Flemish obstetricians' personal preference regarding induction of labor and mode of delivery in term births

INTRODUCTION

In a 2002 survey, 2% of Flemish gynecologists preferred elective cesarean section for themselves or their partner. This study aims to determine actual preference regarding induction of labor and mode of delivery in term cephalic or breech births for gy- necologists or their partners.

MATERIALS AND METHODS

An anonymous postal questionnaire was sent to all gynecologists and trainees in Flanders.

RESULTS

Response rate was 28.2 % (241/852). In case of an uncomplicated cephalic singleton pregnancy, 39 gynecologists (16.2%) preferred cesarean section. Most (n=134, 66.5%) chose induction at 41 weeks, 26 (13%) at 40 weeks, 37 (18%) at 42 weeks, 26 (13%) at 40 weeks, three (1.5%) preferred induction before 40 weeks and two (1%) would wait until after 42 weeks. Concerning term breech, 30% (n=72) opted for vaginal delivery and 70% (n = 169) for planned cesarean section. Ninety-nine (41%) gynecologists pre- ferred to attempt external version first. Only 115 (47.7 %) gynecologists felt professionally capable to assist vaginal breech delivery them- selves; about one-third (n=96; 38%) had performed less than ten vaginal breech deliveries in their career.

CONCLUSIONS

Flemish gynecologists are still in favor of vaginal delivery for themselves in terms of cephalic position, but an increasing number favor planned cesarean section. Most Flemish gynecologists opt for cesarean section for themselves or their partners in case of term breech and state that they do not feel capable in assisting vaginal breech delivery for their patients.

18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) as early imaging biomarker of axillary sentinel lymph node (SLN) status in locally advanced node-positive breast cancer (NPBC) patients (pts) receiving neoadjuvant chemotherapy (NACT)

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Background: Use of FDG-PET in the early evaluation of NACT for NPBC is currently under investigation. The aim of this study is to assess FDG-PET in NPBC pts receiving NACT in order to identify a subset of pts that can be spared axillary lymph node dissection (ALND) in case of response. Methods: All pts (period 2009-2011) had [cT2 (≥3cm)-T4, pN1-3], and no prior BC treatment. All pts received 8 cycles (cy) of NACT +/- trastuzumab. FDG-PET was performed at baseline and after 2 cy. After NACT, mastectomy with SLN and ALND was peformed. As primary endpoint, the change in maximum standardized uptake value (SUVmax) in the primary tumor (PT) and ALNs was compared with pathological response (Jonckheere-Terpstra test). Logistic regression was used to determine the predictive value of a 50% reduction in SUVmax on pathological response and SLN status. Results: Forty-one pts were evaluable for the primary endpoint and 31 pts had successful SN procedures. The median age was 49.8 years (range 27-75). Overall, 9.8% (4/41; 95% CI 2.7 – 23.1) of pts had progressive disease (PD), 7.3% (3/41 ; 95% CI 1.5 – 19.9 ) stable disease (SD), 53.7% (22/41; 95% CI 37.4 – 69.3) partial response (PR), and 21.9% (9/41; 95% CI 10.6 – 37.6) a complete pathological response (pCR). A linear trend existed between pCR and higher decreases in SUVmax of the PT site (p=0.008), but not with lymph node SUVmax (p=0.294). The odds of achieving a pCR, increased significantly when SUVmax of the PT decreased with >50% (OR 10.7; 95% CI 1.2 - 98.0; p=0.03), but not lymph node SUVmax (OR 4.75; 95% CI 0.82 - 27.5; p=0.08). Achieving a true negative SLN status was more likely with >50% reductions in PT SUVmax (OR 41.2; 95% CI 4.0 - 421.9; p= 0.002). A reduction of >50% in nodal SUVmax was not predictive of negative SLN status (OR 3.33; 95% CI 0.66 - 16.8; p=0.1). Conclusions: Early changes in PT metabolism imaged with FDG-PET after only 2 cy of NACT is a promising biomarker in the management of the axilla in NPBC. Molecular imaging of PT biology and to a lesser extent of axillary lymph nodes using FDG-PET warrants further study.

