A resource allocation metric for thyroid biopsies

PURPOSE

The aim of this study was to assess the adequacy of departmental resource allocation to ultrasound-guided biopsies of the thyroid gland.

METHODS

The numbers of image-guided breast, prostate, and thyroid biopsies performed in the authors' radiology department over a 12-month period in 2009 were determined. The predicted deaths in Canada from breast, prostate, and thyroid cancer over the same period were obtained from the Canadian Cancer Society. The number of biopsies performed on each organ was divided by the expected mortality from the respective cancer.

RESULTS

Approximately 2,400 breast biopsies, 910 prostate biopsies, and 610 thyroid biopsies were performed. Using mortality as a measure of cancer burden, the biopsy/cancer burden ratio for thyroid cancer was 7 times that for breast cancer and 15 times that for prostate cancer.

CONCLUSION

The skewed ratio in favor of thyroid biopsies supports concerns that current trends in the investigation of thyroid nodules may represent an overconsumption of health resources.

Malignant transformation within ovarian dermoid cysts: an audit of treatment received and patient outcomes. an Australia New Zealand gynaecological oncology group (ANZGOG) and gynaecologic cancer intergroup (GCIG) study

INTRODUCTION

Malignant transformation in an ovarian dermoid cyst occurs in 1% to 2% of cases. Our knowledge about this tumor type is limited and largely based on case reports. We aimed to collate and analyze the cumulative experience of how these patients have been managed in an effort to identify the most appropriate treatment strategies.

METHODS

A survey was sent to the members of the Gynaecologic Cancer Intergroup. Data collected included age, symptoms, stage, extent of surgery, chemotherapy and radiotherapy details, response to treatment, progression, survival, and salvage therapy.

RESULTS

Data on 33 patients whose conditions were diagnosed between 1979 and 2007 were received from 10 centers in Australia, Canada, Germany, and Austria. The mean age was 49 years. All 15 patients with stage I disease and most of the patients with stages II and III were optimally debulked. Four patients with stage I disease had fertility-sparing surgery with good outcomes. Chemotherapy was not routinely given after surgery and did not seem to be effective. Platinum-based regimens were most commonly used. At relapse, 2 patients had a sustained remission after secondary surgery for relapsed disease. Second-line chemotherapy and radiotherapy were infrequently prescribed. Patients with stage I disease had a good outcome, with all but 2 alive and well at a minimum of 12 months of follow-up.

CONCLUSIONS

Most patients undergo optimal debulking surgery. Fertility-sparing surgery may be a reasonable option in selected patients. Stage I patients have a good prognosis. There is no standard adjuvant treatment, but platinum-based regimens are most commonly used. However, regardless of treatment received, patients with advanced disease do poorly.

Should the ovaries be removed or retained at the time of hysterectomy for benign disease?

BACKGROUND

Bilateral oophorectomy is commonly performed at the time of hysterectomy for benign disease. Indications for oophorectomy vary, but in most cases relatively little high-quality information is available to inform the surgeon or patient regarding the relative risks and benefits of ovarian conservation or removal. This review will address the common clinical situations when oophorectomy may be performed and will evaluate the evidence for risk and benefit in each of these circumstances. The aim of this review is to bring together the evidence regarding oophorectomy in pre- and post-menopausal women and to highlight the areas needing further study.

METHODS

We searched the published literature for studies related to outcomes following surgical menopause, risk-reducing surgery for ovarian cancer, surgical treatment for endometriosis, bilateral oophorectomy for benign disease and treatment for premenstrual syndrome/premenstrual dysphoric disorder.

RESULTS

Rates of oophorectomy at the time of hysterectomy for benign disease appear to be increasing. There is good evidence to support bilateral salpingoophorectomy (BSO) as a risk-reducing surgery for women at high risk of ovarian cancer, but relatively little evidence to support oophorectomy or BSO in other circumstances. There is growing evidence from observational studies that surgical menopause may impact negatively on future cardiovascular, psychosexual, cognitive and mental health.

CONCLUSION

Clinicians and patients should fully consider the relative risks and benefits of oophorectomy on an individual basis prior to surgery.

Morbidity outcomes of 78,577 hysterectomies for benign reasons over 23 years

OBJECTIVE

To investigate the association of the method of hysterectomy for benign reasons with morbidity outcomes in Western Australia after taking other demographic, social and health-related factors into account.

DESIGN

Population-based retrospective observational study.

SETTING

All hospitals in Western Australia where hysterectomies were performed from 1981 to 2003.

POPULATION

All women aged 20 years or older who underwent a hysterectomy for benign reasons.

METHOD

Logistic and zero-truncated negative binomial regression analysis of record-linked administrative health data.

