Search

To compare the immediate operating room (OR), inpatient, and overall costs between three surgical modalities among women with endometrial cancer (EC) and Class III obesity or higher.A multicentre prospective observational study examined outcomes of women, with early stage EC, treated surgically. Resource use was collected for OR costs including OR time, equipment, and inpatient costs. Median OR, inpatient, and overall costs across surgical modalities were analyzed using an Independent-Samples Kruskal-Wallis Test among patients with BMI ≥ 40.Out of 520 women, 103 had a BMI ≥ 40. Among women with BMI ≥ 40: median OR costs were $4197.02 for laparotomy, $5524.63 for non-robotic assisted laparoscopy, and $7225.16 for robotic-assisted laparoscopy (p 0.001) and median inpatient costs were $5584.28 for laparotomy, $3042.07 for non-robotic assisted laparoscopy, and $1794.51 for robotic-assisted laparoscopy (p 0.001). There were no statistically significant differences in the median overall costs: $10 291.50 for laparotomy, $8412.63 for non-robotic assisted laparoscopy, and $9002.48 for robotic-assisted laparoscopy (p = 0.185).There was no difference in overall costs between the three surgical modalities in patient with BMI ≥ 40. Given the similar costs, any form of minimally invasive surgery should be promoted in this population.

Objective This guideline reviews the potential benefits of opportunistic salpingectomy to prevent the development of high grade serous cancers (HGSC) of the ovary/fallopian tube/peritoneum based on current evidence supporting the fallopian tube origin of disease. Intended users Gynaecologists, obstetricians, family doctors, registered nurses, nurse practitioners, residents, and health care providers. Target population Adult women (18 and older): OPTIONS: Women considering hysterectomy who wish to retain their ovaries in situ have traditionally also retained their fallopian tubes. In addition, women undergoing permanent surgical sterilization have usually undergone tubal ligation using various methods rather than undergoing surgical removal of the entire fallopian tube. Evidence For the sections "Evidence Supporting the Hypothesis That HGSC Originates in the Fallopian Tube" and "Current Literature on the Effects and Safety of Opportunistic Salpingectomy," relevant studies were searched in PubMed, Medline, and the Cochrane Systematic Reviews using the following terms, either alone or in combination, with the search limited to English language materials: "high grade serous cancers ovary," "fallopian tube," "peritoneum," "opportunistic salpingectomy," "epithelial ovarian cancers," "origin," "tubal carcinoma in situ," "BRCA mutation," "prophylactic salpingectomy," "inflammation," "clear cell," and "endometrioid." The initial search was performed in March 2015 with a final literature search in March 2016. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. The total number of studies identified was 458, and 56 studies were included in this review. For the section "Other Factors Influencing the Risk of Developing "Ovarian" Cancers" a general Medline search was carried out using the terms "ovarian neoplasm" and "prevention." The search included papers published from December 2005 to March 2016. Meta-analyses were preferentially selected except where no such review was found. Additional searches for each subheading were also conducted (e.g., "ovarian neoplasm" and "tubal ligation.") Additional significant articles were identified through cross-referencing the identified reviews. For the search for "ovarian neoplasm" and "prevention," 10 meta-analyses were identified. For the search for "ovarian neoplasm" and "tubal ligation," an additional 4 meta-analyses were identified. Validation methods The content and recommendations were drafted and agreed on by the principal authors. The Executive and Board of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of the SOGC approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework (Table 1). The interpretation of strong and weak recommendations is described in Table 2. The summary of findings is available on request. Benefits, harms, and/or costs The addition of opportunistic salpingectomy to a planned hysterectomy or permanent sterilization did not increase rates of hospital readmission (OR 0.91, 95% CI 0.75 to 1.10 and OR 0.8, 95% CI 0.56 to 1.21, respectively) or blood transfusions (OR 0.86, 95% CI 0.67 to 1.10 and OR 0.75, 95% CI 0.32 to 1.73, respectively) but did increase the overall operating time (by 16 minutes and 10 minutes, respectively) in a retrospective review of 43 931 women. The risk of repeat surgery for tubal pathology among women with retained fallopian tubes after hysterectomy was at least doubled (OR 2.13, 95% CI 1.88 to 2.42 in a population-based study of 170 000 women). If general gynaecologists were to consider removal of fallopian tubes at the time of every hysterectomy and sterilization procedure with referral of all patients with HGSC for hereditary cancer counselling and genetic testing, experts project a potential reduction in the rate of HGSC by 40% over the next 20 years. Guideline update Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations. Sponsors This guideline was developed with resources funded by the Society of Gynecologic Oncology of Canada and SOGC. Summary statements RECOMMENDATIONS.

