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Does the presence of single compared to multiple endometrial polyps alter the risk of cancer in post-menopausal women? Eur J Obstet Gynecol Reprod Biol 2022; 279:118-121. [DOI: 10.1016/j.ejogrb.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/16/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022]
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Endometrial Cancer in Pre-Menopausal Women and Younger: Risk Factors and Outcome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159059. [PMID: 35897440 PMCID: PMC9330568 DOI: 10.3390/ijerph19159059] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 12/04/2022]
Abstract
Endometrial cancer is the sixth most common malignancy in women, and it is known to be a disease among postmenopausal women, but there is rising in the number of endometrial cancers among premenopausal women. This study aims to determine the clinical characteristic, risk factors, outcomes, and survival in pre and postmenopausal women with endometrial cancer in Malaysia. A retrospective study was conducted in Hospital Melaka that involved all women who were diagnosed with endometrial cancer in Hospital Melaka from January 2002 until July 2020. All subjects’ histopathological examination result was confirmed, and their clinical data were extracted and transferred into a standardized data checklist and analysed. A total number of 392 cases was obtained from the Annual Cancer Registry Hospital Melaka. However, only 281 cases were studied, including 44.8% premenopausal and 55.2% postmenopausal women. In the premenopausal group, there were higher incidence of obesity (30.8 + 8.6 vs. 28.9 + 7.1), younger age at menarche (12.7 + 1.5 vs. 13.3 + 1.6), lesser parity (1.47 vs. 3.26), and a higher number of nulliparous women (46.8% vs. 19.4%) as compared to postmenopausal group. The premenopausal group tends to be presented with a well-differentiated grading of tumour (52.4%) and a higher incidence of having concomitant endometrial hyperplasia (41.3%). The mean survival among the premenopausal group (200.3 + 7.9 months) is higher compared to postmenopausal group (153.9 + 6.5 months). These findings correlate with good survival and prognosis among the premenopausal group compared to the postmenopausal group.
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Nguyen PN, Nguyen VT. Evaluating Clinical Features in Intracavitary Uterine Pathologies among Vietnamese Women Presenting with Peri-and Postmenopausal Bleeding: A Bicentric Observational Descriptive Analysis. J Midlife Health 2022; 13:225-232. [PMID: 36950211 PMCID: PMC10025815 DOI: 10.4103/jmh.jmh_81_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 03/24/2023] Open
Abstract
Background Intracavitary uterine pathologies (IUPs) may be resulting in vaginal bleeding in perimenopausal and postmenopausal women. Especially, malignant disease needed to be investigated due to its adverse impact on the quality of mid-life women as well as the burden of health-care costs in low- and middle-income countries such as Vietnam. Objective Thereby, through this study, we aimed to assess the major clinical features of IUPs in women with perimenopausal and postmenopausal bleeding women. Materials and Methods This was a cross-sectional observational study at Hue University Hospital and Hue Central Hospital from June 2016 to June 2019. The study enrolled 150 women above 40 years old involving with intrauterine bleeding. Results The mean age of the study population was 51.51 ± 7.65. The most common symptom in perimenopausal women was menorrhagia, up to 62.2% of cases. In addition to intrauterine bleeding, there were 54.7% of cases had at least one other functional symptom, they were pale skin (35.9%), and lower abdominal pain (31.3). Endometrial hyperplasia (EH) was the most common pathology in both groups with perimenopausal and postmenopausal bleeding (PMB), respectively, 66.7% and 51.7%. In PMB group, endometrial cancer (EC) occupied approximately 38.3% following EH. Our study revealed age, menstrual characteristics, and diabetes in relation to malignant disease. Other factors seemed to be less associated with EC. Conclusions Menorrhagia was the most common type of abnormal uterine bleeding in perimenopausal women. Besides vaginal bleeding, others symptoms such as pale skin, pelvic pain, and fatigue were also common. Length day and blood loss before hospitalization in perimenopausal women were greater significantly than that in postmenopausal women. Age, menstrual characteristics, and diabetes increased the risk of EC in women with PMB.
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Affiliation(s)
- Phuc Nhon Nguyen
- Department of High-Risk Pregnancy and Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Van Tuan Nguyen
- Department of Obstetrics and Gynecology, Hue Medical College, Thua Thien Hue, Vietnam
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Executive Summary of the Uterine Cancer Evidence Review Conference. Obstet Gynecol 2022; 139:626-643. [PMID: 35272316 PMCID: PMC8936160 DOI: 10.1097/aog.0000000000004711] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/18/2021] [Indexed: 01/21/2023]
Abstract
Evidence for uterine cancer prevention, diagnosis, and special issues from the Uterine Cancer Evidence Review Conference is summarized. The Centers for Disease Control and Prevention recognized the need for educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. The American College of Obstetricians and Gynecologists convened a panel of experts in evidence review from the Society for Academic Specialists in General Obstetrics and Gynecology and content experts from the Society of Gynecologic Oncology to review relevant literature, best practices, and existing practice guidelines as a first step toward developing evidence-based educational materials for women's health care clinicians about uterine cancer. Panel members conducted structured literature reviews, which were then reviewed by other panel members and discussed at a virtual meeting of stakeholder professional and patient advocacy organizations in January 2021. This article is the evidence summary of the relevant literature and existing recommendations to guide clinicians in the prevention, early diagnosis, and special considerations of uterine cancer. Substantive knowledge gaps are noted and summarized to provide guidance for future research.
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Wang W, Xu Y, Yuan S, Li Z, Zhu X, Zhou Q, Shen W, Wang S. Prediction of Endometrial Carcinoma Using the Combination of Electronic Health Records and an Ensemble Machine Learning Method. Front Med (Lausanne) 2022; 9:851890. [PMID: 35308550 PMCID: PMC8931475 DOI: 10.3389/fmed.2022.851890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/28/2022] [Indexed: 11/24/2022] Open
Abstract
Endometrial carcinoma (EC) is a common cause of cancer death in women, and having an early accurate prediction model to identify this disease is crucial. The aim of this study was to develop a new machine learning (ML) model-based diagnostic prediction model for EC. We collected data from consecutive patients between November 2012 and January 2021 at tertiary hospitals in central China. Inclusion criteria included women undergoing endometrial biopsy, dilation and curettage, or hysterectomy. A total of 9 features, including patient demographics, vital signs, and laboratory and ultrasound results, were selected in the final analysis. This new model was combined with three top optimal ML methods, namely, logistic regression, gradient-boosted decision tree, and random forest. A total of 1,922 patients were eligible for final analysis and modeling. The ensemble model, called TJHPEC, was validated in an internal validation cohort and two external validation cohorts. The results showed that the AUC values were 0.9346, 0.8341, and 0.8649 for the prediction of total EC and 0.9347, 0.8073, and 0.871 for prediction of stage I EC. Nine clinical features were confirmed to be highly related to the prediction of EC in TJHPEC. In conclusion, our new model may be accurate for identifying EC, especially in the early stage, in the general population of central China.
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Affiliation(s)
- Wenwen Wang
- Department of Obstetrics and Gynecology, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Xu
- School of Computer Engineering and Science, Shanghai University, Shanghai, China
| | - Suzhen Yuan
- Department of Obstetrics and Gynecology, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiying Li
- Department of Obstetrics and Gynecology, Affiliated Renhe Hospital of China Three Gorges University, Yichang, China
| | - Xin Zhu
- Biomedical Information Engineering Lab, The University of Aizu, Fukushima, Japan
| | - Qin Zhou
- Department of Obstetrics and Gynecology, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Wenfeng Shen
- School of Computer Engineering and Science, Shanghai University, Shanghai, China
- Wenfeng Shen
| | - Shixuan Wang
- Department of Obstetrics and Gynecology, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Shixuan Wang
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Risk Factors for Endometrial Carcinoma in Women with Postmenopausal Bleeding. J Obstet Gynaecol India 2021; 71:417-423. [PMID: 34566302 DOI: 10.1007/s13224-021-01464-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 02/04/2021] [Indexed: 10/21/2022] Open
Abstract
Objectives Most patients with postmenopausal bleeding do not have endometrial cancer. The primary objective was to evaluate risk factors for endometrial cancer among postmenopausal women with bleeding. Methods This was a retrospective cross-sectional study. Women with postmenopausal bleeding presenting to a gynecology clinic were included in the study. Data on potential risk factors for endometrial cancer or atypical hyperplasia were collected. Univariate and multivariate analyses were performed to assess the risk factors. Results Among 212 women studied, 24 (11.3%) women had endometrial cancer. There were 38 (17.9%) with cervical cancer and 3 (1.4%) with ovarian cancer. Women 55 or older had an odds ratio of 7.5 (95% CI 2.2 to 26.2) as compared to women below 55 years (p value = 0.002). Women with 2 or more episodes of postmenopausal bleeding had an odds ratio of 4.9 (95% CI 1.1 to 23.0) and those who had either diabetes or hypertension had an odds ratio of 3.1 (95% CI 1.3 to 7.4) of endometrial cancer as compared to those who did not. Conclusions A third of patients with postmenopausal bleeding had a gynecological cancer. Age, frequency of bleeding, diabetes and hypertension, and increased endometrial thickness were independent risk factors for endometrial cancer.
