Australian and New Zealand Journal of Obstetrics and Gynaecology

Management and long‐term outcomes of women with adenocarcinoma in situ of the cervix: A retrospective study

BackgroundAdenocarcinoma in situ of cervix is increasingly managed by local excision rather than hysterectomy and this study will ascertain if conservative management by excision alone is adequate.AimsTo evaluate the long‐term outcomes of conservative management of adenocarcinoma in situ of cervix, particularly in relation to excisional margin status.Materials and MethodsRetrospective analysis of women diagnosed with adenocarcinoma in situ and their management between 1992 and 2010 retrieved from the Victorian Cervical Cytology Registry, Australia. Failure of conservative treatment is defined by histologically proven adenocarcinoma in situ or adenocarcinoma at follow‐up after negative excisional margins.Resultsadenocarcinoma in situ of the cervix was managed primarily with cold knife cone biopsy or loop electrosurgical excision of the cervix. Most excisions were in one piece (83.4%) with average depth of 16.1 mm and 21.9% had involved excisional margins. Women with adenocarcinoma in situ on any excisional margin were more likely to have residual or recurrent disease (28.7%) compared with negative excisional margins (4.3%). Residual adenocarcinoma in situ was twice as common if adenocarcinoma in situ was present at endocervical (29.6%) and stromal (23.1%) margins compared with an ectocervical margin (13.6%). Cancer incidence at follow‐up was 2.3% for women with positive excisional margins compared to 1.3% with negative margins.ConclusionsWomen with adenocarcinoma in situ of cervix can be managed with local excisional procedures, best in single pieces to provide the important information on excisional margins. Adenocarcinoma in situ at endocervical and stromal excisional margins needs re‐excision or where appropriate, hysterectomy, while negative excisional margins have a low rate of recurrence and can be followed up with test of cure.

Mucinous ovarian carcinoma: A survey of practice in Australia and New Zealand

AbstractBackgroundMucinous ovarian carcinoma (MOC) is a rare ovarian cancer with limited evidence to support clinical care.AimsWe undertook a clinician survey to better understand current practice in treating MOC in Australia and New Zealand, and to determine any features associated with variation in care. In addition, we aimed to understand future research priorities.MethodsA RedCap survey was distributed to clinician members of the Australia New Zealand Gynaecological Oncology Group (ANZGOG). Questions included respondent demographics, three case studies and future research priorities. Clinicians were asked questions specific to their speciality.ResultsRespondents (n = 47) were commonly experienced gynae‐oncology specialists, most often surgical (38%) or medical (30%) oncologists. There was good consensus for surgical approaches for stage I disease; however, variation in practice was noted for advanced or recurrent MOC. Variation was also observed for medical oncologists; in early‐stage disease there was no clear consensus on whether to offer chemotherapy, or which regimen to recommend. For advanced and recurrent disease a wide range of chemotherapy options was considered, with a trend away from an ovarian‐type toward gastrointestinal (GI)‐type regimens in advanced MOC. This practice was reflected in future research priorities, with ‘Is a GI chemotherapy regimen better than an ovarian regimen?’ the most highly ranked option, followed by ‘Should stage 1C patients receive chemotherapy?’ConclusionsAlthough the number of respondents limited the analyses, it was clear that chemotherapy selection was a key point of divergence for medical oncologists. Future research is needed to establish well‐evidenced guidelines for clinical care of MOC.

The socioeconomic gradient in mortality from ovarian, cervical, and endometrial cancer in Australian women, 2001–2018: A population‐based study

BackgroundSocio‐economic (SE) status is closely linked to health status and the mechanisms of this association are complex. One important adverse effect of SE disadvantage is vulnerability to cancer and cancer is a major cause of morbidity and mortality in Australia.AimsWe aimed to estimate the effect of SE status on mortality rates from ovarian, cervical, and endometrial cancer.Materials and MethodsNational mortality data were obtained from the Australian Bureau of Statistics (ABS) for the calendar years from 2001 to 2018, inclusive. Individual deaths were grouped by the ABS Index of Relative Socio‐economic Advantage and Disadvantage. Population data were obtained to provided denominators allowing calculation of mortality rates (deaths per 100 000 women aged 30–79 years). Statistical analyses performed included tabulating point‐estimates of mortality rates and their changes over time and modelling the trends of rates using maximum likelihood method.ResultsAge‐standardised mortality rates for ovarian and cervical cancer fell over the study period but increased for endometrial cancer. There was clear evidence of a SE gradient in the mortality rate for all three cancers. This SE gradient increased over the study period for ovarian and cervical cancer but remained unchanged for endometrial cancer.ConclusionsWomen at greater SE disadvantage have higher rates of death from the commonest gynaecological cancers and this gradient has not reduced over the last two decades. After the COVID‐19 pandemic efforts must be redoubled to ensure that Australians already at risk of ill health do not face even greater risks because of their circumstances.

