Registry-derived stage (RD-Stage) for capturing cancer stage at diagnosis for endometrial cancer

BACKGROUND

Capture of cancer stage at diagnosis is important yet poorly reported by health services to population-based cancer registries. In this paper we describe current completeness of stage information for endometrial cancer available in Australian cancer registries; and develop and validate a set of rules to enable cancer registry medical coders to calculate stage using data available to them (registry-derived stage or 'RD-Stage').

METHODOLOGY

Rules for deriving RD-stage (Endometrial carcinoma) were developed using the American Joint Commission on Cancer (AJCC) TNM (tumour, nodes, metastasis) Staging System (8th Edition). An expert working group comprising cancer specialists responsible for delivering cancer care, epidemiologists and medical coders reviewed and endorsed the rules. Baseline completeness of data fields required to calculate RD-Stage, and calculation of the proportion of cases for whom an RD stage could be assigned, was assessed across each Australian jurisdiction. RD-Stage (Endometrial cancer) was calculated by Victorian Cancer Registry (VCR) medical coders and compared with clinical stage recorded by the patient's treating clinician and captured in the National Gynae-Oncology Registry (NGOR).

RESULTS

The necessary data completeness level for calculating RD-Stage (Endometrial carcinoma) across various Australian jurisdictions varied from 0 to 89%. Three jurisdictions captured degree of spread of cancer, rendering RD-Stage unable to be calculated. RD-Stage (Endometrial carcinoma) could not be derived for 64/485 (13%) cases and was not captured for 44/485 (9%) cases in NGOR. At stage category level (I, II, III, IV), there was concordance between RD-Stage and NGOR captured stage in 393/410 (96%) of cases (95.8%, Kendall's coefficient = 0.95).

CONCLUSION

A lack of consistency in data captured by, and data sources reporting to, population-based cancer registries meant that it was not possible to provide national endometrial carcinoma stage data at diagnosis. In a sample of Victorian cases, where surgical pathology was available, there was very good concordance between RD-Stage (Endometrial carcinoma) and clinician-recorded stage data available from NGOR. RD-Stage offers promise in capturing endometrial cancer stage at diagnosis for population epidemiological purposes when it is not provided by health services, but requires more extensive validation.

Malignant extra-ovarian endometriosis: A case series of ten patients and review of the literature

BACKGROUND

The malignant transformation of endometriosis within the ovary is a recognised condition. There is less literature surrounding the malignant transformation of extra-ovarian endometriosis (MEOE).

AIMS

We report our experience with MEOE in ten patients and present a review of the literature regarding this rare malignancy.

MATERIALS AND METHODS

For this retrospective case series, patients were identified from a practice-based database. Where required, operative notes and pathology reports were reviewed.

RESULTS

Ten patients diagnosed with MEOE between 1991 and 2014 were identified. In each case, the tumour was localised to the pelvis and centred on the pouch of Douglas, broad ligament, obturator fossa, parametrium and rectovaginal septum. Tumour histology was endometrioid adenocarcinoma (six), clear cell carcinoma (two), and adenosarcoma (two). Five patients had a history of endometriosis and four had received oestrogen-only hormone replacement therapy after hysterectomy and bilateral salpingo-oophorectomy. Treatments included surgery (one), surgery and radiotherapy (one), surgery and chemotherapy (one), surgery, radiotherapy and chemotherapy (three), and radiotherapy and chemotherapy (four). Maintenance hormonal therapy was also used in three patients. Curative doses of radiotherapy 45 Gy or more resulted in in-field control in five patients. Six patients had no evidence of disease at a mean follow up period of 15 years (5.5-24 years). Severe G3 long-term bladder morbidity occurred in three patients after radical surgery and radiotherapy.

CONCLUSION

MEOE is a rare condition for which treatment needs to be individualised. Multicentre studies and registries will hopefully define optimal treatment.

Developing an Australian multi-module clinical quality registry for gynaecological cancers: a protocol paper

INTRODUCTION

Gynaecological cancers collectively account for almost 10% of cancer diagnoses made in Australian women. The extent of variation in gynaecological cancer survival rates and treatment outcomes across Australia is not well documented. The purpose of the clinical quality registry described in this paper is to systematically monitor and improve quality of care provided to these women, and facilitate clinical process improvements to ensure better patient outcomes and greater adherence to best practice care. The registry infrastructure has been developed in conjunction alongside the inaugural ovarian, tubal and peritoneal (OTP) module, allowing for concurrent piloting of the methodology and one module. Additional tumour modules will be developed in time to cover the other gynaecological tumour types.