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Molnár S, Farkas Z, Jakab A, Lampé R, Török P. Effectiveness of different methods for polypectomy in the menopause: a retrospective study. Climacteric 2021; 23:325-329. [PMID: 32648828 DOI: 10.1080/13697137.2020.1732915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: Most endometrial polyps represent focal hyperplasia of the endometrium. Endometrial polyps can be diagnosed by ultrasound, hysterocontrast sonography, hysterosalpingography, endometrial biopsy, and uterine curettage, but diagnostic hysteroscopy is considered the gold-standard method, with the greatest sensitivity and specificity and also with the opportunity for treatment at the same time.Study design: A retrospective study was conducted on 424 patients between 2006 and 2018. The polyps were verified during diagnostic hysteroscopy and were removed by resectoscopy or curettage. All samples underwent histological examination. The effectivity of the type of resection and the recurrence rate were evaluated.Results: The average age of the patients was 60.2 ± 9.3 years. Polyps were excised in 62.97% by resectoscopic polypectomy and in 37.03% by curettage. Malignancy was confirmed in 4.24% of cases. Histological verification of polyps was 79.4% in the resectoscopy group and 69.04% in the curettage group; the difference was significant (p < 0.01). The recurrence rate was 20.47% after resectoscopy and 27.12% following curettage.Conclusion: Hysteroscopy remains the best option and the gold-standard method among diagnostic procedures of endometrial pathology. In this study, there was a significant difference in matching hysteroscopic and histological findings in the two methods of polypectomy. The recurrence rate is also lower following resectoscopy.
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Affiliation(s)
- S Molnár
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Z Farkas
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - A Jakab
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - R Lampé
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - P Török
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Liu F, Cheung ECW, Lao TT. Obesity increases endometrial cancer risk in Chinese women with postmenopausal bleeding. Menopause 2021; 28:1093-1098. [PMID: 34183566 DOI: 10.1097/gme.0000000000001822] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We examined the relationship between body mass index (BMI) at referral and subsequent diagnosis of endometrial cancer in a cohort of Chinese women presenting with postmenopausal bleeding, to determine whether BMI of 25 kg/m2 would serve to delineate women at increased risk of endometrial cancer. METHODS This cohort included 4,164 Chinese women referred for postmenopausal bleeding from 2002 to 2013. For all women, a medical history was taken, and physical examination, BMI measurement, transvaginal pelvic ultrasonography, and endometrial sampling were performed. Additional investigations were performed as indicated clinically. The presence of risk factors for endometrial cancer and histological diagnoses were compared among groups defined by the standard Asian BMI cut-off values. RESULTS Within the cohort, 868 (20.8%) were overweight (BMI 23-24.9 kg/m2) and 1,611 (38.7%) were obese (BMI ≥25 kg/m2), and 162 (3.9%) had endometrial cancer. The prevalence of endometrial cancer correlated with BMI category (P < 0.001). On multivariate analysis, BMI ≥25 kg/m2 was independently associated with 1.57 times risk of endometrial cancer (95% CI 1.13-2.20, P = 0.008) compared with BMI less than 25 kg/m2. CONCLUSION When managing postmenopausal bleeding in Chinese women, the Asian BMI standard for obesity at 25 kg/m2 identified 51% of endometrial cancers in this group and denoted a 57% increased risk of endometrial cancer. Thus obesity could be used to triage women presenting with postmenopausal bleeding for prioritized investigations.
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Affiliation(s)
- Fangzi Liu
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Sha Tin, Hong Kong
| | - Eva C W Cheung
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Sha Tin, Hong Kong
| | - Terence T Lao
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong
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Histopathological Findings in Iranian Patients with Postmenopausal Uterine Bleeding. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2021. [DOI: 10.1007/s40944-021-00515-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Stachowicz N, Smoleń A, Ciebiera M, Łoziński T, Poziemski P, Borowski D, Czekierdowski A. Risk Assessment of Endometrial Hyperplasia or Endometrial Cancer with Simplified Ultrasound-Based Scoring Systems. Diagnostics (Basel) 2021; 11:diagnostics11030442. [PMID: 33806571 PMCID: PMC8001089 DOI: 10.3390/diagnostics11030442] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/14/2021] [Accepted: 02/20/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Abnormal uterine bleeding (AUB) represents a common diagnostic challenge, as it might be related to both benign and malignant conditions. Endometrial cancer may not be detected with blind uterine cavity sampling by dilatation and curettage or suction devices. Several scoring systems using different ultrasound image characteristics were recently proposed to estimate the risk of endometrial cancer (EC) in women with AUB. AIM The aim of the present study was to externally validate the predictive value of the recently proposed scoring systems including the Risk of Endometrial Cancer scoring model (REC) for EC risk stratification. MATERIAL AND METHODS It was a retrospective cohort study of women with postmenopausal bleeding. From June 2012 to June 2020 we studied a group of 394 women who underwent standard transvaginal ultrasound examination followed by power Doppler intrauterine vascularity assessment. Selected ultrasound features of endometrial lesions were assessed in each patient. RESULTS The median age was 60.3 years (range ± 10.7). The median body mass index (BMI) was 30.4 (range ± 6.0). Histological examination revealed 158 cases of endometrial hyperplasia (EH) and 236 cases of EC. Of the studied ultrasound endometrial features, the highest areas under the curve (AUCs) were found for endometrial thickness (ET) (AUC = 0.76; 95% CI: 0.71-0.81) and for interrupted endomyometrial junction (AUC = 0.70, 95% CI: 0.65-0.75). Selected scoring systems presented moderate to good predictive performance in differentiating EC and EH. The highest AUC was found for REC model (AUC = 0.75, 95% CI: 0.70-0.79) and for the basic model that included ET, Doppler score and interrupted endometrial junction (AUC = 0.77, 95% CI: 0.73-0.82). REC model was more accurate than other scoring systems and selected single features for differentiating benign hyperplasia from EC at early stages, regardless of menopausal status. CONCLUSIONS New scoring systems, including the REC model may be used in women with AUB for more efficient differentiation between benign and malignant conditions.
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Affiliation(s)
- Norbert Stachowicz
- Chair and Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin, 20-080 Lublin, Poland;
- Correspondence:
| | - Agata Smoleń
- Chair and Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin, 20-080 Lublin, Poland;
| | - Michał Ciebiera
- Center of Postgraduate Medical Education, Second Department of Obstetrics and Gynecology, 01-809 Warsaw, Poland;
| | - Tomasz Łoziński
- Department of Obstetrics and Gynaecology, Pro-Familia Hospital, 35-001 Rzeszów, Poland;
| | - Paweł Poziemski
- Department of Obstetrics and Gynecology, Mińsk Mazowiecki County Hospital, 05-300 Mińsk Mazowiecki, Poland;
| | - Dariusz Borowski
- Clinic of Fetal-Maternal Medicine, Gynecology and Neonatology, Collegium Medicum, Nicolaus Copernicus University in Bydgoszcz, 85-067 Bydgoszcz, Poland;
| | - Artur Czekierdowski
- Department of Gynecological Oncology and Gynecology, Medical University of Lublin, 20-081 Lublin, Poland;
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Long B, Clarke MA, Morillo ADM, Wentzensen N, Bakkum-Gamez JN. Ultrasound detection of endometrial cancer in women with postmenopausal bleeding: Systematic review and meta-analysis. Gynecol Oncol 2020; 157:624-633. [PMID: 32008795 DOI: 10.1016/j.ygyno.2020.01.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/16/2020] [Accepted: 01/20/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the performance of endometrial thickness (ET) cut-offs for detecting endometrial cancer (EC) in women with postmenopausal bleeding (PMB) and evaluate the clinical utility of additional ultrasound measures such as endometrial volume (EV), vascular flow index (VFI), vascularization index (VI), and uterine artery flow index (FI). METHODS Clinicaltrials.gov and MEDLINE database via PubMed were queried for studies published between 1/1990 and 3/2016 using specific MeSH terms. Original, peer-reviewed cohort studies reporting EC outcomes and specific ultrasound findings by PMB status were included. RESULTS Study design, country, clinical setting inclusion/exclusion criteria, aggregate study-level demographic and clinical data were extracted from 44 studies including 17,339 women with PMB and 1341 cases of EC (7.7%). In women with PMB and EC (n = 417), pooled mean ET was 16.4 mm (95% CI, 14.8-18.1 mm). In women with PMB without EC, pooled mean ET was 4.1 mm. 31 studies reported outcomes using different ET cut-off values ranging from 3 to 20 mm. Compared to ≥3 or 4 mm, a cutoff of ≥5 mm had similar sensitivity (96.2, 95%CI 92.3, 98.1) with improved specificity for EC (51.5, 95%CI 42.3-60.7), allowing to reduce the rate of invasive workup for PMB by 17%. EV, VI, VFI, and FI were significantly correlated with EC, but performance of specific cut-offs was not analyzed due to limited data. CONCLUSION Among women with PMB mean ET is substantially higher in women with EC compared to those without EC. An ET cutoff of ≥5 mm shows an acceptable tradeoff between sensitivity and specificity for diagnosis of EC.
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Affiliation(s)
- Beverly Long
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America.
| | - Megan A Clarke
- Clinical Epidemiology Unit, Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute (NCI), Bethesda, MD, United States of America
| | - Arena Del Mar Morillo
- Clinical Epidemiology Unit, Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute (NCI), Bethesda, MD, United States of America
| | - Nicolas Wentzensen
- Clinical Epidemiology Unit, Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute (NCI), Bethesda, MD, United States of America
| | - Jamie N Bakkum-Gamez
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology Surgery, Mayo Clinic, Rochester, MN, United States of America
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Cid Sánchez DR, Rivas Ruiz R, Quijano Castro OF, Garay Villar O, Camacho AR. Chronic Morbidity in Patients with Endometrial Cancer who Received Adjuvant Radiotherapy. Cureus 2019; 11:e6325. [PMID: 31938616 PMCID: PMC6946033 DOI: 10.7759/cureus.6325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Endometrial cancer is the second gynecological neoplasm in our country. The standard treatment is surgery, followed by radiation therapy or chemotherapy according to the stage. Aim The purpose of this study was to determine the frequency and type of chronic morbidity in patients with high to intermediate risk of endometrial cancer according to European Society for Medical Oncology (ESMO) 2016, treated with radiotherapy in its modality of external beam radiation therapy and/or brachytherapy in the Oncology Hospital of National Medical Center XXI Century from 2012 to 2016. Methods This is a longitudinal, observational, retrospective study of 37 patients diagnosed with high to intermediate risk of endometrial cancer, who received external beam radiation therapy and/or high-rate brachytherapy and follow-up in the unit. Results Up to 87% of the patients, who met the criteria of high to intermediate risk, received adjuvant treatment with radiotherapy; 44% brachytherapy, 43% teletherapy, and 13% of patients did not receive adjuvant treatment. Seventy percent presented toxicity associated with radiotherapy, with 65% of the cases being grade 1 and 2 and 5% of cases grade 3; there was no grade 4 toxicity. Regarding the site, the digestive tube occupied the first place with 38% of the cases. The univariate and multivariate analyses showed that age over 65 years is the only factor with statistical significance to develop chronic morbidity. Conclusion Age >65 years is the independent risk factor associated with the development of chronic toxicity.
