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Yap J, Slade D, Goddard H, Dawson C, Ganesan R, Velangi S, Sahu B, Kaur B, Hughes A, Luesley D. Sinecatechins ointment as a potential novel treatment for usual type vulval intraepithelial neoplasia: a single-centre double-blind randomised control study. BJOG 2021; 128:1047-1055. [PMID: 33075197 DOI: 10.1111/1471-0528.16574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To compare the safety and efficacy of 10% sinecatechins (Veregen® ) ointment against placebo in the treatment of usual type vulvar intraepithelial neoplasia (uVIN). DESIGN A Phase II double-blind randomised control trial. SETTING A tertiary gynaecological oncology referral centre. POPULATION All women diagnosed with primary and recurrent uVIN. METHODS Eligible patients were randomised 1:1 to receive either sinecatechins or placebo ointment (applied three times daily for 16 weeks) and were followed up at 2, 4, 8, 16, 32 and 52 weeks. MAIN OUTCOME MEASURES The primary outcome measure, recorded at 16 and 32 weeks, was histological response (HR). Secondary outcome measures included clinical (CR) response, toxicity, quality of life and pain scores. RESULTS There was no observed difference in HR between the two arms. However, of the 26 patients who were randomised, all 13 patients who received sinecatechins showed either complete (n = 5) or partial (n = 8) CR, when best CR was evaluated. In placebo group, three patients had complete CR, two had partial CR, six had stable disease and two were lost to follow up. Patients in the sinecatechins group showed a statistically significant improvement in best observed CR as compared with the placebo group (P = 0.002). There was no difference in toxicity reported in either group. CONCLUSION Although we did not observe a difference in HR between the two treatment arms, we found that 10% sinecatechins application is safe and shows promise in inducing clinical resolution of uVIN lesions and symptom improvement, thus warranting further investigation in a larger multicentre study. TWEETABLE ABSTRACT A randomised control study indicating that sinecatechins ointment may be a novel treatment for uVIN.
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Affiliation(s)
- J Yap
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham, UK
| | - D Slade
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - H Goddard
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham, UK
| | - C Dawson
- Department of Microbiology & Infection, Warwick Medical School, University of Warwick, Coventry, UK
| | - R Ganesan
- Department of Histopathology, Birmingham Women's NHS Foundation Trust, Birmingham, UK
| | - S Velangi
- Department of Dermatology, Queen Elizabeth Hospital, Birmingham, UK
| | - B Sahu
- Department of Obstetrics and Gynaecology, The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - B Kaur
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - A Hughes
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - D Luesley
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Pan Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham, UK
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Tidy JA, Soutter WP, Luesley DM, MacLean AB, Buckley CH, Ridley CM. Management of Lichen Sclerosus and Intraepithelial Neoplasia of the Vulva in the UK. J R Soc Med 2018; 89:699-701. [PMID: 9014882 PMCID: PMC1296034 DOI: 10.1177/014107689608901211] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Women with vulval intraepithelial neoplasia (VIN), lichen sclerosus (LS) and Paget's disease are referred either to gynaecologists or to dermatologists. We have ascertained the caseloads, referral patterns and treatment modalities used in the two specialties. A postal questionnaire was sent to 540 consultant gynaecologists and 225 consultant and senior registrar members of the British Association of Dermatologists. 350 gynaecologists and 161 dermatologists returned completed questionnaires. The workload of LS and Paget's disease was evenly distributed, with 54% of dermatologists and 58% of gynaecologists seeing more than six cases of LS per annum and less than 1% seeing more than five cases of Paget's disease. 92% of responding gynaecologists saw at least one case of VIN per year whereas 43% of dermatologists saw no cases. Patients with VIN and Paget's were referred to gynaecologists for treatment by 66% of dermatologists. Both groups are equally prepared to treat LS. Indications for treatment of VIN and LS were suspicion of invasion and symptoms. Local excision of VIN is the treatment of choice by both gynaecologists and dermatologists. LS is predominantly treated with topical steroids but gynaecologists also use topical oestrogen and testosterone. The great majority of responders favoured establishing a national register to study the outcome of vulval lesions.
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Affiliation(s)
- J A Tidy
- Institute of Obstetrics & Gynaecology, Hammersmith Hospital, London, England
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Yap JKW, O'Neill D, Nagenthiran S, Dawson CW, Luesley DM. Current insights into the aetiology, pathobiology, and management of local disease recurrence in squamous cell carcinoma of the vulva. BJOG 2017; 124:946-954. [PMID: 28081287 DOI: 10.1111/1471-0528.14560] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2016] [Indexed: 01/04/2023]
Affiliation(s)
- JKW Yap
- Institute of Cancer and Genomic Sciences; College of Dental and Medical School; University of Birmingham; Edgbaston UK
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
| | - D O'Neill
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
| | - S Nagenthiran
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
| | - CW Dawson
- Institute of Cancer and Genomic Sciences; College of Dental and Medical School; University of Birmingham; Edgbaston UK
| | - DM Luesley
- Institute of Cancer and Genomic Sciences; College of Dental and Medical School; University of Birmingham; Edgbaston UK
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
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Abstract
Abstract Surgical excision is the management of choice in vulval cancer however, the patient population are typically elderly and comorbid, for whom general anaesthesia (GA) carries considerable risk. The outcome of 107 procedures were reviewed in order investigate the postoperative complication rates associated with general and regional anaesthesia for the surgical management of vulval cancer. GA was used in 78 (72.9%) cases; 27 (22.9%) had a regional anaesthetic (spinal/epidural/ileoinguinal) and two women had a GA following a failed spinal anaesthetic. Women having a regional anaesthetic were significantly older (p = 0.0198), had a higher ACE (p = 0.0001) and ASA score (p < 0.0001) than those having a GA. There was an association between GA and grade II+ complications, compared with regional techniques (odds ratio, OR 2.72) but this was not significant due to the small number of events. Regional anaesthetic techniques are safe, well-tolerated alternatives to GA for the surgical management of vulval cancer, especially in an elderly and comorbid population.
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Affiliation(s)
- E L Moss
- Pan Birmingham Gynaecological Cancer Centre , Birmingham , UK
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Yap JKW, Baker LJ, Balega JZ, Chan KK, Luesley DM. Impact of improving outcome guidance in gynaecological cancer on squamous cell carcinoma of the vulva in the West Midlands, UK. J OBSTET GYNAECOL 2012; 31:754-8. [PMID: 22085070 DOI: 10.3109/01443615.2011.599888] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study aimed to assess the benefits and outcomes of squamous cell carcinoma (SCC) of the vulva managed in a cancer centre post-centralisation of cancer care in the UK. A retrospective study was performed to evaluate the demography and management outcomes of SCC of the vulva in a regional gynaecological cancer centre. The results were then compared with the Rhodes et al. (1998) population-based study. Over the years, disease demography remained largely unchanged. However, centralisation of cancer care has resulted in significant changes in the pattern of care. The number of cases managed has increased by 1.7 times and the permutation of surgeries have reduced from 15 to 4. There is also a significant increased in the number of lymphadenectomies performed (p = 0.003). These changes were accompanied by improvement in 5-year cause-specific survival (p = 0.055).
