• Observational retrospective study of UK national success, risks and costs for 319,105 IVF/ICSI and 30,669 IUI treatment cycles.

      Jayaprakasan, Kanna (2020-03)
      OBJECTIVE: To compare success rates, associated risks and cost-effectiveness between intrauterine insemination (IUI) and in vitro fertilisation (IVF). DESIGN: Retrospective observational study. SETTING: The UK from 2012 to 2016. PARTICIPANTS: Data from Human Fertilisation and Embryology Authority's freedom of information request for 2012-2016 for IVF/ICSI (intracytoplasmic sperm injection)and IUI as practiced in 319 105 IVF/ICSI and 30 669 IUI cycles. Direct-cost calculations for maternal and neonatal expenditure per live birth (LB) was constructed using the cost of multiple birth model, with inflation-adjusted Bank of England index-linked data. A second direct-cost analysis evaluating the incremental cost-effective ratio (ICER) was modelled using the 2016 national mean (baseline) IVF and IUI success rates. OUTCOME MEASURES: LB, risks from IVF and IUI, and costs to gain 1 LB. RESULTS: This largest comprehensive analysis integrating success, risks and costs at a national level shows IUI is safer and more cost-effective than IVF treatment.IVF LB/cycle success was significantly better than IUI at 11.49% (p<0.001) but the IUI success is much closer to IVF at 2.35:1, than previously considered. IVF remains a significant source of multiple gestation pregnancy (MGP) compared with IUI (RR (Relative Risk): 1.45 (1.31 to 1.60), p<0.001) as was the rate of twins (RR: 1.58, p<0.001).In 2016, IVF maternal and neonatal cost was £115 082 017 compared with £2 940 196 for IUI and this MGP-related perinatal cost is absorbed by the National Health Services. At baseline tariffs and success rates IUI was £42 558 cheaper than IVF to deliver 1LB with enhanced benefits with small improvements in IUI. Reliable levels of IVF-related MGP, OHSS (ovarian hyperstimulation syndrome), fetal reductions and terminations are revealed. CONCLUSION: IUI success rates are much closer to IVF than previously reported, more cost-effective in delivering 1 LB, and associated with lower risk of complications for maternal and neonatal complications. It is prudent to offer IUI before IVF nationally.
    • Obstetric and neonatal outcomes for women with reversed and non-reversed type III female genital mutilation.

      Raouf, Sanaria (2011-05)
      OBJECTIVE: To record and compare obstetric and neonatal complication rates in women with reversed and non-reversed type III female genital mutilation (FGM). METHODS: A retrospective observational study comparing cesarean delivery rates and neonatal outcomes of primiparous and multiparous women who had or had not undergone reversal of FGM III. RESULTS: Of the 250 women, 230 (92%) had an FGM reversal. Of these, 50 (21.7%) were primiparous (cesarean delivery rate 17/50; 34%) and 180 (78.3%) were multiparous (cesarean delivery rate 28/180; 15.6%). Of the 20 women who had not had an FGM reversal, 7 (35%) were primiparous (cesarean delivery rate 5/7; 71.4%) and 13 (65%) were multiparous (cesarean delivery rate 7/13; 53.8%). The cesarean delivery rates for primiparae and multiparae were 32.9% and 25%, respectively. Multiparous women with FGM III reversal had a lower possibility of caesarean delivery compared with the hospital multiparous population (P=0.003) and multiparae who had not undergone FGM III reversal (P=0.007). There was no significant association between Apgar scores or blood loss at vaginal delivery and FGM reversal. CONCLUSION: Reversal of FGM III significantly reduced the increased risk of cesarean delivery seen with multiparae who have FGM III.
    • Outcome of women with postcoital bleeding referred for colposcopy

      Tamizian, Onnig (2019-03)
      BACKGROUND: Most causes of postcoital bleeding (PCB) are benign but the most important cause is cervical cancer so it is important to refer women with postcoital bleeding for colposcopy. We evaluated women referred with postcoital bleeding for the prevalence of cervical abnormalities. METHOD(S): This was a retrospective study of 270 women referred with postcoital bleeding to the colposcopy clinic at the Royal Derby Hospital, Derby and those with suspected cervical abnormalities underwent colposcopy-directed cervical biopsies with or without treatment. RESULT S: Eighty-nine out of 124 women (72%) above 35 years and 108 out of 146 women (74%) below 35 years were seen for colposcopy within 4 weeks of referral. Final diagnoses confirmed cervical intraepithelial neoplasia in 35 women (13%) and high-grade cervical intraepithelial neoplasia in 10 women (3.7%). None of the women had cervical cancer and all had recently negative cervical smears. CONCLUSION(S): Although cervical cancer was not detected in the women referred for colposcopy, PCB stills presents a risk of coexisting cervical intraepithelial neoplasia so women should be referred for further assessment promptly within appropriate, improved waiting times. Most cases however will be benign with a high chance of symptom resolution providing reassurance.
    • Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): a randomised controlled trial.