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Affiliation(s)
| | | | | | - Onix Garay Villar
- Radiation Oncology, Mexican Institute of Social Security, Mexico City, MEX
| | - Alejandro R Camacho
- Radiation Oncology, National Institute of Neurology and Neurosurgery, Mexico City, MEX
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Yang H, Pawitan Y, He W, Eriksson L, Holowko N, Hall P, Czene K. Disease trajectories and mortality among women diagnosed with breast cancer. Breast Cancer Res 2019; 21:95. [PMID: 31420051 PMCID: PMC6698019 DOI: 10.1186/s13058-019-1181-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/22/2019] [Indexed: 12/31/2022] Open
Abstract
Purpose Breast cancer is a common disease with a relatively good prognosis. Therefore, understanding the spectrum of diseases and mortality among breast cancer patients is important, though currently incomplete. We systematically examined the incidence and mortality of all diseases following a breast cancer diagnosis, as well as the sequential association of disease occurrences (trajectories). Methods In this national cohort study, 57,501 breast cancer patients (2001–2011) were compared to 564,703 matched women from the general Swedish population and followed until 2012. The matching criteria included year of birth, county of residence, and socioeconomic status. Based on information from the Swedish Patient and Cause of Death Registries, hazard ratios (HR) were estimated for disease incidence and mortality. Conditional logistic regression models were used to identify disease trajectories among breast cancer patients. Results Among 225 diseases, 45 had HRs > 1.5 and p < 0.0002 when comparing breast cancer patients with the general population. Diseases with highest HRs included lymphedema, radiodermatitis, and neutropenia, which are side effects of surgery, radiotherapy, and chemotherapy. Other than breast cancer, the only significantly increased cause of death was other solid cancers (HR = 1.16, 95% CI = 1.08–1.24). Two main groups of disease trajectories were identified, which suggest menopausal disorders as indicators for other solid cancers, and both neutropenia and dorsalgia as diseases and symptoms preceding death due to breast cancer. Conclusions While an increased incidence of other diseases was found among breast cancer patients, increased mortality was only due to other solid cancers. Preventing death due to breast cancer should be a priority to prolong life in breast cancer patients, but closer surveillance of other solid cancers is also needed. Electronic supplementary material The online version of this article (10.1186/s13058-019-1181-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Haomin Yang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, 171 77, Stockholm, Sweden.
| | - Yudi Pawitan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, 171 77, Stockholm, Sweden
| | - Wei He
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, 171 77, Stockholm, Sweden
| | - Louise Eriksson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, 171 77, Stockholm, Sweden.,Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Natalie Holowko
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, 171 77, Stockholm, Sweden
| | - Per Hall
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, 171 77, Stockholm, Sweden
| | - Kamila Czene
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels Väg 12A, 171 77, Stockholm, Sweden
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Dueholm M, Hjorth IMD, Dahl K, Hansen ES, Ørtoft G. Ultrasound Scoring of Endometrial Pattern for Fast-track Identification or Exclusion of Endometrial Cancer in Women with Postmenopausal Bleeding. J Minim Invasive Gynecol 2019; 26:516-525. [DOI: 10.1016/j.jmig.2018.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 03/05/2018] [Accepted: 06/13/2018] [Indexed: 12/18/2022]
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15
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Begum J, Samal R. A Clinicopathological Evaluation of Postmenopausal Bleeding and Its Correlation with Risk Factors for Developing Endometrial Hyperplasia and Cancer: A Hospital-Based Prospective Study. J Midlife Health 2019; 10:179-183. [PMID: 31942153 PMCID: PMC6947719 DOI: 10.4103/jmh.jmh_136_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Objective: The aim of this study is to investigate the clinical data from history and endometrial pathology by endometrial sampling in patients with postmenopausal bleeding and to identify risk factors associated with future development of endometrial cancer (EC). Methods: We prospectively studied 76 postmenopausal women with vaginal bleeding and endometrial thickness (ET) >5 mm undergoing endometrial biopsy or dilatation and curettage. Patient characteristics and endometrial assessment of women with or without EC and hyperplasia were compared. Univariate and multivariate logistic regression identified factors associated with risks of endometrial neoplasia. Results: In this study, the mean age at the time of presentation was 57.17 ± 7.11 years, mean menopausal age was 49.18 ± 3.69 years, and mean thickness of endometrial was 11.13 ± 6.37 mm. The histopathological analysis showed atrophic endometrium (30.3%), proliferative endometrium (27.6%), EC (15.8%), endometrium hyperplasia (11.8%), disordered proliferative endometrium (9.2%), and endometrial polyp (5.3%). Women of EC and hyperplasia group were more likely to be multiparous, diabetic, hypertensive, obese or overweight, has a history of recurrent bleeding episodes or thick endometrium. Using multivariate logistic regression, we found ET (adjusted odds ratio [AOR] = 17.76, confidence interval [CI] 1.91–165.02, P < 0.011, criterion ≥11 mm), recurrent episode of bleeding (AOR = 13.21, CI 1.10–158.91, P < 0.042), diabetes (AOR = 8.03, CI 1.15–55.78, P < 0.035) the best predictors of EC. Conclusion: As clinical characteristics are possible predictors of EC, these should also be taken into account in risk estimations and in the formulation of management plans. This not only has benefit in the process of disease detection but also may result in improved the efficiency of care.
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Affiliation(s)
- Jasmina Begum
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Rupal Samal
- Department of Obstetrics and Gynaecology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
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Sauvan M, Pourcelot AG, Fournet S, Fernandez H, Capmas P. Office hysteroscopy for postmenopausal women: Feasibility and correlation with transvaginal ultrasound. J Gynecol Obstet Hum Reprod 2018; 47:505-510. [DOI: 10.1016/j.jogoh.2018.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 08/13/2018] [Accepted: 08/29/2018] [Indexed: 12/22/2022]
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Lowa M, Sitali L, Siame M, Musonda P. Human mobility and factors associated with malaria importation in Lusaka district, Zambia: a descriptive cross sectional study. Malar J 2018; 17:404. [PMID: 30390654 PMCID: PMC6215643 DOI: 10.1186/s12936-018-2554-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 10/27/2018] [Indexed: 11/24/2022] Open
Abstract
Background Malaria is a major public health problem in Zambia with an estimated 4 million confirmed cases and 2389 deaths reported in 2015. Efforts to reduce the incidence of malaria are often undermined by a number of factors such as human mobility which may lead to introduction of imported infections. The aim of this study was to establish the burden of malaria attributed to human mobility in Lusaka district and identify factors associated with malaria importation among residents of Lusaka district. Methods A cross sectional study was conducted in five randomly selected health facilities in Lusaka district from November 2015 to February 2016. Data was collected from 260 patients who presented with malaria and whose status was confirmed by rapid diagnostic test or microscopy. Each confirmed malaria case was interviewed using a structured questionnaire to establish their demographic characteristics, travel history and preventive measures. Travel history was used as a proxy to classify cases as either imported or local. Residency was also used as a secondary proxy for importation to compare characteristics of residents vs non-residents in relation to malaria importation. Logistic regression was used to determine factors associated with malaria importation among residents of Lusaka district. Results Out of 260 cases, 94.2% were classified as imported cases based on participants’ travel history. There were 131 (50.4%) males and 129 (49.6%) females. Age distribution ranged from 0 to 68 years with a median age of 15 years (IQR 8–27). Imported cases came from all the ten provinces of Zambia with the Copperbelt Province being the highest contributor (41%). Of all imported cases, use of prophylaxis was found to be highly protective [AOR = 0.22 (95% CI 0.06–0.82); p-value = 0.024]. Other factors that significantly influence malaria transmission and importation by residents include duration of stay in a highly endemic region [AOR = 1.25 (95% CI 1.09–1.44); p-value = 0.001] and frequency of travel [AOR = 3.71 (95% CI 1.26–10.84); p-value = 0.017]. Conclusion Human mobility has influenced malaria transmission in Lusaka district through a number of factors by importing infections. This leads to onward transmission and poses a challenge to malaria elimination and control. However, taking of prophylaxis is highly protective and must be highly recommended.
