recurrence. The sensitivity, specificity and accuracy of the FDG-PET scan in assessment of recurrence among patients with cervical cancer were 96.1%, 84.4% and 91.7% respectively. Sixteen patients with no evidence of distant metastasis on FDG-PET scan received pelvic exenteration; complete response was achieved in 6 (37.5%) patients, and all are alive with no evidence of disease. The FDG-PET scan detected FDG-avid lesions in 17 (85.0%) of the 20 asymptomatic patients with recurrent disease, and 8 (40.0%) patients received therapy with curative intent; complete response was achieved in five (25.0%) patients and all are alive with no evidence of disease. Three-year overall survival of this study was 85.6%. CONCLUSIONS: The whole-body FDG-PET scan is a sensitive post-therapy surveillance modality for detection of recurrent cervical cancer even in asymptomatic patients and aids in deciding treatment plans and, eventually, may have favorable impact on prognosis and survival.     

The impact of PET/CT in the management of recurrent ovarian cancer

OBJECTIVES: To evaluate the impact of PET/CT on the restaging and management of recurrent ovarian cancer. METHODS: From January 2002 to July 2003, all women undergoing either surveillance or investigation of possible recurrent ovarian cancer at the Centre for Molecular Imaging, The Peter MacCallum Cancer Centre, were invited to take part in a prospective evaluation of the clinical impact of PET/CT. RESULTS: Fifty-six women having 66 scans were available for analysis. All patients had at least 12months follow-up after the PET/CT unless they died before that time. Apart from one equivocal scan, all scans performed in women with a CA125 higher than 35IU/ml had a positive PET/CT. PET/CT altered the known disease distribution in 40 scans (64%). Overall, PET/CT showed less disease in six scans (9%) and more disease in 34 scans (52%). Regardless of the value of CA125, PET/CT identified a sub group of women with apparently localized disease or no definite evidence of disease. This group showed improved survival compared with women shown to have systemic disease. PET/CT resulted in a major change of management plan in 34 patients (58%). CONCLUSION: PET/CT modifies the assessment of the distribution of recurrent ovarian cancer and alters patient management in a substantial proportion of patients. PET/CT appears to offer prognostic information.     

Clinical impact of integrated PET/CT on the management of suspected cervical cancer recurrence

OBJECTIVES: To assess the value and clinical impact of integrated PET/CT using (18)F-FDG in the diagnosis and management of women with suspected cervical cancer recurrence. METHODS: Fifty-two patients with cervical cancer with suspected recurrence because of clinical, cytological, biochemical and radiological findings were retrospectively evaluated. A final diagnosis of recurrence was confirmed by histologic tissue biopsy or by further clinical or radiological evidence. The clinical impact of information provided by PET/CT on patient management was assessed on the basis of clinical follow-up data concerning further diagnostic or therapeutic approach. RESULTS: Twenty-eight of 32 positive PET/CT scans (87.5%) were proven to have recurrent disease. Seventeen of 20 negative PET/CT scans (85.0%) had no evidence of disease. The sensitivity, specificity, and accuracy of PET/CT for detecting recurrence were 90.3%, 81.0%, and 86.5% respectively. PET/CT changed the management of 12 patients (23.1%) by changing treatment plan (5 patients), by initiating unplanned treatment strategy (4 patients), or by obviating the need for planned diagnostic procedures (3 patients). Median duration after performing PET/CT and last follow-up was 12 (range: 6-27) months, and the 2-year disease-free survival rate of patients with negative PET/CT scan for recurrence was significantly better than that of patients with positive PET/CT (85.0% vs. 10.9%, P=0002). CONCLUSIONS: In patients with a suspected recurrence of cervical cancer, integrated PET/CT using (18)F-FDG provides good anatomic and functional localization of suspicious lesions, and the better diagnostic interpretation has an impact not only on clinical management and treatment planning of patients, but also on disease-free survival.     