      Jenkins, Howard (2016-03)
      BACKGROUND: Ovarian cancer has a poor prognosis, with just 40% of patients surviving 5 years. We designed this trial to establish the effect of early detection by screening on ovarian cancer mortality. METHODS: In this randomised controlled trial, we recruited postmenopausal women aged 50-74 years from 13 centres in National Health Service Trusts in England, Wales, and Northern Ireland. Exclusion criteria were previous bilateral oophorectomy or ovarian malignancy, increased risk of familial ovarian cancer, and active non-ovarian malignancy. The trial management system confirmed eligibility and randomly allocated participants in blocks of 32 using computer-generated random numbers to annual multimodal screening (MMS) with serum CA125 interpreted with use of the risk of ovarian cancer algorithm, annual transvaginal ultrasound screening (USS), or no screening, in a 1:1:2 ratio. The primary outcome was death due to ovarian cancer by Dec 31, 2014, comparing MMS and USS separately with no screening, ascertained by an outcomes committee masked to randomisation group. All analyses were by modified intention to screen, excluding the small number of women we discovered after randomisation to have a bilateral oophorectomy, have ovarian cancer, or had exited the registry before recruitment. Investigators and participants were aware of screening type. This trial is registered with ClinicalTrials.gov, number NCT00058032. FINDINGS: Between June 1, 2001, and Oct 21, 2005, we randomly allocated 202,638 women: 50,640 (25·0%) to MMS, 50,639 (25·0%) to USS, and 101,359 (50·0%) to no screening. 202,546 (>99·9%) women were eligible for analysis: 50,624 (>99·9%) women in the MMS group, 50,623 (>99·9%) in the USS group, and 101,299 (>99·9%) in the no screening group. Screening ended on Dec 31, 2011, and included 345,570 MMS and 327,775 USS annual screening episodes. At a median follow-up of 11·1 years (IQR 10·0-12·0), we diagnosed ovarian cancer in 1282 (0·6%) women: 338 (0·7%) in the MMS group, 314 (0·6%) in the USS group, and 630 (0·6%) in the no screening group. Of these women, 148 (0·29%) women in the MMS group, 154 (0·30%) in the USS group, and 347 (0·34%) in the no screening group had died of ovarian cancer. The primary analysis using a Cox proportional hazards model gave a mortality reduction over years 0-14 of 15% (95% CI -3 to 30; p=0·10) with MMS and 11% (-7 to 27; p=0·21) with USS. The Royston-Parmar flexible parametric model showed that in the MMS group, this mortality effect was made up of 8% (-20 to 31) in years 0-7 and 23% (1-46) in years 7-14, and in the USS group, of 2% (-27 to 26) in years 0-7 and 21% (-2 to 42) in years 7-14. A prespecified analysis of death from ovarian cancer of MMS versus no screening with exclusion of prevalent cases showed significantly different death rates (p=0·021), with an overall average mortality reduction of 20% (-2 to 40) and a reduction of 8% (-27 to 43) in years 0-7 and 28% (-3 to 49) in years 7-14 in favour of MMS.INTERPRETATION: Although the mortality reduction was not significant in the primary analysis, we noted a significant mortality reduction with MMS when prevalent cases were excluded. We noted encouraging evidence of a mortality reduction in years 7-14, but further follow-up is needed before firm conclusions can be reached on the efficacy and cost-effectiveness of ovarian cancer screening. FUNDING: Medical Research Council, Cancer Research UK, Department of Health, The Eve Appeal.
    • Ovarian reserve after salpingectomy: a systematic review and meta-analysis.