MAIN OUTCOME MEASURES

Relative odds of experiencing complications during the hysterectomy admission or readmission and relative length of stay in hospital by type of hysterectomy.

RESULTS

There were 78,577 hysterectomies performed for benign reasons from 1981 to 2003. Procedure-related haemorrhage (2.4%) was the most commonly recorded complication, followed by genitourinary disorders (1.9%), infection (1.6%) and urinary tract infections (1.6%). Vaginal hysterectomy was associated with reduced odds of infection and haemorrhage compared with abdominal procedures during the hysterectomy admission. Readmission rates increased from 5.4% in 1981-84 to 7.2% in 2000-03 as average length of stay decreased by 53% over the same time period. Women who underwent laparoscopically assisted vaginal hysterectomies and vaginal hysterectomies had increased odds of readmission for haemorrhage and genitourinary disorders compared with abdominal hysterectomy. Young age, increasing number of co-morbid conditions and having a complication at hysterectomy admission were also associated with increased odds of readmission.

CONCLUSION

These findings identify women at risk of readmission following hysterectomy and highlight an opportunity to modify early discharge and patient follow-up practices to reduce this risk.

A new prognostic model for FIGO stage 1 epithelial ovarian cancer

BACKGROUND

No consensus exists which patients with surgical stage 1 epithelial ovarian should receive postoperative chemotherapy. The purpose of this study was to evaluate the prognostic impact of preoperative CA-125 and to establish a prognostic index to identify patients in different risk categories.

METHODS

Data of 600 surgically staged patients with FIGO stage 1 EOC treated in eleven gynecological cancer centers in Australia, the USA and Europe were analyzed. Eligible patients include those with invasive EOC where a preoperative CA-125 was obtained and standard surgical staging performed. Overall survival (OS) was chosen as study endpoint. Preoperative CA-125 values were compared with other prognostic factors, and univariate and multivariate Cox models were calculated.

RESULTS

Two hundred and one patients (33.5%) had preoperative CA-125 < or =30 U/ml and CA-125 levels < or =30 U/ml were associated with lower grade, sub-stage 1A and mucinous histologic cell type. Patients with elevated CA-125 levels were more likely to receive chemotherapy. OS probability was 95% and 85% for patients with pretreatment CA-125 < or =30 U/ml and >30 U/ml, respectively (p 0.003). Multivariate analysis confirmed preoperative serum CA-125 >30 U/ml (OR 2.7) and age at diagnosis >70 years (OR 2.6) as the only independent predictors for overall survival.

CONCLUSION

Pretreatment of CA-125 < or =30 U/ml dominates over histologic cell type, sub-stage and grade to identify a subgroup of FIGO stage 1 patients with a genuinely good prognosis with extremely good survival and who could possibly be spared with adjuvant chemotherapy.

Learning from death: a hospital mortality reduction programme

PROBLEM

There are wide variations in hospital mortality. Much of this variation remains unexplained and may reflect quality of care.

SETTING

A large acute hospital in an urban district in the North of England.

DESIGN

Before and after evaluation of a hospital mortality reduction programme.

STRATEGIES FOR CHANGE

Audit of hospital deaths to inform an evidence-based approach to identify processes of care to target for the hospital strategy. Establishment of a hospital mortality reduction group with senior leadership and support to ensure the alignment of the hospital departments to achieve a common goal. Robust measurement and regular feedback of hospital deaths using statistical process control charts and summaries of death certificates and routine hospital data. Whole system working across a health community to provide appropriate end of life care. Training and awareness in processes of high quality care such as clinical observation, medication safety and infection control.

EFFECTS

Hospital standardized mortality ratios fell significantly in the 3 years following the start of the programme from 94.6 (95% confidence interval 89.4, 99.9) in 2001 to 77.5 (95% CI 73.1, 82.1) in 2005. This translates as 905 fewer hospital deaths than expected during the period 2002-2005.

LESSONS LEARNT

Improving the safety of hospital care and reducing hospital deaths provides a clear and well supported goal from clinicians, managers and patients. Good leadership, good information, a quality improvement strategy based on good local evidence and a community-wide approach may be effective in improving the quality of processes of care sufficiently to reduce hospital mortality.

Persistent high rates of hysterectomy in Western Australia: a population-based study of 83 000 procedures over 23 years

OBJECTIVE

To investigate incidence trends and demographic, social and health factors associated with the rate of hysterectomy and morbidity outcomes in Western Australia and compare these with international studies.

DESIGN

Population-based retrospective cohort study.

SETTING

All hospitals in Western Australia where hysterectomies were performed from 1981 to 2003.

POPULATION

All women aged 20 years or older who underwent a hysterectomy.

METHODS

Statistical analysis of record-linked administrative health data.

MAIN OUTCOME MEASURES

Rates, rate ratios and odds ratios for incidence measures and length of stay in hospital and odds ratios for morbidity measures.