Objectif La presente directive clinique examine les avantages potentiels de la salpingectomie opportuniste pour prevenir le developpement du cancer sereux de grade eleve de l'ovaire, de la trompe de Fallope et du peritoine a la lumiere de donnees probantes actuelles selon lesquelles ce type de cancer prendrait naissance dans la trompe de Fallope. Utilisateurs cibles Gynecologues, obstetriciens, medecins de famille, infirmieres autorisees, infirmieres praticiennes, residents et fournisseurs de soins de sante. Population cible Femmes adultes (18 ans et plus) : OPTIONS: Les femmes envisageant une hysterectomie et souhaitant conserver leurs ovaires conservent generalement aussi leurs trompes de Fallope. De plus, celles qui subissent une chirurgie de sterilisation permanente subissent habituellement aussi une ligature des trompes selon des methodes variees plutot qu'un retrait chirurgical complet des trompes. ReSULTATS: Les sections « Donnees probantes appuyant l'hypothese selon laquelle les CSGE prendraient naissance dans la trompe de Fallope » et « Articles recents sur les repercussions et la surete de la salpingectomie opportuniste » reposent sur des etudes pertinentes redigees en anglais, qui ont ete reperees dans PubMed, Medline et la Cochrane Database of Systematic Reviews a l'aide des termes suivants, seuls ou combines : high grade serous cancers ovary, fallopian tube, peritoneum, opportunistic salpingectomy, epithelial ovarian cancers, origin, tubal carcinoma in situ, BRCA mutation, prophylactic salpingectomy, inflammation, clear cell et endometrioid. La recherche initiale a ete menee en mars 2015, et une derniere recherche a ete effectuee en mars 2016. Dans l'ordre, les donnees probantes pertinentes ont ete tirees de meta-analyses, de revues de la litterature, de directives, d'essais cliniques randomises, d'etudes de cohorte prospectives, d'etudes d'observation, de revues non systematiques, d'etudes de serie de cas ainsi que de rapports. Au total, 458 etudes ont ete reperees, et 56 ont ete retenues pour la presente directive. Pour la section « Autres facteurs influant sur le risque de developper un cancer de ″l'ovaire″ », une recherche generale a ete effectuee dans Medline a partir des termes ovarian neoplasm et prevention. Ont ete inclus dans cette recherche des articles rediges entre decembre 2005 et mars 2016. Les meta-analyses ont ete privilegiees lorsque possible. Des recherches supplementaires ont egalement ete menees pour chaque sous-descripteurs (p. ex., ovarian neoplasm et tubal ligation). D'autres articles pertinents ont ete cibles au moyen d'une verification des references des revues de la litterature retenues. Les termes ovarian neoplasm et prevention ont permis de reperer 10 meta-analyses; les termes ovarian neoplasm et tubal ligation, 4 meta-analyses. MeTHODES DE VALIDATION: Le contenu et les recommandations ont ete rediges et acceptes par les auteurs principaux. La direction et le conseil de la Societe de gyneco-oncologie du Canada ont examine le contenu et soumis des commentaires, puis le Conseil d'administration de la SOGC a approuve la version finale avant publication. La qualite des donnees probantes a ete evaluee a partir des criteres de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) (tableau 1). L'interpretation des recommandations solides et conditionnelles est decrite dans le tableau 2. Le resume des conclusions peut etre fourni sur demande. AVANTAGES, INCONVeNIENTS ET COuTS: L'ajout d'une salpingectomie opportuniste a une hysterectomie ou a une procedure de sterilisation permanente prevue n'a pas entraine une augmentation des taux de readmission a l'hopital (RC : 0,91; IC a 95 % : 0,75-1, 10 et RC : 0,8; IC a 95 % : 0,56-1,21, respectivement) ou de transfusion sanguine (RC : 0,86; IC a 95 % : 0,67-1,10 et RC : 0,75; IC a 95 % : 0,32-1,73, respectivement), mais il a entraine une hausse de la duree des operations (de 16 minutes et de 10 minutes, respectivement) selon une etude retrospective portant sur 43 931 femmes. Le risque de subir des interventions repetees pour une pathologie tubaire chez les femmes ayant conserve leurs trompes de Fallope apres une hysterectomie etait au moins deux fois plus eleve (RC : 2,13; IC a 95 % : 1,88-2,42, selon une etude fondee sur une population de 170 000 femmes). Selon des experts, si les gynecologues generalistes envisageaient systematiquement de retirer les trompes de Fallope lors d'une hysterectomie ou d'une procedure de sterilisation et d'aiguiller toutes les patientes aux prises avec un CSGE vers une consultation en oncologie genetique et un depistage genetique, le taux de CSGE pourrait diminuer de 40 % au cours des 20 prochaines annees. MISE a JOUR DE DIRECTIVES CLINIQUES: Une revue des donnees probantes sera menee cinq ans apres la publication de la presente directive clinique afin de determiner si une mise a jour complete ou partielle s'impose. Cependant, si de nouvelles donnees probantes importantes sont publiees avant la fin du cycle de cinq ans, le processus pourrait etre accelere afin que certaines recommandations soient mises a jour rapidement. Parrains La presente directive clinique a ete elaboree a l'aide de ressources financees par la Societe de gyneco-oncologie du Canada et la SOGC. DeCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Resume Objectif Analyser la pratique actuelle et formuler des recommandations en ce qui concerne la prise en charge et le traitement du cancer de l'endometre. Issues La presente directive clinique formule des recommandations a l'egard de l'approfondissement de la stadification chirurgicale, soit une intervention qui offre d'importants renseignements pronostiques et qui contribue a determiner la necessite du recours a des traitements adjuvants. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed, CINAHL et The Cochrane Library au moyen d'un vocabulaire controle (p. ex. « endometrial neoplasms ») et de mots cles (p. ex. « endometrium cancer », « endometrial carcinoma ») appropries. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction n'a ete appliquee en matiere de date ou de langue. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'au 31 decembre 2011. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, aupres de societes de specialite medicale nationales et internationales, et dans des resumes de conference recents. Avantages, desavantages et couts La presente directive clinique analyse les avantages de l'approfondissement de la stadification chirurgicale, par comparaison avec les torts potentiels qui sont associes a la tenue d'une chirurgie limitee en presence d'une maladie de grade 2 ou 3. Valeurs La qualite des resultats est evaluee et les recommandations sont formulees au moyen des criteres decrits par le Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Declarations sommaires 1.Dans les cas de maladie exposant la patiente a un faible risque, rien n'indique que la lymphadenectomie ameliore le taux de survie en presence d'un adenocarcinome de grade 1. (I) 2.La prise en charge du cancer de l'endometre necessite la mise en œuvre d'une approche d'equipe multidisciplinaire coordonnee. (III) 3.La lymphadenectomie a pour objectif de guider la mise en œuvre d'un traitement adjuvant pouvant affecter la survie au sein des populations exposees a des risques eleves ou de prevenir la mise en œuvre de traitements pouvant se solder en une toxicite inutile. (III) 4.Les decisions quant a la mise en œuvre d'un traitement adjuvant dans les cas de cancer de l'endometre dependent tant des facteurs de risque histopathologiques en matiere de recurrence post-hysterectomie que du statut des ganglions lymphatiques retroperitoneaux au moment de l'execution de la lymphadenectomie. (III) Recommandations 1.La chirurgie pourrait se limiter a l'hysterectomie et a la salpingo-ovariectomie bilaterale a titre de solution de rechange acceptable a la stadification des patientes presentant une maladie de grade 1. Toutefois, le fait de se fier a la classification tumorale preoperatoire menera a la sous-estimation de la presence de risques eleves chez une certaine proportion des patientes et pourrait exposer ces femmes a la tenue d'une deuxieme chirurgie ou a une plus grande utilisation de la radiotherapie externe adjuvante. (III-B) 2.L'evaluation preoperatoire ou peroperatoire de la profondeur de l'envahissement myometrial peut faire partie des mesures additionnelles d'evaluation du risque. En ce qui concerne le grade et le stade histopathologiques finaux, les equipes multidisciplinaires regionales devraient en venir a un consensus quant a l'utilisation de facteurs pronostiques pour guider la mise en œuvre d'un traitement adjuvant. (III-B) 3.La tenue de lymphadenectomies pelviennes et/ou para-aortiques devrait etre envisagee chez les patientes qui presentent une maladie preoperatoire de grade 2 ou 3, et ce, pour faciliter la planification de la mise en œuvre d'un traitement adjuvant de facon precise, ce qui est souvent requis a la suite de l'operation. L'avantage que confere la lymphadenectomie en matiere de survie au sein de ce groupe particulier de patientes n'a pas fait l'objet d'etudes. (II-2B) 4.Les patientes qui presentent des sous-types histologiques de cancer de l'endometre les exposant a des risques eleves (comme les adenocarcinomes a cellules claires et sereux papillaires) devraient subir une stadification chirurgicale complete comprenant une omentectomie et une lymphadenectomie pelviennes et/ou para-aortiques. (II-2B) 5.Une approche d'equipe multidisciplinaire coordonnee devrait etre utilisee pour la prise en charge des cas de cancer de l'endometre exposant les patientes a des risques eleves. (III-B) 6.Les equipes multidisciplinaires regionales devraient en venir a un consensus local quant a l'utilisation de facteurs pronostiques pour guider la mise en œuvre d'un traitement adjuvant. (III-B) 7.La tenue d'une lymphadenectomie en fonction de la palpation de ganglions « volumineux » est imprecise et ne devrait pas etre mise en œuvre. (II-2E) 8.Les patientes qui presentent une maladie de stade avance devraient etre orientees vers des gynecologues oncologues, au sein d'un centre anticancereux regional, aux fins de la planification du traitement. (II-2B)