      Mohamed, Ahmed; James, Cathryn; Amer, Saad (2017-07)
      INTRODUCTION: Although there has been a growing concern over the possible damaging effect of salpingectomy on ovarian reserve, this issue remains uncertain. The purpose of this meta-analysis was to test the hypothesis that salpingectomy may compromise ovarian reserve. MATERIAL AND METHODS: A detailed search was conducted using MEDLINE, Embase, Dynamed Plus, ScienceDirect, TRIP database and the Cochrane Library from January 2000 to November 2016. All cohort, cross-sectional and randomized controlled studies investigating changes in circulating anti-Müllerian hormone (AMH) after salpingectomy were considered. Thirty-seven studies were identified, of which eight were eligible. Data were extracted and entered into RevMan software for calculation of the weighted mean difference (WMD) and 95% CI. Two groups of studies were analyzed separately: group 1 (six studies, n = 464) comparing data before and after salpingectomy and group 2 (two studies) comparing data in women who have undergone salpingectomy (n = 169) vs. healthy controls (n = 154). RESULTS: Pooled results of group 1 studies showed no statistically significant change in serum AMH concentration after salpingectomy (WMD, -0.10 ng/mL; 95% CI -0.19 to 0.00, I2 = 0%). Similarly, meta-analysis of group 2 showed no statistically significant difference in serum AMH concentration between salpingectomy group and controls (WMD, -0.11 ng/mL; 95% CI -0.37 to 0.14, I2 = 77%). Subgroup analyses based on laterality of surgery, type of AMH kit and participants' age (<40 years) still showed no statistically significant changes in circulating AMH. CONCLUSION: Salpingectomy does not seem to compromise ovarian reserve in the short-term. However, the long-term effect of salpingectomy on ovarian reserve remains uncertain.
    • Patent foramen ovale as a cause of platypnea orthodeoxia syndrome presenting in pregnancy: A case report and review of the literature

      Dewick, Laura; Ashworth, J (2016-06)
      Background At 8 weeks into her third IVF pregnancy, a 40-yearold doctor presented to the Royal Derby Hospital with dyspnoea. Her breathing had worsened since the drainage of 5 litres of ascites from ovarian hyperstimulation syndrome 3 weeks prior. Her symptoms deteriorated and she was intermittently hospitalised from 28 weeks, as she was unable to sit upright without desaturating to 75% in air. This presentation was consistent with Platypnea-Orthodeoxia Syndrome (shortness of breath and arterial desaturation when upright which improves when supine). Investigations including chest X-ray, VQ scan, CTPA, Spirometry, Echo and ECG were normal. Bubble echo was initially normal, but when repeated 2 weeks later it demonstrated a right to left shunt consistent with a patent foramen ovale (PFO). She underwent a caesarean section at 35 weeks following which her symptoms resolved entirely. Objectives To establish the incidence of PFO in women of reproductive age, presenting symptoms, diagnostic tests and options for management. Methods Review of recent literature via a web based search. Results Patent Foramen Ovale is known to affect up to 1 in 3 adults based on autopsy findings from around 1000 'normal' hearts. The incidence in those aged under 30 years is 34.3%, falling to 25.4% in the over 40s. Size is known to increase with age. PFO affects men and women equally, with no difference in size between genders. It has long been recognised as a cause of unexplained stroke, particularly in those under 55, where the incidence is thought to rise to 56%. The vast majority of adults are asymptomatic, although it is occasionally associated with clinical syndromes including decompression syndrome in scuba divers, migraine (particularly with aura) and rarely with Platypnea-orthodeoxia syndrome. The diagnosis is made via Echocardiography, with trans-oesophageal echo considered the gold standard. In the UK use of 'bubble echo' has improved detection, as saline contrast is injected into a peripheral vein during the valsalva manoeuvre, following which bubbles can be seen crossing the septum. Management options include secondary prevention of paradoxical embolic stroke with anticoagulation, and percutaneous transcatheter closure. This method has now been developed for use in the second trimester to allow closure with minimal fetal radiation exposure. Conclusion Patent foramen ovale is a relatively common phenomenon in women of childbearing age and should therefore feature in the differential diagnosis of worsening shortness of breath in pregnancy, especially if positional
    • Pelvic mass associated with raised CA 125 for benign condition: a case report.

      Asher, Viren (2012-04)
      BACKGROUND: Raised CA 125 with associated pelvic mass is highly suggestive of ovarian malignancy, but there are various other benign conditions that can be associated with pelvic mass and a raised CA 125. CASE PRESENTATION: We present a case of 19 year old, Caucasian British woman who presented initially with sudden onset right sided iliac fossa pain and on imaging was found to have 9.8 x 4.5 cm complex cystic mass in right adnexa with a raised CA 125 of 657, which was initially thought to be highly suspicious of cancer but was subsequently found to be due to pelvic inflammatory disease on histology. CONCLUSION: This case highlights the fact that though a pelvic mass with raised CA 125 is highly suggestive of malignancy, pelvic inflammatory disease should always be considered as a differential diagnosis especially in a young patient and a thorough sexual history and screening for pelvic infection should always be carried out in these patients.
    • Practical Guidance for Measuring and Reporting Surgical Margins in Vulvar Cancer

