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Notes: Objective To examine the feasibility of achieving designated target standards for the management of women with cervical and vulval cancer.Design Retrospective casenote review.Setting The Gynaecological Oncology Centre at Hammersmith Hospital, London.Population Sixty-one women with cervical and vulval cancer presenting to the gynaecological oncology clinic at the Hammersmith Hospital during 1996 and 1997. Various aspects of the management of those women were compared with standards suggested by a multidisciplinary panel of local experts. Targets included the referral and treatment process, the accuracy of staging, and measures of surgical performance.Results The target interval of seven days between receipt of the referral and the first visit at the cancer centre was achieved in 93% of women. Surgical treatment was administered to 92% of the women within the target of 20 working days from the first clinic appointment. Tumour close to or involving the margins of the specimen was noted in 13% of cervical and 9% of vulval cancers. The node count fell below the target standards in 13% of pelvic and 10% of groin dissections. Appropriate imaging investigations for staging were not undertaken in 15 of 39 cases (38%) of cervical cancer and in 5 out of 22 (23%) of vulval cancers.Conclusion The suggested targets of process and surgical performance are reasonable and achievable. These standards would be appropriate for national use. The area most clearly identified where these targets were not achieved was the requesting of complementary staging investigations. This could be addressed by the use of a simple investigation protocol to be included in each patient's notes and available at specialist clinics and gynaecology wards.

Notes: Objective  To evaluate pretreatment tumour volume as a predictor of survival in patients with cervical cancer using both endovaginal and external coil magnetic resonance imaging in order to achieve high spatial resolution and delineate small volume disease.Design  A retrosfection case series.Setting  A tertiary referral centre for gynaecological oncology.Population/Sample  One hundred and six consecutive women with invasive carcinoma of the cervix underwent endovaginal and external coil magnetic resonance imaging on a 0.5-T or 1.5-T scanner.Methods  T2-W FSE images, sagittal and transverse to the cervix, were obtained and tumour volume was calculated on the sagittal images by the standard technique of multiplying the sum of the areas by the slice thickness. Patients were treated in accordance with normal clinical practice and their subsequent outcome was recorded. The relationships between clinical or imaging parameters and survival were assessed with Cox's proportional hazard method.Main outcome measures  Disease-free survival.Results  In 89 of these women, the tumour was Stage I and 88 of the 106 were treated principally by surgery. The median tumour volume was 4.75 cm3 (upper and lower quartiles 22 and 0.6). The median length of follow up of surviving patients was 223 weeks (quartiles 158 and 274 weeks). Stage, treatment type, lymphovascular space involvement, invasion of the parametrium, closeness of the excision margin, lymph node metastases, and magnetic resonance imaging measurements of tumour volume, parametrial invasion and lymph node disease were all significantly associated with survival in univariate analysis. Only magnetic resonance imaging measurement of tumour volume remained consistently and strongly associated with survival after multivariate analysis of parameters available prior to treatment (P= 0.001, Wald statistic 10.74). A receiver operating characteristic curve of tumour volume and disease-free survival confirmed the utility of this investigation and suggested that a cutoff around 13.0 cm3 would predict survival with a positive predictive value of 0.93 and a negative predictive value of 0.75.Conclusion  Magnetic resonance imaging assessment of tumour volume using both an endovaginal and an external coil approach provides an accurate prediction of prognosis in cervical cancer and defines a population of women at high risk of recurrence and death. The predictive value of this investigation is superior to the clinical and histological parameters previously used. Use of this technique permits a more accurate choice of treatment options. These results suggest that it is the size of tumour burden that determines the outcome rather than invasion beyond the anatomical margins of the uterus.

Notes: Objective  To determine whether lowwwer rates or incomplete resection of cervical intraepithelial neoplasia (CIN) may be achieved by needle excision of the transformation zone (NETZ) than with loop excision (LLETZ).Design A prospective randomised controlled trial.Setting A gynaecological oncology centre and a teaching hospital in West London.Population Four hundred and four women due to receive treatment for suspected CIN.Methods  Women were randomised to receive either LLETZ or NETZ.Main outcome measures The study was designed to demostrate a difference in the proportion of women with clear histological margins of 82% for LLETZ compared to 94% for NETZ with 90% power at a 5% significance level, allowing for absence of CIN in the treatment specimen in 15%.Results  Four randomised women were excluded from the analysis, as they were ineligible for the study. Three hundred and forty-seven (87%) had CIN in the treatment specimen and could be included in the analysis of excision margins. More women in the NETZ arm had clear histological margins (84.8%vs 75%, (P= 0.03). The median volume of specimens in the NETZ arm was 739 mm3 larger (P= 0.33) and they were less likely to be removed in multiple pieces (2.5%vs 29.5%, RR 0.09, 95% CI 0.04 to 0.20). Needle excision took longer to perform (median treatment time 210 vs 90 seconds, P〈0.0001) and surgeons more often reported the procedure as ‘difficult’ (9.5%vs 3.0%, RR = 3.17%, 95% CI 1.33 to 7.58). No difference in peri-operative or post-operative complication rates could be demonstrated between the two groups.Conclusion  NETZ is more likely to produce a specimen in one piece and with clear margins compared to LLETZ.