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Affiliation(s)
- J K W Yap
- Pan-Birmingham Gynaecological Cancer Centre, City Hospital, Birmingham, UK.
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Connolly C, Chan KK, Singh K, Sundar S, Luesley D, Anwar MS, Fernando IN. Outcomes following interval debulking surgery in primary peritoneal carcinoma. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.e15515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Moss EL, Hirschowitz L, Luesley DM. Skin scar recurrence following removal of a sentinel lymph node containing a solitary micrometastasis of squamous cell vulval cancer. Gynecol Oncol 2010; 121:239-40. [PMID: 21190726 DOI: 10.1016/j.ygyno.2010.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 12/01/2010] [Accepted: 12/02/2010] [Indexed: 11/28/2022]
Affiliation(s)
- E L Moss
- Pan Birmingham Gynaecological Cancer Centre, UK
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Nevin J, Luesley D. Defining the surgical management of suspected early-stage ovarian cancer by estimating patient numbers through alternative management strategies. BJOG 2010; 117:114; author reply 114-6. [PMID: 20002373 DOI: 10.1111/j.1471-0528.2009.02431.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Nevin J, Luesley D, Chan KK, Singh K, Balega J, Sundar S. Meeting the challenge of developing and maintaining radical hysterectomy skills. BJOG 2010; 117:1-4. [DOI: 10.1111/j.1471-0528.2009.02417.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Narain S, Nevin J, Luesley DM. Hysteroscopy under general anaesthesia: are we meeting the standards? J OBSTET GYNAECOL 2009; 29:347-8. [PMID: 19835507 DOI: 10.1080/01443610902829406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- S Narain
- Department of Gynae-Oncology, Pan Birmingham Cancer Centre, City Hospital, Birmingham, UK.
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Swancutt DR, Luesley DM, Eastaugh JL, Wilson S. Anaesthetic choice in the colposcopy clinic: a retrospective analysis of routinely collected data. BJOG 2008; 115:646-52. [DOI: 10.1111/j.1471-0528.2008.01664.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Affiliation(s)
- L J Eva
- Department of Gynaecological Oncology, City Hospital, Birmingham, UK.
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Thangaratinam S, Walker P, Freeman-Wang T, Luesley D, Cruickshank M, Redman CWE. Identifying the performance criteria for appraisal of colposcopists: benchmarking Delphi. BJOG 2007; 114:1288-91. [PMID: 17877682 DOI: 10.1111/j.1471-0528.2007.01442.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Colposcopy forms an essential part of National Health Service Cervical Screening Programme (NHSCSP). With an increased emphasis on accountability and improved performance, there is a need to identify the performance criteria that are essential to be satisfied by the colposcopists at the time of appraisal. OBJECTIVE To identify the performance criteria essential for appraisal of colposcopists by two-generational Delphi survey. DESIGN Delphi survey. SETTING Annual British Society for Colposcopy and Cervical Pathology conference (BSCCP 2005, Edinburgh, UK). POPULATION Four hundred and ninety-nine delegates attending the above conference. METHOD A two-generational Delphi survey was undertaken to identify the criteria needed for appraisal. The participants were asked to rate the relevance of quality items that might be considered necessary for appraisal of performance of colposcopists. After the first round, the results were presented, and the respondents were given the chance to reflect on their response and change it if necessary. MAIN OUTCOME MEASURES Criteria considered to be essential for appraisal of colposcopists in areas of training, diagnostic and therapeutic aspects and communication. RESULTS In the first round, 306/499 (61%) participants returned the completed questionnaire. Sixty percent (187/306) of participants returned their questionnaire in the second round. In addition to BSCCP certification, four other criteria were identified, which were quality of recorded findings, biopsy rate when atypia noted, proportion of biopsies histologically adequate and proportion of normal initial posttreatment follow-up smears. CONCLUSION This Delphi survey has been the first to identify criteria to be used in the annual appraisal of professionals. It has resulted in a number of criteria that could be considered for the appraisal and possible revalidation of colposcopists practising in UK.
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Luesley DM, Downey GP. Authors response to: Topical tacrolimus in the management of lichen sclerosus. BJOG 2006. [DOI: 10.1111/j.1471-0528.2006.01104.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
The effective management of vulval lichen sclerosus (LS) currently depends upon the use of topical steroids and emollients. There are concerns with regard to the long-term toxicity of potent steroids and therefore is a need to consider effective alternatives. Immunomodulatory macrolactams offer an alternative to steroids in the management of some other inflammatory skin disorders and it would seem reasonable therefore to assess their activity in LS. This pilot study of 16 histologically confirmed cases of LS suggests that macrolactams have a positive pharmacological effect.
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Affiliation(s)
- D M Luesley
- Department of Obstetrics and Gynaecology, City Hospital, Birmingham, UK
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Singh K, Orakwue CO, Honest H, Balogun M, Lopez C, Luesley DM. Accuracy of magnetic resonance imaging of inguinofemoral lymph nodes in vulval cancer. Int J Gynecol Cancer 2006; 16:1179-83. [PMID: 16803503 DOI: 10.1111/j.1525-1438.2006.00456.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Inguinofemoral lymphadenectomy contributes to the high morbidity related to surgical treatment of vulval cancer. The objective of this study was to assess the accuracy of magnetic resonance imaging (MRI) in predicting inguinofemoral lymph nodes metastasis in women with vulval cancer. We reviewed the clinical, MRI, surgical, and pathologic findings of 59 women with vulval cancer who were treated at our institution from January 2000 to June 2004. Histology was available for 39 women who had undergone inguinofemoral lymphadenectomy. Clinical and MRI findings were compared with histology result to assess test accuracy. MRI had a positive likelihood ratio (LR+) of 4.8 (95% confidence interval of 2.7-8.6) and negative likelihood ratio (LR-) of 0.17 (0.06-0.49). It had a sensitivity of 85.7% (63.7-97), specificity of 82.1% (69.6-91.1), positive predictive value (PPV) of 64.3% (44.1-81.4), and negative predictive value (NPV) of 93.9% (83.1-98.7). Clinical examination had an LR+ of 6.1 (1.8-21.6) and LR- of 0.69 (0.5-0.96). It had a sensitivity of 35% (15.3-59.4), specificity of 94.3% (84.3-98.8), PPV of 70% (34.7-93.3), and NPV of 79.4% (67.3-88.5). Kappa statistics for interobserver and intraobserver agreement were 0.9091 and 0.8475, respectively. MRI assessment was accurate in predicting negative nodal status that is clinically useful in identifying women who can be spared inguinofemoral lymphadenectomy. It is noninvasive and is superior to clinical assessment. In clinical practice, this should encourage toward nodal sparing surgery, thus lowering surgical-related patient morbidity.