Audit of waiting time‐to‐treatment of atypical endometrial hyperplasia

BackgroundAtypical endometrial hyperplasia (AEH) is the precursor lesion in endometrial carcinoma, the most common gynaecological malignancy in New Zealand, with inequities in disease burden and outcome for Māori and Pacific women.AimsIn women diagnosed with AEH at two hospitals, to audit five standards of care for surgical management and time‐to‐treatment, and identify variation in care by ethnicity and other factors.Materials and MethodsDemographic, referral, diagnostic and treatment characteristics were collected for women with a new AEH diagnosis between 1/1/2019 and 31/12/2020. Surgical management and time‐to‐treatment were audited against Royal College of Obstetricians and Gynaecologists and New Zealand Ministry of Health Faster Cancer Treatment recommendations.ResultsOf 124 participants, 60% were Pacific, 86% premenopausal, and 80% had obesity. For 55 women managed surgically, surgical standards of care were met. There were delays between referral, diagnosis and treatment – only 18% and 56% of women met the 62‐day (referral to treatment) and 31‐day (decision‐to‐treat to treatment) targets, respectively. Wait times were prolonged for women who had dilation and curettage (vs pipelle), magnetic resonance imaging (MRI) (vs no MRI), and surgery (vs medical management). Ethnic disparities were not identified for any standard.DiscussionDelays to treatment were found throughout women's journeys. Hospital services can streamline their clinical pathways for women referred for abnormal uterine bleeding, flagging obesity as a high suspicion for cancer indicator, increasing access to endometrial sampling in primary care and establishing ‘one‐stop‐shop’ outpatient assessment with empiric initiation of intrauterine progestogen.

Safety and feasibility of hyperthermic intraperitoneal chemotherapy during interval cytoreductive surgery in patients with advanced high‐grade serous ovarian, fallopian tube, peritoneal cancer in an Australian context

AimsTo assess the safety and feasibility of hyperthermic intraperitoneal chemotherapy (HIPEC) during cytoreduction surgery (CRS) in advanced high‐grade serous ovarian, fallopian tube and peritoneal cancer within an Australian context.MethodsData were collected from 25 consecutive patients undergoing CRS and HIPEC from December 2018 to July 2022 at the Peritoneal Malignancy Service at the Mater Hospital Brisbane, Australia. Data collected included demographics, clinical variables, surgical procedures and complications and intra‐operative and post‐operative indexes of morbidity.ResultsTwenty‐five women who underwent CRS and HIPEC from December 2018 to July 2022 were included in analysis. Findings indicate that CRS with HIPEC is associated with low morbidity.ConclusionWhile judicious patient selection is imperative, HIPEC during CRS was well tolerated by all patients and morbidity was comparable to results from the previously reported OVHIPEC‐1 trial. HIPEC appears to be a safe and feasible addition to CRS for the treatment of advanced ovarian cancer in Australian practice.

Accuracy of Self‐Reported Cervical Screening Status Among Pregnant Women

ABSTRACT Background Pregnancy provides a special opportunity to improve cervical screening test (CST) uptake and reduce cervical cancer. Screening in Australia is free for Medicare‐eligible women ≥ 25 years if performed 5‐yearly, but not sooner. Either women's self‐reported last CST date or the National Cancer Screening Register (NCSR) can inform screening needs. However, accessing the NCSR is relatively difficult in public antenatal care. Aims To assess if pregnant women's self‐reported last CST year is reliable in determining whether to offer CST in pregnancy or not. Methods A retrospective Australian hospital study compared the self‐reported last CST recorded in the maternity database to NCSR records for all Medicare‐eligible women ≥ 25 years booked‐in for public antenatal care between 1 June and 30 November 2023. Results The cohort ( n  = 1772) had median age 33 years (interquartile range 29–36). Nearly half ( n  = 862; 49%) were CST‐overdue/never‐screened. Self‐reported last CST dates were concordant with the NCSR for 80% ( n  = 1420) of participants in terms of needing (35%) or not needing (45%) a CST. However, 244 (14%) over‐reported being CST‐current when they were actually overdue/never‐screened, while 108 (6%) under‐reported their CST‐currency. Of the 862 women due for a CST, over‐reporting represented 28%. If clinicians relied solely on self‐reporting, these women would miss out on needed CST screening. Conclusion Measures to improve the reliability of Australian women's self‐reported last CST are needed. This includes clinicians ensuring a woman always knows if a CST has been collected, the NCSR sending CST results to women (not just their practitioners) and promoting easier NCSR database accessibility for women.