Resume Objectifs Optimiser la prise en charge des masses annexielles et aider les medecins de premier recours et les gynecologues a identifier les patientes presentant une masse ovarienne qui s'accompagne d'un risque considerable de malignite pour lesquelles une orientation et une prise en charge en oncologie gynecologique devraient etre envisagees. Options Evaluation laparoscopique, stadification par chirurgie exhaustive (pour ce qui est du cancer de l'ovaire precoce) ou chirurgie de reduction tumorale (pour ce qui est du cancer de l'ovaire de stade avance). Issues Optimiser la prise en charge conservatrice (par comparaison avec la prise en charge operatoire) des femmes presentant une possible malignite ovarienne et optimiser la participation des gynecologues oncologues a la planification et a la mise en œuvre du traitement. Resultats La litterature publiee a ete localisee par l'intermediaire de recherches menees dans PubMed ou MEDLINE, CINAHL et la Cochrane Library, au moyen d'un vocabulaire controle approprie et de mots cles. Les resultats ont ete limites aux analyses systematiques, aux essais comparatifs randomises / cliniques et aux etudes observationnelles. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes du domaine de l'evaluation des technologies de sante, les collections de directives cliniques, les registres d'essais cliniques et les sites Web de societes de specialite medicale nationales et internationales. Recommandations 1.Les medecins de premier recours et les gynecologues devraient toujours envisager la possibilite d'un cancer de l'ovaire sous-jacent chez toute patiente, quel qu'en soit l'âge, qui presente une masse annexielle ou ovarienne (II-2B). 2.Le bilan approprie d'une femme perimenopausee ou postmenopausee presentant une masse annexielle devrait comprendre une evaluation des symptomes evoquant une affection maligne, tels que la douleur pelvienne / abdominale persistante, la miction imperieuse / la pollakiurie, l'accroissement de la taille de l'abdomen / le ballonnement et la difficulte de manger. De plus, la determination du taux de CA125 devrait etre envisagee (II-2B). 3.La tenue d'une echographie transvaginale ou transabdominale est recommandee dans le cadre du bilan initial d'une masse annexielle / ovarienne complexe (II-2B). 4.Les rapports d'echographie devraient etre standardises de facon a inclure la taille et l'emplacement (unilateral / bilateral) de la masse annexielle et son origine possible, l'epaisseur des cloisons, la presence d'excroissances et de composants internes solides, la distribution du debit vasculaire et la presence ou l'absence d'ascites. Ces donnees sont essentielles pour le calcul du score de l'indice du risque de malignite II servant a identifier les masses pelviennes qui presentent un fort potentiel malin (IIIC). 5.Les patientes qui semblent courir un risque eleve de presenter une affection maligne sous-jacente devraient faire l'objet d'un examen, mene avec le concours d'un gynecologue oncologue, aux fins de l'evaluation de la situation et de la mise en œuvre d'une prise en charge chirurgicale optimale (II-2B).

