Impact of Patient Body Mass Index on Post-Operative Recovery from Robotic-Assisted Hysterectomy

A longitudinal, descriptive, prospective, and prolective study of individuals with endometrial or cervical cancer/pre-cancer diagnoses and high BMI (over 35 kg/m2) undergoing RH was conducted. Of the 53 participants recruited, 3 (6%) were converted to open surgery. The 50 RH participants had median BMI 42 kg/m2 (range 35 to 60): the range 35-39.9 kg/m2 had 17 cases; the range 40-44.9 kg/m2 had 15 cases; 45-49.9 kg/m2 8 cases; and those ≥50 kg/m2 comprised 10 cases. The mean RH operating time was 128.1 min (SD 25.3) and the median length of hospital stay was 2 days (range 1-14 days). Increased BMI was associated with small, but statistically significant, increases in operating time and anaesthetic time, 65 additional seconds and 37 seconds, respectively, for each unit increase in BMI. The median self-reported time for individuals who underwent RH to return to their pre-operative activity levels was 4 weeks (range 2 to >12 weeks). There was a significant improvement in pain and physical independence scores over time (p = 0.001 and p < 0.001, respectively) and no significant difference in scores for overall QOL, pain, or physical independence scores was found between the BMI groups. Patient-reported recovery and quality of life following RH is high in individuals with high BMI (over 35 kg/m2) and does not appear to be impacted by the severity of obesity.

Endometrial Cancer Incidence in Patients With Atypical Endometrial Hyperplasia According to Mode of Management

BACKGROUND/AIM

It is well established that around one-third of patients with atypical endometrial hyperplasia (AEH) go on to develop endometrial cancer (EC).

PATIENTS AND METHODS

This retrospective cohort study included 119 patients recruited from the University Hospitals of Leicester from 01/01/2015 to 01/01/2020 with a diagnosis of AEH by endometrial biopsy. Patients were divided into two groups according to the management modality: Primary surgery (n=99), and conservative treatment (n=20). The aim of this study was to determine the incidence of EC in patients with AEH in University Hospitals of Leicester, UK, and to explore the reasons why patients with AEH opted for conservative management.

RESULTS

EC was diagnosed in 34.4% of patients with AEH managed by primary surgery. Moreover, the incidence of EC in patients with AEH managed conservatively was 25%. The main reason for opting for conservative management was that patients were unfit for surgery when assessed in the high-risk Anaesthetic Clinic (35%).

CONCLUSION

AEH is a pre-malignant lesion that has high risk of EC regardless of the mode of management. Total hysterectomy is the safest first line of treatment in AEH due to the high risk of concurrent EC and progression to EC. Currently, there is no reliable follow-up intervention to distinguish between concurrent EC and progression of AEH. Adequate discussion and counselling are essential when discussing conservative management for women with complex AEH. Patients should be counselled regarding the high risk of developing concurrent EC and risk of progression to EC.

Peri-operative Variables Associated With Prolonged Intensive Care Stay Following Cytoreductive Surgery for Ovarian Cancer

BACKGROUND

Peri-operative variables associated with prolonged Intensive Care Unit (ICU) admission following cytoreductive surgery for ovarian cancer were investigated.

PATIENTS AND METHODS

A retrospective review was carried out of patients admitted to the ICU following cytoreductive surgery for ovarian cancer in a single tertiary referral centre from 2015-2019. Patients were categorized according to length of ICU stay (<48 h and ≥48 h), and peri-operative variables were compared across the two groups.

RESULTS

A total of 56 patients were admitted to the ICU post-operatively, 37 for <48 h and 19 for ≥48 h (range=3-11 days). Greater duration of procedure and estimated blood loss, bowel resection, higher post-operative lactate level, lower post-operative albumin level and requirement for post-operative blood products were associated with prolonged ICU stay. Increased intraoperative fluid requirement was an independent predictor of extended ICU stay.

CONCLUSION

Utilizing identified intra-operative risk factors to perform individualized risk assessments might improve planning of ICU resources. Optimizing intraoperative fluid management may improve short-term patient outcomes.

Impact of Obesity on Surgeon Ergonomics in Robotic and Straight-Stick Laparoscopic Surgery

STUDY OBJECTIVE

Work-related musculoskeletal symptoms (WMSs) are reported to be increasing in surgeons performing minimally invasive procedures. Therefore, we investigated the use of inertial measurement units (IMUs) and electromyography (EMG) sensor recorders to record real-time information on the muscle movement/activity required to perform training exercises in simulated in normal and high body mass index (BMI) models.

DESIGN

Prospective study.

SETTING

University hospital.