An endometrial thickness of <12 mm does not exclude malignancy or pre‐malignancy in cases of abnormal uterine bleeding: An observational study

BackgroundIt remains unclear if there is an endometrial thickness (ET) threshold below which malignancy can be excluded. Guidance on whether endometrial biopsy is needed based on ET varies among regions in New Zealand and there is a desire to standardise guidance nationwide. This study evaluates the potential impact of limiting endometrial biopsy in pre‐menopausal persons with abnormal uterine bleeding (AUB) to those with an ET of less than 12 mm.AimsTo determine the number of pre‐menopausal patients with AUB with an ET of less than 12 mm undergoing endometrial sampling annually and assess the prevalence of pathology among these patients.Materials and MethodsEndometrial samples from patients aged 18–50 years processed at a tertiary hospital between 15/06/2022 and 13/06/2023 were identified via a pathology lab search. Clinical, radiologic, and pathological data were obtained by case note review for those with AUB whose ET was less than 12 mm.ResultsOf 1271 endometrial samples, 355 patients met the eligibility criteria, and 2.2% of these were cancerous (three cases) or pre‐malignant (five cases).ConclusionsIf sampling thresholds would change to not perform biopsies in those with an ET of less than 12 mm, eight cases of treatable disease would be missed in pre‐menopausal people. This represents 13.6% of all endometrial cancers diagnosed in pre‐menopausal people in the same time period. There is no ET cut‐off to reliably exclude high‐risk pathology and endometrial sampling should be performed in all cases of AUB with risk factors.

Management of Molar‐Pregnancy and Associated Gestational Trophoblastic Neoplasia at a Specialised Unit: 10‐Year Review

ABSTRACT Patients diagnosed with gestational trophoblastic diseases (GTD) can develop malignant gestational trophoblastic neoplasia (GTN). ß‐hCG monitoring is important in the early detection of GTN. The primary outcome of this study was to describe ß‐hCG monitoring completion rates and time from GTN diagnosis to chemotherapy commencement for patients cared for by a specialised GTD unit within a Gynecologic Oncology department. Secondary outcomes included imaging findings, quantitative ß‐hCG levels and gestational age at the time of GTD diagnosis, WHO/FIGO scores and chemotherapy outcomes for those who developed GTN, and the time taken for ß‐hCG normalisation for both groups. We collected data for 164 patients with molar pregnancies and 28 patients with GTN requiring chemotherapy. ß‐hCG monitoring completion was 93.9%, and the median time to chemotherapy commencement was 7 days. Additional data found a low risk of GTN diagnosis following a negative ß‐hCG and high complete response rates to chemotherapy for GTN.

High Cervical Cancer Screening Rates and Low Human Papillomavirus Detection in the Remote Torres Strait, Far North Queensland

ABSTRACT Across Australia, cervical cancer incidence and mortality rates is highest in those living in rural and remote areas, First Nations people and those residing in areas of high socioeconomic disadvantage. One such area is the Torres Strait, Queensland, with 81% of residents identifying as a First Nations person. To date, cervical cancer screening rates have not been examined in this area. This retrospective review aims to review the cervical cancer screening rates among people living in the Torres Strait over a 4‐year and 7‐month period from December 1, 2017, to June 30, 2022. Our findings revealed that, of those eligible for a cervical screening test, 2060/2920 (70.5%) had one or more cervical screening tests during the study period, resulting in an estimated five‐year cervical screening coverage rate of 75.1%. No human papilloma virus was detected in 1935/2060 (93.9%) of tests. These findings we hope will refine local healthcare delivery to achieve the targets in the National Strategy, eliminating cervical cancer as a public health problem by 2035 in Australia.