To optimize the management of adnexal masses and to assist primary care physicians and gynaecologists determine which patients presenting with an ovarian mass with a significant risk of malignancy should be considered for gynaecologic oncology referral and management.Laparoscopic evaluation, comprehensive surgical staging for early ovarian cancer, or tumour debulking for advanced stage ovarian cancer.To optimize conservative versus operative management of women with possible ovarian malignancy and to optimize the involvement of gynaecologic oncologists in planning and delivery of treatment.Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified by searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

Objective To evaluate patient-reported outcomes (PROs) between women treated by laparoscopic, robotic and open approaches for endometrial cancer. Methods Prospective cohort study comparing PRO at baseline, short- (1 and 3 weeks) and long-term (12 and 24 weeks) follow-up postoperatively. Quality of life (QOL) measures were the Functional Assessment of Cancer Therapy (FACT-G), EuroQol Five Dimensions (EQ-5D), and Brief Pain Inventory (BPI). Sexual health measures were the Female Sexual Function Index (FSFI) and the Sexual Adjustment and Body Image Scale for Gynecologic Cancer (SABIS-G). Results 468 eligible patients (laparotomy = 92, laparoscopy = 152, robotic = 224) were recruited. There were no significant differences between the laparoscopy and robotic groups for any PRO ( P > 0.05). At short-term follow-up, patients who underwent minimally invasive surgery (robotic or laparoscopy) had significantly higher FACT-G ( P P P = 0.02) and improved pain interference ( P = 0.0008), than patients undergoing laparotomy. At long-term follow-up, there were sustained improvements in the FACT-G ( P = 0.035) and the health state EQ-5D visual analogue scale ( P = 0.022). Surgical approach had no impact on sexual health ( P > 0.05); however the mean FSFI score for the entire cohort met clinical cut-offs for sexual dysfunction. Conclusion Minimally invasive approaches result in improved QOL beyond the short-term postoperative period, with benefits noted up to 12 weeks after surgery. This prolonged QOL advantage provides further evidence that MIS should be the standard surgical approach for women with early stage endometrial cancer.

Objective The risk of unexpected uterine leiomyosarcoma (LMS) following surgery for presumed benign leiomyoma is quoted to be between 1 in 498 and 1 in 5000. The objectives of the present study were to determine the prevalence of uterine LMS in a specific patient population and the rate of diagnosis of occult uterine LMS and to evaluate the risk of unintended morcellation of LMS in Saskatchewan. Methods This study was a Canadian Task Force Classification II-2 multicentre retrospective cohort study in academic-affiliated tertiary care centres. All women with the histopathologic diagnosis of uterine LMS in Saskatchewan between January 2000 and December 2014 were included. Women with metastatic LMS at diagnosis or other types of uterine sarcomas were excluded. Data including patients' characteristics, clinical presentation, physical examination findings, imaging, pathology reports, surgical interventions, and survival outcomes were reviewed. Results A total of 28 patients had a confirmed histopathologic diagnosis of LMS over the 15-year study period. Approximately 26 212 hysterectomies were performed in Saskatchewan over the same time frame. The prevalence of uterine LMS in this patient population over the study time frame is estimated to be one in 853. Mean age at diagnosis was 53.8 ± 10.0. Medical records of 25 patients could be retrieved, and 15 cases (60%) had an occult diagnosis. There were five cases of unintended morcellation (one power, four mechanical). Survival outcomes were comparable in women with unintended morcellation of occult disease and in those without morcellation. Conclusion This study contributes to the existing body of literature on morcellation of occult LMS, and it ascertains the rate of LMS in a patient population. The results of this study provide valuable information to health care professionals, policy makers, and women in Saskatchewan so that they may make more informed decisions concerning uterine masses.