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Affiliation(s)
- K Singh
- Department of Gynaecological Oncology, Birmingham Women's Hospital, Metchley Park Road, Birmingham B15 2TG, UK.
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Selman TJ, Luesley DM, Acheson N, Khan KS, Mann CH. A systematic review of the accuracy of diagnostic tests for inguinal lymph node status in vulvar cancer. Gynecol Oncol 2005; 99:206-14. [PMID: 16081147 DOI: 10.1016/j.ygyno.2005.05.029] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2005] [Revised: 05/15/2005] [Accepted: 05/18/2005] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the accuracy of minimally and non-invasive tests to assess the groin node status in squamous cell vulvar cancer. METHODS A systematic review of published research from 1979 to 2004 that compares the results of tests to determine groin node status with histology at inguinofemoral lymphadenectomy was made. Studies included in the review were those that compared the index test to the standard surgical intervention of inguinofemoral lymphadenectomy and allowed the construction of two-by-two tables. From these tables, sensitivity, specificity, and the likelihood ratios (with 95% confidence intervals) were reported and, where feasible, meta-analysis was used to pool results for each test separately. Sentinel node biopsy using technetium-99m-labelled nanocolloid ((99m)Tc) had a pooled sensitivity and negative LR of 97% (91-100 95% CI) and 0.12 (0.053-0.28 95% CI), respectively, and was the most accurate test reviewed. CONCLUSION Five diagnostic tests were identified in a total of 29 studies (961 groins). Although the studies were small and the design often poor, this represents the best summary of the data to date. Sentinel node identification using (99m)Tc appeared to be the most promising test for accurately excluding lymph node metastases in squamous cell vulvar cancer and potentially reducing the radicality of surgery. Its efficacy as a tool in reducing the need for radical surgery and associated patient morbidity without reducing survival needs further assessment probably in a randomised control trial.
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Affiliation(s)
- T J Selman
- Birmingham Women's Hospital, Metchley Park Road, Edgbaston, Birmingham B15 2TG, UK.
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Watts A, Kehoe S, Luesley D. Community-based post-operative follow-up visit after major surgery for benign gynaecological conditions: a prospective study. J OBSTET GYNAECOL 2005; 17:468-71. [PMID: 15511924 DOI: 10.1080/01443619750112466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The time from surgery to discharge after major procedures for benign gynaecological conditions continues to fall. This small prospective study was undertaken to assess the postoperative problems encountered by patients after gynaecological surgery for a variety of benign disorders, and the potential of the 6-week surgical follow-up to be performed by the patient's family doctor rather than the hospital. The patients' and doctors' satisfaction with such care was determined. The study showed that follow-up in the community was acceptable to both patient and doctor. When problems arose after discharge most patients ( 50%) contacted their family doctor. At the 6-week visit few had physical problems, though most (58-100% depending on the Group) felt that a 6-week follow-up was required. Six-week postoperative follow-up by the family doctor is acceptable, and could permit more effective use of hospital specialists, though would increase the workload of family doctors.
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Affiliation(s)
- A Watts
- City Hospital Trust, Birmingham, UK
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Abstract
Radical hysterectomy and pelvic lymphadenectomy is the standard surgical treatment for early stage cervical cancer. This operation is well recognised as having a higher morbidity and mortality rate than a simple hysterectomy. We studied the histology results of 131 patients who had standard surgery for cervical cancer to ascertain if a radical hysterectomy was required for adequate treatment. Of 110 (84%) patients with negative pelvic lymphadenopathy, only 9 (8%) had positive parametrial histology and all required adjuvant therapy independent of their parametrial histology. This study confirms that a less radical hysterectomy and pelvic lymphadenectomy provides adequate treatment and allows us to consider a more conservative, minimal access approach to the management of these patients.
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Affiliation(s)
- T J Selman
- Birmingham Women's Hospital, Birmingham B15 2TG, UK
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Cuzick J, Szarewski A, Cubie H, Hulman G, Kitchener H, Luesley D, McGoogan E, Menon U, Terry G, Edwards R, Brooks C, Desai M, Gie C, Ho L, Jacobs I, Pickles C, Sasieni P. Management of women who test positive for high-risk types of human papillomavirus: the HART study. Lancet 2003; 362:1871-6. [PMID: 14667741 DOI: 10.1016/s0140-6736(03)14955-0] [Citation(s) in RCA: 365] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Certain types of human papillomavirus (HPV) are the primary cause of almost all cervical cancers. HPV testing of cervical smears is more sensitive but less specific than cytology for detecting high-grade cervical intraepithelial neoplasia (CIN2+). HPV testing as a primary screening approach requires efficient management of HPV-positive women with negative or borderline cytology. We aimed to compare the detection rate and positive predictive values of HPV assay with cytology and to determine the best management strategy for HPV-positive women. METHODS We did a multicentre screening study of 11085 women aged 30-60 years. Women with borderline cytology and women positive for high-risk HPV with negative cytology were randomised to immediate colposcopy or to surveillance by repeat HPV testing, cytology, and colposcopy at 12 months. FINDINGS HPV testing was more sensitive than borderline or worse cytology (97.1% vs 76.6%, p=0.002) but less specific (93.3% vs 95.8%, p<0.0001) for detecting CIN2+. Of 825 randomised women, surveillance at 12 months was as effective as immediate colposcopy. In women positive for HPV at baseline, who had surveillance, 73 (45%) of 164 women with negative cytology and eight (35%) of 23 women with borderline cytology were HPV negative at 6-12 months. No CIN2+ was found in these women, nor in women with an initial negative HPV test with borderline (n=211) or mild (32) cytology. INTERPRETATION HPV testing could be used for primary screening in women older than 30 years, with cytology used to triage HPV-positive women. HPV-positive women with normal or borderline cytology (about 6% of screened women) could be managed by repeat testing after 12 months. This approach could potentially improve detection rates of CIN2+ without increasing the colposcopy referral rate.
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Abstract
Adenocarcinoma in situ (AIS) of the uterine cervix is a rare condition. Pap smear screening is unsatisfactory, and the disease has no morphologic reliable colposcopic features. Diagnosis is often made by chance during the treatment of squamous pre-invasive disease, which commonly coexists with AIS. Although the entire endocervical canal can be the site of disease, most lesions lie within 1 cm of the squamocolumnar junction. Skip lesions are rare, making fertility-sparing surgery a possibility under certain conditions. Recurrent disease occurs in 14% of cases when cone margins are free of disease and rise to more than 50% if the margins are involved. The method of conization is immaterial provided a large enough specimen is taken and that the endocervical margins can be evaluated by the pathologist. Follow-up of conservatively managed women is not defined; however, we recommend that regular endocervical cytology be performed in addition to conventional cytology and colposcopy.