Patient Satisfaction With Rapid Access Hysteroscopy Clinics for Postmenopausal Bleeding—A Single Centre Observational Study

ABSTRACT Background Endometrial cancer (EC) is the leading gynaecological cancer and is increasing in incidence. The Counties Manukau area has higher rates of EC than the rest of New Zealand. Hysteroscopy is the gold standard for the investigation of those with risk factors for EC. To reduce time to diagnosis, our service developed a rapid access clinic (RAC) where hysteroscopy occurs at the first specialist clinic (FSA) visit. Aim To describe patient experience and satisfaction with the RAC. Methods Postmenopausal patients referred to the RAC were invited to participate in a survey about their experience. Survey responses were summarised, with patient satisfaction, acceptability of FSA and procedure in the same appointment, and pain scores considered as primary outcomes. Results The RAC had 194 attendances over 6 months and 74/112 approached patients consented to participate in the survey (approached response rate 66%). All patients surveyed reported high satisfaction with their care, and all were comfortable having the FSA and procedure in the same appointment. 57% described pain of hysteroscopy equal to or less than a menstrual period. Conclusion The results indicate that the RAC is well received by our postmenopausal patients, including higher risk ethnicities, and aligns with existing literature. These findings support the continuation of the outpatient hysteroscopy service and can aid in providing accurate counselling, patient expectations and reproduction of similar service models across other gynaecology units.

A retrospective cohort study of tubal occlusion or salpingectomy for permanent contraception in Australia

Background:Laparoscopic permanent contraception was previously accomplished most commonly using tubal occlusion procedures. Bilateral salpingectomy (BS) has recently been introduced as an alternative due to possibly superior contraception and greater protection against ovarian cancer.Aims:The aim of this study is to assess uptake, feasibility and perioperative outcomes of laparoscopic BS as an alternative to tubal occlusion in Australia.Materials and Methods:A retrospective review of permanent female contraception at two Australian hospitals from January 2014 through December 2020 was performed. The primary outcome was the uptake of BS. Secondary outcomes were feasibility, procedure length, number of ports, perioperative complications and admission length.Results:A total of 414 women were included; 92 (22.2%) underwent BS and 322 (77.8%) underwent tubal occlusion. There was a slow uptake of BS from 2014 to 2016 (0–3.2%), with a steep uptake from 2017 to 2020 (30–72%) (P = 0.001). Procedure feasibility was 96.8% (62/64) and 99.3% (282/284) for BS and tubal occlusion group, respectively (P = 0.64). BS procedure time was longer by 23 min (P < 0.001). Three or more surgical ports were used in all cases of BS compared to 4.5% of the tubal occlusion group (P < 0.001). There were no intraoperative complications. There were nine and six postoperative complications in the tubal occlusion versus BS group, respectively (P = 0.10). The median admission length was 7.1 (tubal occlusion) versus 7.3 (BS) h (P = 0.10), with five unintended overnight admissions.Conclusion:BS is an increasing choice for permanent contraception. It appears equally feasible as tubal occlusion but typically requires a longer procedure time and a minimum of three surgical ports.

Reply to Letter to the Editor‐ 'Management of patients with advanced ovarian cancer‐ role of complete cytoreduction and HIPEC: Attitudes of gynaecologist oncologists in two different continents’

Management of patients with advanced ovarian cancer – Role of complete cytoreduction and HIPEC: Attitudes of gynaecologist oncologists in two different continents

HIPEC: Turning up the heat on ovarian cancer

Clinical trials of heated intraperitoneal chemotherapy (HIPEC ) for the treatment of advanced ovarian cancer are showing promising survival outcomes. HIPEC has the potential to eliminate ovarian cancer cells from peritoneal surfaces more effectively than systemic chemotherapy through enhanced pharmacokinetic and hyperthermia effects. However, many questions remain to be answered, particularly regarding the true place of HIPEC in the current era of new and effective targeted treatments. Concerns around the potential for increased morbidity, adverse effects on quality of life, and increased resource use following HIPEC use, can only be properly evaluated with ongoing high‐quality clinical trials.