      Van Schalkwyk, Gerhard (2019-08)
      Surgical resection with free surgical margins is the cornerstone of successful primary treatment of vulvar squamous cell carcinoma (VSCC). In general reexcision is recommended when the minimum peripheral surgical margin (MPSM) is <8 mm microscopically. Pathologists are, therefore, required to report the minimum distance from the tumor to the surgical margin. Currently, there are no guidelines on how to make this measurement, as this is often considered straightforward. However, during the 2018 Annual Meeting of the British Association of Gynaecological Pathologists (BAGP), a discussion on this topic revealed a variety of opinions with regard to reporting and method of measuring margin clearance in VSCC specimens. Given the need for uniformity and the lack of guidance in the literature, we initiated an online survey in order to deliver a consensus-based definition of peripheral surgical margins in VSCC resections. The survey included questions and representative diagrams of peripheral margin measurements. In total, 57 pathologists participated in this survey. On the basis of consensus results, we propose to define MPSM in VSCC as the minimum distance from the peripheral edge of the invasive tumor nests toward the inked peripheral surgical margin reported in millimeters. This MPSM measurement should run through tissue and preferably be measured in a straight line. Along with MPSM, other relevant measurements such as depth of invasion or tumor thickness and distance to deep margins should be reported. This manuscript provides guidance to the practicing pathologist in measuring MPSM in VSCC resection specimens, in order to promote uniformity in measuring and reporting.
    • Prenatal thoraco-amniotic chest drain insertion to manage a case of fetal hydrops secondary to FOXC2.

      Gulati, Nidhi (2018-06)
      Lymphoedema-distichiasis is an inherited autosomal dominant disorder of the lymphatic system. Rarely, it is associated with fetal hydrops; the risk and severity of which increases with successive generations. The causative gene is a member of the forkhead transcription factor family (FOXC2). We describe a fetus presenting with early-onset, rapidly progressing body wall oedema, bilateral pleural effusions and a pericardial effusion in a mother with known FOXC2 mutation. First trimester chorionic villus sampling confirmed FOXC2 mutation in the fetus when there was only a large nuchal translucency. As the phenotype progressed, the couple consented to in utero ultrasound-guided insertion of sequential bilateral pleuro-amniotic chest drains (at 23 weeks) which successfully drained the pleural effusions. The fetus was delivered at 39 weeks gestation by elective caesarean section in good condition. The shunts were removed postnatally, and the baby was discharged after 7 days. This is the first case described of a fetus with severe early-onset fetal hydrops secondary to FOXC2 mutation successfully treated by the prenatal insertion of bilateral pleuro-amniotic shunts.
    • Preoperative serum albumin is an independent prognostic predictor of survival in ovarian cancer.

      Asher, Viren; Lee, Joanne; Bali, Anish (2011-07)
      Ovarian cancer is associated with high mortality due to asymptomatic nature of the disease and advance stage at presentation. In advanced stages, it is associated with cachexia and ascites leading to malnutrition. Nutritional status of a patient with cancer has been well known to be associated with survival and can be assessed by level of albumin in blood. Therefore, in this study, we sought to determine preoperative serum albumin as prognostic predictor of survival in patients with ovarian cancer. Preoperative serum albumin was determined in 235 patients undergoing surgery for ovarian cancer at Royal Derby Hospital. The prognostic predictive value of serum albumin, along with other prognostic markers was then analysed using univariate and multivariate analyses. Low serum albumin was associated with poor survival (P 35 g/l were associated with median survival of 43.2 months (95% CI 11.6-20.9). Serum albumin (P < 0.001) retained its significance as an independent predictor of poor survival on Cox's multivariate regression analysis along with Age (P < 0.001) and FIGO stage (P < 0.001). Serum albumin can be used as an independent prognostic predictor of survival in patients with ovarian cancer.
    • The prevalence of hyperprolactinaemia in subfertile ovulatory women and its impact on fertility treatment outcome.