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Affiliation(s)
- I J Etherington
- *City Hospital NHS Trust, Dudley Road, Birmingham, B18 7QH, UK †Academic Department of Obstetrics & Gynaecology, Birmingham Womenʼs Hospital and University of Birmingham, Birmingham, B15 2TT, UK
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Poole CJ, Perren T, Burton A, Jordan SD, Jenkins AH, Mould JJ, Spooner DA, Luesley D, Chan KK, Sturman S, Earl HM. Phase II clinical trials of cisplatin-then-paclitaxel and paclitaxel-then-cisplatin in patients with previously untreated advanced epithelial ovarian cancer. Ann Oncol 2000; 11:1603-8. [PMID: 11205470 DOI: 10.1023/a:1008343519687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To examine the activity and safety of two sequentially scheduled chemotherapy regimens comprising four cycles of paclitaxel (pctx) 200 mg/m2/3 hours then four cycles ofcisplatin (cisDDP) 100 mg/m2, and vice versa, in patients with previously untreated advanced ovarian cancer. PATIENTS AND METHODS Between January 1994 and February 1996, we recruited 30 patients to the pctx-then-cisDDP regimen and 29 to cisDDP-then-pctx, in parallel phase II trials. RESULTS Both regimens were predictably active with responses seen in 22 of 30 patients (OR 74%; CR 27%, PR 47%) treated with pctx-then-cisDDP, as against 13 of 21 patients (OR 62%; CR 38%, PR 24%) treated with cisDDP-then-pctx. The OR rate to four cycles of pctx (induction) was 43%, with 27% disease progression; the OR to four cycles of cisDDP (induction) was 57%, with 5% progression. However, progression rates across both induction and consolidation phases were 16% (pctx-then-cisDDP) and 29% (cisDDP-then-pctx). Both regimens were unacceptably neurotoxic. II patients suffering grade 3 sensory neurotoxicity (5 on pctx-then-cisDDP, 6 on cisDDP-then-pctx) and 20 having grade 3 deafness (9 on pctx- then-cisDDP, 11 on cisDDP-then-pctx). CONCLUSION The activity of these sequential regimens justifies their further development using the less neurotoxic platinum analogue carboplatin, perhaps combining paclitaxel with other platinum non-cross resistant drugs.
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Affiliation(s)
- C J Poole
- CRC Trials Unit, Institute for Cancer Studies, University of Birmingham, UK.
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Affiliation(s)
- D Luesley
- Department of Obstetrics and Gynaecology, Birmingham Women's Hospital
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Herod J, Burton A, Buxton J, Tobias J, Luesley D, Jordan S, Dunn J, Poole CJ. A randomised, prospective, phase III clinical trial of primary bleomycin, ifosfamide and cisplatin (BIP) chemotherapy followed by radiotherapy versus radiotherapy alone in inoperable cancer of the cervix. Ann Oncol 2000; 11:1175-81. [PMID: 11061615 DOI: 10.1023/a:1008346901733] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Phase II studies have shown primary (neo-adjuvant) chemotherapy with bleomycin, ifosfamide and cisplatin (BIP) is active against inoperable cervical cancer. We present here results of a randomised phase III multicentre trial comparing radical radiotherapy with neo-adjuvant BIP chemotherapy followed by radical radiotherapy in patients with inoperable cervical cancer, designed to discover whether this combination might improve survival. PATIENTS AND METHODS Patients with inoperable cervical carcinoma were randomised to pelvic radiotherapy alone [RT] or two to three cycles of bleomycin 30 units/24-hour infusion, ifosfamide 5 g/m2/24 hours, and cisplatin 50 mg/m2) chemotherapy followed by pelvic radiotherapy (BIP + RT). Randomisation was stratified by stage and radiotherapy centre. RESULTS One hundred seventy-two eligible women were randomised into this trial; eighty-six to RT and eighty-six to BIP + RT. A total of 190 cycles of chemotherapy were given. Median follow-up for the 47 patients still alive is 9 years with a minimum follow-up of 3 years. Complete or partial response occurred in 51 of 86 (59%) of those randomised to RT and 60 of 86 (69%) of those randomised to BIP + RT. The difference between response rates does not reach statistical significance (chi2 = 2.06, P = 0.15). Median survival is two years with an actuarial survival at five years of 32% (95% confidence interval (95% CI): 25%-39%). There is no significant difference between the treatment groups (chi2log-rank = 0.11, P = 0.74). CONCLUSIONS This study does not show any survival benefit from the use of neo-adjuvant BIP chemotherapy in advanced cervical cancer.
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Affiliation(s)
- J Herod
- CRC Trials Unit, Institute for Cancer Studies, University of Birmingham, Edgbaston, UK
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Teale GR, Moffitt DD, Mann CH, Luesley DM. Management guidelines for women with normal colposcopy after low grade cervical abnormalities: population study. BMJ 2000; 320:1693-6. [PMID: 10864542 PMCID: PMC27411 DOI: 10.1136/bmj.320.7251.1693] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To develop an evidence based protocol for the follow up of women with low grade cervical abnormalities for whom treatment is not immediately indicated. DESIGN Population outcome study. SETTING Colposcopy clinic of an inner city teaching hospital. PARTICIPANTS 566 women with low grade cytological abnormalities who were not treated at a first visit to the colposcopy clinic, followed up for a total of 881 years. MAIN OUTCOME MEASURES Resolution of abnormalities, persistence of disease, and treated disease. RESULTS Abnormalities resolved in 306 (54.1%) women, whereas 138 (24.4%) had persistent disease and 122 (21.5%) were subsequently treated. Colposcopic opinion, smear test results, age, smoking history, and number of pregnancies were all significantly related to outcome. Logistic regression analysis produced a model that correctly identified 70% of women whose abnormalities resolved. Only 23 of 295 women (7.8%) with a normal cervix on colposcopy and a smear without dyskaryosis at a first visit were treated by the end of the observation period. CONCLUSIONS Women referred with low grade cytological abnormalities who have a normal cervix on colposcopy and a negative or borderline repeat smear test result may be discharged from the colposcopy clinic. We propose a follow up protocol that could safely avoid unnecessary visits to a clinic.
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Affiliation(s)
- G R Teale
- Birmingham Women's NHS Trust, Edgbaston, Birmingham B15 2TG.