The role of PET scanning in the detection of recurrent cervical cancer

OBJECTIVES: [(18)F] Fluoro-2-deoxyglucose positron emission tomography (FDG PET) has recently been established as a sensitive and specific method of detecting lymph node metastases in newly diagnosed cervical cancer. Little is known about the efficacy of PET for detecting recurrent disease. We evaluated the potential role of FDG PET in the context of suspected recurrent cervical cancer.METHODS: The records of patients undergoing PET scan to evaluate for cervical cancer recurrence between July 1998 and February 2002 were reviewed. Radiographic findings were classified as negative, suspicious, or equivocal. PET scan findings were compared to available clinical data to classify each PET result as a true positive, true negative, false positive, or false negative. Clinical proof of recurrence consisted of a tissue biopsy revealing recurrent cancer within 3 months of the PET scan. Clinical proof of no evidence of disease consisted of a negative tissue biopsy within 3 months or no clinical evidence of recurrence within 6 months after the PET scan. RESULTS: Twenty-eight patients underwent 37 PET scans. Twenty-nine cases among 22 patients were clinically evaluable for recurrence status. Median age was 42, and stage distribution was IB 1 (n = 3), IB2 (n = 4), IIA (n = 1), IIB (n = 10), IIIB (n = 9), IVB (n = 1). Histologic types included squamous (n = 23) adenocarcinoma (n = 4) and unknown (n = 1). There were 12 true positive PET scans, 13 true negatives, 2 false positives, and 2 false negatives. The sensitivity and specificity of FDG PET for detecting recurrent cervical cancer were 85.7 and 86.7%, respectively. The positive and negative predictive values were 85.7 and 86.7%, respectively. CONCLUSIONS: Whole-body FDG PET is a sensitive and specific tool for the detection of recurrent cervical cancer in patients who have clinical findings suspicious for recurrence. A larger prospective trial will determine whether this modality should be used routinely in conjunction with, or in lieu of, other imaging studies to detect recurrent disease in a broader population of cervical cancer patients.     

Follow-up of women after a first episode of postmenopausal bleeding and endometrial thickness greater than 4 millimeters

OBJECTIVE: To estimate the incidence of recurrent postmenopausal bleeding among women who were diagnosed with an endometrial thickness greater than 4 mm. METHODS: We designed a prospective cohort study and included consecutive women not using hormone replacement therapy, presenting with a first episode of postmenopausal bleeding. We evaluated patients who had an endometrial thickness greater than 4 mm at transvaginal ultrasonography and benign endometrial sampling; presence of carcinoma was ruled out by office endometrial sampling, hysteroscopy, and/or dilation and curettage. Time until recurrent bleeding was measured, and diagnosis at recurrent bleeding was recorded. RESULTS: Among 318 patients who had an endometrial thickness greater than 4 mm, 222 patients had benign histology results and were available for follow-up. During follow-up, 47 (21%, 95% confidence interval 16-27%) patients had recurrent bleeding, with a median time to recurrent bleeding of 49 weeks (interquartile range 18 to 86 weeks). There was no difference with respect to recurrence rate between patients with polyp removal, patients with a normal hysteroscopy, and patients with office endometrial sampling alone at the initial workup. Two patients were diagnosed with atypical endometrial hyperplasia upon recurrent bleeding. CONCLUSION: The recurrence rate of postmenopausal bleeding in women with endometrial thickness greater than 4 mm is 20%. This recurrence rate is not related to incorporation of hysteroscopy or polyp removal at the initial workup. LEVEL OF EVIDENCE: II.     

Combined PET/CT for detecting recurrent ovarian cancer limited to retroperitoneal lymph nodes

OBJECTIVE: To evaluate the utility of combined positron emission tomography/computed tomography (PET/CT) for detecting recurrent epithelial ovarian cancer limited to retroperitoneal adenopathy. METHODS: Fourteen patients (median age = 53 years) with rising serum CA125 levels, and negative or equivocal conventional CT imaging > or = 6 months after primary therapy were retrospectively identified as having recurrent disease limited to retroperitoneal lymph nodes by combined PET/CT and underwent surgical reassessment of targeted nodal basins. Fisher's Exact Test was used to measure the ability of PET/CT to predict isolated retroperitoneal nodal disease. RESULTS: The median increase in serum CA125 from baseline nadir was 14 U/ml (range = 2-76 U/ml). There were 29 target nodes in 15 nodal basins identified with increased metabolic uptake on combined PET/CT. Eleven patients (78.6%) had recurrent ovarian cancer in retroperitoneal lymph nodes targeted by PET/CT. Of 143 nodes retrieved, 59 contained recurrent ovarian cancer (median nodal diameter = 2.5 cm, range = 0.8-5.2 cm). For all target nodal basins, the sensitivity, specificity, positive and negative predictive values, and accuracy for recurrent ovarian cancer in dissected lymph nodes were: 40.7% (24/59), 94.0% (79/84), 82.8% (24/29), 69.3% (79/114), and 72.0% (103/143) (P < 0.001). PET/CT failed to identify microscopic disease in 59.3% of pathologically positive nodes. CONCLUSION: Combined PET/CT demonstrates high positive predictive value in identifying recurrent ovarian cancer in retroperitoneal lymph nodes when conventional CT findings are negative or equivocal. The high incidence of occult disease within the target nodal basins suggests that regional lymphadenectomy may be necessary for complete secondary cytoreduction of recurrent disease.     