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Affiliation(s)
- Miriam Lowa
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, P.O. Box 50110, Lusaka, Zambia. .,Department of Public Health, National Malaria Programme, Ministry of Health and Wellness, P.O. Box 82343, Gaborone, Botswana.
| | - Lungowe Sitali
- Department of Biomedical Sciences, School of Health Sciences, University of Zambia, P.O. Box 50110, Lusaka, Zambia
| | - Mwiche Siame
- Department of Policy and Planning, Ministry of Health, P.O. Box 30205, Lusaka, Zambia
| | - Patrick Musonda
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, P.O. Box 50110, Lusaka, Zambia
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Pergialiotis V, Pouliakis A, Parthenis C, Damaskou V, Chrelias C, Papantoniou N, Panayiotides I. The utility of artificial neural networks and classification and regression trees for the prediction of endometrial cancer in postmenopausal women. Public Health 2018; 164:1-6. [DOI: 10.1016/j.puhe.2018.07.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/23/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
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19
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Alblas M, Velt KB, Pashayan N, Widschwendter M, Steyerberg EW, Vergouwe Y. Prediction models for endometrial cancer for the general population or symptomatic women: A systematic review. Crit Rev Oncol Hematol 2018; 126:92-99. [DOI: 10.1016/j.critrevonc.2018.03.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 03/13/2018] [Accepted: 03/28/2018] [Indexed: 12/22/2022] Open
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Comparison of Three Clinical Models for Estimating the Risk of Endometrial Cancer in Post-Menopausal Women with Abnormal Vaginal Bleeding. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2018. [DOI: 10.5812/ijcm.55934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Ghoubara A, Sundar S, Ewies AAA. Endometrial pathology in recurrent postmenopausal bleeding: observational study of 385 women. Climacteric 2018; 21:391-396. [PMID: 29741102 DOI: 10.1080/13697137.2018.1461825] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- A. Ghoubara
- University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynecology, Aswan University, Aswan, Egypt
- Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - S. Sundar
- University of Birmingham, Birmingham, UK
- Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - A. A. A. Ewies
- University of Birmingham, Birmingham, UK
- Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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22
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Abdelraheim AR, Khairy M, Mohammed M, Lawrence A. Two week waits: What are we waiting for? Eur J Obstet Gynecol Reprod Biol 2017; 215:112-117. [PMID: 28609712 DOI: 10.1016/j.ejogrb.2017.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/04/2017] [Accepted: 06/06/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the two-week referral system by analysing the 2-week wait (2WW) referrals to the rapid access gynaecology clinic over one year. We have also sought to identify the risk factors for endometrial cancer to help setting criteria that can be used to prioritise urgent appointments, refine subsequent management strategies. STUDY DESIGN Retrospective review of the data of all women referred for suspected gynaecological cancers over one year via the 2 WW office at Queen's Hospital, Romford, UK. Data of all other women in whom a diagnosis of a gynaecological malignancy was made during the same period following non-urgent (non-2WW) referrals were also collected. RESULTS Over one year, a total of 1105 women were referred under the 2WW for suspected gynaecological malignancy. A total of 765 patients (69.23%) were referred with suspected endometrial cancer and the main indication for referral was postmenopausal bleeding. Hundred-seventy nine women (16.20%) were referred with suspected ovarian cancer. A pelvic mass found in 62 of these women and this was the main indication of referral. The number of women referred with suspected cervical cancer was 117 (10.59%) and the main indication for referral was postcoital bleeding. Forty-four women (3.98%) referred with suspected vulvo-vaginal cancer and the main presentation was vulval lesion. The positive predictive value of referrals for diagnosing endometrial, ovarian, cervical and vulvo-vaginal malignancy was 8.1%, 9.5%, 5.98% and 13.64% and the overall predictive value for diagnosing gynaecological malignancy was 8.33%. The predictive values of the 2WW referrals for diagnosing different types of gynaecological cancers in premenopausal women are low compared to postmenopausal women (1.86% and 9.89% respectively, p<0.001). The number of cancers diagnosed through non-urgent system was higher than the number diagnosed through urgent system (95 vs. 92). Presence of diabetes mellitus, increased endometrial thickness, prolonged bleeding and advancing age represent the best model for predicting endometrial cancer. CONCLUSION The overall predictive value of the 2WW system for suspected gynaecological malignancies is low particularly in premenopausal women. The current referral criteria need to be modified with a view to incorporating risk factors to prioritise urgent appointments and refine subsequent management plans.
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Affiliation(s)
- Ahmed R Abdelraheim
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Minia University, Egypt; Gynaecological Oncology unit, Queen's Hospital, Romford, UK.
| | - Mohammed Khairy
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Minia University, Egypt
| | - Mo'men Mohammed
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Minia University, Egypt
| | - Alexandra Lawrence
- Gynaecological Oncology unit, Queen's Hospital, Romford, UK; Gynaecological Cancer center, St. Bart's Hospital, London, UK
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Turnbull HL, Akrivos N, Simpson P, Duncan TJ, Nieto JJ, Burbos N. Investigating vaginal bleeding in postmenopausal women found to have an endometrial thickness of equal to or greater than 10 mm on ultrasonography. Arch Gynecol Obstet 2016; 295:445-450. [PMID: 27909879 DOI: 10.1007/s00404-016-4249-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/22/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE This aim of this study is to determine the risk of endometrial cancer in symptomatic postmenopausal women, when endometrial thickness on transvaginal ultrasonography is equal to or greater than 10 mm, and subsequent office-based endometrial sampling histology is negative. METHODS This is a prospective cross-sectional study, performed in a gynaecological oncology centre in the United Kingdom between February 2008 and July 2012. All postmenopausal women presenting with vaginal bleeding were investigated using transvaginal ultrasonography. Women with endometrial thickness measurements equal to or greater than 10 mm and negative office-based endometrial biopsy underwent hysteroscopy and endometrial biopsies. RESULTS Over a 52-month period, 4148 women were investigated for postmenopausal vaginal bleeding. 588 (14.2%) women were found to have endometrial thickness measurements of equal to or greater than 10 mm on transvaginal ultrasonography. 170 (28.9%) cases of endometrial cancer were diagnosed in this group: 149 (87.6%) of the cancer cases were diagnosed in the outpatient setting with a Pipelle® endometrial sampler, whilst 21 (12.4%) had a negative Pipelle® sample and were diagnosed with hysteroscopy. The group diagnosed with hysteroscopy had lower BMI (32.7 kg/m2 versus 39.7 kg/m2, p < 0.001) whilst the group diagnosed with Pipelle was more likely to have a history of hypertension and diabetes mellitus (p = 0.019 for both). The sensitivity of Pipelle was 87.65%. CONCLUSION For women presenting with postmenopausal bleeding and where the endometrial thickness is equal to or greater than 10 mm and Pipelle sampling is negative, hysteroscopic evaluation with directed biopsy is strongly recommended.
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Affiliation(s)
- Hilary L Turnbull
- Department of Obstetrics and Gynecology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK.
| | - Nikolaos Akrivos
- Department of Obstetrics and Gynecology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK
| | - Paul Simpson
- Department of Obstetrics and Gynecology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK
| | - Timothy J Duncan
- Department of Obstetrics and Gynecology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK
| | - Joaquin J Nieto
- Department of Obstetrics and Gynecology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK
| | - Nikolaos Burbos
- Department of Obstetrics and Gynecology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK
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Shao X, Wang K, Liu X, Gu C, Zhang P, Xie J, Liu W, Sun L, Chen T, Li Y. Screening and verifying endometrial carcinoma diagnostic biomarkers based on a urine metabolomic profiling study using UPLC-Q-TOF/MS. Clin Chim Acta 2016; 463:200-206. [PMID: 27784637 DOI: 10.1016/j.cca.2016.10.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/19/2016] [Accepted: 10/21/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Endometrial carcinoma (EOC) is a gynecological disease with one of the highest worldwide incidences. Due to the lack of typical clinical symptoms and limited sensitive screening methods used to diagnose endometrial carcinoma, the disease is easily neglected before patients are aware of its presence. Therefore, EOC results in serious impacts on women's lives and health. We screened diagnostic biomarkers of EOC with a noninvasive method that compared healthy individuals and endometrial hyperplasia (EOH) patients. METHODS The morning urine of 25 healthy individuals, 25 patients with EOC and 10 patients with EOH were analyzed using an ultra-performance liquid chromatography quadrupole time-of-flight mass spectrometry (UPLC-Q-TOF/MS) platform. Metabolomics data were used to screen the different metabolites according to principal component analysis (PCA) and partial least squares discriminant analysis (PLS-DA) analyses. Furthermore, the screened biomarkers of the newly diagnosed EOC and EOH candidates and healthy individuals were verified using the predictive model of the support vector machine (SVM) to obtain EOC diagnostic biomarkers. RESULTS An EOC diagnostic biomarker group was found according to the metabolomics method. Five diagnostic biomarkers, including porphobilinogen, acetylcysteine, N-acetylserine, urocanic acid and isobutyrylglycine, were significantly changed in the EOC patients. Among them, porphobilinogen and acetylcysteine were significantly down-regulated, while N-acetylserine, urocanic acid and isobutyrylglycine were significantly up-regulated. CONCLUSIONS Disturbances in these biomarkers have negative impacts on the body's metabolic functioning. The EOC diagnostic biomarker group can provide a clinical reference for diagnosing EOC and insight into the diagnosis of other diseases in the clinic.
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Affiliation(s)
- Xidong Shao
- College of Management and Economics, Tianjin University, 92 Weijin Road, Tianjin 300193, China
| | - Ke Wang
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China
| | - Xinyu Liu
- Tianjin State Key Laboratory of Modern Chinese Medicine, School of Traditional Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, 312 Anshan West Road, Tianjin 300193, China
| | - Caiyun Gu
- Tianjin State Key Laboratory of Modern Chinese Medicine, School of Traditional Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, 312 Anshan West Road, Tianjin 300193, China
| | - Pengjie Zhang
- Tianjin State Key Laboratory of Modern Chinese Medicine, School of Traditional Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, 312 Anshan West Road, Tianjin 300193, China
| | - Jiabin Xie
- Tianjin State Key Laboratory of Modern Chinese Medicine, School of Traditional Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, 312 Anshan West Road, Tianjin 300193, China
| | - Wenxin Liu
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China
| | - Lu Sun
- National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China
| | - Tong Chen
- College of Management and Economics, Tianjin University, 92 Weijin Road, Tianjin 300193, China
| | - Yubo Li
- Tianjin State Key Laboratory of Modern Chinese Medicine, School of Traditional Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, 312 Anshan West Road, Tianjin 300193, China.