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Mann CH, Kehoe S, Brown A, Luesley DM. A study of the follow up patterns of women treated for CIN 2 and 3 before and after the introduction of the 1992 guidelines. Br J Obstet Gynaecol 1999; 106:1126-9. [PMID: 10549955 DOI: 10.1111/j.1471-0528.1999.tb08136.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To analyse the five year cytology follow up data after discharge on women treated for histologically proven cervical intraepithelial neoplasia (CIN) 2 and 3. To assess whether the introduction of the 1992 Guidelines for Clinical Practice and Programme Management affected follow up patterns. To identify who was lost to follow up and for what reasons. DESIGN A retrospective cohort study of cervical cytological follow up data from 186 women treated for CIN 2 and 3. SETTING Primary care services, West Midlands, United Kingdom. POPULATION One hundred and eighty-six women with CIN 2 or 3 treated with large loop excision of the transformation zone at the City Hospital, Birmingham, in whom the first follow up smear at six months was normal. The women were divided into two groups: Group 1 consisted of women treated before the introduction of the Guidelines (1988-1990), and Group 2 consisted of women treated at the time of the introduction of the Guidelines in 1992. INTERVENTION Introduction of the 1992 Guidelines for Clinical Practice and Programme Management. MAIN OUTCOME MEASURES To determine the number of follow up smears each woman had over a five year period, to determine the number of women who had the recommended number of follow up smears, and to identify the number of women lost to follow up. RESULTS The median (interquartile range) number of smears in Group 1 was five (four to six) and in Group 2 was four (four to five). A similar proportion of women in both groups subsequently had abnormal smears (15% and 13.6%). Only one woman required further treatment. 22% of women in Group 1 and 10.2% of women in Group 2 had the correct number of smears to fulfil the 1992 Guidelines. There were 21 women (11.3%) who only had one smear following discharge from the clinic in the five year follow up period. CONCLUSIONS The data from both cohorts shows follow up to be poor, and the introduction of the 1992 Guidelines has yet to result in an improvement in follow up patterns. The absence of a national cervical cytology database means that surveys of cytology follow up data will continue to be difficult due to the problems of data collection from numerous health authorities and the mobility of women in this age group.
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Affiliation(s)
- C H Mann
- Department of Gynaecological Oncology, City Hospital Trust, Birmingham, UK
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Clark TJ, Etherington IJ, Luesley DM. Response of vulvar lichen sclerosus and squamous cell hyperplasia to graduated topical steroids. J Reprod Med 1999; 44:958-62. [PMID: 10589407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
OBJECTIVE To determine whether symptomatic remission could be obtained equally effectively in patients with vulvar lichen sclerosus, squamous cell hyperplasia or mixed disease in response to a standardized course of graduated topical steroids. STUDY DESIGN A retrospective analysis of 137 patients with biopsy-proven lichen sclerosus (84), squamous cell hyperplasia (42) or mixed disease (11) treated between 1990 and 1997 with a standard, three-month regimen of graduated topical steroids was carried out. Presence or absence of symptoms and side effects of treatment were recorded three and six months following induction of the initial graduated topical steroid regimen. RESULTS On completion of the graduated topical steroid course, 59% of patients were asymptomatic (P = .035), and at six months, 58% were asymptomatic (P = .11). Remission of symptoms was more easily achieved in patients with lichen sclerosus as compared to patients with squamous cell hyperplasia and mixed disease at both three and six months (P = .09 at three and P = .035 at six). Four cases of local reactions to the steroids were recorded, as were two cases of vulvar malignancy. CONCLUSION Symptomatic remission was significantly easier to achieve in patients with vulvar lichen sclerosus as compared to those with squamous cell hyperplasia following treatment with graduated topical steroids.
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Affiliation(s)
- T J Clark
- Department of Obstetrics and Gynaecology, Walsgrave Hospital, Coventry, U.K.
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Sinha P, Sorinola O, Luesley DM. Lichen sclerosus of the vulva. Long-term steroid maintenance therapy. J Reprod Med 1999; 44:621-4. [PMID: 10442326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
OBJECTIVE To assess the efficacy of graduated topical steroids for long-term maintenance therapy for vulvar lichen sclerosus. STUDY DESIGN A prospective observational study was performed in the Gynaecological Oncology Department, City Hospital, Birmingham, U.K. Fifty-four patients were recruited for the study. The diagnosis was confirmed with histopathologic examination. After confirmation of the diagnosis, patients were started on a diminishing regimen of topical steroid. RESULTS Of the 54 patients in the study, 51 responded to the steroid regimen, and three did not. CONCLUSION The graduated topical steroid regimen has a high response rate and takes a relatively short time to achieve, justifying the use of graduated topical steroids for this condition. Graduated dose reduction allows the majority of patients to remain in asymptomatic remission and minimize steroid exposure.
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Affiliation(s)
- P Sinha
- City Hospital, Birmingham, U.K
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Abstract
OBJECTIVE A prospective study to evaluate the success of a modified vestibulectomy in treating vulvar vestibulitis. METHODS Fifty seven consecutive women with vulvar vestibulitis and suitable for surgery based on the criteria: superficial dyspareunia, erythematous vestibular region, positive Q-tip test, symptoms reduced with local anesthetic cream. A modified vestibulectomy with or without a modified Fentons procedure was performed. Response was based on return to normal coitus, 3 months after surgery. RESULTS Most women suffered from chronic conditions (median duration of symptoms = 18 months). The median age was 28 years (range 18-53). Any infections were treated prior to surgery. All but 4 (7%) had histological abnormalities, mainly non-specific inflammation. In 18% of women who had cervical cytology some abnormality was detected. Mean follow-up time was 12 months (range 2-42). Three women were not evaluable. Complete response to surgery was achieved in 33 (61.1%) of the women, partial response was achieved in 15 (27.8%). Six (11.1%) had persistent symptoms, four of whom has psychosexual problems. CONCLUSION Presently, surgery remains the most successful intervention for vulvar vestibulitis. Modified surgery which is less destructive seems to afford acceptable results. The completion of randomized studies are needed to recognise the optimum surgical procedure.
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Affiliation(s)
- S Kehoe
- Department of Gynaecological Oncology, City Hospital Trust, Birmingham, UK.
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Abstract
BACKGROUND Human papillomavirus type 16 variants have been described and may have different biologic activities: this has implications for the design of HPV vaccines. OBJECTIVES The aim of this study was to see if the HPV16 variant E-G 131 can be detected in women with preinvasive disease and to consider the histological and immunological implications of such infection. DESIGN A prospective observational cross-sectional study on a cohort of women with minor cervical cytological abnormalities was performed. METHODS Samples were tested for HPV DNA by polymerase chain reaction and restriction enzyme digestion. Blood samples were tested for antibodies to HPV16 virus-like particles (VLP) and to determine class I HLA types. Women found to have abnormal colposcopy were treated by large-loop excision of the transformation zone on a see-and-treat basis. RESULTS Two hundred forty-one women were included in the study. Infection with the variant was detected in 20. 9% of cases and was not associated with any specific HLA type. These cases were more likely to have high-grade CIN than those with wild-type HPV16 or no HPV16 (chi2 = 18.85, P < 0.001). There were significant differences in seropositivity to HPV16 virus-like particles between the three groups (chi2 = 32.43, P < 0.001). CONCLUSIONS The E-G 131 variant may have increased oncogenic potential by evading host immune responses, but its identification is only weakly predictive of high-grade disease in stepwise logistic regression. The lack of seropositivity to HPV16 VLP has implications for the design of prophylactic vaccines based on VLP to HPV16.