RESULTS

The age-standardised rate of hysterectomy adjusted for the underlying prevalence of hysterectomy decreased 23% from 6.6 per 1000 woman-years (95% CI 6.4-6.9) in 1981 to 4.8 per 1000 woman-years (95% CI 4.6-4.9) in 2003. Lifetime risk of hysterectomy was estimated as 35%. In 2003, 40% of hysterectomies were abdominal. The rate of hysterectomy to treat menstrual disorders fell from 4 per 1000 woman-years in 1981 to 1 per 1000 woman-years in 1993 and has since stabilised. Low socio-economic status, having only public health insurance, nonindigenous status and living in rural or remote areas were associated with increased risk of having a hysterectomy for menstrual disorders. Indigenous women had higher rates of hysterectomy to treat gynaecological cancers compared with nonindigenous women, particularly in rural areas. The odds of a serious complication were 20% lower for vaginal hysterectomies compared with abdominal procedures.

CONCLUSION

Western Australia has one of the highest hysterectomy rates in the world, although proportionally, significantly fewer abdominal hysterectomies are performed than in most countries.

Training, assessment and competency in gynaecologic surgery

The trainee gynaecologist requires specific teaching to achieve competency in gynaecological surgery. Basic skills such as knot tying and suturing should be acquired outside the operating theatre. They can be learned on simulations, including bench models, using synthetic materials, life-like models and animal tissue. Video training equipment is useful for the development of basic laparoscopic hand-eye coordination. Intermediate and advanced skills require simulations using more sophisticated bench models, live animals and virtual reality computerised systems. Structured teaching and assessment methods are essential. Surgical skills training models should be reliable and valid, and can be incorporated into an objective structured clinical examination, which could be used to assess individual development and allow progression through a training programme. Simulation training does translate into improved operative performance. Supervised operating experience on patients is crucial to training and should be assessed regularly using a global rating form with constructive feedback to facilitate improvement.

Prognostic Importance of Preoperative CA-125 in International Federation of Gynecology and Obstetrics Stage I Epithelial Ovarian Cancer: An Australian Multicenter Study

Purpose

To evaluate the prognostic significance of preoperative CA-125 levels on overall survival of patients with International Federation of Gynecology and Obstetrics (FIGO) stage I epithelial ovarian cancer (EOC).

Patients and Methods

Data from 518 patients with FIGO stage I EOC treated in seven gynecologic oncology centers throughout Australia between 1990 and 2002 were analyzed. Patients with borderline tumors and nonepithelial ovarian carcinomas were excluded, as were women in whom CA-125 had not been determined preoperatively. Preoperative CA-125 levels were studied in surgically staged and incompletely staged patients and compared with prognostic factors, such as substage, grade, and histologic type. Multivariate Cox models were calculated.

Results

CA-125 levels more than 30 U/mL were associated with higher grade, substage 1B and 1C, nonmucinous histologic type, and older age. In univariate analysis, higher histologic grade, the absence of surgical staging, and preoperative CA-125 levels more than 30 U/mL were associated with impaired survival. Multivariate analysis identified histologic grade, preoperative CA-125, and surgical staging as independent predictors for survival. In the subgroup of completely surgically staged patients, the 5-year overall survival rate was 82% (95% CI, 76% to 88%) for patients with CA-125 levels more than 30 U/mL and 95% (95% CI, 90% to 99%) for patients with CA-125 levels of 30 U/mL or less (P = .028). In the group of incompletely staged patients, the 5-year survival rates were similar for patients with elevated and normal serum CA-125 levels.

Conclusion

Complete surgical staging, histologic grade, and preoperative serum CA-125 levels are independent prognostic factors and should be included in the decision making for chemotherapy.

Gastric adenocarcinoma presenting as uterine metastasis—A case report

BACKGROUND

Metastases to the uterus are rare, especially from extrapelvic malignancies.

CASE

We report a 75-year-old woman who underwent hysterectomy for a FIGO Grade I endometrial carcinoma and was found to have evidence of a second malignant process involving the myometrium. The patient underwent a gastroscopy, which showed nonspecific superficial gastric and duodenal erosions. Random biopsies, however, confirmed a diagnosis of primary gastric adenocarcinoma. CT scan also showed pulmonary metastasis. The patient developed progressive disease despite two cycles of chemotherapy consistent of etoposide, doxorubicin and carboplatin.

CONCLUSION

This case illustrates the presence of two spatially separated tumours found in the uterus. Malignant cells present deep in the lymphovascular spaces have morphological features different from the primary endometrial carcinoma. The microscopic appearances of these cells are similar to that of the gastric biopsy, supporting the diagnosis of metastatic gastric adenocarcinoma.