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Development and validation of prediction models for endometrial cancer in postmenopausal bleeding. Eur J Obstet Gynecol Reprod Biol 2016; 203:220-4. [PMID: 27344124 DOI: 10.1016/j.ejogrb.2016.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/25/2016] [Accepted: 05/04/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To develop and assess the accuracy of risk prediction models to diagnose endometrial cancer in women having postmenopausal bleeding (PMB). METHODS A retrospective cohort study of 4383 women in a One-stop PMB clinic from a university teaching hospital in Hong Kong. Clinical risk factors, transvaginal ultrasonic measurement of endometrial thickness (ET) and endometrial histology were obtained from consecutive women between 2002 and 2013. Two models to predict risk of endometrial cancer were developed and assessed, one based on patient characteristics alone and a second incorporated ET with patient characteristics. Endometrial histology was used as the reference standard. The split-sample internal validation and bootstrapping technique were adopted. The optimal threshold for prediction of endometrial cancer by the final models was determined using a receiver-operating characteristics (ROC) curve and Youden Index. The diagnostic gain was compared to a reference strategy of measuring ET only by comparing the AUC using the Delong test. RESULTS Out of 4383 women with PMB, 168 (3.8%) were diagnosed with endometrial cancer. ET alone had an area under curve (AUC) of 0.92 (95% confidence intervals [CIs] 0.89-0.94). In the patient characteristics only model, independent predictors of cancer were age at presentation, age at menopause, body mass index, nulliparity and recurrent vaginal bleeding. The AUC and Youdens Index of the patient characteristic only model were respectively 0.73 (95% CI 0.67-0.80) and 0.72 (Sensitivity=66.5%; Specificity=68.9%; +ve LR=2.14; -ve LR=0.49). ET, age at presentation, nulliparity and recurrent vaginal bleeding were independent predictors in the patient characteristics plus ET model. The AUC and Youdens Index of the patient characteristic plus ET model where respectively 0.92 (95% CI 0.88-0.96) and 0.71 (Sensitivity=82.7%; Specificity=88.3%; +ve LR=6.38; -ve LR=0.2). Comparison of AUC indicated that a history alone model was inferior to a model using ET alone (difference=0.19, 95% CI 0.15-0.24; p<0.0001) and History plus ET (difference=0.19, 95% CI 0.16-0.23, p<0.0001) and history plus ET was similar to that of using ET alone (difference=0.001 95% CI -0.015 to 0.0018, p=0.84). CONCLUSIONS A risk model using only patient characteristics showed fair diagnostic accuracy. Addition of patient characteristics to ET did not improve the diagnostic accuracy as compared to ET alone in our cohort.
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Ozer A, Ozer S, Kanat-Pektas M. Correlation between transvaginal ultrasound measured endometrial thickness and histopathological findings in Turkish women with abnormal uterine bleeding. J Obstet Gynaecol Res 2016; 42:573-8. [DOI: 10.1111/jog.12937] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 11/08/2015] [Accepted: 11/29/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Alev Ozer
- Departments of Obstetrics and Gynecology; Kahramanmaras Sutcu Imam University Medical Faculty Hospital; Kahramanmaras Turkey
| | - Serdar Ozer
- Department of Obstetrics and Gynecology; Pazarcik State Hospital; Kahramanmaras Turkey
| | - Mine Kanat-Pektas
- Department of Obstetrics and Gynecology; Afyon Kocatepe University Medical Faculty Hospital; Afyonkarahisar Turkey
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Hüsing A, Dossus L, Ferrari P, Tjønneland A, Hansen L, Fagherazzi G, Baglietto L, Schock H, Chang-Claude J, Boeing H, Steffen A, Trichopoulou A, Bamia C, Katsoulis M, Krogh V, Palli D, Panico S, Onland-Moret NC, Peeters PH, Bueno-de-Mesquita HB, Weiderpass E, Gram IT, Ardanaz E, Obón-Santacana M, Navarro C, Sánchez-Cantalejo E, Etxezarreta N, Allen NE, Khaw KT, Wareham N, Rinaldi S, Romieu I, Merritt MA, Gunter M, Riboli E, Kaaks R. An epidemiological model for prediction of endometrial cancer risk in Europe. Eur J Epidemiol 2016; 31:51-60. [PMID: 25968175 DOI: 10.1007/s10654-015-0030-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 04/07/2015] [Indexed: 01/12/2023]
Abstract
Endometrial cancer (EC) is the fourth most frequent cancer in women in Europe, and as its incidence is increasing, prevention strategies gain further pertinence. Risk prediction models can be a useful tool for identifying women likely to benefit from targeted prevention measures. On the basis of data from 201,811 women (mostly aged 30-65 years) including 855 incident EC cases from eight countries in the European Prospective Investigation into Cancer and Nutrition cohort, a model to predict EC was developed. A step-wise model selection process was used to select confirmed predictive epidemiologic risk factors. Piece-wise constant hazard rates in 5-year age-intervals were estimated in a cause-specific competing risks model, five-fold-cross-validation was applied for internal validation. Risk factors included in the risk prediction model were body-mass index (BMI), menopausal status, age at menarche and at menopause, oral contraceptive use, overall and by different BMI categories and overall duration of use, parity, age at first full-term pregnancy, duration of menopausal hormone therapy and smoking status (specific for pre, peri- and post-menopausal women). These variables improved the discriminating capacity to predict risk over 5 years from 71% for a model based on age alone to 77% (overall C statistic), and the model was well-calibrated (ratio of expected to observed cases = 0.99). Our model could be used for the identification of women at increased risk of EC in Western Europe. To achieve an EC-risk model with general validity, a large-scale cohort-consortium approach would be needed to assess and adjust for population variation.
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Affiliation(s)
- Anika Hüsing
- Division of Cancer Epidemiology (C020), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120, Heidelberg, Germany.
| | - Laure Dossus
- Inserm, Centre for Research in Epidemiology and Population Health (CESP), U1018, Nutrition, Hormones and Women's Health Team, 94805, Villejuif, France
- UnivParis Sud, UMRS 1018, 94805, Villejuif, France
- IGR, 94805, Villejuif, France
| | - Pietro Ferrari
- International Agency for Research on Cancer, Lyon, France
| | | | - Louise Hansen
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Guy Fagherazzi
- Inserm, Centre for Research in Epidemiology and Population Health (CESP), U1018, Nutrition, Hormones and Women's Health Team, 94805, Villejuif, France
- UnivParis Sud, UMRS 1018, 94805, Villejuif, France
- IGR, 94805, Villejuif, France
| | - Laura Baglietto
- Cancer Epidemiology Centre, Cancer Council Victoria, Melbourne, 3053, Australia
- Centre for Molecular, Environmental, Genetic, and Analytic Epidemiology, The University of Melbourne, Melbourne, 3010, Australia
| | - Helena Schock
- Division of Cancer Epidemiology (C020), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120, Heidelberg, Germany
| | - Jenny Chang-Claude
- Unit of Genetic Epidemiology, Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Heiner Boeing
- German Institute of Human Nutrition in Potsdam-Rehbruecke, Potsdam, Germany
| | - Annika Steffen
- German Institute of Human Nutrition in Potsdam-Rehbruecke, Potsdam, Germany
| | - Antonia Trichopoulou
- Hellenic Health Foundation, 13 Kaisareias Street, 115 27, Athens, Greece
- Bureau of Epidemiologic Research, Academy of Athens, 23 Alexandroupoleos Street, 115 27, Athens, Greece
| | - Christina Bamia
- Department of Hygiene, Epidemiology and Medical Statistics, University of Athens Medical School, 75 M. Asias Street, Goudi, 115 27, Athens, Greece
| | - Michalis Katsoulis
- Hellenic Health Foundation, 13 Kaisareias Street, 115 27, Athens, Greece
| | - Vittorio Krogh
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian, 1, 20133, Milan, Italy
| | - Domenico Palli
- Molecular and Nutritional Epidemiology Unit, Cancer Research and Prevention Institute - ISPO, Florence, Italy
| | - Salvatore Panico
- Dipartimento Di Medicina Clinica E Chirurgia, Federico II University, Naples, Italy
| | - N Charlotte Onland-Moret
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK
| | - Petra H Peeters
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK
| | - H Bas Bueno-de-Mesquita
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
- Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, The Netherlands
| | - Elisabete Weiderpass
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
- Department of Research, Cancer Registry of Norway, Oslo, Norway
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Samfundet Folkhälsan, Helsinki, Finland
| | - Inger T Gram
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, UiT The Arctic University of Norway, Tromsø, Norway
| | - Eva Ardanaz
- Navarre Public Health Institute, Pamplona, Spain
- CIBER Epidemiology and Public Health CIBERESP, Madrid, Spain
| | - Mireia Obón-Santacana
- Unit of Nutrition, Environment and Cancer. Cancer Epidemiology Research Program, Catalan Institute of Oncology (ICO-IDIBELL), Barcelona, Spain
| | - Carmen Navarro
- CIBER Epidemiology and Public Health CIBERESP, Madrid, Spain
- Department of Epidemiology, Murcia Regional Health Council, Murcia, Spain
- Department of Health and Social Sciences, Universidad de Murcia, Murcia, Spain
| | - Emilio Sánchez-Cantalejo
- CIBER Epidemiology and Public Health CIBERESP, Madrid, Spain
- Escuela Andaluza de Salud Pública, Instituto de Investigación Biosanitaria de Granada (Granada.ibs), Granada, Spain
| | - Nerea Etxezarreta
- CIBER Epidemiology and Public Health CIBERESP, Madrid, Spain
- Public Health Division of Gipuzkoa-BIODONOSTIA, Basque Regional Health Department, San Sebastián, Spain
| | - Naomi E Allen
- CTSU, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Kay Tee Khaw
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Nick Wareham
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Sabina Rinaldi
- International Agency for Research on Cancer, Lyon, France
| | | | - Melissa A Merritt
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK
| | - Marc Gunter
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK
| | - Elio Riboli
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, UK
| | - Rudolf Kaaks
- Division of Cancer Epidemiology (C020), German Cancer Research Center (DKFZ), Im Neuenheimer Feld 581, 69120, Heidelberg, Germany
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Vicennati V, Garelli S, Rinaldi E, Rosetti S, Zavatta G, Pagotto U, Pasquali R. Obesity-related proliferative diseases: the interaction between adipose tissue and estrogens in post-menopausal women. Horm Mol Biol Clin Investig 2015; 21:75-87. [PMID: 25781553 DOI: 10.1515/hmbci-2015-0002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 01/21/2015] [Indexed: 01/12/2023]
Abstract
Epidemiological studies have shown that overweight and cancer are closely related, even though obesity alone does not apparently heighten cancer risk by the same amount. Given the low overall risk of all cancers with obesity, it is unlikely that obesity alone causes cancer, but should instead be considered as a tumor promoter. There are three main hypotheses that could explain how obesity might contribute to cancer development and growth: the inflammatory cytokines from adipose tissue hypothesis, the insulin resistance and hyperinsulinemia hypothesis, and the unopposed estrogen cancer hypothesis. The link between obesity and cancer is that adipocytes constitute a major component of the tumor microenvironment for breast and abdominally metastasizing cancers, promoting tumor growth. This review will mainly focus attention on the relationship between adipose tissue, estrogens, and cancer risk.