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Affiliation(s)
- I J Etherington
- Division of Gynaecological Oncology, University of Birmingham, Nottingham
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Cope G, Thorpe G, Holder R, Luesley D, Jordan J. Serum and tissue antioxidant capacity in cervical intraepithelial neoplasia investigated using an enhanced chemiluminescent reaction. Ann Clin Biochem 1999; 36 ( Pt 1):86-93. [PMID: 10370766 DOI: 10.1177/000456329903600112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Depleted antioxidant defence has been implicated in the pathogenesis of cervical neoplasia. We determined the systemic and local antioxidant status of women with this condition. Thirty-four women with varying grades of cervical intraepithelial neoplasia, 25 patients who had been treated successfully with diathermy loop excision, and 56 women who had no evidence of cervical abnormality acted as controls. Total antioxidant capacity of serum and protein-free serum, and of neat and protein-free homogenized cervical punch biopsies were determined using enhanced chemiluminescence. Mean serum antioxidant capacity of patients with current neoplasia and treated patients was not significantly different from that of controls. However, mean antioxidant capacity of homogenized cervical tissue from women with neoplasia was significantly lower than control means (P < 0.005), while results for treated patients were intermediate between those from diseased and normal samples (P < 0.05). The enhanced chemiluminescence technique has potential as a suitable method for measuring total antioxidant capacity of cervical tissue, and warrants further investigations using other tissue types. Significant antioxidant depletion in cervical intra-epithelial neoplasia appears to be confined to the local cervical mucosa.
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Affiliation(s)
- G Cope
- Wolfson Applied Technology Laboratory, University of Birmingham, Queen Elizabeth Medical Centre, Edgbaston, UK.
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Abstract
The National Health Service Cervical Screening Programme has issued minimum standards for a colposcopy service that facilitates audit. We have looked at the performance of a teaching hospital colposcopy service by analysing the case notes of 639 women who underwent large loop excision of the transformation zone over a nine-month period in 1995. We found delays in patient assessment and communication of results. There was overtreatment, particularly at first visit, and an excessive number of treatments were performed under general anaesthesia. A worrying number of women failed to have a follow up smear performed, but in those that did we found a reassuring treatment success rate. Our findings led to changes in the structure and functioning of the colposcopy clinic that should improve the detection of significant disease and improve the timeliness of diagnosis and the speed with which we communicate results.
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Affiliation(s)
- G Teale
- Colposcopy Dept, Birmingham Women's Hospital, NHS Trust, UK
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Abstract
This article reviews the recent literature on urological complications in gynaecological oncology. In particular it focuses on the current controversies in the management of urinary fistulae and reconstruction or urinary diversion after pelvic exenteration.
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Affiliation(s)
- Q Davies
- Department of Gynaecological Oncology, City Hospital, Birmingham, UK
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Kehoe S, Luesley D, Chan KK. A pilot study on early post-operative morbidity and technique of inguinal node dissection in vulval carcinoma. EUR J GYNAECOL ONCOL 1998; 19:374-6. [PMID: 9744729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Inguinal lymphadenectomy is part of the management plan for most cases of vulval carcinoma. The surgical techniques have been modified over the years resulting in less destructive operations. Even so, inguinal lymphadenectomy continues to pose difficulties particularly relating to wound breakdown and lymphocyst formation. Many different methods are described, though none have undergone any comparative assessment regarding morbidity. This small study compares two methods performed on the same patients. The radical procedure included excision of the fascia lata and exposure of the femoral vessels and nerve. The anatomically-directed method was more conservative with surgery directed at removing the nodes as described in anatomical textbooks. Both methods resulted in equal lymph node retrieval, though the subjective short-term morbidity was reduced with the more conservative surgery. This approach did not result in any detrimental outcomes regarding relapse disease, though a randomised trial is required to corroborate these findings.
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Affiliation(s)
- S Kehoe
- Department of Gynaecological Oncology, City Hospital Trust, Birmingham, UK
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Clark TJ, Herod JJ, Kehoe S, Luesley DM. The development of invasive vulvar cancer in a patient with Job's syndrome, a rare immunodeficient condition. Br J Obstet Gynaecol 1998; 105:468-70. [PMID: 9609279 DOI: 10.1111/j.1471-0528.1998.tb10137.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- T J Clark
- Academic Department of Obstetrics and Gynaecology, City Hospital, Birmingham, UK
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Etherington IJ, Luesley DM, Shafi MI, Dunn J, Hiller L, Jordan JA. Observer variability among colposcopists from the West Midlands region. Br J Obstet Gynaecol 1997; 104:1380-4. [PMID: 9422016 DOI: 10.1111/j.1471-0528.1997.tb11007.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess variation in diagnoses and management decisions among colposcopists when presented with cervical images; to see the impact of the referral cytology report on diagnostic accuracy. DESIGN A two-part video questionnaire study. PARTICIPANTS Colposcopists from West Midlands Region. METHODS Twenty cervical images displaying a range of transformation zones from normal through varying abnormalities up to cervical intraepithelial neoplasia (CIN) grade 3 were shown on video tape together with basic patient information. Two sets of videos were made, the second being identical to the first other than including the referral cytology. Participants recorded their diagnoses and management decisions on prepared questionnaires. The two sets of videos were viewed several weeks apart. RESULTS Completed questionnaires to both videos were received from 30 colposcopists. Diagnostic accuracy improved with knowledge of the cervical cytology result in cases of CIN 2/3 (chi 2 = 19.45, P < 0.0001) but not where the histology was CIN 1 or less (chi 2 = 2.64, P = 0.10). Overall interobserver agreement improved slightly from kappa = 0.169 to kappa = 0.212 when the cytology was revealed. While only 2.6% of cases of CIN 2/3 would have been under-managed after the second questionnaire, 37.5% cases where the abnormality did not amount to CIN would have been overtreated. CONCLUSION There is considerable inter-observer variability and variation in diagnostic accuracy in scoring cervical images particularly at the lower end of the spectrum of abnormality which has the potential to lead to over-treatment. We rely considerably on the cervical cytology result in forming a diagnosis. We recommend that a see-and-treat approach be abandoned when the referral smear shows minor abnormalities. The study has implications for both training and audit in colposcopy.