METHOD AND ANALYSIS

The National Gynae-Oncology Registry (NGOR) aims to capture clinical data on all newly diagnosed cancers of the uterus, ovary, fallopian tubes, peritoneum, cervix, vulva and vagina in Australia with a view to using these data to support improved clinical care and increased adherence to 'best practice'. Data are sourced from existing clinical databases maintained by clinicians and/or hospital gynaecological cancer units. A pilot phase incorporating only OTP cancers has recently been conducted to assess the feasibility of the registry methodology and assess the support of a quality initiative of this nature among clinicians and other key stakeholders.

ETHICS AND DISSEMINATION

The NGOR has received National Mutual Acceptance (NMA) ethics approval from Monash Health Human Research Ethics Committee (HREC), NMA HREC Reference Number: HREC/17/MonH/198. We also have approval from Mercy Health HREC and University of Tasmania HREC. Data will be routinely reported back to participating sites illustrating their performance against measures of agreed best practice. It is through this feedback system that the registry will support changes to quality of care and improved patient outcomes.

Adenocarcinoma in situ of the uterine cervix: an experience with 100 cases

OBJECTIVE

The aim of this study was to ascertain whether cold knife conization alone for cervical adenocarcinoma in situ is safe.

METHODS

One hundred consecutive patients with a histologically proven adenocarcinoma in situ (AIS) of the cervix were studied from 1970 to 1992.

RESULTS

Ninety-two women presented with abnormal smears, and of these 56% contained abnormal glandular cells. Sixty-seven (74%) of 90 women who underwent colposcopy had an abnormal examination, but a glandular abnormality was suspected in only 19 (28%). In all, 80 cold knife conizations were performed. In 7, no abnormality was found following punch biopsy. The margins were free of disease in 55 (75%). The most commonly involved margin in the remainder was the apical. Conization was followed by hysterectomy in 20 women: in 8 of these the cone margins were free and residual disease was found in 2 of the extirpated uteri: as these were extramural cases, inadequate sampling could not be excluded. Of the 12 women where hysterectomy followed conization with diseased margins, 9 had residual disease in the hysterectomy specimen. The definitive therapy was cold knife conization in 56 patients, hysterectomy in 38, and electrocoagulation diathermy in 6. Follow-up of the 53 patients treated by conization alone ranging from 1 to 16 years, with a mean of 8 years (3 have been lost to follow-up) revealed no recurrence of AIS or adenocarcinoma to date.

CONCLUSION

It is concluded that cold knife conization is a safe therapeutic modality, provided that the cone biopsy has been adequately sampled and the margins are free.

Determination of benzalkonium chloride in drug formulations by capillary electrophoresis (CE)

A Capillary Electrophoresis method was developed and applied successfully to test the quality of different drug formulations for release and stability studies. In the method an uncoated fused-silica capillary was employed containing a phosphoric acid buffer electrolyte which was brought to pH by triethylamine. The benzalkonium chlorides (BAC-C12 and BAC-C14) present in the standard were completely separated from each other and from the peaks of the main compound. Performance results of the method in terms of system repeatability, precision and accuracy are discussed.

Abnormal cervical cytology in pregnancy: experience of 811 cases

This paper reviews our hospital's experience spanning 15 years and involving 811 women referred with abnormal cervical cytology in pregnancy. It supports the safety and accuracy of managing dysplasia in pregnancy with colposcopy, directed punch biopsy and deferral of treatment until the postpartum period. The histologically-proven progression in pregnancy to a higher grade of dysplasia postpartum was 7%. None of the women are known to have developed microinvasive or invasive cancer between antenatal assessment and postpartum review. Of these 811 women, 16% were lost to follow-up, 1 of whom subsequently represented 4 years later with invasive cervical cancer.

A phase II trial of carboplatin and etoposide for relapsed or metastatic carcinoma of the cervix

This study reports the results of a phase II trial of carboplatin 100 mg/m2 combined with etoposide 120 mg/m2 each given for 3 consecutive days every 28 days in women with recurrent or metastatic carcinoma of the cervix. Seventeen eligible patients were treated between August, 1990 and May, 1993. In the 16 evaluable patients, there were 2 complete responses, and no partial responses with an overall objective response rate of 12.5% (95% confidence interval 1.6%-38%). The main toxicities of this regimen related to myelosuppression and emesis. The combination of carboplatin and etoposide did not achieve either a better response rate or a substantially improved toxicity profile than is seen with single agent cisplatin.

Microinvasive adenocarcinoma of the cervix: a clinicopathologic study of 77 women

OBJECTIVE

To prove that microinvasive adenocarcinoma of the cervix exists and, like its squamous counterpart, carries an excellent prognosis.