Sentinel node detection in a patient with recurrent endometrial cancer initially treated by hysterectomy and radiotherapy

This is the first article reporting sentinel node identification in a patient with endometrial cancer recurring in the vagina. A 79-year-old woman presented with a midvaginal recurrence of a stage IB, grade II endometroid carcinoma that had been treated 3 years earlier by a total abdominal hysterectomy, bilateral salpingoophorectomy, and pelvic lymph node sampling, followed by adjuvant brachytherapy to the vaginal vault. A staging examination under anesthetic was performed. Preoperatively, 60-MBq technetium-labeled nannocolloid was injected in the mucosa at 3, 6, 9, and 12 o'clock just adjacent to the tumor recurrence. Three sentinel nodes were detected, respectively, in the left obturator fossa (two) and the right external iliac region, using a laparoscopic probe (Navigator) and removed for pathological assessment. As they proved to be negative, the patient underwent a total vaginectomy, parametrectomy with pelvic lymphadenectomy. The tumor was completely removed, and all lymph nodes proved to be negative. The accuracy of sentinel node identification in patients with recurrent gynecological tumors needs further evaluation. This unique case shows that sentinel node detection is possible after previous radiotherapy and surgery and hopes to stimulate further research in this field.

Sentinel node detection in a patient with recurrent endometrial cancer initially treated by hysterectomy and radiotherapy

This is the first article reporting sentinel node identification in a patient with endometrial cancer recurring in the vagina. A 79-year-old woman presented with a midvaginal recurrence of a stage IB, grade II endometroid carcinoma that had been treated 3 years earlier by a total abdominal hysterectomy, bilateral salpingoophorectomy, and pelvic lymph node sampling, followed by adjuvant brachytherapy to the vaginal vault. A staging examination under anesthetic was performed. Preoperatively, 60-MBq technetium-labeled nannocolloid was injected in the mucosa at 3, 6, 9, and 12 o'clock just adjacent to the tumor recurrence. Three sentinel nodes were detected, respectively, in the left obturator fossa (two) and the right external iliac region, using a laparoscopic probe (Navigator) and removed for pathological assessment. As they proved to be negative, the patient underwent a total vaginectomy, parametrectomy with pelvic lymphadenectomy. The tumor was completely removed, and all lymph nodes proved to be negative. The accuracy of sentinel node identification in patients with recurrent gynecological tumors needs further evaluation. This unique case shows that sentinel node detection is possible after previous radiotherapy and surgery and hopes to stimulate further research in this field.

Sentinel node detection in patients with vaginal carcinoma

OBJECTIVE

The objective was to describe sentinel ode detection in patients with primary and recurrent vaginal carcinoma.

METHOD

Preoperatively 60-mBq technetium-labeled nannocolloid was injected in the mucosa at 3, 6, 9, and 12 o'clock, just adjacent to the vaginal cancer. Sentinel nodes were detected using a laparoscopic or hand-held probe (Navigator) and removed for pathological assessment.

RESULTS

Sentinel nodes could be found in two of three patients with primary stage I or II carcinoma of the vagina. In the first patient the sentinel nodes, located in the groin and obturator region, proved to be negative and she was treated with a wide local excision of the tumor, pelvic and groin lymphadenectomy, and adjuvant radiotherapy. The second patient had tumor metastases in the sentinel node, which was found just below of the junction of the iliac vessels, and she underwent combined chemo- and radiotherapy. In a third patient no sentinel node could be detected at lymphoscintigraphy. A last patient with stage III carcinoma of the upper vagina was initially treated by combined chemo-radiotherapy but recurred 6 months later. During a staging procedure the sentinel nodes could be detected in the right obturator fossa and were removed laparoscopically. As they were negative, she underwent a posterior pelvic exenteration with complete resection of the tumor.

CONCLUSION

Laparoscopic detection of sentinel nodes using 99mTc-labeled colloid is feasible in patients with primary and recurrent vaginal cancer and may provide important information to direct further management.