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Diagnostic utility of three-dimensional power Doppler ultrasound for postmenopausal bleeding. Taiwan J Obstet Gynecol 2015; 54:221-6. [DOI: 10.1016/j.tjog.2013.10.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2013] [Indexed: 11/22/2022] Open
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Wong ASW, Lao TTH, Cheung CW, Yeung SW, Fan HL, Ng PS, Yuen PM, Sahota DS. Reappraisal of endometrial thickness for the detection of endometrial cancer in postmenopausal bleeding: a retrospective cohort study. BJOG 2015; 123:439-46. [PMID: 25800522 DOI: 10.1111/1471-0528.13342] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To estimate the accuracy of transvaginal ultrasound (TVS) measurement of endometrial thickness (ET) in diagnosing endometrial cancer in postmenopausal women with vaginal bleeding (PMB). DESIGN Retrospective cohort study. SETTING One-stop PMB clinic in a Hong Kong teaching hospital. POPULATION A cohort of 4383 women with PMB. METHODS Transvaginal ultrasonic measurement of ET and endometrial biopsies were obtained in women presenting with PMB between 2002 and 2013. Endometrial histology was used as the reference standard to calculate accuracy estimates. MAIN OUTCOME MEASURES Accuracy data for TVS ET presented as sensitivity, specificity, and area under the receiver operator characteristic (ROC) curve. RESULTS Endometrial cancer was diagnosed in 3.8% of women. The median ET in those with endometrial cancer was significantly higher than those with benign conditions (15.7 versus 3.2 mm, P < 0.001). The area under the ROC curve was 0.92 (95% CI 0.89-0.94). The sensitivity for the detection of endometrial cancer at 3-, 4-, and 5-mm cut-offs were 97.0% (95% CI 94.5-99.6%), 94.1% (95% CI 90.5-97.6%), and 93.5% (95% CI 89.7-97.2%), respectively. The corresponding estimates of specificity at these thresholds were 45.3% (95% CI 43.8-46.8%), 66.8% (65.4-68.2%), and 74.0% (72.7-75.4%). CONCLUSIONS Transvaginal ultrasound using a 3-mm cut-off has high sensitivity for detecting endometrial cancer and can identify women with PMB who are highly unlikely to have endometrial cancer, thereby avoiding more invasive endometrial biopsy.
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Affiliation(s)
- A S-W Wong
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
| | - T T-H Lao
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
| | - C W Cheung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
| | - S W Yeung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
| | - H L Fan
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
| | - P S Ng
- Department of Obstetrics and Gynaecology, Union Hospital, Hong Kong City, Hong Kong
| | - P M Yuen
- Department of Obstetrics and Gynaecology, Hong Kong Sanatorium & Hospital, Hong Kong City, Hong Kong
| | - D S Sahota
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
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Genc M, Genc B, Sahin N, Celik E, Turan GA, Gur EB, Guclu S. Endometrial pathology in postmenopausal women with no bleeding. Climacteric 2014; 18:241-5. [PMID: 25017611 DOI: 10.3109/13697137.2014.944152] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to determine the rate of unexpected uterine pathology in postmenopausal women admitted to a gynecology clinic with symptoms other than vaginal bleeding and who were scheduled to undergo hysterectomy. MATERIALS AND METHODS We reviewed retrospectively the medical records of 283 postmenopausal patients who had gynecological surgery between September 2007 and January 2014. We reviewed their presenting symptoms on admission, the indications for surgery, and their transvaginal ultrasonographic findings. Postoperative histopathological results based on uterine specimens were also recorded. The results were analyzed statistically. RESULTS Of 283 patients who had surgery, 209 had no vaginal bleeding at the time of admission. From this group, 75.6% were found to have unsuspected pathology, including endometrial hyperplasia, endometrial polyps, uterine fibroids, adenomyosis, and one case of endometrial carcinoma (0.5%). The remaining 74 patients had experienced postmenopausal bleeding and in 87.8% there were pathological findings including 13 cases (17.6%) of endometrial cancer (p = 0.0001). CONCLUSION Vaginal bleeding in postmenopausal women is indicative of a wide array of gynecological pathologies, including endometrial carcinoma. However, uterine fibroids, pelvic masses, or even endometrial cancer may develop without co-morbid vaginal bleeding. Therefore we advocate that postmenopausal women should undergo yearly screening and consultation, without waiting for an episode of vaginal bleeding.
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Affiliation(s)
- M Genc
- Departments of Obstetrics and Gynecology, Sifa University , İzmir , Turkey
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Liao C, Zhang D, Mungo C, Tompkins DA, Zeidan AM. Is diabetes mellitus associated with increased incidence and disease-specific mortality in endometrial cancer? A systematic review and meta-analysis of cohort studies. Gynecol Oncol 2014; 135:163-71. [PMID: 25072931 DOI: 10.1016/j.ygyno.2014.07.095] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 07/22/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the association between diabetes mellitus (DM) and the incidence and disease-specific mortality of endometrial cancer (EC). METHODS MEDLINE, EMBASE and conference abstracts of the 2011-2013 Annual Meetings of Society of Gynecological Oncology were searched for reports of original cohort studies that enrolled diabetic and non-diabetic women who were free of EC at baseline to compare the incidence and disease-specific mortality of EC by DM status. The included reports were examined for demographic characteristics of study populations, study design, effect measures and risk of bias. Statistical heterogeneity was evaluated with Chi-square test of the Cochrane Q statistics at the 0.05 significance level and I(2) statistic. Publication bias was assessed by visual examination of a funnel plot and the Egger's test for small-study effects. RESULTS Twenty-nine cohort studies (17 prospective, 12 retrospective) were eligible for this review, 23 of which reported EC incidence, five reported disease-specific mortality and one reported both. For incidence of EC among women with versus without DM, the summary relative risk (RR) was 1.89 (95%CI, 1.46-2.45; p<0.001) and the summary incidence rate ratio was 1.61 (95%CI, 1.51-1.71; p<0.001). The pooled RR of disease-specific mortality was 1.32 (95%CI, 1.10-1.60; p=0.003), while results in the studies reporting standardized mortality ratios were inconsistent. There remains considerable amount of clinical and methodological heterogeneity among the included studies; moreover, the hazard ratios for incident EC showed significant statistical heterogeneity and therefore were not quantitatively synthesized. CONCLUSIONS There is consistent evidence for an independent association between DM and an increased risk of incident EC, while the association between DM and EC-specific mortality remains uncertain. Further studies with better considerations for selection bias, information bias and confounding will further facilitate causal inference involving DM and EC.
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Affiliation(s)
- Caiyun Liao
- The Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Dongyu Zhang
- The Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Chemtai Mungo
- The Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - D Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine Behavioral Pharmacology Research Unit, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University, and Yale Cancer Center, New Haven, CT, USA.
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A risk-scoring model for the prediction of endometrial cancer among symptomatic postmenopausal women with endometrial thickness > 4 mm. BIOMED RESEARCH INTERNATIONAL 2014; 2014:130569. [PMID: 24991535 PMCID: PMC4065750 DOI: 10.1155/2014/130569] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 05/18/2014] [Accepted: 05/19/2014] [Indexed: 12/02/2022]
Abstract
Objective. To develop and test a risk-scoring model for the prediction of endometrial cancer among symptomatic postmenopausal women at risk of intrauterine malignancy. Methods. We prospectively studied 624 postmenopausal women with vaginal bleeding and endometrial thickness > 4 mm undergoing diagnostic hysteroscopy. Patient characteristics and endometrial assessment of women with or without endometrial cancer were compared. Then, a risk-scoring model, including the best predictors of endometrial cancer, was tested. Univariate, multivariate, and ROC curve analysis were performed. Finally, a split-sampling internal validation was also performed. Results. The best predictors of endometrial cancer were recurrent vaginal bleeding (odds ratio (OR) = 2.96), the presence of hypertension (OR = 2.01) endometrial thickness > 8 mm (OR = 1.31), and age > 65 years (OR = 1.11). These variables were used to create a risk-scoring model (RHEA risk-model) for the prediction of intrauterine malignancy, with an area under the curve of 0.878 (95% CI 0.842 to 0.908; P < 0.0001). At the best cut-off value (score ≥ 4), sensitivity and specificity were 87.5% and 80.1%, respectively. Conclusion. Among symptomatic postmenopausal women with endometrial thickness > 4 mm, a risk-scoring model including patient characteristics and endometrial thickness showed a moderate diagnostic accuracy in discriminating women with or without endometrial cancer. Based on this model, a decision algorithm was developed for the management of such a population.