METHODS

Seventy-seven women with microinvasive adenocarcinoma of the cervix were seen from 1971 to 1995. Microinvasion was defined as depth of invasion or tumor thickness of at most 5 mm. Microscopic assessment was made on punch biopsies, serially sectioned conization specimens, and extensively sampled hysterectomy specimens.

RESULTS

Most of the women had abnormal Papanicolaou smears. We made definitive diagnoses on conization specimens in 49 women, hysterectomy specimens in 22, and colposcopically directed punch biopsies in six (three being no residual disease in the subsequent conization-hysterectomy specimens). The length of microinvasive adenocarcinomas ranged from 0.8 to 21 mm, and the volume was between 3 and 1000 mm. The tumors were multicentric in 21 cases, but no true "skip" lesions were found. Overall, 58 cold-knife conizations were performed: the margins were free in 39 cases, involved in 18, and inconclusive in one. The one loop conization had involved margins. Definitive therapy included cold-knife conization in 16 women, combined with pelvic-node dissection in four. In the remainder of the women, we performed some type of hysterectomy. None of the 26 women who had radical hysterectomy had parametrial spread, and none of the 48 who had pelvic-node dissection or the 23 in whom one or both adnexa were removed had metastases. There have been two "recurrences" to date; one was an adenocarcinoma and the other a squamous cell carcinoma, both at the vault.

CONCLUSION

Microinvasive adenocarcinoma of the cervix is a clinicopathologic entity that appears to have the same prognosis, and should be treated in the same way, as its squamous counterpart.

Struma ovarii presenting as acute pseudo-Meigs syndrome with an elevated CA 125 level

A 62-year-old woman presented with acute hydrothoraces and ascites. The CA 125 level was greatly elevated and pelvic ultrasound revealed an adnexal mass with solid and cystic components. At surgery a benign pure struma ovarii was diagnosed and following removal of the tumour the patient had immediate and complete resolution of her symptoms. This is the first report of struma ovarii causing both pseudo-Meigs syndrome and a marked elevation of CA 125.

Screening for ovarian cancer using serum CA125 and vaginal examination: report on 2550 females

This study was undertaken to assess the effectiveness of using serum CA125 and vaginal examination as a screening test for ovarian cancer in apparently healthy females. Two thousand five hundred and fifty healthy females aged 40 and over were recruited to participate in a screening study involving a questionnaire, serum CA125 measurement and vaginal examination. Females with either an elevated CA125 level or abnormal vaginal examination had a pelvic ultrasound performed as a secondary procedure. The positive predictive values of an elevated serum CA125 level, and a combination of CA125 level measurement and vaginal examination for ovarian cancer, were 1/100 and 1/3, respectively. The specificities of serum CA125 levels, vaginal examination and both in combination were 96.1%, 98.5% and 99.9%, respectively. In postmenopausal females the positive predictive values were improved with CA125 measurement alone, giving a positive predictive value of 1/24. Seventeen females underwent operative procedure as a result of the screening-only one of these was for an ovarian cancer. The combination of serum CA125 measurement and vaginal examination is not an effective screening test in the general population, although in postmenopausal females it does achieve acceptable specificities and positive predictive values.

A prospective study of inhibin in granulosa cell tumors of the ovary

Elevated preoperative serum inhibin concentrations have been reported in patients with granulosa cell tumor of the ovary. The aim of this study was to determine if elevations in serum inhibin predated clinical recurrence in patients with a diagnosis of granulosa cell tumor. Twenty-seven consecutive patients with granulosa cell tumor were followed prospectively to assess the relationship between serum inhibin concentrations and disease status. The serum inhibin concentrations in normal postmenopausal women were < 77-130 U/liter. In patients with granulosa cell tumor at initial surgery, mean inhibin concentrations preoperatively were 2831 U/liter in 4 postmenopausal subjects (range 2130-3323 U/liter) and 3680 U/liter in each of 2 premenopausal women. In 5 postmenopausal subjects with a histological diagnosis of granulosa cell tumor who underwent secondary surgery because of a recurrent palpable mass, mean inhibin concentrations were 4216 U/liter (range 2672-7360). In 3 patients with known or suspected residual disease despite a secondary debulking operation the serum inhibin concentrations were 475, 1000, and 2541 U/liter. In 13 subjects who were clinically disease free with a previous diagnosis of granulosa cell tumor, serum inhibin concentrations remained within the normal range for reproductive status. We conclude: (1) Preoperative serum inhibin concentrations are typically elevated sevenfold above the normal premenopausal follicular phase levels in women with granulosa cell tumor; (2) after surgery, serum inhibin levels may become elevated up to 2 years before further surgery is undertaken; and (3) serum inhibin concentrations appear to be a valuable tumor marker for the diagnosis of primary or recurrent granulosa cell tumor.

