Lyndal Anderson

Patterns of care and development of quality indicators in patients with non-epithelial and rare ovarian tumors in Australia: insights from the National Gynae-Oncology Registry

The Rare Ovarian Tumor Module forms part of the National Gynae-Oncology Registry (NGOR) which measures compliance with the optimal care pathways for gynecologic cancer in Australia. Our objectives were to evaluate patterns of care in patients with non-epithelial ovarian tumors and to develop appropriate clinical quality indicators. A multidisciplinary reference group developed a module dataset in the NGOR REDCap database to collect clinical data using an opt-out recruitment model across participating Australian hospitals. Clinical quality indicators were developed and refined using consensus methods, with annual reports provided to participating sites to benchmark performance and drive improvement in patient care. As of November 2023, 232 patients from 18 Australian hospitals were enrolled. All cases had histologic confirmation with the majority being adult granulosa cell tumors (47.8%). Almost all patients (97.8%) were presented at a multidisciplinary team meeting. Most had early-stage disease (stage, I 70.3%; II 9.9%; III 9.1%; IV 3.4%; not documented 7.3%) and had surgery alone (72.4%). Thirty-four patients underwent multiple surgeries as primary treatment (14.7%), with a median time to a second surgical procedure of 47 days (interquartile range 36-71). Two-thirds of patients (65.4%) had their first surgery performed by a gynecologic oncologist. Rates of intra-operative and 30-day post-operative adverse events (Clavien-Dindo ≥ grade III) were low, 4.3% and 1.9% respectively. Of 52 patients with stage II disease and higher, 37 (71.2%) received systemic therapy. A high rate of adherence to the 4 clinical quality indicators as measures of best practice care was observed. The NGOR Rare Ovarian Tumor Module has successfully collated relevant data to study patterns of care to inform the development of clinical quality indicators and enable research for these rare tumors. This national collaboration has the potential for benchmarking outcomes in Australia with international experience.

Controversies in the management of ovarian granulosa cell and Sertoli-Leydig cell tumors

Ovarian sex cord-stromal tumors are rare and include adult granulosa cell tumors, juvenile granulosa cell tumors, and Sertoli-Leydig cell tumors. Adult granulosa cell tumors the most prevalent malignant ovarian sex cord stromal tumors are the focus of the review which synthesizes published data to highlight the diagnostic challenges and the controversies surrounding the management of adult granulosa cell tumors, juvenile granulosa cell tumors, and Sertoli-Leydig cell tumors. Adult granulosa cell tumors have frequently been misdiagnosed, with up to 30% of cases reassigned after a contemporary review of historical cases, which could affect the interpretation of older studies. Diagnostic accuracy improved in 2009 following the identification of a somatic FOXL2 c.402C>G missense point in almost all adult granulosa cell tumors. Surgery is the mainstay of treatment at diagnosis and recurrence, and fertility-sparing surgery is recommended for younger patients with stage 1 ovarian sex cord-stromal tumors. The role of adjuvant chemotherapy in stage I high-risk adult granulosa and Sertoli-Leydig cell tumors remains controversial, with guidelines providing varied and conflicting recommendations based on limited evidence. Surveillance strategies, including the frequency of follow-up, duration of surveillance, sensitivity, and specificity of tumor markers, and the timing and nature of imaging, are debatable. We reviewed the evolution of systemic therapy for ovarian sex cord-stromal tumors over the last 4 decades and raised questions regarding the choice of chemotherapy regimens and evidence to support adjuvant chemotherapy. The efficacy of endocrine therapy in adult granulosa cell tumors is contentious, and most studies are retrospective with variable criteria to define response and clinical benefit. The available data are discussed, including trials in progress. In conclusion, the management of ovarian sex cord-stromal tumors requires a nuanced understanding of their unique pathologic and biological characteristics and an appreciation of the limitations of the existing evidence. There is a high priority to encourage international collaboration through prospective data collection and randomized trials to provide the required evidence to support treatment guidelines and ultimately improve patient outcomes.

Endocrine cells micronests and ossification associated with an ovarian mucinous neoplasm: two rare findings

The impact of primary human papillomavirus screening on negative loop excision histology following biopsy‐proven high‐grade cervical intra‐epithelial lesions: A review from a large tertiary colposcopy unit

BackgroundThe renewed National Cervical Screening Program incorporating primary human papillomavirus (HPV) screening was implemented in Australia in December 2017. In a previous study conducted in the UK, primary HPV screening was found to be associated with a 25% reduction in the incidence of negative histology following loop electrosurgery excision procedure (LEEP).AimTo examine the change in incidence and associated risk factors for a negative LEEP with introduction of primary HPV screening.Materials and MethodsA retrospective review of the records of all patients undergoing a LEEP excision for biopsy‐proven high‐grade cervical intra‐epithelial lesions between 1 January 2014 and 30 June 2019 in a specialised centre.ResultsThere were 1123 patients who underwent a LEEP included in the analysis. The incidence of a negative LEEP specimen was 7.5% (59/784) and 5.3% (18/339) in the pre‐ and post‐HPV screening cohort. More patients in the post‐HPV screening group had low‐grade cytology on referral (P < 0.001), smaller cervical lesions on colposcopy (P = 0.012) and longer biopsy to treatment interval (P = 0.020). Primary HPV screening was associated with a significant reduction in the incidence of a negative LEEP specimen in a propensity matched cohort (11.2% to 5.1%, P = 0.006) and a 41% (P = 0.045) decreased relative risk of a negative LEEP on multivariate analysis.ConclusionsPrimary HPV screening results in a lower incidence of negative LEEP histology, despite a longer biopsy to treatment wait time and higher proportion of low‐grade cytology at triage.

Malignant sex cord tumour of the ovary in Peutz‐Jeghers syndrome

Follow‐up after treatment of high‐grade cervical dysplasia: The utility of six‐month colposcopy and cytology and routine 12‐month colposcopy

BackgroundAustralian Cervical Screening Program guidelines no longer recommend colposcopy and cytology at six months following treatment of cervical intraepithelial neoplasia (CIN2/3) and a co‐test of cure can be performed at 12 months without colposcopy.AimsTo determine the usefulness of six‐month colposcopy and cytology and routine colposcopy with co‐testing at 12 months in detecting persistent or recurrent disease in patients treated for CIN2/3.Materials and MethodsWe conducted a review of all patients with histologically proven CIN2/3 who underwent a cervical excisional procedure between March 2012 and March 2017 in one specialised centre.ResultsWe examined 1215 cases and 750 remained after exclusions for analysis. At six months (722 cases, 96.2%) seven of 42 (16.7%) patients with high‐grade cytology had a high‐grade colposcopy and 24 of 42 (57.1%) had a normal colposcopy. Persistent CIN2/3 was diagnosed in 12 cases (1.7%) and only 1/3 had a high‐grade colposcopy. Cytology was more useful than colposcopy in detecting persistent disease. At 12 months (638 cases, 85%) routine colposcopy at the time of co‐testing had a high false positive rate with all high‐grade changes negative on biopsy and co‐test. Recurrent CIN2/3 was diagnosed in five cases, and four had normal colposcopy at co‐testing.ConclusionsThere may be a delay in detection of persistent/recurrent CIN2/3 in a small number of cases without six‐month colposcopy and cytology; however, it is not likely to negatively impact overall clinical outcome. Co‐testing at 12 months following treatment of CIN2/3 without colposcopy is safe and routine colposcopy at collection of the co‐test can be omitted.