Vertebral Fractures: Which Radiological Criteria Are Better Associated With the Clinical Course of Osteoporosis?

STUDY PURPOSE

Morphometric methods categorize potential osteoporotic vertebral fractures (OVF) on the basis of loss of vertebral height. A particular example is the widely used semiquantitative morphometric tool proposed by Genant (GSQ). A newer morphologic algorithm-based qualitative (mABQ) tool focuses on vertebral end-plate damage in recognizing OVF. We used data from both sexes in the Canadian Multicentre Osteoporosis Study (CaMos) to compare the 2 methods in identifying OVF at baseline and during 10 years of follow-up.

MATERIALS AND METHODS

We obtained lateral thoracic and lumbar spinal radiographs (T4-L4) 3 times, at 5-year intervals, in 828 participants of the population-based CaMos. Logistic regressions were used to study the association of 10-year changes in bone mineral density (BMD) with incident fractures.

RESULTS

At baseline, 161 participants had grade 1 and 32 had grade 2 GSQ OVF; over the next 10 years, only 9 of these participants had sustained incident GSQ OVF. Contrastingly, 21 participants at baseline had grade 1 and 48 grade 2 mABQ events; over the next 10 years, 79 subjects experienced incident grade 1 or grade 2 mABQ events. Thus, incident grades 1 and 2 morphologic fractures were 8 times more common than morphometric deformities alone. Each 10-year decrease of 0.01 g/cm² in total hip BMD was associated with a 4.1% (95% CI: 0.7-7.3) higher odds of having an incident vertebral fracture.

CONCLUSIONS

This analysis further suggests that morphometric deformities and morphologic fractures constitute distinct entities; morphologic fractures conform more closely to the expected epidemiology of OVF.

The Radiology of Osteoporotic Vertebral Fractures Revisited

Until recently there has been little evidence available to validate any method by which to make an accurate diagnosis of an osteoporotic vertebral fractures (OVFs) from plain radiographs. In part this reflects a lack of a completely satisfactory "gold standard," but primarily it relates to the absence of well-designed prospective studies in this context. Historically, OVFs were recognized by evidence of macroscopic structural failure in vertebrae using the criteria applied elsewhere in the skeleton. This comprised altered alignment, fragmentation, cortical disruptions, and breaks, among other changes. However, these morphological criteria were replaced by vertebral morphometry, referring to the use of quantitative or quasi-quantitative measurement tools for fracture diagnosis. Vertebral morphometry emerged as an understanding of and treatment for osteoporosis evolved, mainly in response to the need for expeditious assessments of large numbers of spine images for epidemiological and pharmaceutical purposes. Although most of the descriptions of such morphometric tools have stressed that they were not to be applied to clinical diagnosis with respect to individual patients, this constraint has been widely disregarded. Here we review the major attempts to develop a diagnostic strategy for OVF and describe their characteristics in adults and children. Recent evidence suggests that morphometric (quantitative; ie, based on measurement of dimensions and shape description) criteria are inferior to morphologic (qualitative; ie, based on structural integrity) vertebral damage assessment in identifying people with low bone density and at an increased risk of future fracture. Thus there is now an evidentiary basis for suggesting that morphological assessment is the preferred strategy for use in diagnosing OVF from radiographs. © 2019 American Society for Bone and Mineral Research.

Learning from Death: A Hospital Mortality Reduction Programme

PROBLEM

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

SETTING

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

DESIGN

Before and after evaluation of a hospital mortality reduction programme.

STRATEGIES FOR CHANGE

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

EFFECTS

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

LESSONS LEARNT

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

Lower serum magnesium is associated with vascular calcification in peritoneal dialysis patients: a cross sectional study

BACKGROUND

Coronary artery calcification (CAC) is highly prevalent among dialysis patients and is associated with increased cardiovascular and all cause mortality. Magnesium (Mg) inhibits vascular calcification in animal and in-vitro studies but whether the same effect occurs in humans is uncertain.

METHODS

A single centre cross-sectional study of 80 prevalent peritoneal dialysis (PD) patients; on PD only for a minimum of 3 months. A radiologist blinded to patient status calculated their abdominal aortic calcification (AAC) scores on lateral lumbar spine radiographs, a validated surrogate for CAC.

RESULTS

Eighty patients provided informed consent and underwent lumbar spine radiography. The mean serum Mg was 0.8 mmol/L (standard deviation 0.2) and mean AAC score 8.9 (minimum 0, maximum 24). A higher serum Mg level was associated with a lower AAC score (R ² = 0.06, unstandardized coefficient [B] = -7.81, p = 0.03), and remained after adjustment for age, serum phosphate, serum parathyroid hormone, low-density lipoprotein cholesterol, smoking history, and diabetes (model adjusted R ² = 0.36, serum Mg and AAC score B = -11.44, p = 0.00). This translates to a 0.1 mmol/L increase in serum Mg being independently associated with a 1.1-point decrease in AAC score.