      Amer, Saad; Jayaprakasan, Kanna
      Subtle hyperprolactinaemia is not an uncommon finding in ovulatory subfertile women. The objective of this study is to evaluate the prevalence of hyperprolactinaemia in subfertile ovulatory and oligo-anovulatory women, and to determine if hyperprolactinaemia influences fertility treatment outcome. All women (n = 1010) who attended the fertility clinic of a UK tertiary hospital during 2015-2019 were included. Out of 804 eligible women analysed, 575 women (71.5%) were ovulatory and 229 (28.5%) were oligo-anovulatory. Prevalence of hyperprolactinaemia was higher in the ovulatory group than in the oligo-anovulatory group (26.8% vs. 14.4%; OR: 2.2; 95% confidence interval (CI): 1.4-3.2). On sub-group analysis, the prevalence of mild, moderate and severe hyperprolactinaemia was 23.0%, 3.7% and 0.2% in ovulatory women and 11.8%, 1.7% and 0.9% in oligo-anovulatory women. Mild hyperprolactinaemia was found to be more prevalent in the ovulatory group (OR: 2.2; 95%CI: 1.4-3.5). Ongoing pregnancy/livebirth rates were similar between hyperprolactinaemic and normoprolactinaemic women (42.8% vs. 46.7%). Hyperprolactinaemia did not have an impact on ongoing pregnancy/livebirth rates in both ovulatory and oligo-anovulatory women (OR:0.8; 95%CI: 0.5-1.1; OR: 1.2; 95%CI: 0.6-2.5, respectively). Hyperprolactinaemia is prevalent among ovulatory women, although most had mildly raised clinically insignificant levels. Elevated prolactin levels in ovulatory women do not seem to impact on pregnancy outcome. Impact StatementWhat is already known on this subject? Prolactin has been linked to ovulation and fertility. Prolactin testing is not generally recommended for subfertile women with regular menstrual cycles, which is a surrogate marker of ovulation. However, some clinicians, particularly in the general practice, still perform prolactin test as part of baseline endocrine profile.What do the results of this study add? Prevalence of hyperprolactinaemia in subfertile ovulatory women was 26.8% (154/575), of which 86% (132/154) were mild. Further, the livebirth/ongoing pregnancy rates were similar between hyperprolactinaemic and normoprolactinaemic women. Prolactin being a sensitive hormone, responsive to even minimal stress and its high levels not influencing clinical pregnancy outcome, prolactin measurement is not needed in women having regular menstrual cycles.What are the implications of these findings for clinical practice and/or further research? Hyperprolactinaemia was not uncommon in ovulatory women, although most had mildly elevated levels. Hyperprolactinaemia did not have any impact on fertility treatment outcome. Serum prolactin should not be tested in ovulating women, as mild elevations are commonly present and have no clinical significance.
    • Prospective study of one-stop diagnostic and see-and-treat outpatient hysteroscopy service at Royal Derby Hospital

      Kolhe, Shilpa (2014-04)
      Introduction Abnormal uterine bleeding is the most common problem that a woman is referred with to a gynaecology clinic. This study evaluates the important role of a one-stop diagnostic, see-and-treat outpatient hysteroscopy service set up in an ambulatory gynaecology unit at Royal Derby Hospital. Methods This is a prospective study of 762 consecutive patients attending ambulatory hysteroscopy clinics. Ambulatory clinic included outpatient hysteroscopy (OPH) clinic, one-stop postmenopausal bleeding clinic and polyp treatment clinic. Results 323/762 (42.3%) patients were referred with postmenopausal bleeding (to one-stop PMB clinic); 148 (19.4%) with ultrasound diagnosis of endometrial polyp (to polyp treatment clinic); 262 (34%) with other menstrual disorders and other indications to other OPH clinics. Outpatient hysteroscopywas performedsuccessfully in 694 cases (success rate of 91%). In further 39 cases, OPH was attempted but abandoned due to cervical stenosis (n = 17), poor views (n = 10), severe vasovagal attack (n = 2) or patient discomfort (n = 10). OPH was performed using vaginoscopic approach in 60% cases. Among those with recorded BMI, 60 women attending OPH clinics had BMI over 40. 223 endometrial polyps and 37 cervical polyps were removed successfully in one-stop setting. Endometrial polyps were treated using either bipolar electrosurgical versapoint electrode (58%), mechanical hysteroscopic devices such as polyp snare or grasping forceps under direct vision (15.5%) or more recently miniature hysteroscopictruclearmorcellator (26.5%) enabling diagnosis and treatment of this common lesion in the same setting. Hysteroscopic retrieval of IUCD with lost threads was done in 100% cases (n = 22). Local anaesthetic was only required in 12% cases. In a patient satisfaction survey conducted in a random sample of 100 women, 94% said they were very satisfied or fairly satisfied with their OPH procedure and 89% reported pain scores of <2.9 on a visual analog scale (VAS) of 1-5. 59.7% (n = 455) seen in this one-stop clinic were reassured and discharged from the clinic with subsequent written notification of histology result; 31% (n = 234) had follow-up arranged for histology review either in oncology clinic if anticipated abnormal result or in general gynaecology clinic for any other reason to follow-up; 9.3% (n = 71) were added to waiting list for general anaesthetic procedure. Conclusion OPH is a safe, minimally invasive surgical procedure not only for diagnosis in women with abnormal uterine bleeding, but is also a feasible, cost-effective and patient-friendly way of treating the causes of abnormal bleeding in majority of cases in the same sitting.
    • Risk Algorithm Using Serial Biomarker Measurements Doubles the Number of Screen-Detected Cancers Compared With a Single-Threshold Rule in the United Kingdom Collaborative Trial of Ovarian Cancer Screening.