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Affiliation(s)
- I J Etherington
- Academic Department of Obstetrics and Gynaecology, City Hospital NHS Trust, Birmingham, UK
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Mulherin DM, Sheeran TP, Kumararatne DS, Speculand B, Luesley D, Situnayake RD. Sjögren's syndrome in women presenting with chronic dyspareunia. Br J Obstet Gynaecol 1997; 104:1019-23. [PMID: 9307528 DOI: 10.1111/j.1471-0528.1997.tb12060.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To identify cases of Sjögren's syndrome among women with chronic dyspareunia who did not already have a diagnosed rheumatological disorder. DESIGN Prospective recruitment over 12 months. SETTING Tertiary referral service for the assessment of vulval disease. PARTICIPANTS Women with chronic dyspareunia who had musculoskeletal symptoms, Raynaud's phenomenon or symptoms of ocular or oral dryness. METHODS The women underwent a Schirmer tear test and a comprehensive auto-antibody screen including latex fixation test for rheumatoid factor, antinuclear, anti-Ro, anti-La and anti-salivary duct antibodies. A labial salivary gland biopsy and vaginal biopsy were taken for routine histological analysis. MAIN OUTCOME MEASURES Cases of definite and probable Sjögren's syndrome were identified using the European criteria. RESULTS Eleven women were assessed for features of Sjögren's syndrome. Four had definite primary Sjögren's syndrome, two had probable primary Sjögren's syndrome and one had probable secondary Sjögren's syndrome. Among these seven women the median duration of vaginal symptoms was seven years (range 0.25-20), of ocular symptoms was one year (range 0.25-2) and of oral symptoms was 1.5 years (range 0-6). In all but one woman dyspareunia presented before ocular or oral symptoms, often by many years. CONCLUSIONS Although well-recognised as a feature of established Sjögren's syndrome, this study emphasises that chronic dyspareunia can be a presenting feature in these women, antedating the emergence of ocular or oral symptoms by many years. Symptoms of ocular or oral dryness, Raynaud's phenomenon or musculoskeletal symptoms should be sought in women with chronic dyspareunia to identify those who merit further investigation.
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Affiliation(s)
- D M Mulherin
- Department of Rheumatology, City Hospital, Birmingham, UK
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Shafi MI, Luesley DM, Jordan JA, Dunn JA, Rollason TP, Yates M. Randomised trial of immediate versus deferred treatment strategies for the management of minor cervical cytological abnormalities. Br J Obstet Gynaecol 1997; 104:590-4. [PMID: 9166203 DOI: 10.1111/j.1471-0528.1997.tb11538.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To compare immediate and deferred treatment in women with cervical smears showing borderline nuclear abnormalities or mild dyskaryosis. DESIGN Prospective randomised trial. SETTING Colposcopy clinics at Birmingham and Midland Hospital for Women and the City Hospital NHS Trust, Dudley Road, Birmingham. PARTICIPANTS Four hundred and thirty-five women with minor cytological abnormality younger than 35 years of age, of whom 353 were randomised to immediate treatment or deferred treatment. MAIN OUTCOME MEASURES Comparison of histologies in the subsequent two years in the immediate and deferred treatment groups. RESULTS Thirty-six women (21%) defaulted from follow up. The percentage of high grade abnormalities (CIN II and III) in the deferred treatment arm at two years is similar to that in the immediate treated arm at first colposcopy (25% vs 24%). Cytology failed to pick up two cases of CIN III and there was one case of early invasive carcinoma at the six month follow up. If treatment is deferred, the proportion with CIN I is almost halved (25% vs 13%); the proportion with koilocytic atypia is slightly reduced (51% vs 42%) and the proportion with no abnormality is substantially increased (0.6% vs 20%). CONCLUSION Immediate referral and a select-and-treat management strategy of all women with any degree of dyskaryosis is recommended based on the case of invasive cervical cancer, high default rate and the failure of cytology to pick up two cases of CIN III.
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Affiliation(s)
- M I Shafi
- Academic Department of Obstetrics and Gynaecology, City Hospital NHS Trust, Birmingham, UK
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Ellis JR, Etherington I, Galloway D, Luesley D, Young LS. Antibody responses to HPV16 virus-like particles in women with cervical intraepithelial neoplasia infected with a variant HPV16. Lancet 1997; 349:1069-70. [PMID: 9107250 DOI: 10.1016/s0140-6736(05)62292-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Houghton SJ, Shafi MI, Rollason TP, Luesley DM. Is loop excision adequate primary management of adenocarcinoma in situ of the cervix? Br J Obstet Gynaecol 1997; 104:325-9. [PMID: 9091010 DOI: 10.1111/j.1471-0528.1997.tb11462.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the efficacy of cervical loop excision as primary management of adenocarcinoma in situ. DESIGN A two-centre retrospective study. SETTING Birmingham and Midlands Hospital for Women and City Hospital NHS Trust. POPULATION Nineteen women with a histological diagnosis of adenocarcinoma in situ (high grade CIGN) of the cervix made on diathermy loop excision. MAIN OUTCOME MEASURES Presence or absence of adenocarcinoma in situ at loop specimen margins, results of cervical cytological examinations following loop excision, results of histopathological assessment of any surgical specimens taken after initial loop excision. RESULTS Of the 19 women with confirmed adenocarcinoma in situ on loop excision, the median age was 31, and 8 (42%) were nulliparous. The median follow up of these women was 19 months. Eleven women were treated by loop excision alone and have had normal follow up to 18 months. Five women have undergone further surgical procedures, four had a hysterectomy and one had a repeat loop excision. No residual disease was found in any of these surgical specimens, confirming that loop excision was adequate primary management of the disease. Three women have had abnormal endocervical follow up cytology suggestive of residual disease. One of these three women may represent a case of residual endocervical disease. Excision margins of the loop specimen were not involved by adenocarcinoma in situ in 11 women. However, excision margin status of the loop specimen did not appear to be predictive of residual disease. CONCLUSIONS Our small retrospective study suggests that diathermy loop excision of the cervix is adequate primary management of adenocarcinoma in situ of the cervix. Cytological and colposcopic follow up, including cytobrush endocervical cytological sampling and long term follow up, is recommended in these women.
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Affiliation(s)
- S J Houghton
- Academic Department of Obstetrics and Gynaecology, City Hospital NHS Trust, Birmingham, UK
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Abstract
OBJECTIVE To assess the diagnostic accuracy of a new technique of cervical imaging and to consider its potential as a secondary cervical screening method. DESIGN A prospective cross-sectional study with each case acting as its own control, comparing video colpography with colposcopy. SETTING University of Birmingham colposcopy clinics, City Hospital and Birmingham Women's Hospital. PARTICIPANTS Fifty women referred for colposcopy. INTERVENTIONS The women had a video colpogram recording made prior to colposcopy. MAIN OUTCOME MEASURES The proportion of technically suitable colpograms obtained and the level of agreement between colposcopist and video screener. RESULTS The images were satisfactory or good in 94% cases, and there was a very high level of agreement between colposcopist and video screener (kappa = 0.79). If the technique had been used in a primary health care setting as a secondary screening method for women with low grade cervical smear abnormalities, 61% would have avoided referral for colposcopy. CONCLUSIONS Video colpography is an accurate, portable and quick method of cervical imaging. It combines the simplicity of a video camera with the versatility of computerised digital imaging and has great potential in the fields of teaching, audit and screening of low grade smear abnormalities.