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Risk of uterine cancer in symptomatic women in primary care: case-control study using electronic records. Br J Gen Pract 2014; 63:e643-8. [PMID: 23998845 DOI: 10.3399/bjgp13x671632] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Uterine cancer is the fourth most common cancer in women in the UK, with approximately 7700 new diagnoses and 1700 deaths annually. AIM To identify and quantify features of uterine cancer in primary care. DESIGN AND SETTING Case-control study using electronic primary care records in primary care in the UK. METHOD Putative features of uterine cancer were identified in the year before diagnosis, and odds ratios (ORs) calculated using conditional logistic regression. Positive predictive values (PPVs) were calculated for women who consulted. RESULTS A total of 2732 women aged ≥40 years with uterine cancer between 2000 and 2009, and 9537 age-, sex- and practice-matched controls were selected from the General Practice Research Database. The median age at diagnosis was 67 years. Nine features were significantly associated with uterine cancer: postmenopausal bleeding (OR = 160; 95% confidence interval [CI] = 100 to 240), excessive vaginal bleeding (OR = 22; 95% CI = 12 to 42), irregular menstruation (OR = 42; 95% CI = 27 to -63), vaginal discharge (OR = 14; 95% CI = 10 to 21), haematuria (OR = 8.7; 95% CI = 5.0 to 15), abdominal pain (OR = 2.0; 95% CI = 1.4 to 2.8), low haemoglobin (OR = 2.1; 95% CI = 1.5 to 2.9), raised platelets (OR = 1.5; 95% CI = 1.0 to 2.3), and raised glucose (OR = 1.4; 95% CI = 1.1 to 1.8); all P<0.01, other than raised platelets, P = 0.05 and raised glucose, P = 0.02. In the year before diagnosis, 1725 (63%) cases had a record of abnormal vaginal bleeding compared to 135 (1%) controls. The PPV of uterine cancer with postmenopausal bleeding was 4%, and was higher in women with multiple or repeated symptoms. CONCLUSION This study confirms the importance of several features, particularly postmenopausal bleeding, for uterine cancer. Haematuria is an important risk marker. The results of this study may inform GPs in the selection of women for investigation and should assist the NICE in their update of GP referral guidance.
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Vinogradova Y, Coupland C, Hippisley-Cox J. Exposure to bisphosphonates and risk of common non-gastrointestinal cancers: series of nested case-control studies using two primary-care databases. Br J Cancer 2013; 109:795-806. [PMID: 23868009 PMCID: PMC3738131 DOI: 10.1038/bjc.2013.383] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 06/05/2013] [Accepted: 06/11/2013] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Bisphosphonates are the most commonly prescribed osteoporosis drugs but long-term effects are unclear, although antitumour properties are known from preclinical studies. METHODS Nested case-control studies were conducted to investigate bisphosphonate use and risks of common non-gastrointestinal cancers (breast, prostate, lung, bladder, melanoma, ovarian, pancreas, uterus and cervical). Patients 50 years and older, diagnosed with primary cancers between 1997 and 2011, were matched to five controls using the UK practice-based QResearch and Clinical Practice Research Datalink (CPRD) databases. The databases were analysed separately and the results combined. RESULTS A total of 91 556 and 88 845 cases were identified from QResearch and CPRD, respectively. Bisphosphonate use was associated with reduced risks of breast (odds ratio (OR): 0.92, 95% confidence interval (CI): 0.87-0.97), prostate (OR: 0.87, 95% CI: 0.79-0.96) and pancreatic (OR: 0.79, 95% CI: 0.68-0.93) cancers in the combined analyses, but no significant trends with duration. For alendronate, reduced risk associations were found for prostate cancer in the QResearch (OR: 0.81, 95% CI: 0.70-0.93) and combined (OR: 0.84, 95% CI: 0.75-0.93) analyses (trend with duration P-values 0.009 and 0.001). There were no significant associations from any of the other analyses. CONCLUSION In this series of large population-based case-control studies, bisphosphonate use was not associated with increased risks for any common non-gastrointestinal cancers.
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Affiliation(s)
- Y Vinogradova
- Division of Primary Care, University Park, Nottingham NG2 7RD, UK.
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Van den Bosch T, Valentin L, Van Schoubroeck D, Luts J, Bignardi T, Condous G, Epstein E, Leone FP, Testa AC, Van Huffel S, Bourne T, Timmerman D. Detection of intracavitary uterine pathology using offline analysis of three-dimensional ultrasound volumes: interobserver agreement and diagnostic accuracy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:459-463. [PMID: 22461338 DOI: 10.1002/uog.11163] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/13/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To estimate the diagnostic accuracy and interobserver agreement in predicting intracavitary uterine pathology at offline analysis of three-dimensional (3D) ultrasound volumes of the uterus. METHODS 3D volumes (unenhanced ultrasound and gel infusion sonography with and without power Doppler, i.e. four volumes per patient) of 75 women presenting with abnormal uterine bleeding at a 'bleeding clinic' were assessed offline by six examiners. The sonologists were asked to provide a tentative diagnosis. A histological diagnosis was obtained by hysteroscopy with biopsy or operative hysteroscopy. Proliferative, secretory or atrophic endometrium was classified as 'normal' histology; endometrial polyps, intracavitary myomas, endometrial hyperplasia and endometrial cancer were classified as 'abnormal' histology. The diagnostic accuracy of the six sonologists with regard to normal/abnormal histology and interobserver agreement were estimated. RESULTS Intracavitary pathology was diagnosed at histology in 39% of patients. Agreement between the ultrasound diagnosis and the histological diagnosis (normal vs abnormal) ranged from 67 to 83% for the six sonologists. In 45% of cases all six examiners agreed with regard to the presence/absence of intracavitary pathology. The percentage agreement between any two examiners ranged from 65 to 91% (Cohen's κ, 0.31-0.81). The Schouten κ for all six examiners was 0.51 (95% CI, 0.40-0.62), while the highest Schouten κ for any three examiners was 0.69. CONCLUSION When analyzing stored 3D ultrasound volumes, agreement between sonologists with regard to classifying the endometrium/uterine cavity as normal or abnormal as well as the diagnostic accuracy varied substantially. Possible actions to improve interobserver agreement and diagnostic accuracy include optimization of image quality and the use of a consistent technique for analyzing the 3D volumes.
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Affiliation(s)
- T Van den Bosch
- Department of Obstetrics & Gynecology, University Hospitals K.U. Leuven, Leuven, Belgium.
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van Hanegem N, Breijer MC, Opmeer BC, Mol BWJ, Timmermans A. Prediction models in women with postmenopausal bleeding: a systematic review. ACTA ACUST UNITED AC 2012; 8:251-62. [PMID: 22554173 DOI: 10.2217/whe.12.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Postmenopausal bleeding is associated with an elevated risk of having endometrial cancer. The aim of this review is to give an overview of existing prediction models on endometrial cancer in women with postmenopausal bleeding. In a systematic search of the literature, we identified nine prognostic studies, of which we assessed the quality, the different phases of development and their performance. From these data, we identified the most important predictor variables. None of the detected models completed external validation or impact analysis. Models including power Doppler showed best performance in internal validation, but Doppler in general gynecological practice is not easily accessible. We can conclude that we have indications that the first step in the approach of women with postmenopausal bleeding should be to distinguish between women with low risk versus high risk of having endometrial carcinoma and the next step would be to refer patients for further (invasive) testing.
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Affiliation(s)
- Nehalennia van Hanegem
- Department of Obstetrics & Gynecology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, the Netherlands.
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Rafi A, Devaki R, Sabitha K, Mohanty S, Rao P. Importance of Serum Copper and Vascular Endothelial Growth Factor (VEGF-A) Levels in Postmenopausal Bleeding. Indian J Clin Biochem 2012; 28:147-51. [PMID: 24426200 DOI: 10.1007/s12291-012-0240-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 06/23/2012] [Indexed: 11/26/2022]
Abstract
The main aim of this study is association of serum copper and vascular endothelial growth factor (VEGF-A) in postmenopausal bleeding (PMB) patients. Blood samples were collected from female patients suffering with postmenopausal bleeding (n = 50) as well as healthy females as controls (n = 50). Serum copper levels were estimated by spectrophotometric method and serum VEGF-A by ELISA technique and compared with ultrasonographic measurement of endometrial thickness in both patients and controls. A significant increase in serum copper levels and an almost twofold increase in serum VEGF-A was observed in DUB patients when compared with controls. Correlation (r) between serum VEGF-A levels and endometrial thickness was 0.96. Odds ratio for copper, VEGF-A and combination of copper and VEGF-A was 0.0426, 0.0947 and 0.0313 respectively, in all these cases odds ratio was <1. The abnormal angiogenesis in PMB could be due to increased serum copper levels,which in turn stimulates factors like VEGF-A, thereby causing an increase in endometrial growth.
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Affiliation(s)
- Afshan Rafi
- Department of Biochemistry, Kamineni Institute of Medical Sciences, Sreepuram, Narkatpally, Nalgonda, 508 254 Andhra Pradesh India
| | - Ramakrishna Devaki
- Department of Biochemistry, Kamineni Institute of Medical Sciences, Sreepuram, Narkatpally, Nalgonda, 508 254 Andhra Pradesh India
| | - K Sabitha
- Chalmeda Anandrao Institute of Medical Sciences, Bommakal, Karimnagar, Andhra Pradesh India
| | - Shruti Mohanty
- Department of Biochemistry, Kamineni Institute of Medical Sciences, Sreepuram, Narkatpally, Nalgonda, 508 254 Andhra Pradesh India
| | - Pragna Rao
- Department of Biochemistry, Kasturba Medical College, Manipal University, Manipal, 576104 Karnataka India
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Choi CH, Park YA, Choi JJ, Song T, Song SY, Lee YY, Lee JW, Kim TJ, Kim BG, Bae DS. Angiotensin II type I receptor and miR-155 in endometrial cancers: synergistic antiproliferative effects of anti-miR-155 and losartan on endometrial cancer cells. Gynecol Oncol 2012; 126:124-31. [PMID: 22525818 DOI: 10.1016/j.ygyno.2012.04.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 04/11/2012] [Accepted: 04/16/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVE MicroRNA-155 (miR-155) is one of the micro RNAs (miRNA) most consistently involved in neoplastic diseases, and it is known to repress the angiotensin II type 1 receptor (AGTR1). The aim of the present study was to evaluate the expressions of miR-155 and AGTR1, and to clarify the potential efficacy of anti-miR-155, alone and in combination with AGTR1 blocker losartan in endometrial cancers. METHODS Expressions of miR-155 and AGTR1 were evaluated using real-time PCR and immunohistochemistry. And the MTT assay was performed in endometrial cancer cells following anti-miR-155 and AGTR1 blocker (losartan) treatment, alone and in combination. RESULTS miR-155 was over-expressed and AGTR1 was underexpressed in endometrial carcinoma tissues. AGTR1 immunoreactivity was found in six of ten (60.0%) normal endometrium, 11 of 14 (78.6%) endometrial hyperplasia, and 27 of 62 (43.5%) endometrial carcinoma tissues (P=0.051), and patients with AGTR1 expression showed trend towards improved survival after multivariate analysis (P=0.08). We checked that abolishing the function of miR-155 and AGTR1 by anti-miR-155 or losartan inhibited cell survival of endometrial carcinoma cells, respectively, and furthermore, combined treatment showed synergistic effects. CONCLUSIONS In this study, we characterized the expressions of miR-155 and AGTR1 in endometrial tissues. The combined treatment with anti-miR-155 and losartan has a synergistic antiproliferative effect and an improved understanding is required to clarify whether miR-155 and AGTR1 can be used as a novel therapeutic target in endometrial cancer.