      Jenkins, Howard; Scott, Ian (2015-06)
      PURPOSE: Cancer screening strategies have commonly adopted single-biomarker thresholds to identify abnormality. We investigated the impact of serial biomarker change interpreted through a risk algorithm on cancer detection rates. PATIENTS AND METHODS: In the United Kingdom Collaborative Trial of Ovarian Cancer Screening, 46,237 women, age 50 years or older underwent incidence screening by using the multimodal strategy (MMS) in which annual serum cancer antigen 125 (CA-125) was interpreted with the risk of ovarian cancer algorithm (ROCA). Women were triaged by the ROCA: normal risk, returned to annual screening; intermediate risk, repeat CA-125; and elevated risk, repeat CA-125 and transvaginal ultrasound. Women with persistently increased risk were clinically evaluated. All participants were followed through national cancer and/or death registries. Performance characteristics of a single-threshold rule and the ROCA were compared by using receiver operating characteristic curves. RESULTS: After 296,911 women-years of annual incidence screening, 640 women underwent surgery. Of those, 133 had primary invasive epithelial ovarian or tubal cancers (iEOCs). In all, 22 interval iEOCs occurred within 1 year of screening, of which one was detected by ROCA but was managed conservatively after clinical assessment. The sensitivity and specificity of MMS for detection of iEOCs were 85.8% (95% CI, 79.3% to 90.9%) and 99.8% (95% CI, 99.8% to 99.8%), respectively, with 4.8 surgeries per iEOC. ROCA alone detected 87.1% (135 of 155) of the iEOCs. Using fixed CA-125 cutoffs at the last annual screen of more than 35, more than 30, and more than 22 U/mL would have identified 41.3% (64 of 155), 48.4% (75 of 155), and 66.5% (103 of 155), respectively. The area under the curve for ROCA (0.915) was significantly (P = .0027) higher than that for a single-threshold rule (0.869). CONCLUSION: Screening by using ROCA doubled the number of screen-detected iEOCs compared with a fixed cutoff. In the context of cancer screening, reliance on predefined single-threshold rules may result in biomarkers of value being discarded.
    • Serum Albumin as a Predictor of Survival after Interval Debulking Surgery for Advanced Ovarian Cancer (AOC): A Retrospective Study

      Phillips, A (2020-10)
      Objective: To investigate the impact of serum albumin (at diagnosis and pre-operatively) on survival in patients undergoing cytoreductive surgery for advanced ovarian cancer(AOC) and whether improvement in albumin achieved following neoadjuvant chemotherapy (NACT) affects overall survival (OS). Methods: Outcomes of 441 patients who underwent cytoreduction for AOC were reviewed. Albumin was recorded at diagnosis and pre-operatively. Further analysis was performed if patients were hypoalbuminaemic at diagnosis.Analysis was stratified according to whether the patientreceived primary debulking surgery (PDS) or interval debulking surgery (IDS) and if their albumin was corrected. Results: 308 patients had a serum albumin level at diagnosis and 400 patients had a pre-operative albumin available for analysis. For patients with an albumin at diagnosis ≤ 35g/L and ≥36 g/L, median OS was 31.5 (95% CI 23.5-39.5) and 50.4 (95% CI 38.9-61.9) months respectively (P = 0.003). Followingmultivariate analysis (MVA), albumin at diagnosis remained statistically significant as an independent marker for survival, even after adjusting for cytoreductive outcome, stage and grade(p = 0.04, Hazard ratio 1.38, 95% CI 1.01-1.89). Hypoalbuminaemic patients at diagnosis achieved complete cytoreduction in 53% of cases.For PDS patients, median OS was 19.7 months (95% CI 11.5-27.9). For IDS patients, median OS was 27.9 months (n = 1).IDS patients with a corrected albumin had a median OS of 42.9 months (95% CI 31.5-54.3) (p > 0.05). Conclusion: Hypoalbuminaemia at diagnosis is a poor prognostic factor in AOC. Normalization of serum albumin after NACT is a potential predictor of survival.
    • Setting up of ambulatory hysteroscopy service.