Cisplatin-based chemotherapy for ovarian germ cell malignancies: the Australian experience

PURPOSE

This study was performed to evaluate the Australian experience with cisplatin-based treatment of ovarian germ cell tumors (OGCT) with respect to survival and toxicity of treatment.

PATIENTS AND METHODS

A retrospective review was undertaken based on a standardized questionnaire, which was sent to all major gynecologic oncology centers in Australia.

RESULTS

Data on 58 patients were obtained. Overall survival at 5 years for all patients was 87%. There was one death from disease among 14 patients with dysgerminoma, and four deaths from disease among 44 patients with nondysgerminomas. Cisplatin-based chemotherapy was associated with a low incidence of serious complications, with only one treatment-related death (from bleomycin-induced respiratory failure).

CONCLUSION

Our large series demonstrates that cisplatin-based chemotherapy is highly effective for patients with OGCT. Although direct comparisons cannot be made, the survival of our patients with advanced tumors was comparable to that seen in male germ cell tumors, rather than inferior as is commonly believed. Future studies should aim to refine treatment to minimize toxicity, while further increasing curability.

Elevated serum inhibin concentrations in postmenopausal women with ovarian tumors

BACKGROUND

Inhibin is an ovarian hormone that inhibits the secretion of follicle-stimulating hormone (FSH) by the anterior pituitary gland. Women with granulosa-cell tumors of the ovary have elevated serum inhibin concentrations, but whether the concentrations are increased in women with other ovarian tumors is unknown.

METHODS

We measured serum inhibin and FSH concentrations before surgery in 212 postmenopausal women with suspected ovarian cancer and after surgery in 210 of them.

RESULTS

Eighteen of the 22 women (82 percent) with mucinous carcinomas (mucinous cystadenocarcinomas and mucinous borderline cystic tumors) of the ovary had elevated serum inhibin concentrations, whereas only 9 of the 53 women (17 percent) with serous carcinomas (serous cystadenocarcinomas and serous borderline cystic tumors) had elevated levels. Serum inhibin concentrations were also elevated in 2 of 12 women (17 percent) with clear-cell carcinomas, 4 of 26 women (15 percent) with undifferentiated carcinomas, 3 of 3 women (100 percent) with granulosa-cell tumors, and 5 of 27 women (19 percent) with other ovarian cancers. The serum concentrations of inhibin were increased in 2 of 28 women (7 percent) with nonovarian pelvic cancers and 11 of 41 women (27 percent) with benign ovarian diseases. All women but one with initially elevated serum inhibin concentrations had low values one week after surgery. Serum inhibin concentrations correlated negatively with serum FSH concentrations (P = 0.05) in women with granulosa-cell tumors but not in women with other tumors, suggesting that the inhibin secreted by tumors in the latter group has decreased biologic activity.

CONCLUSIONS

Serum inhibin concentrations are elevated in most postmenopausal women with mucinous carcinomas of the ovary and in some women with other types of epithelial ovarian tumors. The concentrations fall after tumor removal.

Women with a pelvic mass--when to perform an ultrasound

A retrospective study of 264 patients with a pelvic mass who had a preoperative serum CA 125 level performed was undertaken to compare the sensitivity, specificity and predictive values of this test as a predictor of malignancy, compared with clinical impression and ultrasonography (USG). The values were calculated for each parameter alone and in combination, and the effect of menopausal status, histological type and stage of disease was also assessed. The results indicate that in postmenopausal women with a pelvic mass, a CA 125 level should be performed and the patient referred to a gynaecological oncologist if the value is raised. In contrast both CA 125 and USG should be performed in the premenopausal woman to allow appropriate referral. In this study a CA 125 level of 35 u/ml or more correctly identified malignancy in 90% of postmenopausal women.

Adenocarcinoma in situ of the cervix

Adenocarcinoma in situ (ACIS) of the cervix is rare and is frequently overlooked. To characterize this disease more fully, 21 cases were studied. All except two patients presented with abnormal smears. The distribution of ACIS was focal in two cases, multicentric in three, and diffuse and continuous in 15 (in one case it was unknown). The depth of crypt involvement varied from 0.5 to 4 mm and the volume was estimated to range from 0.25 to 1,500 mm3. ACIS should and can be distinguished from early ("microinvasive") adenocarcinoma in most cases by its limitation to the glandular field, by the constant admixture of neoplastic and normal glands, and by the lack of stromal response. Invasive adenocarcinoma cannot be excluded by target biopsy, the diagnosis of ACIS requiring conization. If the surgical margins are disease free, conization alone may be adequate therapy.