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Kehoe S, Herod J, van Geene P, Shafi M, Redman C, Luesley D, Chan K. Intentional non-radical surgery and survival in advanced ovarian cancer: results of a pilot study. Int J Gynecol Cancer 1996. [DOI: 10.1046/j.1525-1438.1996.06060448.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Affiliation(s)
- S Kehoe
- Department of Obstetrics & Gynaecology, City Hospital Trust, Birmingham, U.K
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Herod JJ, Shafi MI, Rollason TP, Jordan JA, Luesley DM. Vulvar intraepithelial neoplasia: long term follow up of treated and untreated women. Br J Obstet Gynaecol 1996; 103:446-52. [PMID: 8624318 DOI: 10.1111/j.1471-0528.1996.tb09771.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To investigate the long term outcome of patients with vulvar intraepithelial neoplasia. DESIGN A retrospective study using information obtained from patient casenotes. SAMPLE One hundred and thirty-three women with a primary diagnosis of vulvar intraepithelial neoplasia (VIN), identified during a 15-year period. RESULTS The diagnosis of vulvar intraepithelial neoplasia increased throughout the study period. Human papilloma virus changes were noted in 104 patients (78%); these women were significantly younger than those without (P < or = 0.001). Nineteen (14%) were managed by observation or medical treatment and the remainder by surgical methods. Histological or symptomatic recurrence after surgical treatment occurred in 55 (48%). When disease recurred, it usually did so within four years of treatment. Recurrence was more common following laser vapourisation than after local excision (75% vs 40%; P < or = 0.01). Progression to invasive disease occurred in nine patients (7%), none of whom were in the group being observed. Four deaths occurred in this group, three from gynaecological malignancies of the lower genital tract. CONCLUSION Patients with vulvar intraepithelial neoplasia require long term follow up, and the risk of invasion may be higher than previously thought. Surgical treatment when required should be by excisional rather than ablative methods in most instances. In selected cases it is also possible to safely manage patients by more conservative methods.
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Affiliation(s)
- J J Herod
- Academic Department of Obstetrics and Gynaecology, City Hospital NHS Trust, Birmingham, UK
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Herod JJ, Shafi MI, Rollason TP, Jordan JA, Luesley DM. Vulvar intraepithelial neoplasia with superficially invasive carcinoma of the vulva. Br J Obstet Gynaecol 1996; 103:453-6. [PMID: 8624319 DOI: 10.1111/j.1471-0528.1996.tb09772.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To investigate the long-term outcome of patients presenting with vulvar intraepithelial neoplasia (VIN) with superficially invasive carcinoma of the vulva (SICa). DESIGN A retrospective study using information obtained from patient case notes. SAMPLE Twenty-six women found at presentation to have VIN in association with superficially invasive carcinoma were identified during a 15-year period. RESULTS Pruritus vulvae was the most frequent presenting symptom in 18 patients (69%). Sixteen women (61.5%) had multiple symptoms. Features noted at vulvar examination were variable and none were pathognomonic of either VIN or of superficial invasion. All patients had VIN 3 in association with a superficially invasive carcinoma. Histological changes associated with human papillomavirus were found in 19 (73%) women. Half had a co-existent or previous abnormality of the lower genital tract. Local excision was the most frequent initial treatment (n = 9 [35%]). Mean follow up time was 65 months (range 12-174). Disease persisted after primary treatment in five women (19%). Both histological recurrence (of either VIN or SICa) or symptomatic recurrence occurred in 10 patients (38%). All patients who experienced recurrence did so within 36 months of treatment. Overall, 12 patients (46%) relapsed (histological or symptomatic recurrence); the mean time was 18 months. Fourteen patients (54%) were managed satisfactorily by their initial treatment. One patient died of recurrent cervical cancer. Three progressed to frankly invasive disease: two (aged 31 and 39 years) with carcinoma of the vulva and one aged 34 years with carcinoma of the perianal margin. All are alive and well after treatment. One patient had recurrence of superficially invasive carcinoma treated by local excision with no further problems. No episode of metastasis via lymphatic or vascular channels has been seen. CONCLUSIONS Patients with superficially invasive carcinoma of the vulva may be safely treated by local excisional methods without recourse to lymphadenectomy. Relapse after primary treatment is common, and there appears to be a significant risk of progression to frankly invasive carcinoma.
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Affiliation(s)
- J J Herod
- Academic Department of Obstetrics and Gynaecology, City Hospital NHS Trust, Birmingham, UK
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Chenoy R, Billingham L, Irani S, Rollason TP, Luesley DM, Jordan JA. The effect of directed biopsy on the atypical cervical transformation zone: assessed by digital imaging colposcopy. Br J Obstet Gynaecol 1996; 103:457-62. [PMID: 8624320 DOI: 10.1111/j.1471-0528.1996.tb09773.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine the effect of directed punch biopsy trauma on the natural history of atypical cervical transformation zones. DESIGN A prospective randomised clinical trial. SETTING Academic Unit colposcopy clinics in Birmingham. PARTICIPANTS One hundred and eighty women attending the colposcopy clinics were recruited over an 18 month period, of which 161 were eligible for analysis. METHODS Three-way randomisation of patients into 1. no biopsy, 2. central biopsy and 3. peripheral biopsy groups. Quantitative assessment of the change in surface area and severity of cervical intra-epithelial neoplasia (CIN) lesions in each group measured six weeks apart using digital imaging colposcopy. RESULTS No significant difference in change in lesion size (P = 0.40) was noted in the three treatment groups. Results suggest that the severity of the lesion was underestimated by the peripheral biopsy. CONCLUSIONS The results of this study suggest that directed punch biopsy trauma does not have a significant effect on the immediate natural history of CIN. No statistically significant differences were found in lesion size whether biopsy was employed or not. In addition, the site of biopsy had no influence on the outcome. It appears, therefore, that tissue trauma from punch biopsy and the subsequent inflammatory and wound healing processes do not modify the course of CIN. The regressive changes observed after punch biopsy in previous natural history studies are probably not a result of the initial inflammatory response to biopsy trauma and subsequent re-epithelialisation with normal cells, but may result from processes that continue long after tissue repair is completed.
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Affiliation(s)
- R Chenoy
- Academic Department of Obstetrics and Gynaecology, Birmingham Women's Hospital, Edgbaston, UK
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