PARTICIPANTS

Four consultant gynecologic oncology surgeons experienced in complex straight-stick (SS) laparoscopic and robotically assisted (RA) surgery.

INTERVENTIONS

Three exercises (hoops onto pegs and wire chase) using SS and RA surgery on 2 abdominal models: normal BMI and high BMI.

MEASUREMENTS AND MAIN RESULTS

We measured time to complete exercise and surgeon muscle movement/activity. The time to complete all exercises was significantly lower for RA surgery as compared with SS laparoscopy (p <.05 or better). The movement of the surgeons' core was significantly greater in high BMI SS laparoscopy compared with normal BMI SS laparoscopy for exercises 1 and 2 (p <.001). Muscle usage, as determined by EMG peak, was significantly higher in normal BMI SS laparoscopy and even higher in high BMI SS laparoscopy but was generally flat for all normal and high BMI RA surgery exercises (p <.05 or better).

CONCLUSION

Detailed real-time information can be collected through IMUs/EMG sensors. Our results indicate that RA surgery requires less surgeon movements and muscle activity to complete tasks compared with SS laparoscopy, particularly in a high BMI model. The implications of these results are that RA surgery in high BMI patients may therefore have less physical impact on the surgeon compared with SS laparoscopy and may result in lower WMS rates.

Cervical cancer still presents symptomatically 20 years after the introduction of a structured national screening programme

OBJECTIVE

To investigate the pattern of presentation of cervical cancer and to identify the characteristics of women who present symptomatically with cervical cancer.

METHODS

A retrospective study of all cervical cancer cases diagnosed over a 4-year period. Details of mode of presentation, stage at diagnosis and cytological/gynaecological history were collated.

RESULTS

In total, 148 cases were identified with a median age of 46 years (range, 20-91 years). In this population, 112 (75.7%) women were within the screening age range. Forty-eight (33.6%) were asymptomatic at diagnosis and presented through the colposcopy clinic. All asymptomatic women (100%) had stage I disease at diagnosis, compared with 37.2% of the symptomatic group (P < 0.001). Postmenopausal bleeding was the most common presenting symptom (33%), followed by postcoital bleeding (14.2%), intermenstrual bleeding (12.2%) and increased vaginal discharge (3.4%). The majority of symptomatic women presented through colposcopy, gynaecological oncology or gynaecology clinics (87.6%); however, 6.5% presented through the emergency department. Women who presented symptomatically were significantly older than asymptomatic women (54.9 versus 38.1 years, P < 0.001). Women at risk of social isolation (non-English speakers, alcohol abusers, heavy smokers, receiving treatment for psychiatric disease) were more likely to present with symptoms, through the emergency department and with advanced disease at diagnosis (stage II+) (P < 0.001).

CONCLUSIONS

A review of local cervical cancer cases can highlight areas of weakness in a screening programme and can identify populations who are at risk in presenting symptomatically with advanced disease.

Validation of endogenous control reference genes for normalizing gene expression studies in endometrial carcinoma

Real-time quantitative RT-PCR (qRT-PCR) is a powerful technique used for the relative quantification of target genes, using reference (housekeeping) genes for normalization to ensure the generation of accurate and robust data. A systematic examination of the suitability of endogenous reference genes for gene expression studies in endometrial cancer tissues is absent. The aims of this study were therefore to identify and evaluate from the thirty-two possible reference genes from a TaqMan(®) array panel their suitability as an internal control gene. The mathematical software packages geNorm qBasePLUS identified Pumilio homolog 1 (Drosophila) (PUM1), ubiquitin C (UBC), phosphoglycerate kinase (PGK1), mitochondrial ribosomal protein L19 (MRPL19) and peptidylpropyl isomerase A (cyclophilin A) (PPIA) as the best reference gene combination, whilst NormFinder identified MRPL19 as the best single reference gene, with importin 8 (IPO8) and PPIA being the best combination of two reference genes. BestKeeper ranked MRPL19 as the most stably expressed gene. In addition, the study was validated by examining the relative expression of a test gene, which encodes the cannabinoid receptor 1 (CB1). A significant difference in CB1 mRNA expression between malignant and normal endometrium using MRPL19, PPIA, and IP08 in combination was observed. The use of MRPL19, IPO8 and PPIA was identified as the best reference gene combination for the normalization of gene expression levels in endometrial carcinoma. This study demonstrates that the arbitrary selection of endogenous control reference genes for normalization in qRT-PCR studies of endometrial carcinoma, without validation, risks the production of inaccurate data and should therefore be discouraged.