Whole-body positron emission tomography with 18F-fluorodeoxyglucose is an effective method to detect extra-pelvic recurrence in uterine sarcomas

PURPOSE OF INVESTIGATION: To assess the clinical use of F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) in the post-therapy surveillance of uterine sarcoma. METHODS: Eight whole-body FDG-PET studies were performed in seven women with previously treated uterine sarcoma. Conventional image studies (computed tomography) and physical examinations were performed for follow-up. All FDG-PET studies were indicated to localize suspected recurrences noted by conventional methods. RESULTS: The per case sensitivity of the FDG-PET studies and CT scans was 85.7% (6/7) and 100% (7/7), respectively (p = 0.174). FDG-PET was able to detect seven extrapelvic metastastic sites below the diaphragm (7/7, sensitivity: 100%), including the liver, spleen, paraaortic lymph node, spine and paracolic gutter, as well as pulmonary lesions in five patients, while the CT scan detected only three lesions (3/7, sensitivity: 42.9%; p = 0.070). FDG-PET detected only four recurrent pelvic lesions (4/6) and CT scan detected six (6/6) recurrent pelvic lesions (66.7% vs 100%, p = 0.455). CONCLUSIONS: The FDG-PET showed a better detection rate than the abdominal CT scan for extrapelvic metastatic lesions and a similar detection rate as well as abdominal CT scan. FDG-PET can serve as a useful detection tool for patients with uterine sarcomas because nearly 80% of recurrence involve an extrapelvic site.     

Histopathologic correlation of dilatation and currettage and hysterectomy specimens in patients with postmenopausal bleeding

PURPOSE OF INVESTIGATION: To evaluate the consistency of preoperative and postoperative histopathological findings in postmenopausal patients with abnormal bleeding. METHODS: Pathologic diagnoses of 42 postmenopausal women with abnormal bleeding or increased endometrial thickness who underwent both dilatation and curettage (D and C), and hysterectomy for proper indications were retrospectively examined. RESULTS: The most common diagnosis was irregular proliferative endometrium in both the pre- and postoperative groups with 16 patients each (38%). After subgroup analysis, 50% of the patients with a preoperative diagnosis of complex hyperplasia without atypia, had complex atypical hyperplasia, and two-thirds of the patients with a preoperative diagnosis of complex atypical hyperplasia had endometrial cancer as the final diagnoses. CONCLUSION: Preoperative D and C endometrial pathology findings positively correlated with postoperative hysterectomy pathology results. However, as the real pathology gets worse , D and C seems to under-diagnose the real pathology. In cases with complex hyperplasia with or without atypia , a second D and C or hysteroscopic evaluation may be recommended.     

Analysis of vaginal recurrences in stage I endometrial adenocarcinoma

OBJECTIVE: To determine the risk of vaginal recurrence in Stage 1 endometrial cancer and treatment morbidity associated with different therapeutic approaches MATERIAL AND METHODS: Between 1995 and 2005, 341 patients with clinical Stage I endometrial cancer were treated at Istanbul Medical Faculty. One hundred and forty-four women were included in this study as the follow-ups and records were complete. The patients with no myometrial invasion received no further therapy following hysterectomy. When there was superficial myometrial invasion postoperative vaginal vault radiation was used, and if deep myometrial invasion was present, external pelvic radiation was given. RESULTS: Overall 5-year survival rate for all patients with Stage I disease was 80%. Nine patients (6.25%) developed recurrent disease, three of whom had vaginal recurrences. All three vaginal recurrences were small and diagnosed at routine follow-up exam within 51 months of primary therapy. CONCLUSION: This selective treatment protocol for patients with Stage I endometrial cancer avoided radiation entirely in 38% of the patients while achieving a very low rate of vaginal recurrence and good overall survival.     