      Kolhe, Shilpa (2015-10)
      There is an obvious trend towards developing ambulatory procedures in gynaecology with ambulatory hysteroscopy as its mainstay. In the recent years, the fast pace of modern technological advances in gynaecologic endoscopy, and particularly in the field of hysteroscopy, have been both thrilling and spectacular. Despite this, the uptake of operative hysteroscopy in ambulatory settings has been relatively slow. There is some apprehension amongst gynaecologists to embark on therapeutic outpatient hysteroscopy, and an organisational change is required to alter the mindset. Although there are best practice guidelines for outpatient hysteroscopy, there are unresolved issues around adequate training and accreditation of future hysteroscopists. Virtual-reality simulation training for operative hysteroscopy has shown promising preliminary results, and it is being aggressively evaluated and validated. This review article is an attempt to provide a useful practical guide to all those who wish to implement ambulatory hysteroscopy services in their outpatient departments.
    • Skene’s Gland Derivatives in the Female Genital Tract and Cervical Adenoid Basal Carcinoma are Consistently Positive With Prostatic Marker NKX3.1

      Hawari, Rand; Fernandes, Larissa (2020-10)
      Cervical ectopic prostatic tissue and vaginal tubulosquamous polyp are rare lesions which exhibit variable, and often focal, immunohistochemical expression with traditional prostatic markers [prostate-specific antigen and prostatic acid phosphatase (PSAP)]. These lesions are thought to arise from periurethral Skene’s glands, the female equivalent of prostatic glands in the male. Adenoid basal carcinoma is a rare and indolent cervical neoplasm. Expression of the prostatic marker NKX3.1 in ectopic prostatic tissue and tubulosquamous polyp has been reported but no studies have examined immunoreactivity with this marker in adenoid basal carcinoma. We stained 19 cases [adenoid basal carcinoma (n=6), cervical ectopic prostatic tissue (n=11), and vaginal tubulosquamous polyp (n=3); 1 case contained both adenoid basal carcinoma and ectopic prostatic tissue] with NKX3.1. In all cases, the glandular component of these lesions exhibited diffuse nuclear immunoreactivity while normal endocervical glands were negative. Prostate-specific antigen was positive in 4 of 9 and 0 of 3 cases of ectopic prostatic tissue and tubulosquamous polyp, respectively, while PSAP was positive in 3 of 4 and 2 of 2 cases of ectopic prostatic tissue and tubulosquamous polyp respectively; 3 of 5 cases of adenoid basal carcinoma tested were focally positive with PSAP and all 5 were negative with prostate-specific antigen. While the specificity of NKX3.1 should be investigated in future studies, positivity with this marker may be useful in diagnosing these uncommon lesions. NKX3.1 appears a more sensitive marker of ectopic prostatic tissue and tubulosquamous polyp than traditional prostatic markers and positive staining provides further support that these lesions exhibit “prostatic” differentiation and are of Skene’s gland origin. NKX3.1 and PSAP positivity in adenoid basal carcinoma raises the possibility of an association with benign glandular lesions exhibiting prostatic differentiation and we critically discuss the possible association.
    • Socioeconomic differences impact overall survival in advanced ovarian cancer (AOC) prior to achievement of standard therapy.

      Phillips, A (2019-08)
      PURPOSE: Survival difference between socioeconomic groups with ovarian cancer has persisted in the United Kingdom despite efforts to reduce disparities in care. Our aim was to delineate critical episodes in the patient journey, where deprivation has most impact on survival. METHODS: A retrospective review of 834 patients with advanced ovarian cancer (AOC) between 16/8/07-16/2/17 at a large cancer centre serving one of the most deprived areas of the UK. Using the Index of Multiple Deprivation (IMD), patients were categorised into five groups. RESULTS: Surgery was more common in less deprived patients (p < 0.00001). Across IMD groups, there were no differences in complete (R0) cytoreduction rate (r = 0.18, p > 0.05), age, or comorbidity. The R0/total cohort rate increased with increasing IMD group (p < 0.0001). Patients refusing any intervention belonged exclusively to the three most deprived groups; 5/7 patients who refused surgery belonged to the most deprived IMD group. Overall survival in the total patient group was less in IMD group 1-2 compared to 9-10 (p = 0.002). On multivariate analysis, IMD group was not an independent predictor of survival (p > 0.05). CONCLUSIONS: Socioeconomic differences in survival manifest in patients not receiving surgical treatment for AOC and are not purely explained by comorbidity, age, stage, or histological factors.
    • The strength of evidence supporting luteal phase progestogen after assisted reproduction: A systematic review with reference to trial registration and pre-specified endpoints.