Effect of anandamide on endometrial adenocarcinoma (Ishikawa) cell numbers: implications for endometrial cancer therapy

BACKGROUND

We have previously shown that patients with endometrial carcinoma express elevated concentrations of the endocannabinoid, anandamide (AEA), in both their plasma and their endometrial tissue and that the endometrial carcinoma cell line, Ishikawa, contains the receptors to which AEA binds. Several studies have reported that human and rodent cancer cell lines die in response to high AEA concentrations. The incidence of endometrial carcinoma continues to escalate and, although surgical treatment has improved, morbidity and mortality rates have not. A move towards a novel non-surgical therapeutic option is thus required, and the endocannabinoid system provides a good candidate target. We aimed to investigate the effects of AEA on the survival and proliferation of an endometrial carcinoma cell model.

METHODS

This prospective basic research study was conducted at a UK teaching hospital. Ishikawa cells were cultured in vitro, and a range of AEA concentrations (0-10 000 nM) were added to the cells. The effect of AEA was measured at different timepoints (4, 18, 24, 48, and 72 h). Primary outcome was cell proliferation and cell viability as measured with a commercial proliferation-apoptosis assay in which assay colour at 420 nm is directly proportional to cell density. One-way ANOVA was performed with Prism (version 7).

FINDINGS

Ishikawa cells were sensitive to AEA-mediated cytotoxicity in a pseudo dose-dependent manner. AEA caused a significant decrease in cell number only at concentrations above 1000 nM (mean 28·1% [SE 7·8], n=12; p<0·0001). The decrease in cell viability that occurred at 4, 18, and 24 h was partly restored at 48 and 72 h suggesting that the AEA growth inhibitory effect is time limiting.

INTERPRETATION

Our results show that AEA induces a decrease in Ishikawa cell number probably through inhibition of cell proliferation rather than cell death. These data suggest that the increased plasma and tissue AEA concentrations observed in patients with endometrial cancer is a counter mechanism against further cancer growth and points to the endocannabinoid system as a potentially new therapeutic target.

FUNDING

University Hospitals of Leicester NHS Trust.

Ectopic prolactin secretion secondary to an ovarian tumour

Ectopic hormone secretion is a well-recognised phenomenon; however, ectopic prolactin secretion is exceptionally rare. Hoffman and colleagues reported the first ever well-documented case of ectopic prolactin secretion secondary to a gonadoblastoma. We report a lady who presented with galactorrhoea and a large ovarian tumour that was found to secrete high levels of prolactin.

Patient satisfaction with daycase laparoscopy

A prospective audit was performed on all patients preselected for daycase surgery over a 3-month period. The aim of the study was to evaluate patient acceptability and satisfaction with laparoscopy performed as a daycase procedure. Patients completed standard questionnaires before operation and at 4 weeks after surgery. Questions included satisfaction with daycase surgery, subjective pain experience, time taken to resume normal activities, adequacy of analgesia and necessity to call general practioners. Analysis of results revealed that 69% of patients were satisfied with day surgery laparoscopy. However there were highly significant differences (P less than 0.001) between resumption of normal activity, pain experienced and length of stay between patients satisfied and dissatisfied with daycase surgery. This study suggests that guidelines for daycase procedures may be overambitious as 31% of patients already pre-selected, were dissatisfied with daycase surgery.

A distinctive vulval fibroma of so-called prepubertal type in a postmenopausal patient

The case of a 65-year-old female patient who has had a large right vulval mass for over 30 years is reported here. The mass was excised, but the hypocellular mesenchymal tumour was difficult to classify histologically. On further specialist assessment, it was found to be identical to the recently recognised distinctive prepubertal vulval fibroma. These are very rarely reported in children, and till now, has never been reported in an adult.

Should women with postcoital bleeding be referred for colposcopy?

This study was to determine the risk of finding significant cervical pathological abnormality in women referred to the colposcopy clinic primarily because of postcoital bleeding. We evaluated the cervical smear history of such women and correlated this with any colposcopic or pathological abnormality. There were 142 women seen over a period of 12 months. The age range of the study population was 16 - 61 years (mean age of 34.1 years). There was no case of lower genital tract invasive neoplasia. Out of the 142 cases, 56 women (39.4%) had normal findings at colposcopy and 44 (31%) were secondary to cervical ectopy. A total of 27 (19%) had cervical intraepithelial neoplasia (CIN) out of which there were 15 (10.6%) cases of high-grade disease (CIN II and CIN III); and, 20 (74%) out of the 27 women with CIN had a recently negative cervical smear (within the previous 36 months). Seven women (4.9%) had benign cervical polyps that were removed during colposcopy. The frequency of finding invasive lower genital tract neoplasia in women with postcoital bleeding is low. However, a good proportion of them would have a diagnosis of cervical intraepithelial neoplasia even with a recently negative cervical smear. Therefore, postcoital bleeding should remain an indication for referral to the colposcopy clinic for a detailed evaluation of the lower genital tract.