Intraoperative sentinel node identification with Technetium-99m-labeled nanocolloid in patients with cancer of the uterine cervix: a feasibility study

The objective of this study is to determine the feasibility of intraoperative lymphatic mapping in patients with cervical carcinoma. Patients with early-stage cervical cancer, scheduled to undergo a Wertheims radical hysterectomy and pelvic lymphadenectomy, were eligible for the study. Technetium-99-m-labeled nanocolloid was injected intracervically at two locations around the tumor 3-6 hours before the operation. Images were recorded immediately and 2.5 hours later using a gamma camera. During the operation sentinel nodes (SLN) were identified using a handheld or laparoscopic gamma-detection probe (Navigator, Auto-Suture). After resection of the SLNs a standard pelvic (and para-aortic) lymphadenectomy was performed. The results of the histopathology of SLNs and non-SLNs were compared. The procedure was well tolerated by 24 of 25 patients. One or more SLN could be identified in 21 out of 25 patients. In one patient who was preoperatively irradiated, in two patients who had had a cone biopsy, and in one patient without previous interventions, no SLN could be detected. The mean time for identification was 5 minutes. In 16 patients, pathologic examination showed no metastatic disease in both SLNs and non-SLNs, whereas metastases were found in the SLN in five patients (in one case only SLN involved, four cases SLN and respectively 3, 11, 22 and 31 other positive nodes). This study shows that identification of SLNs in cancer of the uterine cervix is feasible with preoperatively administered 99mTc-labeled nanocolloid. To date, no false negative SLNs have been found, but expansion of the study is necessary to determine possible clinical application of this new technique.

Intraoperative sentinel node identification with Technetium-99m-labeled nanocolloid in patients with cancer of the uterine cervix: A feasibility study

The objective of this study is to determine the feasibility of intraoperative lymphatic mapping in patients with cervical carcinoma. Patients with early-stage cervical cancer, scheduled to undergo a Wertheims radical hysterectomy and pelvic lymphadenectomy, were eligible for the study. Technetium-99-m-labeled nanocolloid was injected intracervically at two locations around the tumor 3–6 hours before the operation. Images were recorded immediately and 2.5 hours later using a gamma camera. During the operation sentinel nodes (SLN) were identified using a handheld or laparoscopic gamma-detection probe (Navigator, Auto-Suture). After resection of the SLNs a standard pelvic (and para-aortic) lymphadenectomy was performed. The results of the histopathology of SLNs and non-SLNs were compared. The procedure was well tolerated by 24 of 25 patients. One or more SLN could be identified in 21 out of 25 patients. In one patient who was preoperatively irradiated, in two patients who had had a cone biopsy, and in one patient without previous interventions, no SLN could be detected. The mean time for identification was 5 minutes. In 16 patients, pathologic examination showed no metastatic disease in both SLNs and non-SLNs, whereas metastases were found in the SLN in five patients (in one case only SLN involved, four cases SLN and respectively 3, 11, 22 and 31 other positive nodes). This study shows that identification of SLNs in cancer of the uterine cervix is feasible with preoperatively administered 99mTc-labeled nanocolloid. To date, no false negative SLNs have been found, but expansion of the study is necessary to determine possible clinical application of this new technique.

Angiogenesis in cervical intraepithelial neoplasia and the risk of recurrence

OBJECTIVE

We sought to investigate whether angiogenesis can predict the risk of recurrence of cervical intraepithelial neoplasia after treatment.

STUDY DESIGN

Microvessel density was studied in 75 patients with grade 3 cervical intraepithelial neoplasia and in 20 patients with microinvasive squamous carcinoma (International Federation of Gynecology and Obstetrics stage IA1) of the uterine cervix by staining representative tissue sections with the specific endothelial marker anti-CD31. The microvessel density was determined with a digital image analyzer. The results were correlated with clinical and histopathologic data.

RESULTS

The mean vessel density was 264 per field (range, 86-674 per field) in grade 3 cervical intraepithelial neoplasia and 378 per field (range, 161-848 per field; P = .001) in microinvasive squamous carcinoma. Thirteen patients with grade 3 cervical intraepithelial neoplasia had recurrent cervical intraepithelial neoplasia (microvessel density, recurrent vs nonrecurrent; not significant). Multiple regression analysis in the noninvasive group confirmed that the mean vessel density (P = .121) had no prognostic value. Furthermore, it showed that the age at diagnosis (P = .011), menopausal status (P = .052), and treatment modality (P = .022) proved to be independent prognostic factors for recurrence.

CONCLUSIONS

During the progression from noninvasive to microinvasive cervical carcinoma, the microvessel density increases significantly. However, the vessel density does not predict recurrence of noninvasive lesions.