Usefulness of (18)F-fluorodeoxyglucose positron emission tomography to detect para-aortic lymph nodal metastasis in advanced cervical cancer with negative computed tomography findings

OBJECTIVE: In advanced cervical cancer, it has been reported that progression-free survival is significantly related to para-aortic lymph node metastasis. Computed tomography (CT) has been widely used for clinical staging, but its sensitivity for lymph nodal metastasis is low. Therefore, this prospective study was undertaken to evaluate (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in detecting para-aortic lymph nodal metastasis in patients with locally advanced cervical carcinoma when CT findings were negative. METHODS: Fifty women with advanced cervical cancer confined to the pelvis with negative abdominal CT findings were included in this study. After 10 mCi of FDG was administered intravenously, the abdomens were scanned by PET. Para-aortic lymph node metastases were diagnosed as present or absent according to a standardized staging procedure. RESULTS: Retroperitoneal surgical exploration revealed 14 patients with para-aortic lymph nodal metastasis. Two patients had false-negative FDG-PET findings and the other two patients had false-positive FDG-PET findings. CONCLUSION: Overall, FDG-PET imaging had a sensitivity of 85.7%, a specificity of 94.4%, and an accuracy of 92%. When abdominal CT findings are negative, the use of FDG-PET can accurately detect para-aortic lymph nodal metastatis in patients with advanced cervical cancer.     

Characterization of surgically transposed ovaries in integrated PET/CT scan in patients with cervical cancer

BACKGROUND: The purpose of this study was to determine the ovarian findings on integrated positron emission tomography/computed tomography scans during follow-up in cervical cancer patients with ovarian transposition. METHOD: We retrospectively reviewed the clinical data and integrated 18F-fluorodeoxyglucose positron emission tomography/computed tomography of women with ovarian transposition during radical hysterectomy for cervical cancer between December 2003 and March 2006. RESULTS: Eighty-four premenopausal women had ovarian transposition performed during the study period. Twelve positron emission tomography/computed tomography scans from 11 patients were registered for the current study and three women were diagnosed with metastasis: two in lung and one in pelvis. Two patients complained of menopausal symptoms during follow-up, and the hormonal tests were consistent with it. In the current study, an integrated positron emission tomography/computed tomography scan detected one patient with right lower abdominal mass with increased 18F-fluorodeoxyglucose uptake, which was identified as a transposed right ovary. Clinical information of ovarian transposition was helpful in interpretation of the lesion. In the patient, transposed ovary was associated with increased fluorodeoxyglucose uptake, with standard uptake values ranging from 3.7 to 5.5. Other positron emission tomography/computed tomography scans did not show abnormal uptake of 18F-fluorodeoxyglucose. CONCLUSIONS: Transposed ovary in premenopausal women may appear on integrated positron emission tomography/computed tomography scan as a mass with increased 18F-fluorodeoxyglucose uptake, which may be associated with preserved ovarian function. Clinical information regarding transposition should be noted in order not to interpret these as recurrent or metastatic lesions.     

Natural language processing with machine learning to predict outcomes after ovarian cancer surgery

ObjectiveTo determine if natural language processing (NLP) with machine learning of unstructured full text documents (a preoperative CT scan) improves the ability to predict postoperative complication and hospital readmission among women with ovarian cancer undergoing surgery when compared with discrete data predictors alone.MethodsMedical records from two institutions were queried to identify women with ovarian cancer and available preoperative CT scan reports who underwent debulking surgery. Machine learning methods using both discrete data predictors (age, comorbidities, preoperative laboratory values) and natural language processing of full text reports (preoperative CT scans) were used to predict postoperative complication and hospital readmission within 30 days of surgery. Discrimination was measured using the area under the receiver operating characteristic curve (AUC).ResultsWe identified 291 women who underwent debulking surgery for ovarian cancer. Mean age was 59, mean preoperative CA125 value was 610 U/ml and albumin was 3.9 g/dl. There were 25 patients (8.6%) who were readmitted and 45 patients (15.5%) who developed postoperative complications within 30 days. Using discrete features alone, we were able to predict postoperative readmission with an AUC of 0.56 (0.54–0.58, 95% CI); this improved to 0.70 (0.68–0.73, 95% CI) (p < 0.001) with the addition of NLP of preoperative CT scans.Conclusions: Natural language processing with machine learning improved the ability to predict postoperative complication and hospital readmission among women with ovarian cancer undergoing surgery.     