Aggressive angiomyxoma of the perineum

We report the case of perineal aggressive angiomyxoma in a 46-year-old woman presenting as left perineal swelling associated with superficial dyspareunia. Initial clinical examination revealed a 4- to 5-cm cystic mass in the posterior aspect of the left labia majora, not thought to be typical of a Bartholin cyst. A magnetic resonance imaging (MRI) scan revealed a well-defined 2- x 1.5- x 2-cm area posterolateral to the lower vagina on the left but anterolateral to the anal canal extending into the left ischiorectal fossa, with no obvious involvement of the anal sphincter complex. Excision biopsy was performed via an incision in the left labia majus under general anesthesia. Histologic findings were consistent with aggressive angiomyxoma of the vulva. This was confirmed by immunohistochemistry showing spindle cells positive for vimentin with strong nuclear staining for estrogen and progestogen receptors. Postoperative management following discussion at the multidisciplinary gynecological oncology meeting was to perform a repeat MRI scan 6 weeks postoperatively, and treatment with raloxifene was commenced for its antiestrogenic property.

Endocervical curettage at the time of colposcopic assessment of the uterine cervix

Colposcopic examination of the uterine cervix remains the gold standard in the evaluation of patients with abnormal cervical cytology. Endocervical curettage (ECC) still forms a limited part of the overall assessment of women with abnormal cervical smears (Pap test) in the United States and in certain other parts of the world. To date, there are no properly randomized trials on the place of ECC in the overall care of women with abnormal Pap test. This review critically appraises the available evidence to look at the possible role of ECC in the complete evaluation of abnormal cervical smears.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to list the proposed indications for endocervical curettage (ECC), to summarize the data in support of the routine use of ECC at the time of colposcopy, and to outline the evidence against the use of routine ECC at colposcopy.

Characterisation of a thermophilic L-glutamate dehydrogenase biosensor for amperometric determination of L-glutamate by flow injection analysis

Carbon paste wax electrodes incorporating thermophilic L-glutamate dehydrogenase, NADP and a polymeric toluidine blue O (poly-TBO) mediator have been characterised for the amperometric determination of L-glutamate at 313-318 K in a flow injection analysis (FIA) system. The biosensors exhibit good sensitivity, mechanical stability and reproducibilty, unlike carbon paste- or carbon wax-based electrodes under the same conditions. The carbon paste wax electrode responds linearly to L-glutamate up to 40 mM, the detection limit is 0.3 mM and the RSD (n = 10) for 5 mM L-glutamate was 7.6%. The response to some potential interferents has been quantified. Addition of finely ground hexaammineruthenium (III) trichloride ([Ru(NH3)6]Cl3) to the carbon paste wax electrodes decreases the FIA peak width and increases the peak current. The metal complex appears to accelerate the rate of oxidation of NAD(P)H by poly-TBO.

An immunoscintigraphic evaluation of the engineered human monoclonal antibody (hCTMO1) for use in the treatment of ovarian carcinoma

OBJECTIVE

To assess the safety and targeting ability of the engineered human antibody (hCTMO1) in women with ovarian carcinoma.

DESIGN

The monoclonal antibody labelled with Indium-111 was administered to women with suspected primary or recurrent ovarian carcinoma six days pre-operatively. The first group of women was given a dose of 0.1 mg per kg body weight of radiolabelled antibody. A second group of women received 1 mg per kg body weight and finally a third group was given 1 mg per kg body weight of unlabelled antibody followed one hour later by 0.1 mg per kg body weight of radiolabelled antibody. All the women were then imaged using a gamma camera one hour and up to 96 hours after injection.

PARTICIPANTS

Fourty-four women in whom there was a high suspicion of primary ovarian carcinoma on the basis of ultrasound or CT imaging and serum CA125 and those in whom there was a suspicion of recurrent ovarian carcinoma after being treated for histologically confirmed carcinoma.

SETTING

The Queen's Medical Centre, Nottingham and University Hospital Vrije Universiteit, Amsterdam, The Netherlands.

RESULTS

At the low dose of antibody the sensitivity for detection of ovarian carcinoma was 70%. After increasing the dose of antibody and also after pre-dosing with unlabelled antibody the sensitivity increased to 100%, but there was a large number of false positive results at the higher dose, and therefore the specificity was low. The liver and bone marrow were the organs with the highest activities.

CONCLUSION

The genetically engineered antibody hCTMO1 is safe for use in women. This antibody effectively targets ovarian carcinoma and has greater potential as a vector for therapeutic use than as a diagnostic agent.