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Affiliation(s)
- Chel Hun Choi
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Burbos N, Musonda P, Crocker SG, Morris EP, Duncan TJ, Nieto JJ. Outcome of investigations for postmenopausal vaginal bleeding in women under the age of 50 years. Gynecol Oncol 2012; 125:120-3. [PMID: 22233690 DOI: 10.1016/j.ygyno.2011.12.453] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 12/28/2011] [Accepted: 12/30/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVE The objective of this study is to determine the incidence of endometrial cancer in young postmenopausal women presenting with vaginal bleeding. METHODS Cross-sectional study of postmenopausal women presenting with vaginal bleeding in a gynaecological oncology centre in the United Kingdom. All women underwent transvaginal ultrasound scanning (TVS) as the initial investigation tool to evaluate the endometrium. Endometrial biopsy was performed only in cases where endometrial thickness measured equal to or greater than 5mm. The patients were divided into two groups based on their age: less than 50 years (Group A) and 50 years or older (Group B). RESULTS Over a 57-month period, 4454 women were investigated for postmenopausal vaginal bleeding. Of these, 259 (5.8%) women were diagnosed with endometrial carcinoma. 260 (5.8%) women were younger than 50 years. Endometrial biopsy was not performed in 130 women in Group A that had an endometrial thickness measurement of less than 5mm on ultrasonography. With a median follow-up period of 3 (1-5) years, we found no cases of endometrial cancer in women under the age of 50 that did not undergo endometrial biopsy at the time of initial evaluation. Overall, no cases of endometrial cancer were diagnosed in postmenopausal women under the age of 50 years. CONCLUSIONS We found no cases of endometrial cancer amongst 260 women presenting with postmenopausal vaginal bleeding under the age of 50 years. These women could be investigated on a less urgent basis depending on the available resources.
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Affiliation(s)
- Nikolaos Burbos
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK.
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Abstract
ABSTRACT
Uterine bleeding is a symptom seen by gynecologists in approximately 70% of their visits with women of peri and postmenopausal age. A common symptom, postmenopausal bleeding sometimes can be indicative of malignant pathology. While traditional diagnosis took place via endometrial biopsy, diagnosis is trending toward the use of ultrasound. Benefits of ultrasound include its noninvasive nature, decreased cost, and increased accuracy in diagnosis of postmenopausal bleeding. We present a case-based approach to the usage of various ultrasonography techniques including 2D and color Doppler ultrasound, saline infusion sonography (SIS), 3D and 3D power Doppler ultrasound, as complements to traditional diagnosis of endometrial biopsy. In each of the cases, ultrasonography reveals the diagnosis of postmenopausal pathologies, including atrophic endometrium, endometrial polyps, endometrial hyperplasia, and the malignant pathology, such as endometrial carcinoma, uterine leiomyosarcoma and cervical carcinoma. By the end of our case-based discussion, learners are encouraged to test their knowledge in self-assessment quiz.
How to cite this article
Appleton K, Plavsic SK. Role of Ultrasound in the Assessment of Postmenopausal Bleeding. Donald School J Ultrasound Obstet Gynecol 2012;6(2):197-206.
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Vinogradova Y, Coupland C, Hippisley-Cox J. Exposure to bisphosphonates and risk of cancer: a protocol for nested case-control studies using the QResearch primary care database. BMJ Open 2012; 2:e000548. [PMID: 22240651 PMCID: PMC3278492 DOI: 10.1136/bmjopen-2011-000548] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction Bisphosphonates are becoming a common treatment for osteoporosis particularly after discovery of the association between hormone replacement therapy and increased risk of breast cancer. As osteoporosis develops with age, treatment is a long-term intervention. Randomised control trials typically have limited follow-up times, which restricts investigation of the effects of the drugs on risk of primary cancers. A few observational studies have demonstrated a reduced risk of breast cancer and possibly of endometrial cancer in bisphosphonate users. Two epidemiological studies have studied the effect of the drugs on oesophageal cancer but did not reach any definite conclusions. So far, no effects on colorectal and stomach cancer have been shown. This study will investigate the association of bisphosphonates with risks of the 10 most common primary cancers. Methods and analysis A series of nested case-control studies will be based on the general population using records from 660 UK general practices within the QResearch Database. Cases will be patients with primary cancers diagnosed between 1996 and 2011. Each case will be matched by age, sex, practice and calendar year to five controls, who are alive and registered with the practice at the time of diagnosis of the case. Exposure to bisphosphonates will be defined as at least one prescription during the study period. For the most common cancers with substantial numbers of observations, the effect of the duration of the treatment and different types of bisphosphonates will be studied. Conditional logistic regression will be applied to produce ORs adjusted for smoking status, socioeconomic status, ethnicity, cancer-specific co-morbidities and use of other medications.
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Affiliation(s)
- Yana Vinogradova
- Division of Primary Care, University of Nottingham, School of Community Health Sciences, Division of Primary Care, University Park, Nottingham, UK
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Musonda P, Burbos N, Duncan TJ, Crocker SG, Morris EP, Nieto JJ. Comparing the performance of two clinical models in estimating the risk of endometrial cancer in symptomatic postmenopausal women. Eur J Obstet Gynecol Reprod Biol 2011; 159:433-8. [PMID: 21975177 DOI: 10.1016/j.ejogrb.2011.09.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 06/29/2011] [Accepted: 09/01/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to internally evaluate the accuracy measures of the two newly developed predictive models, called DEFAB and DFAB, used to estimate the risk of endometrial cancer in postmenopausal women presenting with vaginal bleeding. STUDY DESIGN Prospective study including postmenopausal women presenting with vaginal bleeding. RESULTS Over a 46-month-period, 3795 postmenopausal women presented with vaginal bleeding and were included in the study. A total of 221 (6%) women were diagnosed with endometrial carcinoma. The DEFAB predictive model incorporates known risk factors such as presence of Diabetes, Endometrial thickness measurement on transvaginal ultrasonography, Frequency of bleeding, Age, and Body mass index. The DFAB model is based on the above clinical characteristics excluding the ultrasonography result. For the recommended cut-off values, there was no evidence (p-value=0.221) of a difference in the diagnostic ability with respect to sensitivity, specificity, area under receiver operating curve, positive predictive value and negative predictive value. There was strong evidence (p-value<0.0001) to suggest that the diagnostic ability of DEFAB and DFAB agree as evidenced by the excellent Kappa statistic 0.950 (95% CI 0.940-0.960). We found strong evidence (p-value<0.0001) that the variables incorporated in both predictive models simultaneously correctly classify an individual to either having cancer or not having cancer with respect to logistic discriminant analysis. CONCLUSION We recommend that these two predictive models can be used interchangeably.
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Affiliation(s)
- Patrick Musonda
- Medical Statistician, School of Medicine, Health Policy & Practice, University of East Anglia, Norwich NR4 7TJ, United Kingdom.
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Estimating the Risk of Endometrial Cancer in Symptomatic Postmenopausal Women: A Novel Clinical Prediction Model Based on Patients' Characteristics. Int J Gynecol Cancer 2011; 21:500-6. [DOI: 10.1097/igc.0b013e31820c4cd6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IntroductionThe aim of this study was to develop a multivariable model to predict the risk of endometrial carcinoma in postmenopausal women with vaginal bleeding using individuals' clinical characteristics.Patients and MethodsThis prospective study of consecutive postmenopausal women presenting with vaginal bleeding was conducted at a gynecological oncology center in the United Kingdom for a 46-month period. All women underwent transvaginal ultrasound scanning as the initial investigation tool to evaluate the endometrium. Women found to have an endometrial thickness 5 mm or more had endometrial sampling performed.ResultsOf a total of 3548 women presenting with vaginal bleeding during the study period, 201 (6%) women had a diagnosis of endometrial carcinoma. An investigator-led best model selection approach used to select the best predictors of cancer in the multiple logistic regression model showed that patient's age (odds ratio [OR], 1.06), body mass index (OR, 1.07), recurrent episodes of bleeding (OR, 3.64), and a history of diabetes (OR, 1.48) increased the risk of endometrial malignancy when corrected for other characteristics. The mentioned clinical variables satisfied the criteria for inclusion in our predictive model called FAD 31 (F for the frequency of bleeding episodes, A for the age of the patient, D for diabetes, and the number 31 represents the BMI cut-off value). The total score for the model varies from 0 to 8. The area under the receiver operating characteristics curve for the developed model was 0.73 (95% confidence interval, 0.70-0.77).DiscussionWe have developed a simple model based on patients' clinical characteristics in estimating the risk of endometrial cancer for postmenopausal women presenting with vaginal bleeding. The model shows reasonable discriminatory ability for women with cancer and without, with an area under the receiver operating characteristics curve of 0.73. This will allow clinicians to individualize the diagnostic pathway for women with postmenopausal vaginal bleeding.
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