Can ultrasound replace dilation and curettage? A longitudinal evaluation of postmenopausal bleeding and transvaginal sonographic measurement of the endometrium as predictors of endometrial cancer

OBJECTIVE: The purpose of this study was to evaluate postmenopausal bleeding and transvaginal sonographic measurement of endometrial thickness as predictors of endometrial cancer and atypical hyperplasia in women whose cases were followed for > or =10 years after referral for postmenopausal bleeding. STUDY DESIGN: Women (n = 394) who had postmenopausal bleeding from November 1987 to October 1990 underwent transvaginal sonographic measurement of endometrial thickness and curettage. It was possible to assess the medical records (regarding recurrence of a postmenopausal bleeding, development of endometrial cancer, and death) in 339 of the 394 women (86%) > or =10 years after referral for postmenopausal bleeding. RESULTS: Thirty-nine of the 339 women (11.5%) had endometrial cancer, and 5 women (1.5%) had atypical hyperplasia. The relative risk of endometrial cancer in women who were referred for postmenopausal bleeding was 63.9 (95% CI, 46.0-88.8); the corresponding relative risk for endometrial cancer and atypical hyperplasia together was 72.1 (95% CI, 52.8-98.5) compared with women of the same age from the general population of the same region of Sweden. No woman with an endometrial thickness of < or =4 mm was diagnosed as having endometrial cancer. The relative risk of the development of endometrial cancer in women with an endometrial thickness of >4 mm was 44.5 (95% CI, 6.5-320.1) compared with women with an endometrial thickness of < or =4 mm. The reliability of endometrial thickness (cutoff value, < or =4 mm) as a diagnostic test for endometrial cancer was assessed: Sensitivity, 100%; specificity, 60%; positive predictive value, 25%; and negative predictive value, 100%. The incidence of endometrial cancer or atypical hyperplasia in women with an intact uterus whose cases had been followed for > or =10 years was 5.8% (15/257 women) compared with 22.7% (15/66 women) in women who had < or =1 episode of recurrent bleeding. No endometrial cancer was diagnosed in women with a recurrent postmenopausal bleeding who had an endometrial thickness of < or =4 mm at the initial scan. CONCLUSION: Postmenopausal bleeding incurs a 64-fold increase risk for endometrial cancer. There was no increased risk of endometrial cancer or atypia in women who did not have recurrent bleeding, whereas women with recurrent bleeding were a high-risk group. No endometrial cancer was missed when endometrial thickness measurement (cutoff value, < or =4 mm) was used, even if the women were followed up for < or =10 years. We conclude that transvaginal sonographic scanning is an excellent tool for the determination of whether further investigation with curettage or some form of endometrial biopsy is necessary     

External pelvic radiation therapy in stage IC endometrial carcinoma

OBJECTIVE: To evaluate outcomes of patients with stage IC endometrial carcinoma treated with external whole pelvic radiation but not vaginal brachytherapy. METHODS: Sixty-one women with stage IC endometrial carcinoma had postoperative pelvic radiation without vaginal brachytherapy. The median age was 69 years (range 44-87 years). Most subjects had histologic findings of adenocarcinoma (71%) and grade 2 or 3 disease (74%). The median pelvic irradiation dose was 48.6 Gy (range 43.2-50.4 Gy). No patients received adjuvant chemotherapy or hormonal therapy. The median follow-up time was 69.5 months (range 7-196 months). RESULTS: The 5-year actuarial disease-free and overall survivals of the entire group were 86.7% and 97.6%, respectively. No patient developed local (vaginal) recurrence. One patient had recurrent disease in the lateral pelvis. Ten patients (16.4%) had distant (extrapelvic) metastases. No serious sequelae were noted, including vaginal necrosis, small bowel obstruction, proctitis, or fistulae. CONCLUSION: Local control was excellent in stage IC endometrial carcinoma treated with adjuvant radiation therapy alone. Attention needs to be focused on efforts to control extrapelvic recurrence in patients with this disease.     

Intrauterine Sonography for Preoperative Assessment of Cervical Invasion in Endometrial Carcinoma

Cervical involvement is one of the major prognostic factors in carcinoma of the endometrium confined to the uterus. The purpose of this study was to determine whether intrauterine ultrasound with a high-frequency miniature probe can depict the degree of cervical involvement of the disease. Thirty-two women with endometrial carcinoma underwent preoperative transvaginal and intrauterine sonography. By both scans, the degree of cervical involvement was prospectively evaluated. Sonograms were compared with the findings from histologic examination. Intrauterine sonography was completed in 30 of the 32 patients. In these 30 patients, the degree of cervical involvement (none, endocervical gland, or cervical stroma) based on transvaginal scan was correct in 23 cases (77%), and that based on intrauterine scan was correct in 26 cases (87%). Three tumors with endocervical glandular involvement were correctly diagnosed by intrauterine sonography, whereas they were incorrectly diagnosed by transvaginal scan. The specificity and positive predictive value of intrauterine sonography for the assessment of the presence of cervical stromal invasion are 100% (26/26 and 3/3, respectively). Although this study is preliminary, our experience with intrauterine sonography shows that it has potential for assessing cervical stromal invasion in endometrial carcinoma.