      Jayaprakasan, Kanna (2019-12)
      OBJECTIVE: To measure the potential for outcome switching and selective reporting, in trials of luteal phase progestogen in assisted reproduction. STUDY DESIGN: Trials identified through Medline and Embase in August 2017 using the MeSH term "assisted reproductive technology, luteal phase support" and associated text words. Randomised controlled trials (RCTs) comparing progestogen of any type, dose, and route of administration, with placebo or no treatment as luteal phase support in subfertile women undergoing in vitro fertilization (IVF) or intrauterine insemination (IUI). Eight trials after IVF and eleven after IUI, involving 1040 and 2764 participants respectively, were included. RESULTS: None of the eight trials of progestogen therapy after IVF had been registered. Only 5/11 trials of progestogen after IUI had been registered, and only two of these prospectively. One of these had a registered primary outcome of "pregnancy sac plus heartbeat", but reported "pregnancy sac alone"; we judged this as an altered primary outcome. Three other trial had a registered primary outcome of "clinical pregnancy undefined" and reported "intra or extra-uterine pregnancy with a heartbeat"; we judged this alteration as minimal. That trial was negative. Overall, 26 different outcomes had been reported by the various trials. The three outcomes reported most often were pregnancy undefined (9/19), miscarriage (11/19) and clinical pregnancy (9/19). This suggests considerable potential for selective outcome reporting or outcome switching. CONCLUSION: Apart from one negative trial, none of the evidence on luteal phase progestogen after assisted reproduction comes from prospectively registered trials: a slender reed indeed.
    • Synovial sarcoma of the vulva: a case report.

      Asher, Viren; Van Schalkwyk, Gerhard; Bali, Anish (2011-03)
      INTRODUCTION: Contrary to its name, synovial sarcoma does not arise from the synovial membrane but from multipotent stem cells and can present in any part of the body. Very few cases of vulval synovial sarcoma have been reported in the literature; we report on such a presentation. These tumors can present as painless lumps, which must be completely excised to give the best prognosis. Therefore the diagnosis of synovial sarcoma should always be kept in mind in the management of vulval masses, especially in young patients. CASE PRESENTATION: We report the case of a 28-year-old Caucasian woman with synovial sarcoma of the vulva. Complete excision was possible in this case. CONCLUSION: We have presented a rare case of synovial sarcoma of the vulva, which can be easily confused with lipoma of the vulva. The management of this tumor requires referral to a cancer centre, with a multidisciplinary approach.
    • The test accuracy of antenatal ultrasound definitions of fetal macrosomia to predict birth injury: A systematic review.

      Robinson, R (2020-03)
      OBJECTIVES: To determine which ultrasound measurement for predicted fetal macrosomia most accurately predicts adverse delivery and neonatal outcomes. STUDY DESIGN: Four biomedical databases searched for studies published after 1966. Randomised trials or observational studies of women with singleton pregnancies, resulting in a term birth who have undergone an index test of interest measured and recorded as predicted fetal macrosomia ≥28 weeks. Adverse outcomes of interest included shoulder dystocia, brachial plexus injury (BPI) and Caesarean section. RESULTS: Twenty-five observational studies (13,285 participants) were included. For BPI, the only significant positive association was found for Abdominal Circumference (AC) to Head Circumference (HC) difference > 50 mm (OR 7.2, 95 % CI 1.8-29). Shoulder dystocia was significantly associated with abdominal diameter (AD) minus biparietal diameter (BPD) ≥ 2.6 cm (OR 4.2, 95 % CI 2.3-7.5, PPV 11 %) and AC > 90th centile (OR 2.3, 95 % CI 1.3-4.0, PPV 8.6 %) and an estimated fetal weight (EFW) > 4000 g (OR 2.1 95 %CI 1.0-4.1, PPV 7.2 %). CONCLUSIONS: Estimated fetal weight is the most widely used ultrasound marker to predict fetal macrosomia in the UK. This study suggests other markers have a higher positive predictive value for adverse outcomes associated with fetal macrosomia.