Vulvar cancer is an uncommon tumor and represents 3%-5% of all female genital tract malignancies. The overall incidence is 1.5/100,000 women. Histopathologically the vast majority (90%) are squamous cell carcinomas. Primary cloacogenic carcinoma of the vulva is extremely rare with less than 20 cases reported in English literature [1]. These tumors are thought to arise from embryonic or ectopic rests of cloacogenic tissue. The majority of these reported cases is relatively indolent cancer, only one case of cloacogenic carcinoma of the vulva reported metastatic spread to the inguinal lymph nodes and none that describe distant metastases. Here we present an aggressive and diagnostically challenging case of cloacogenic carcinoma of the vulva and a review of current literature to date.

Vulvar cancer is an uncommon tumor and represents 3%-5% of all female genital tract malignancies. Squamous cell carcinoma (SCC) is the most common carcinoma of the vulva. Distant metastasis of recurrent vulvar squamous cell carcinoma is rare and occurs late in the disease process. We report the first case of kidney metastasis from a vulvar squamous cell carcinoma in a 68-year-old Caucasian female. On initial presentation she was treated with radical vulvectomy, upper urethrectomy with bilateral inguinal and deep femoral lymph node dissection. She was staged as FIGO stage IVA and also received adjuvant chemo-radiation. She remained in remission for 24 months. Subsequently she was found to have a kidney tumor and underwent nephrectomy and was diagnosed with metastatic squamous cell carcinoma from the vulva to the kidney. In cases of recurrent vulvar carcinoma distant metastasis to the bones, breast, and brain is only rarely reported. Metastasis to kidneys from vulvar carcinoma is exceptionally rare with no reported cases in the literature. Renal metastasis should be considered in the differential diagnosis of kidney tumor in this group of women.

Objectives Our objectives were (1) to review the rate of concurrent endometrial cancer in patients with a preoperative diagnosis of atypical endometrial hyperplasia (AEH); (2) to determine the proportion of patients with concurrent endometrial cancer who have high-risk disease; and (3) to re-evaluate our surgical management of AEH. Methods We performed a retrospective chart review of all patients who had surgery on the basis of a preoperative diagnosis of atypical endometrial hyperplasia between January 2001 and December 2006. Demographic data, the method of preoperative diagnosis, postoperative grade of tumour, and other postoperative findings were recorded. When applicable, this included cancer stage, lymph node status, and presence of lymphovascular space invasion. In postoperative review, patients were considered to be high risk if they had disease beyond the uterus or a combination of other risk factors. Results Of 70 patients, 25 (35.7%) were found to have concurrent endometrial cancer. This was higher than the commonly accepted rate of 25% ( P = 0.03). Of the 25 patients upgraded, 4 (16%) had high-risk cancer on final pathologic evaluation. Conclusion Simple hysterectomy in women with AEH may result in inadequate surgical management. Simple methods are required to identify patients with a preoperative diagnosis of AEH who may harbour significant cancers.

Objective To provide guidance for referring physicians regarding what gynaecologic oncologists want and do not require in the referral package for a new patient. Methods An email survey was circulated to all members of the Society of Gynecologic Oncology of Canada (GOC) asking what they felt was required in a new patient referral package so that they could provide a timely consultation and management plan. Results The survey had a 79% response rate among 121 GOC members. Before referral of patients with endometrial cancer, 50% of respondents did not want additional investigations; only 4% wanted an MRI performed prior to them seeing the patient. For patients with high-grade cancers of the uterus (including serous), 40% wanted to see the patient without further investigations, while 42% wanted a CT scan report to be included in the referral package. For patients with cervical cancer, 56% of respondents wanted to see the patient without any further investigations, while 24% wished to have an MRI report included in the referral package. For patients with vulvar cancer, 50% of respondents did not want any further investigations; for patients with a pelvic mass, the majority of respondents wanted a serum CA 125 level in the referral package, while 0% to 3% only wanted an MRI. The preferred modality for imaging of the chest was a chest X-ray only. Conclusion Our survey indicated that gynaecologic oncologists want little information in the referral package beyond the biopsy result. MRI is not required in the workup of most patients with a pelvic mass or uterine cancer.