Notes: Objective To assess the value of high resolution endovaginal magnetic resonance images (MRI) of the uterine cervix in planning management of early cervical cancer.Design Prospective cross-sectional study.Setting Specialist gynaecological oncology unit of a postgraduate teaching hospital.Participants Thirty nine women aged 25–76 years old (mean 42.5 years) with invasive carcinoma Stage I or IIa of the cervix.Methods A ring coil was positioned endovaginally around the cervix. Imaging was performed on a 1.0 T HPQ Vista or 0.5 T Asset (Picker, Highland Heights, Ohio, USA) using T1 weighted and T2 weighted sequences in transverse and sagittal planes with thin slices (2.5 mm) and small fields of view (12 cm). Tumour volumes were measured and any extension into adjacent organs and parametrium was noted. The patients were followed up after treatment and the outcome related to the MRI findings.Results There was one false positive and one false negative result among five Stage Ia patients being assessed for residual disease after cone biopsy or LLETZ. The MRI assessment of the size and distribution of the tumour was confirmed histologically in all 31 patients with Stage Ib or IIa disease who were treated surgically. One of these patients in whom no endocervical tumour was visible on MRI underwent radical trachelectomy. Three patients had radiotherapy as primary treatment. Patients with Stage Ib or IIa disease who had tumour volumes 〉 10 cm3 with early parametrial extension on MRI had a substantially worse prognosis at 24 months (disease-free survival 58.3% vs 95.5%, P= 0.003).Conclusion High resolution MRI with an endovaginal coil allows precise measurement of tumour volume and identifies patients with small volume disease who might be considered for more conservative therapy. This technique also reveals early parametrial invasion that cannot be identified reliably by any other method. Early parametrial invasion in women with large tumours appears to have a very much worse prognosis.

Notes: Summary. The first phase of a paperless computer record has been developed at Hammersmith Hospital. The system was designed around the work practices of the clinic staff. In this phase the data are collected on forms which replace the normal case notes. This information is entered onto an IBM compatible computer by the secretary using a quick, user-friendly program written in a dBASE dialect and compiled with Quicksilver. The program produces letters to patients and their doctors and a printed record of the clinic findings for the case sheet to replace the handwritten form. When funding for hardware becomes available the data will be entered directly into the system by the medical staff in the clinic. Clinic appointment lists are maintained and patients ‘lost to follow-up’ can be identified. Ad hoc enquiries can be made using dBASE III Plus or any similar program. This approach has integrated the computerized recording of data in a colposcopy clinic with the normal work of the staffinvolved so that no extra effort is required from medical or secretarial staff. The immediate accessibility of patient data and the ability to audit the work of the clinic have been particularly useful.

Notes: The Hamou microcolpohysteroscope was used to measure the extension of cervical intraepithelial neoplasia into the endocervical canal in patients before cone biopsy of the cervix. These measurements showed good correlation with those found on subsequent histological assessment.

Notes: Summary. Fifty-four patients with advanced ovarian cancer have been treated with combination chemotherapy using cyclophosphamide, adriamycin and cis-platinum. The toxicity of the regimen was manageable but few patients were prepared to tolerate more than 6 months of treatment. Those in complete clinical remission at that time were offered second-look laparotomy and if apparently free of disease, therapy was discontinued. Forty-seven patients could be assessed of whom 33 had had no previous therapy. Twenty-two of these were clinically free of disease after completion of chemotherapy of whom 12 had no detectable disease at second-look laparotomy. Of 14 patients who had failed previous therapy only one remains clinically free of disease. The results in the untreated patients demonstrate the primary importance of bulk reduction at initial laparotomy. The use of the regimen in patients who have failed on previous treatment or in patients with bulk disease seems to be palliative and the toxicity should be assessed in this context.