An Australian, single‐centre study of surgical management outcomes for early‐stage cervical cancer

BackgroundThe Laparoscopic Approach to Cervical Cancer (LACC) trial is the first phase III randomised, multicentred trial to compare oncologic outcomes associated with open radical hysterectomy vs minimally invasive surgery (MIS) for treatment of early cervical cancer.AimTo evaluate our surgical experience in patients with early cervical cancer.Methods and MaterialsThe Lifehouse Gynaecologic Oncology database was queried based upon the eligibility criteria of the LACC study and included all FIGO 2009 stage (1A1 with lymph vascular space invasion, 1A2, 1B1) cervical cancer women from 2008–2018. Patients were also included in our study if they had abdominal radical trachelectomy (ART), laparoscopic radical hysterectomy (TLRH) and robotic radical trachelectomy (RRT).ResultsForty‐six women were identified with four exclusions. Thirty‐seven women had stage 1B1 disease, 24 had a squamous cell carcinoma, 15 had an adenocarcinoma and three had an adenosquamous carcinoma of the cervix. Of the 42 eligible patients, 32 underwent an open abdominal approach (26 total abdominal radical hysterectomy (TARH), six ART) and ten a MIS approach (nine TLRH and one RRT) with a mean follow‐up of 4.8 years. All 42 women had a pelvic lymph node dissection, eight women had nodal metastases and 16 patients received adjuvant chemoradiation. Two of the nine women in the laparoscopic radical hysterectomy group had a recurrence. Both had adenocarcinoma, stage 1B1 disease. There were no recurrences in the TARH group or radical trachelectomy groups.ConclusionOur data, albeit limited in number, have reflected the results of the LACC trial that MIS was associated with a lower disease‐free survival than open radical hysterectomy.

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.

Recurrent post‐coital bleeding: Should colposcopy still be mandatory?

BackgroundColposcopy has been recommended for all women with recurrent post‐coital bleeding (PCB) even if their cervical cytology or co‐test (involving oncogenic human papillomavirus (HPV) DNA testing and cytology) are negative.AimsTo determine the risk of cervical cancer and its precursors among women with recurrent PCB with negative cytology or co‐test.Materials and MethodsA retrospective analysis of two cohorts of women with PCB referred to a tertiary colposcopy clinic. Cohort (1) (n = 1846) between 1 January 2000 and 31 December 2016 (cytology‐based screening) and Cohort (2) (n = 215) from 1 January 2018 to 31 December 2019 after introduction of primary HPV screening.ResultsIn 1217 (65.9%) women in Cohort (1) referred with negative cytology, there was one cancer (0.08%) and 22 high‐grade squamous intraepithelial lesions (HSIL (cervical intraepithelial neoplasia 2/3)) on histopathology. In Cohort (2), there was no cancer or HSIL in 83 women with negative co‐tests (negative for oncogenic HPV and cytology). False‐negative cytology after a negative referral cytology or co‐test was low with 2% of repeat cytology at initial colposcopy showing possible HSIL or worse.ConclusionsWomen presenting with PCB and negative cytology alone have a low risk of cancer and could have HPV testing before being triaged to colposcopy. We showed that with the assurance of a negative co‐test and the low likelihood of false‐negative cytology, these women could avoid colposcopy unless cervical cancer is clinically suspected. There is a need for a larger cohort study to substantiate our findings with more precision.

Implementing changes to cervical screening: A qualitative study with health professionals

BackgroundProfound changes were made to the Australian National Cervical Screening Program in December 2017, which included a reduction in the frequency of screening and a new cervical screening test.AimTo explore the attitudes and experiences of health professionals practising in Australia since implementation of these changes.Materials and MethodsThirty‐one semi‐structured interviews were conducted with general practitioners, obstetricians and gynaecologists, pathologists and nurses involved in cervical screening Australia‐wide. Data were analysed using Framework Analysis.ResultsOverall, health professionals had positive attitudes toward the changes but described many challenges associated with their implementation. Participants discussed practical system challenges, communication and education, finding ways around the guidelines and other perceived ‘collateral’. Practical system challenges included increased colposcopy referrals, limited access to the National Cancer Screening Register, a complex primary screening approach, and issues with self‐collection. In terms of communication and education, limited public education was recognised, in addition to challenges with particular age groups of women. Finding ways around the guidelines were described, for example over‐referring women for co‐testing by stating symptoms, which could lead to overtreatment. Other perceived collateral were demonstrated through reduced opportunistic screening opportunities due to less frequent primary care presentations, and concern over the potential for further underscreening in already under‐screened populations.ConclusionsThese findings provide insight into the challenges health professionals face with renewing programs, in terms of practical issues and unexpected downstream effects which need to be addressed to ensure future implementation of the program is streamlined.