Objectives Sentinel lymph node (SLN) procedure could be an attractive solution to the debate on lymphadenectomy in endometrial cancer; however challenges to interpreting the literature include marked heterogeneity across studies, a wide variety of injection techniques and a lack of uniformly accepted definitions for important outcomes. We aim to critically appraise the published literature and streamline terminology and methodology for future studies in this field. Methods We conducted a PubMed search and included all original research of endometrial cancer patients having undergone SLN procedure with an n>30. Data collected included injection technique, unilateral, bilateral, and para-aortic detection rates, and ultrastaging results. When different definitions were used for reporting outcomes, we recalculated the original study results according to our proposed definitions. Data was analyzed using descriptive statistics. Results Seventeen studies met our inclusion criteria. Injection sites were categorized into cervical versus corporeal. Overall detection rates ranged from 60 to 100%; studies with n>100 all had overall detection rates of >80%. Bilateral detection rates were higher with a combination of two injection agents. Para-aortic mapping was most frequent after corporeal injection techniques (39%), and was higher after deep vs. standard cervical injection (17% vs. 2%). The proportion of metastatic lymph nodes diagnosed through ultrastaging was high (around 40%) and ultrastaging of SLN upstaged approximately 5% of patients. Retrospectively applying a surgical algorithm revealed a sensitivity of 95%, a negative predictive value of 99%, and a false negative rate of 5% (with only 9 false negative cases remaining in total). Conclusion Results of SLN research for endometrial cancer are promising. We believe that in future studies, uniform reporting is needed to improve our understanding of the safety and feasibility of SLN in EC. We propose 2 strategies: a checklist of elements to include in future reports and the standardization of key definitions.

Objective. To evaluate the relationship between surgical specialty and survival in patients receiving initial surgical management for ovarian epithelial cancer. Study methods. An analytic framework was constructed to address the principle question ‘does the type of surgeon operating on patients with newly diagnosed ovarian epithelial cancer influence survival?' A literature search addressing the components of this analytic framework was carried out using the Cochrane Library, Medline, EMBASE, and HealthSTAR databases. Relevant articles were selected and graded using U.S. Preventive Services Task Force and Canadian Task Force guidelines. Results were summarized by quality as well as level of evidence. Results. Eighteen studies were reviewed. The quality of evidence was good in 3, fair in 8, and poor in 7 of the studies. The most common study flaws encountered were ‘failure to account for confounders' and ‘incompleteness of data'. In studies focusing on advanced disease, there was good quality evidence to support a 6- to 9-month median survival benefit for patients operated on by gynecologic oncologists rather than general gynecologists and/or general surgeons ( P values 0.009 to 0.01). Studies focusing on early stage disease found gynecologic oncologists more likely to carry out optimal staging ( P values 0.001 to 0.01). Increased survival could be explained by improved identification of true stage I patients. Conclusion. Patients receiving initial surgical management for ovarian epithelial cancer should be operated on by gynecologic oncologists.

Objectives. The goal of this study was to review our experience with transrectal ultrasound (TRUS)-guided biopsies in women with a pelvic mass, with respect to obtaining an adequate sample, the influence of biopsy results on patient management, and patient tolerance. Study methods. We conducted a chart review of all women at the Princess Margaret Hospital (PMH) that had been clinically referred for TRUS-guided biopsies of a pelvic mass. Data collected included patient age, previous type of malignancy, size and location of lesion being biopsied, postbiopsy diagnosis, and subsequent management. Statistics were purely descriptive. Results. Eight women have had this procedure at PMH. The smallest size of lesion biopsied was 1.7 × 1.4 × 2.3 cm. In all eight women, the tissue obtained was adequate for the determination of a histological diagnosis and subsequently influenced patient management. The procedure was well tolerated and there were no complications. Conclusion. TRUS-guided biopsy of a pelvic mass is a feasible method of establishing a pathological diagnosis. In this small series of patients, it was found to be accurate, well tolerated, and useful in guiding patient management. In selected patients, the TRUS biopsy provides a useful alternative to transabdominal and transvaginal biopsy.

Objective To review the evidence relating to the use of adjuvant therapy after surgical treatment for endometrial cancer. Options Women with endometrial cancer can be given the option of receiving adjuvant radiotherapy and/or chemotherapy according to pathologic findings at time of surgery. Outcomes The outcomes measured are postoperative progressionfree and overall survival in endometrial cancer patients. Evidence Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary (e.g., endometrial neoplasms) and key words (e.g., endometrium cancer, endometrial carcinoma). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 31, 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, national and international medical specialty societies, and recent conference abstracts. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Benefits, harms, and costs This guideline is intended to help standardize postoperative treatment of endometrial cancer and minimize undertreatment and overtreatment. Validation The guideline was reviewed for accuracy by content experts in pathology, radiation oncology, and medical oncology. Guideline content was also compared with relevant documents from the American Congress of Obstetricians and Gynecologists.