Response of a mucinous ovarian tumor of borderline malignancy to human chorionic gonadotropin

Plasma and urinary steroid hormones were measured before and after an injection of human chorionic gonadotropin (hCG) to a postmenopausal woman with a mucinous ovarian tumor of borderline malignancy. Hormones were also measured in blood from a vein draining the tumor, and circulating gonadotropins and plasma and urinary steroids were measured before and after tumor removal. Baseline levels of plasma progesterone (P), androstenedione (delta 4 A), and estradiol (E2), and urinary estrogens and pregnanediol were high; they increased dramatically in response to hCG and fell after tumor removal. A less striking increase in testosterone, dihydrotestosterone, dehydroepiandrosterone (DHEA), and DHEA sulfate was noted after hCG injection. A gradient existed between tumor vein and peripheral vein levels of P, 17 alpha-hydroxyprogesterone, delta 4 A, E2, DHEA, and cortisol. Plasma follicle-stimulating and luteinizing hormones initially low but rose to the postmenopausal range after surgery. These results indicate the presence of delta 4 and delta 5 androstene pathways within the tumor. The responsiveness of the tumor to hCG provides further evidence that hCG may be the endogenous stimulus to steroid hormone production by epithelial ovarian tumors.

Cytoplasmic steroid receptors in ovarian tumours

Cytoplasmic oestrogen receptors were measured in 40 primary and four secondary ovarian tumors; of these, 43 tumors were also analysed for cytoplasmic progesterone receptors and 34 tumours for cytoplasmic androgen receptors. Serous tumours were significantly more likely to be oestrogen-receptor positive than mucinous tumours, but the incidence of positive progesterone and androgen receptors was similar in serous, mucinous and endometrioid tumours. The mean oestrogen receptor content of serous tumours was significantly higher than that of endometrioid tumours. Well-differentiated epithelial tumours were significantly more likely to be oestrogen-receptor and progesterone-receptor positive than less differentiated epithelial tumours. Two granulosa cell tumours were oestrogen-receptor positive and one of these was also progesterone-receptor and androgen-receptor positive. Four normal ovaries were also analysed for receptor content and two were found to be androgen-receptor positive. The presence of cytoplasmic receptors in ovarian tumours may explain their reported response to endocrine therapy.

Limitations of the clonal agar assay for the assessment of primary human ovarian tumour biopsies

114 biopsy specimens from 70 patients with ovarian carcinoma at all stages of disease were submitted for assessment of clonogenic capacity in agar. A highly significant correlation was found between agar clonogenicity and patient survival after biopsy. However, problems related to inherent tumour heterogeneity, quality of sample and tissue disaggregation indicate that this technique may have limited applicability in the routine assessment of patients. Only 41 biopsy specimens (36%) from 31 patients (44.3%) complied with the prerequisite criteria for agar clonogenic assessment, namely: (a) the confirmed presence of malignant cells in the biopsy, (b) the ability to prepare a single-cell suspension, and (c) adequate viable cell numbers for assay. Furthermore, although the dominant patterns of agar clonogenic growth could be identified and correlated with stage of disease, the heterogeneity in both initial clonogenic capacity and "self-renewal" capacity assessed by the ability of primary clones to propagate in liquid culture and reclone in agar was too inconsistent for the assay to be used as a prognostic index for the individual patient.

Diurnal variation in glucose tolerance: associated changes in plasma insulin, growth hormone, and non-esterified fatty acids

Oral glucose tolerance tests were performed in the morning and afternoon of separate days on 31 people derived from a normal population sample. Blood sugar levels were higher in the afternoon test from and including 60 minutes after the glucose load. The degree of diurnal variation was similar in men and women, but greater in the older half of the group. It was negatively correlated with the degree of obesity. The plasma insulin response was less at the 30 minute time point in the afternoon, but significantly exceeded the morning values at 120 and 150 minutes after the glucose load. Growth hormone levels were similar in morning and afternoon tests. Fasting non-esterified fatty acid levels were significantly higher before the afternoon test.The relatively impaired glucose tolerance in the afternoon is associated with a delayed insulin response to the glucose load. This seems unlikely to be the sole explanation, however, and increased non-esterified fatty acid metabolism with a consequent decrease in glucose disposal may also contribute.