Cancer of the cervix – The view from Australia’s nearest neighbour

Cytopathological review of cervical pathology: Impact for women and follow‐up results

BackgroundCervical screening programs have had an important effect on the reduction of cervical cancer rates. Comprehensive programs require access to pathological review to improve the sensitivity of screening cytology and the specificity of diagnostic histology.AimsTo determine the number of cases where cervical cytology or histology was amended at cytopathological review; whether amendments were ‘upgrades’ or ‘downgrades’, and how amendments aligned with follow‐up results for these patients.Materials and MethodsA retrospective cohort study was performed of all patients reviewed from January 2016 to December 2017 (n = 287 cases, from 254 patients) at colposcopy multidisciplinary meetings at Wellington Hospital, a tertiary referral hospital. Where amendments to cytology or histology were made, follow‐up results were retrieved where available (85.7% and 84.2% respectively).ResultsCytology or histology was amended in 24.7% of cases. Smear cytology was amended in 16.7%. Where cytology was upgraded (n = 9), 44% had subsequent results of equal or higher grade including one case of adenocarcinoma. Where cytology was downgraded (n = 19), 93.8% (81.9–100%) had follow‐up studies showing equal or lower results. Cervical biopsy histology was amended in 12.2% of cases (upgraded n = 19, downgraded n = 6). Large loop excision of the transformation zone or cone biopsy histology was amended in three cases (7.9%).ConclusionsCytopathological review appears to improve the specificity of the comprehensive cervical screening program, leading to a reduction in unnecessary treatment. Additionally, a small number of cases of malignant or premalignant disease were detected.

CIN III and cervical SCC with negative oncogenic HPV PCR: A case series

With the recent introduction of the renewed National Cervical Screening Program (NCSP) in Australia, utilising primary human papillomavirus (HPV) nucleic acid testing (NAT) for known oncogenic HPV types rather than cervical cytology, we reflect on three asymptomatic women with negative oncogenic HPV test results and high‐grade cervical abnormalities including cervical intraepithelial neoplasia (CIN) III and cervical squamous cell carcinoma (SCC). The two cases with CIN III had a ‘probable’ oncogenic subtype (HPV 53) identified on further testing, while the case of SCC had no HPV virus identified. These cases serve as a reminder of the need for ongoing diligence despite low‐risk screening under the new program.

Colposcopic outcomes for symptomatic patients with a negative oncogenic human papillomavirus test

This study assesses outcomes of colposcopy referrals for post‐coital, intermenstrual, or other abnormal bleeding with negative oncogenic human papillomavirus and negative to low‐grade cytology. Of 112 cases with median age of 34.5 years, cervical biopsy occurred in 19%, treatment of ectropion in 19%, endometrial sampling in 8%, polypectomy in 4%, and contraceptive change in 2%. No cervical or endometrial neoplasia was detected. Patients with bleeding symptoms and reassuring co‐test may instead attend a general gynaecology clinic.

No longer recommended for cervical screening: How women aged 18–24 feel about the renewed National Cervical Screening Program

BackgroundSince December 2017, the Australian National Cervical Screening Program no longer recommends screening for women under 25 years of age.AimTo explore the attitudes of women under 25 years toward the changes.MethodsIn December 2019, women aged 18–24, residing in Australia, were recruited via the social media platform Instagram and Facebook. Descriptive analysis, t‐tests, χ2 tests and multivariable regressions were used to analyse the data.ResultsFive hundred and twelve women completed a cross‐sectional web‐based survey. Women who were older (22–24: 3.1 vs 18–21: 2.8, P < 0.001), sexually active (3.1 vs 2.7, P = 0.003), vaccinated against human papillomavirus (mean = 3.2 vs 2.7, P = 0.005) or who had screened previously (mean = 3.5 vs 2.8, P < 0.001) had significantly greater knowledge about the current cervical screening practices. Older women (odds ratio (OR) = 0.85, 95% CI 0.80–0.95) or those who had screened previously (OR = 0.51, 95% CI 0.31–0.83) were less positive about the delayed start age of screening and five‐yearly screening (OR = 0.54, 95% CI 0.35–0.85). A significant association was determined between being sexually active (χ2(4) = 32.71, P < 0.001) and women who had screened previously (χ2(4) = 34.43, P < 0.001), with a greater intention to screen in the future. Regarding health information, 64.6% of women had never heard of the ‘National Cervical Screening Program’ website and 38.9% of the sample (n = 199/512) reported they had ‘rarely’ noticed any health information regarding cervical screening in the past 12 months.ConclusionFurther work is required to rectify women’s knowledge of cervical screening to ensure women under 25 are aware of the screening guidelines and reduce the potential for over‐testing and overtreatment in this age group.