With the widespread implementation of screening programs internationally, there will be an increase in early stage cervical cancer cases. In response to this, the Ministry of Health in each country will need to plan strategies to provide care such as radical surgery or radiation for this potentially curable group of women.The Gynaecologic Oncologists of Canada created a teaching module to intensively train a small number of locally identified gynecologists to perform radical hysterectomy and pelvic lymphadenectomy. The process was based on adult learning principles; it involved a Canadian gynecologic oncologist working in the low- or middle-resource country with the gynecologists and problem-solving local issues in health care delivery.The teaching process included a pretest and a posttest on the basis of the objectives of the module. There were 7 modules including preoperative evaluation of the patient, cone biopsy, radical hysterectomy, pelvic lymphadenectomy, ureteric injury, vascular injury, and follow-up after surgery. Each module was divided into background information, techniques, and complications. There were video clips imbedded in the modules. After the educational modules had been reviewed, the learners were walked through the surgical procedures repeatedly including a detailed assessment of performance after each case. Participants had the opportunity to provide feedback on the training program. The module was reviewed in Mongolia and implemented in Kenya.In low- and middle-resource countries where there is an urgent need to provide a curative surgical option for the management of early cervical cancer, a focused high-intensity curriculum delivered by a trained surgeon can translate into immediate change in clinical and surgical practice.

Detection of human papillomavirus (HPV) E6/E7 oncogene expression may be more predictive of cervical cancer risk than testing for HPV DNA. The Aptima HPV test (Gen-Probe) detects E6/E7 mRNA of 14 oncogenic types. Its clinical performance was compared with that of the Hybrid Capture 2 DNA test (HC2; Qiagen) in women referred for colposcopy and those routinely screened. Aptima was also compared with the PreTect HPV-Proofer E6/E7 mRNA assay (Proofer; Norchip) in the referral population. Cervical specimens collected in PreservCyt (Hologic Inc.) were processed for HPV detection and genotyping with the Linear Array (LA) method (Roche Molecular Diagnostics, Laval, Quebec, Canada). Histology-confirmed high-grade cervical intraepithelial neoplasia (CIN 2) or worse (CIN 2+) served as the disease endpoint. On the basis of 1,418 referral cases (CIN 2+, n = 401), the sensitivity of Aptima was 96.3% (95% confidence interval [CI], 94.4, 98.2), whereas it was 94.3% (95% CI, 92.0, 96.6) for HC2. The specificities were 43.2% (95% CI, 40.2, 46.2) and 38.7% (95% CI, 35.7, 41.7), respectively ( P < 0.05). In 1,373 women undergoing routine screening (CIN 2+, n = 7), both Aptima and HC2 showed 100% sensitivity, and the specificities were 88.3% (95% CI, 86.6, 90.0) and 85.3% (95% CI, 83.5, 87.3), respectively ( P < 0.05); for women ≥30 years of age ( n = 845), the specificities were 93.9% (95% CI, 92.3, 95.5) and 92.1% (95% CI, 90.3, 93.9), respectively ( P < 0.05). On the basis of 818 referral cases (CIN 2+, n = 235), the sensitivity of Aptima was 94.9% (95% CI, 92.1, 97.7) and that of Proofer was 79.1% (95% CI, 73.9, 84.3), and the specificities were 45.8% (95% CI, 41.8, 49.8) and 75.1% (95% CI, 71.6, 78.6), respectively ( P < 0.05). Both Aptima and Proofer showed a higher degree of agreement with LA genotyping than HC2. In conclusion, the Aptima test is as sensitive as HC2 but more specific for detecting CIN 2+ and can serve as a reliable test for both primary cervical cancer screening and the triage of borderline cytological abnormalities.

Objective Women attending the University of Saskatchewan Student Health Services are being offered human papillomavirus (HPV) vaccination but are not filling their prescriptions. We sought to identify gaps in knowledge of the link between HPV infection, cervical dysplasia, and cervical cancer among women attending the Student Health Services, and to identify barriers to HPV vaccination among this cohort of women. Methods Women attending the University of Saskatchewan Student Health Services for any reason were invited to complete an 18-question survey. The survey included questions regarding knowledge of the purpose of Pap smears, the role of HPV infection in cervical dysplasia and cancer, and HPV vaccination. The questions were designed to elicit both quantitative and qualitative data. Data analysis included basic descriptive analysis and summarization of qualitative data. Results Four hundred surveys were distributed, and 371 (91 %) were returned. Eighty-two percent of participants were aware of the HPV vaccine, and 40% ranked their knowledge of HPV as good or very good; however, only 6% correctly answered questions about methods of preventing HPV infection. Participants identified cost (62%), concerns over adverse effects (43%), and lack of knowledge (36%) as barriers to undergoing vaccination. Comments about the HPV vaccine reflected frustration with cost and concerns about adverse effects. When participants were asked if they would undergo vaccination if it were free, 60% responded "yes," 31 % responded "maybe," and 8% responded "no." Conclusion The young women in our survey had significant gaps in knowledge of HPV infection and prevention, and educational programs must be structured to address these deficits. Institutions promoting vaccination must deal with the barriers of cost and fear of adverse effects.

