Sean Kehoe

Diagnostic tests for ovarian cancer in premenopausal women with non-specific symptoms (ROCkeTS): prospective, multicentre, cohort study

Abstract Objective To investigate the accuracy of risk prediction models and scores for diagnosing ovarian cancer in premenopausal women presenting to secondary care with symptoms and abnormal test results. Design Prospective cohort study. Setting Secondary care in 23 hospitals in the UK between June 2015 and March 2023. Participants Premenopausal women presenting with non-specific symptoms, and raised serum levels of cancer antigen 125 or abnormal imaging results, were prospectively recruited, predominantly referred through the NHS urgent suspected cancer pathway from primary care. A head-to-head comparison of the accuracy of the six risk prediction models and scores was conducted using donated blood and ultrasound scans performed by NHS staff trained in the use of International Ovarian Tumour Analysis (IOTA) imaging terminology. The index tests used were Risk of Malignancy Index 1 (with pre-stated thresholds of 200, 250), Risk of Malignancy Algorithm (7.4%, 11.4%, 12.5%, 13.1%), IOTA Assessment of Different Neoplasias in the adnEXa (ADNEX) (3%, 10%), IOTA simple rules risk model (3%, 10%), IOTA simple rules, and cancer antigen 125 (CA 125, 87 IU/mL). Participants were classified as having primary invasive ovarian cancer versus having benign or normal pathology according to the reference standard determined from surgical specimens or biopsies by histology or cytology, if undertaken, or else at 12 month follow-up. After June 2018, because of covid restrictions and concerns about sample size, recruitment was restricted to only women undergoing surgery within three months of presentation to clinic (in whom ovarian cancer was more likely). Main outcome measures Diagnostic accuracy at predicting primary invasive ovarian cancer versus benign or normal histology, assessed by analysing the sensitivity, specificity, C index, area under receiver operating characteristic curve, positive and negative predictive values, and calibration plots in participants with conclusive reference standard results and available index test data. Results 88 of 1211 premenopausal women received diagnoses of primary ovarian cancer: 49 of 857 women in the pre-June 2018 cohort (prevalence of 5.7%) and 39 of 354 women in the post-June 2018 cohort (11.0%). For the diagnosis of primary ovarian cancer (n=799 women, after exclusion of 58 other diagnoses), Risk of Malignancy Index 1 at the 250 threshold had a sensitivity of 42.6% (95% confidence interval (CI) 28.3 to 57.8; specificity 96.5%, 94.7 to 97.8). Compared with Risk of Malignancy Index 1 at the 250 threshold, CA 125 and all other tests had higher sensitivity (CA 125 at 87 IU/mL threshold: 55.1%, 40.2 to 69.3, P=0.06; Risk of Malignancy Algorithm at 11.4% threshold: 79.2%, 65.0 to 89.5, P<0.001; IOTA ADNEX at 10% threshold: 89.1%, 76.4 to 96.4, P<0.001; IOTA simple rules risk at 10% threshold: 83.0%, 69.2 to 92.4, P<0.001; IOTA simple rules: 75.0%, 56.6 to 88.5, P=0.01) and lower specificity (CA 125 at 87 IU/mL threshold: 89.0%, 86.5 to 91.2, P<0.001; Risk of Malignancy Algorithm at 11.4% threshold: 73.1%, 69.6 to 76.3, P<0.001; IOTA ADNEX at 10% threshold: 75.1%, 71.4 to 78.6, P<0.001; IOTA simple rules risk at 10% threshold: 76.0%, 72.4 to 79.3, P<0.001; IOTA simple rules: 95.2%, 93.0 to 96.9, P=0.06). Results for IOTA simple rules were inconclusive in 120 of 799 participants. Analysis of the complete cohort (n=1211), including the 354 premenopausal women with a higher likelihood of developing ovarian cancer, yielded similar results. Conclusions Compared to Risk of Malignancy Index 1 at 250 threshold—the test currently used in NHS secondary care to triage women to tertiary care—most tests improve sensitivity but reduce specificity. Ultrasound triage with the IOTA ADNEX model at 10% in secondary care demonstrated the highest sensitivity gain, with a comparable decline in specificity to other comparator tests. Ultrasound with the IOTA ADNEX model at 10% should be considered the new standard of care test for triaging premenopausal women in secondary care. Implementation should incorporate staff training and quality assurance. Trial registration ISRCTN17160843 .

