Erica R. Hope

The art of cold knife conization: a demonstration of technique in live patients and a low-fidelity simulation model

Cervical excision via cold knife conization is recommended for conditions, such as adenocarcinoma in situ or predominantly endocervical high-grade dysplasia. A successful cold knife conization involves visualization, targeting of the pathology, obtaining an unfragmented specimen, and consideration of postexcision endocervical curettage. This article presents a video that demonstrates cold knife conization techniques to facilitate pathologic analysis and a low-fidelity simulation model for learners. The video depicts 2 cold knife conizations in nulliparous patients with (1) high-grade lesion on endocervical curettage and (2) high-grade dysplasia on ectocervical biopsy. In addition, this article demonstrates a low-fidelity simulation model that can be used to familiarize physicians with the conization procedure and essential hemostatic techniques. Although the authors acknowledge the limitations of the model to include lack of bleeding, corresponding patient cases demonstrate essential hemostatic techniques. Using standard surgical instruments, cold knife conization was performed for both patients, allowing for the excision of an appropriately sized intact specimen. Differences in technical approach when excising the ectocervix vs the endocervix were detailed. Endocervical curettage was performed after specimen removal, and the tissue bed was made hemostatic. Both conizations were performed without complication, and negative margins were achieved. In the simulation model, easily obtainable supplies, including small cups, balloons, cling wrap, cotton balls, and hot dogs, were used to create an imitation cervix. This can allow for demonstration and practice with suture placement, excision of an intact specimen, and hemostatic techniques. Using proper technique for adequate cold knife conization specimens facilitates pathologic analysis of dysplasia, cancer, and margin status. Negative margins have a substantial effect on recurrence and the need for future cervical procedures, which may affect future obstetrical outcomes. Low-fidelity simulation models can provide accessible avenues for technical familiarization and training in this procedure.

Management of Endometrial Cancer Precursors in the Military Health System: A Survey-Based Study

ABSTRACT Introduction Endometrial intraepithelial neoplasia (EIN) and atypical endometrial hyperplasia (AEH) are precancerous pathologies which carry a 40-50% concurrent cancer incidence. National guidelines recommend an individualized approach to gynecologic oncologist (GO) referral for a new EIN-AEH diagnosis. With the risk of underlying carcinoma, exactly who should manage EIN-AEH is controversial. In the military health system, gynecologic specialists (GS) may be remote with significant barriers to GO consultation, presenting a complex medical and social burden with potential impact to mission readiness. To our knowledge, no study has evaluated EIN-AEH practice patterns in the military health system. As practice patterns may vary, we surveyed EIN-AEH management by active duty GS and GO. Materials and Methods An observational, voluntary, tri-service, survey-based study was conducted (eIRB protocol #966986) using two web-based surveys designed by military GO: one completed by active duty GS, the other by active duty GO. Demographics examining influential factors were collected. Surveys examined attitudes and practice patterns regarding referral and management of EIN-AEH. Univariate analysis was performed. Results Of eligible physicians, 72 of 269 GS (26.8%) and 18 of 19 GO (94.7%) responded. More than 80% of GS/GO completed military medical training (81.9% vs. 88.9%), 72.2% vs. 61.1% were specialty-specific board-certified, 72.2% vs. 88.9% had a CONUS assignment, and 52.8% vs. 100% were part of large gynecologic surgery and obstetrics (GS&O) departments, respectively. Most GS (61.1%) had access to a GO at their facility or within 60 miles and 56.9% had no formal EIN-AEH policy. Half of GS (50%) were willing to manage EIN-AEH in an appropriately counseled and biopsied patient; however, less than a quarter (23.6%) felt comfortable with fertility-sparing management. Most GS (68%) were willing to perform EIN-AEH surgical management if GO back-up was available and 83.5% of GOs indicated willingness to provide virtual consultation. When offered co-management with GO virtual consultation, GS expressed a 3-fold increased comfort with hysterectomy surgical management, including those stationed overseas (OR = 3.10; 95% CI = 1.55-6.21, P < .0014; overseas P = NS), and an 8-fold increased comfort with fertility-sparing management (OR = 7.86; 95% CI = 3.73-16.4, P < .0001). Conclusions Management and referral of EIN-AEH by military GS varies widely with no policy at most facilities. A solution is needed, particularly in remote and overseas locations, to reduce medical, health system and social burden, and to conserve the fighting strength.

Best Practice Recommendations for Endometrial Intraepithelial Neoplasia/Atypical Endometrial Hyperplasia in the Military Health System

ABSTRACT Endometrial cancer is the most prevalent gynecologic cancer in the United States and has rising incidence and mortality. Endometrial intraepithelial neoplasia or atypical endometrial hyperplasia (EIN-AEH), a precancerous neoplasm, is surgically managed with hysterectomy in patients who have completed childbearing because of risk of progression to cancer. Concurrent endometrial carcinoma (EC) is also present on hysterectomy specimens in up to 50% of cases. Conservative medical management with progestins and close surveillance can be employed for certain populations after evaluating for concurrent EC. Currently, national professional guidelines recommend an individualized approach based on community access to care and patient factors. There is, however, no US civilian consensus on who should primarily manage EIN-AEH: Physician gynecologic specialists (GSs) and/or gynecologic oncologist (GO) subspecialists. Military health care presents an additional challenge with beneficiaries stationed at remote or overseas locations. While patients may not have local access to a GO subspecialist, many locations are staffed with GSs. Travel for care with a GO incurs additional cost for the patient and the military health care system, removes patients from local support systems, and can impact mission readiness. To provide the best care, optimize clinical outcomes, and avoid over- or under-treatment, military-specific guidelines for EIN-AEH management are needed. We propose a clinical decision tree incorporating both GS and GO subspecialists in the care of military beneficiaries with EIN-AEH. The subject matter expert panel recommends referral of EIN-AEH to a military (preferrable) or civilian GO for management if local access is available within 100 miles[Q1] . If travel of >100 miles is required, the patient should be offered the choice of a military GO referral if available within 250 miles (preferred) versus management by a GS. If travel is >100 miles from a GO or the patient declines a GO referral, the panel recommends that the GS should attempt to exclude concurrent EC by performing a hysteroscopic assessment of the endometrium with a directed biopsy, if not already done. A pelvic ultrasound should be obtained to evaluate the endometrial thickness (>2 cm more likely to harbor EC) along with a secondary gynecologic pathology review with immunohistochemical testing for Lynch syndrome (MLH1, MSH2, MSH6, and PMS2) and p53 expression. If any major additional risk factors are uncovered, the patient should be referred to a GO subspecialist for further management. If no additional major risk factors for concurrent EC are identified and hysteroscopy with expert gynecologic pathology review confirms no presence of EC in the pathology specimen, a virtual consultation and counseling with a military GO can be offered, with local surgical and/or medical management provided by a GS. If on subsequent pathology, EC is identified, the patient should be referred to a GO for further treatment considerations and counseling. Determining the optimal treatment for patients with EIN-AEH is nuanced and, within the military health care system, is complicated by varied access to expert management by a GO subspecialist. Military beneficiaries with this diagnosis present a unique challenge and warrant a standardized approach to maximize clinical outcomes.