CONCLUSIONS

Our findings suggest that Mg may inhibit vascular calcification. If this association is replicated across larger studies with serial Mg and vascular calcification measurements, interventions that increase serum Mg and their effect on vascular calcification warrant further investigation in the PD population.

Effect of Total Laparoscopic Hysterectomy vs Total Abdominal Hysterectomy on Disease-Free Survival Among Women With Stage I Endometrial Cancer: A Randomized Clinical Trial

IMPORTANCE

Standard treatment for endometrial cancer involves removal of the uterus, tubes, ovaries, and lymph nodes. Few randomized trials have compared disease-free survival outcomes for surgical approaches.

OBJECTIVE

To investigate whether total laparoscopic hysterectomy (TLH) is equivalent to total abdominal hysterectomy (TAH) in women with treatment-naive endometrial cancer.

DESIGN, SETTING, AND PARTICIPANTS

The Laparoscopic Approach to Cancer of the Endometrium (LACE) trial was a multinational, randomized equivalence trial conducted between October 7, 2005, and June 30, 2010, in which 27 surgeons from 20 tertiary gynecological cancer centers in Australia, New Zealand, and Hong Kong randomized 760 women with stage I endometrioid endometrial cancer to either TLH or TAH. Follow-up ended on March 3, 2016.

INTERVENTIONS

Patients were randomly assigned to undergo TAH (n = 353) or TLH (n = 407).

MAIN OUTCOMES AND MEASURES

The primary outcome was disease-free survival, which was measured as the interval between surgery and the date of first recurrence, including disease progression or the development of a new primary cancer or death assessed at 4.5 years after randomization. The prespecified equivalence margin was 7% or less. Secondary outcomes included recurrence of endometrial cancer and overall survival.

RESULTS

Patients were followed up for a median of 4.5 years. Of 760 patients who were randomized (mean age, 63 years), 679 (89%) completed the trial. At 4.5 years of follow-up, disease-free survival was 81.3% in the TAH group and 81.6% in the TLH group. The disease-free survival rate difference was 0.3% (favoring TLH; 95% CI, -5.5% to 6.1%; P = .007), meeting criteria for equivalence. There was no statistically significant between-group difference in recurrence of endometrial cancer (28/353 in TAH group [7.9%] vs 33/407 in TLH group [8.1%]; risk difference, 0.2% [95% CI, -3.7% to 4.0%]; P = .93) or in overall survival (24/353 in TAH group [6.8%] vs 30/407 in TLH group [7.4%]; risk difference, 0.6% [95% CI, -3.0% to 4.2%]; P = .76).

CONCLUSIONS AND RELEVANCE

Among women with stage I endometrial cancer, the use of total abdominal hysterectomy compared with total laparoscopic hysterectomy resulted in equivalent disease-free survival at 4.5 years and no difference in overall survival. These findings support the use of laparoscopic hysterectomy for women with stage I endometrial cancer.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00096408; Australian New Zealand Clinical Trials Registry: CTRN12606000261516.

Optimal Management Strategies for Primary HPV Testing for Cervical Screening: Cost-Effectiveness Evaluation for the National Cervical Screening Program in Australia

BACKGROUND

Several countries are implementing a transition to HPV testing for cervical screening in response to the introduction of HPV vaccination and evidence indicating that HPV screening is more effective than cytology. In Australia, a 2017 transition from 2-yearly conventional cytology in 18-20 to 69 years to 5-yearly primary HPV screening in 25 to 74 years will involve partial genotyping for HPV 16/18 with direct referral to colposcopy for this higher risk group. The objective of this study was to determine the optimal management of women positive for other high-risk HPV types (not 16/18) ('OHR HPV').

METHODS

We used a dynamic model of HPV transmission, vaccination, natural history and cervical screening to determine the optimal management of women positive for OHR HPV. We assumed cytology triage testing was used to inform management in this group and that those with high-grade cytology would be referred to colposcopy and those with negative cytology would receive 12-month surveillance. For those with OHR HPV and low-grade cytology (considered to be a single low-grade category in Australia incorporating ASC-US and LSIL), we evaluated (1) the 20-year risk of invasive cervical cancer assuming this group are referred for 12-month follow-up vs. colposcopy, and compared this to the risk in women with low-grade cytology under the current program (i.e. an accepted benchmark risk for 12-month follow-up in Australia); (2) the population-level impact of the whole program, assuming this group are referred to 12-month surveillance vs. colposcopy; and (3) the cost-effectiveness of immediate colposcopy compared to 12-month follow-up. Evaluation was performed both for HPV-unvaccinated cohorts and cohorts offered vaccination (coverage ~72%).