Five‐year follow‐up after cervical cytology and histology discordance: A retrospective cohort study

BackgroundCervical smear cytology and colposcopic biopsy histology are prone to error at both collection and interpretation stages, leading to a large number of discordant cases.AimsInvestigation of five‐year outcomes for women who have cervical cytology that is discordant and higher grade than histology results.Materials and MethodsA retrospective cohort study was carried out for 111 women with cervical cytology discordant and higher grade than histology, after cytopathological review, over a three‐year period. Five‐year follow‐up data were reviewed to identify the highest level of pathology seen within five years from the discordance.ResultsWomen with atypical squamous cells with possible high‐grade change (ASC‐H) cytology and negative biopsy (n = 28) had a 46% chance of high‐grade histological disease within 5 years; with cervical intraepithelial neoplasia grade 1 (CIN1) histology (n = 20), this was reduced to 30%. With high‐grade cytology and negative histology (n = 23), 48% had high‐grade disease within five years, including one case of invasive disease; with CIN1 histology 50% had high‐grade disease within five years.ConclusionsThis study demonstrates a 30–50% chance of high‐grade disease within five years, in the setting of ASC‐H or high‐grade cytology with a negative or low‐grade colposcopic biopsy. This highlights that in the setting of cytology and histology discordance, at least one of the tests indicating high‐grade pathology warrants the need for treatment or close ongoing surveillance.

Understanding women’s choices for management of cervical intraepithelial neoplasia 2 (CIN2): Qualitative analysis of a randomised experimental study

BackgroundActive surveillance for cervical intraepithelial neoplasia 2 (CIN2) would allow time for most cases to regress naturally and in turn avoid potentially unnecessary and harmful treatment.AimTo determine reasons for choosing active surveillance over surgery among women given a hypothetical diagnosis of CIN2.Materials and MethodsWomen residing in Australia aged 25–40 years with no prior diagnosis of cervical cancer, cervical abnormality CIN2 or above, and/or previous hysterectomy, were randomised to one of four identical hypothetical scenarios of testing human papillomavirus (HPV)‐positive: high‐grade cytology and a diagnosis of CIN2 that used alternate terminology to describe resolution of abnormal cells and/or inclusion of an overtreatment statement. Participants selected active surveillance or surgery after viewing the scenario and free‐text reason/s for their choice were thematically analysed.ResultsOf the 1638 women randomised, 79% (n = 1293) opted for active surveillance. The most common reasons for choosing active surveillance included concerns about surgery and associated risks, preferring to ‘wait and see’, trusting the doctor’s recommendations and having an emotional response toward surgery. For women who chose surgery, being risk‐averse, addressing the issue straight away and perceiving surgery to be the better option for them were the most common themes identified.ConclusionWhen presented with balanced information on the benefits and harms of different management options for CIN2 and given a choice, most women in this hypothetical situation chose active surveillance over surgery. Addressing women’s concerns about active surveillance may open up the possibility that if deemed safe, it could be an acceptable alternative for women.

Using Google Trends to assess the Australian public's interest in topical gynaecology issues

Our primary objective is to assess public awareness of topical issues in gynaecology by observing Google Trends information on internet searches in Australia and explore the linear relationship with landmark changes in policy or management. Following notable interventions such as new government policies, action plans and publications, there has been a 26.4% increase in searches for endometriosis, 3.9% increase in searches into transvaginal mesh, a 48.8% increase in searches for cervical screening and a 20.9% overall increase in searches for polycystic ovarian syndrome. This analysis appears to show that patient interest largely mirrors real world events.

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.