Human papillomavirus (HPV) DNA testing has a higher clinical sensitivity than cytology for the detection of high-grade cervical intraepithelial neoplasia or worse (CIN 2+). However, an improvement in specificity would be desirable. As malignant transformation is induced by HPV E6/E7 oncogenes, detection of E6/E7 oncogene activity may improve specificity and be more predictive of cervical cancer risk. The PreTect HPV-Proofer assay (Proofer; Norchip) detects E6/E7 mRNA transcripts from HPV types 16, 18, 31, 33, and 45 with simultaneous genotype-specific identification. The clinical performance of this assay was assessed in a cross-sectional study of women referred for colposcopy in comparison with the Hybrid Capture 2 (HC2; Qiagen) test, which detects DNA of 13 high-risk oncogenic HPV types collectively. Cervical specimens were collected in PreservCyt, and cytology was performed using the ThinPrep method (Hologic). The samples were processed for HPV detection with Proofer and HC2 and genotyping with the Linear Array method (Roche Molecular Systems). Histology-confirmed CIN 2+ served as the disease endpoint to assess the clinical performance of the tests. A total of 1,551 women were studied, and of these, 402 (25.9%) were diagnosed with CIN 2+ on histology. The Proofer assay showed a sensitivity of 78.1% (95% confidence interval [CI], 74.1 to 82.1) versus 95.8% (95% CI, 93.8 to 97.8) for HC2 ( P < 0.05) and a specificity of 75.5% (95% CI, 73.0 to 78.0) versus 39.6% (95% CI, 36.8 to 42.4), respectively ( P < 0.05). The lower sensitivity and higher specificity of Proofer for detection of CIN 2+ can be attributed to the fact that this test detects the expression of E6/E7 genes beyond a threshold from a limited number of oncogenic HPV types. In conclusion, Proofer is more specific than HC2 in identifying women with CIN 2+ but has a lower sensitivity.

To optimize the management of adnexal masses and to assist primary care physicians and gynaecologists determine which patients presenting with an ovarian mass with a significant risk of malignancy should be considered for gynaecologic oncology referral and management.Laparoscopic evaluation, comprehensive surgical staging for early ovarian cancer, or tumour debulking for advanced stage ovarian cancer.To optimize conservative versus operative management of women with possible ovarian malignancy and to optimize the involvement of gynaecologic oncologists in planning and delivery of treatment.Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified by searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.1. Primary care physicians and gynaecologists should always consider the possibility of an underlying ovarian cancer in patients in any age group who present with an adnexal or ovarian mass. (II-2B) 2. Appropriate workup of a perimenopausal or postmenopausal woman presenting with an adnexal mass should include evaluation of symptoms and signs suggestive of malignancy, such as persistent pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating. In addition, CA125 measurement should be considered. (II-2B) 3. Transvaginal or transabdominal ultrasound examination is recommended as part of the initial workup of a complex adnexal/ovarian mass. (II-2B) 4. Ultrasound reports should be standardized to include size and unilateral/bilateral location of the adnexal mass and its possible origin, thickness of septations, presence of excrescences and internal solid components, vascular flow distribution pattern, and presence or absence of ascites. This information is essential for calculating the risk of malignancy index II score to identify pelvic mass with high malignant potential. (IIIC) 5. Patients deemed to have a high risk of an underlying malignancy should be reviewed in consultation with a gynaecologic oncologist for assessment and optimal surgical management. (II-2B).

Objective To review current practice and make recommendations for the management and treatment of endometrial cancer. Outcomes This guideline makes recommendations with respect to extended surgical staging, which provides important prognostic information and aids in determining the need for adjuvant treatments. Evidence Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary (e.g., endometrial neoplasms) and key words (e.g., endometrium cancer, endometrial carcinoma). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 31, 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, national and international medical specialty societies, and recent conference abstracts Benefits, harms, and costs This guideline reviews the benefit of extended surgical staging compared with the potential harm of a limited surgery in grade 2 and 3 disease. Values The quality of evidence is rated and recommendations are made using the criteria described by the Canadian Task Force on Preventive Health Care (Table).

Objective To review the evidence relating to the epidemiology of endometrial cancer and its diagnostic workups. Options Women with possible endometrial cancer can undergo an endometrial evaluation by office biopsy, hysteroscopy, or dilatation and curettage. To assist in treatment planning, pelvic ultrasound, CT scan, or MRI may be considered. Outcomes The identification of optimal diagnostic tests to evaluate patients with possible endometrial cancer. Evidence Published literature was retrieved through searches of PubMed, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary (e.g., endometrial neoplasms) and key words (e.g., endometrium cancer, endometrial carcinoma). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to December 31, 2011. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, national and international medical specialty societies, and recent conference abstracts. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Benefits, harms, and costs This document is intended to guide the development of a standardized cost-effective investigation of patients with suspected endometrial cancer. Validation The guideline was reviewed for accuracy by experts in pathology, radiation oncology, and medical oncology. Guideline content was also compared with relevant documents from the American Congress of Obstetricians and Gynecologists.

Objective: Women attending the University of Saskatchewan Student Health Services are being offered human papillomavirus (HPV) vaccination but are not filling their prescriptions. We sought to identify gaps in knowledge of the link between HPV infection, cervical dysplasia, and cervical cancer among women attending the Student Health Services, and to identify barriers to HPV vaccination among this cohort of women.