Urological problems and the treatment of gynaecological cancer

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.

Biodistribution of 111In-labelled engineered human antibody CTM01 (hCTM01) in ovarian cancer patients: influence of prior administration of unlabelled hCTM01

mAb hCTM01 binds a carcinoma-associated antigen, the MUC1 gene product. The antigen is also present in the circulation, and administration of 111In-labelled hCTM01 results in the formation of immune complexes with enhanced accumulation in the liver. To avoid the unwanted effect of circulating radioactive immune complexes, a strategy to remove the circulating antigen was investigated using a split-dosage schedule. Eleven patients suspected of having ovarian carcinoma were injected with 1 mg/kg unlabelled hCTM01, 1 h before receiving 0.1 mg/kg 111In-labelled hCTM01 (100 M Bq). The amount of radioactivity was determined in resected tumour tissue, various normal tissues and blood samples obtained at laparotomy 6 days postinjection (p.i.). In all patients, the circulating antigen decreased to its nadir after the unlabelled antibody infusion and immune complex formation was demonstrated. Uptake in tumour deposits 6 days p.i. was 11.1 times higher than in normal tissues (P < 0.0001) and 5.9 times higher than in blood (P < 0.0001). 111In activity in liver tissue was comparable to 111In uptake in tumour tissue, and considerably lower than previously reported in patients not pretreated with unlabelled antibody. The split-dosing strategy would appear to be advantageous for use of hCTM01 as a specific carrier for the delivery of cytotoxic agents to patients with ovarian cancer.

The effect of circulating antigen on the biodistribution of the engineered human antibody hCTM01 in a nude mice model

Clinical studies are currently underway to assess the biodistribution and therapeutic potential of the genetically engineered human antibody hCTM01 directed against polymorphic epithelial mucin (PEM) in patients with ovarian carcinoma. The present study was undertaken to assess the effect of circulating PEM antigen on the biodistribution of the anti-PEM antibody in mice bearing MUC-1 transfected adenocarcinoma cell lines. Tumour xenografts were established from three cell lines: 413-BCR, which expressed antigen on the cell surface and also shed antigen into the circulation, E3P23, which expressed the antigen but did not shed into the circulation, and a negative control (410.4 MUCI). Groups of five mice were injected with 1.0 mg/kg antibody, imaged after 72 h and then sacrificed, followed by assay of tissue uptake. The results showed a clear difference in the tumour and liver uptake, with the non-secreting cell line showing almost twice the tumour uptake and approximately 20% of the liver uptake of the secreting cell line.

Biodistribution of (111)indium-labeled engineered human antibody CTMO1 in ovarian cancer patients: influence of protein dose

Thirty-one patients suspected of having ovarian cancer received a single i.v. injection of radiolabeled (100 MBq (111)In) engineered human CTMO1 (hCTMO1) to investigate its potential as an internalizing drug carrier. hCTMO1 is a complementary-determining region-grafted human IgG4 monoclonal antibody recognizing an ovarian carcinoma-associated antigen, the MUC-1-gene product. The amount of radioactivity was determined in tumor tissue, various normal tissues, including liver biopsies, and blood samples obtained at laparotomy, 6 days after injection of either 0.1 or 1.0 mg hCTMO1/kg of body weight. Circulating antigen-15-3 was measurable in all patients before injection, and immune complex formation was already present at the end of infusion. In the 0.1 mg/kg group, most of the radioactivity was bound to immune complexes, whereas in the 1.0 mg/kg group, most was bound to IgG monomers. Increasing the hCTMO1 dose 10-fold did not influence the overall disappearance of (111)In from the blood, but the elimination half-life of (111)indium bound to immune complexes was increased 2-fold. Uptake in tumor tissue 6 days postinjection at the 0.1 mg/kg dose was 7.6 times higher (P = 0.0009) than in normal tissue and 2.5 times higher (P = 0.03) than in blood. At the 1.0 mg/kg dose, the uptake in tumor tissue was 14.0 times higher (P = 0.0003) than in normal tissue and 8.1 times higher (P = 0.0007) than in blood. Liver activity was substantial (23.7 +/- 10.5 and 18.3 +/- 6.7% of the injected dose/kg for the 0.1 and 1.0 mg/kg dose group, respectively). These results are superior to those found with other clinically tested anti-MUC-1 gene product antibodies. hCTMO1 seems to be a suitable carrier for cytotoxic agents in ovarian carcinoma patients; the better uptake results and tumor-to-blood ratios are obtained at the higher dose of 1.0 mg hCTMO1/kg body weight.