FIGO staging of endometrial cancer: 2023

Many advances in the understanding of the pathologic and molecular features of endometrial cancer have occurred since the FIGO staging was last updated in 2009. Substantially more outcome and biological behavior data are now available regarding the several histological types. Molecular and genetic findings have accelerated since the publication of The Cancer Genome Atlas (TCGA) data and provide improved clarity on the diverse biological nature of this collection of endometrial cancers and their differing prognostic outcomes. The goals of the new staging system are to better define these prognostic groups and create substages that indicate more appropriate surgical, radiation, and systemic therapies. The FIGO Women's Cancer Committee appointed a Subcommittee on Endometrial Cancer Staging in October 2021, represented by the authors. Since then, the committee members have met frequently and reviewed new and established evidence on the treatment, prognosis, and survival of endometrial cancer. Based on these data, opportunities for improvements in the categorization and stratification of these factors were identified in each of the four stages. Data and analyses from the molecular and histological classifications performed and published in the recently developed ESGO/ESTRO/ESP guidelines were used as a template for adding the new subclassifications to the proposed molecular and histological staging system. Based on the existing evidence, the substages were defined as follows: The updated 2023 staging of endometrial cancer includes the various histological types, tumor patterns, and molecular classification to better reflect the improved understanding of the complex nature of the several types of endometrial carcinoma and their underlying biologic behavior. The changes incorporated in the 2023 staging system should provide a more evidence-based context for treatment recommendations and for the more refined future collection of outcome and survival data.

Strategic approaches for global cervical cancer elimination: An update review and call for national action

AbstractCervical cancer remains a major health burden, particularly in low‐ and middle‐income countries, despite being one of the most preventable cancers. WHO's 90–70–90 targets aim to eliminate cervical cancer globally by 2030. These targets include 90% of girls fully vaccinated with the HPV vaccine by the age of 15 years, 70% of women screened using a high‐performance test by the age of 35 years and again by 45 years, and 90% of women with cervical disease receiving appropriate treatment. Achieving these goals requires coordinated national efforts to strengthen health systems, ensure equitable access to care, and integrate cervical cancer control into broader health policies. This review outlines key strategic approaches, including the transition from conventional screening methods to HPV‐based screening, the adoption of innovative triage techniques, the implementation of single‐dose HPV vaccination, and the integration of primary treatment with palliative care. The strategy places strong emphasis on addressing health inequities, enhancing monitoring systems, and fostering partnerships between governments, non‐governmental organizations, and the private sector. With concerted global and national action, the elimination of cervical cancer is not only a possibility but an imminent reality.

Synchronous ovarian and Bartholin gland carcinoma: Case report and review of literature

AbstractTo our knowledge, this is the first reported case of synchronous ovarian and vulva (Bartholin gland) cancer. A postmenopausal woman presented with a complex multiloculated left adnexal mass and 2‐cm right Bartholin gland mass. CA 125 was 59 IU/mL. Computed tomography of chest, abdomen, and pelvis showed a very large (32 × 13.5 × 22.5 cm) complex mass arising from the pelvis and extending to the level of the T12/L1 disk space. A right Bartholin mass with suspicious right inguinal nodes was seen. Midline laparotomy, total abdominal hysterectomy, bilateral salpingo‐oophrectomy, infracolic omentectomy, pelvic peritoneal biopsies, and peritoneal washings were carried out. Wide local excision of the right Bartholin gland mass was carried out in the same setting. Histopathology came back as Stage 2B left ovarian clear‐cell carcinoma and synchronous right Bartholin gland adenoid cystic carcinoma with lymphovascular invasion, incompletely excised, staged at least FIGO Stage 1B. Following local multidisciplinary team discussion and positron emission tomography scan review, the local committee agreed to start three cycles of adjuvant chemotherapy then proceed with Bartholin gland scar re‐excision and bilateral groin lymph node dissection. After the three cycles, the groin lymph nodes came back as metastatic adenocarcinoma with overall morphologic and immunohistochemical features consistent with metastatic ovarian clear‐cell carcinoma. Postoperative adjuvant chemotherapy was given. Initial follow‐up period over 9 months was uneventful.

FIGO staging in ovarian carcinoma and histological subtypes