FINDINGS

The estimated 20-year risk of cervical cancer is ≤1.0% at all ages if this group are referred to colposcopy vs. ≤1.2% if followed-up in 12 months, both of which are lower than the ≤2.6% benchmark risk in women with low-grade cytology in the current program (who are returned for 12-month follow-up). At the population level, immediate colposcopy referral provides an incremental 1-3% reduction in cervical cancer incidence and mortality compared with 12-month follow-up, but this is in the context of a predicted 24-36% reduction associated with the new HPV screening program compared to the current cytology-based program. Furthermore, immediate colposcopy substantially increases the predicted number of colposcopies, with >650 additional colposcopies required to avert each additional case of cervical cancer compared to 12-month follow-up. Compared to 12-month follow-up, immediate colposcopy has an incremental cost-effectiveness ratio (ICER) of A$104,600/LYS (95%CrI:A$100,100-109,100) in unvaccinated women and A$117,100/LYS (95%CrI:A$112,300-122,000) in cohorts offered vaccination [Indicative willingness-to-pay threshold: A$50,000/LYS].

CONCLUSIONS

In primary HPV screening programs, partial genotyping for HPV16/18 or high-grade triage cytology in OHR HPV positive women can be used to refer the highest risk group to colposcopy, but 12-month follow-up for women with OHR HPV and low-grade cytology is associated with a low risk of developing cervical cancer. Direct referral to colposcopy for this group would be associated with a substantial increase in colposcopy referrals and the associated harms, and is also cost-ineffective; thus, 12-month surveillance for women with OHR HPV and low-grade cytology provides the best balance between benefits, harms and cost-effectiveness.

A Qualitative Examination of the Ward Region of Interest as Imaged on Dual-Energy X-ray Absorptiometry Examinations: The "Wandering Ward Sign"

While analyzing dual-energy X-ray absorptiometry (DXA) examinations, we observed that, on occasion, the Ward region of interest (ROI) was positioned either unexpectedly or differently between successive examinations. When this occurred, it appeared to be either a marker of a compromised examination or of incident disease. This prompted a systematic inquiry. It became apparent that, while in general seeking the region of least areal density, the Ward ROI is positioned differently by the machines available to us from 2 particular manufacturers (General Electric Co. and Hologic Inc.). Three reviews were thus undertaken: (1) a prospective systematic examination of 200 unselected consecutive DXA examinations made with a General Electric Co. machine, 80 having had follow-up examinations and 245 made with a Hologic Inc. device; (2) a prospective systematic examination of 625 consecutive, unselected DXA examinations that were repeat examinations; and (3) a retrospective examination of a file of 86 cases collected for pedagogical purposes, predominantly made with a Hologic Inc. device. The commonest cause of an unusual position of the Ward area was compromised patient positioning or change in body habitus. Changes between examinations were, in addition if less often, apt to reflect physiological change or disease. Unusual positioning or a change in position of the Ward ROI is easily observed. It does not occur frequently, but, when it does, it may be useful in directing attention to either technical factors or incidental diseases. Observation of the position of the Ward ROI may thus be a quality assurance, and occasionally a diagnostic, tool.

Computed Tomography and Magnetic Resonance Imaging in the Differentiation of Osteoporotic Fractures From Neoplastic Metastatic Fractures

Determining whether a low-intensity vertebral fracture in an older person, particularly one with a history of cancer, is due to osteoporosis (OP) or is the result of a metastasis, is a not infrequent clinical problem that has important prognostic and therapeutic implications. The 2 types of fracture are usually indistinguishable on plain radiographs and require higher order imaging for diagnosis. Magnetic resonance imaging is the modality of choice because of its unique ability to depict the bone marrow, which becomes transiently edematous in an acute OP fracture. Preservation of at least part of the normal marrow signal, the visualization of a fracture line parallel to the end plates, the presence of an intravertebral cleft, lack of pedicle involvement, and no extra-osseous mass all favor a benign OP fracture. Absence of the preceding signs, particularly if there is complete replacement of the normal bone marrow and a convex posterior contour of the vertebral body, favors a fracture of malignant origin. Non-routine magnetic resonance sequences using diffusion-weighted imaging and/or chemical shift imaging may be helpful in difficult cases.

A resource allocation metric for thyroid biopsies

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

Population-based retrospective observational study.

SETTING

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

POPULATION

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

METHOD

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

A new prognostic model for FIGO stage 1 epithelial ovarian cancer

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Learning from death: a hospital mortality reduction programme

PROBLEM

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

SETTING

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

DESIGN

Before and after evaluation of a hospital mortality reduction programme.

STRATEGIES FOR CHANGE

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

EFFECTS

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

LESSONS LEARNT

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

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

OBJECTIVE

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

DESIGN

Population-based retrospective cohort study.

SETTING

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

POPULATION

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

METHODS

Statistical analysis of record-linked administrative health data.

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Training, assessment and competency in gynaecologic surgery

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

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Gastric adenocarcinoma presenting as uterine metastasis—A case report

BACKGROUND

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

CASE

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

CONCLUSION

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