Outcomes of women with positive oncogenic HPV and reflex cytology showing possible high‐grade squamous intraepithelial lesion

AimTo examine outcomes in women following cervical screening detection of oncogenic human papillomavirus (HPV), with reflex cytology showing possible high‐grade squamous intraepithelial lesion (pHSIL).Materials and methodsA retrospective observational study of 523 women seen in the Royal Women’s Hospital Colposcopy Clinic from 1 January 2018 to 31 July 2020.ResultsTwo hundred eighty‐two (53.9%) women had histology‐confirmed HSIL, encompassing CIN2 or worse (CIN2+), including seven cancers (1.3%) and two adenocarcinoma in situ (AIS) (0.4%). In 81.2% (229/282) of women with CIN2+, this was detected on cervical biopsy at initial colposcopy, with another 8.9% (25/282) of CIN2+ detected at cervical excision following initial colposcopy and the remaining 9.9% (28/282) at follow‐up colposcopy thereafter. When discordant cervical biopsy results were discussed at multidisciplinary meeting (MDM), 66.7% of women with pHSIL cytology upgraded to definite HSIL were found to have CIN2+, but only 20.8% when pHSIL cytology was retained and none when downgraded to low‐grade (LSIL) or normal. No significant difference was found in the proportion of CIN2+ based on patient age above or below 40, HPV16 and/or 18 versus non 16/18, or whether discordant findings were reviewed at MDM.ConclusionsWe propose a pathway for management of women with positive oncogenic HPV and reflex pHSIL cytology. MDM review is recommended when CIN2+ is not identified on cervical biopsy at initial colposcopy. Conservative management is safe with low risk of CIN2+ when LBC prediction of pHSIL is confirmed or downgraded at MDM with no high‐grade change on colposcopy or repeat cytology.

Australian National Cervical Screening Program renewal: Attitudes and experiences of general practitioners, and obstetricians and gynaecologists

BackgroundIn 2017, the Australian National Cervical Screening Program (NCSP) implemented five‐yearly primary human papillomavirus (HPV) screening for women aged 25–74. It is important that clinicians are able to explain the NCSP changes to women and confidently address concerns.AimsThis study examined Australian clinicians’ attitudes toward and experiences of the NCSP renewal since its implementation.Materials and MethodsCross‐sectional survey of clinicians (general practitioners, obstetricians and gynaecologists) involved in cervical screening, distributed two years after implementation of the renewed NCSP. Responses were analysed using descriptive statistics and thematic analysis.ResultsSix hundred and seven participants completed the survey. More than 80% of clinicians were comfortable with the main NCSP changes: extended screening intervals, increased age of first screening, and screening test used. However, only 47% of clinicians reported having utilised the National Cancer Screening Register, and a third of clinicians did not believe that self‐collection was a reasonable alternative to practitioner‐collected screening for under‐screened women. Increased demands for colposcopy were reported. All clinicians identified at least one area of educational need, including the management of women with a history of screen‐detected abnormalities in the previous program (34.9%), post‐colposcopy management for women with no abnormalities detected (25.5%), and screening in complex scenarios (eg immunocompromise) (26.5%).ConclusionsOverall, Australian clinicians are comfortable with the main changes to the cervical screening program. Certain areas may require further policy review, such as screening in complex clinical scenarios, colposcopy availability, accessibility of the Register and self‐collection. These issues could be meaningful for other countries switching to HPV‐based screening.

Identifying risk factors for post‐operative bleeding in women undergoing loop electrosurgical excision procedure for cervical dysplasia

BackgroundLoop electrosurgical excision is a procedure utilised in the treatment of high‐grade squamous intraepithelial lesion (HSIL) of the cervix. Post‐operatively women may experience immediate and/or delayed per vaginal bleeding.AimsThe objective of this prospective pilot study was to assess the feasibility of identifying and quantifying patients' subjective experiences of post‐operative bleeding following a loop electrosurgical excision procedure (LEEP) for HSIL. In addition, an analysis of demographical, lifestyle and surgical factors was undertaken to assess for any statistically significant correlation with post‐operative bleeding.Materials and MethodsThis study included 110 patients who underwent a LEEP for biopsy‐proven or suspected HSIL between 2017 and 2020. Subjective data were collected from weekly post‐operative surveys and correlated with procedural data. Primary outcome assessed was the subjective rate of bleeding experienced. Baseline demographics were age, body mass index (BMI), specimen size, human papilloma virus variant and histopathology. Other variables of interest collected were exercise intensity, and alcohol intake.ResultsNo association of statistical significance was discovered between age, BMI, or day of menstrual cycle. There was a statistically significant association between exercise intensity or specimen size (greater than the median) and increased bleeding, primarily in the first 2 weeks.ConclusionsWomen who undergo intense or prolonged exercise in the post‐operative period may experience heavier bleeding particularly in the first 2 weeks post‐LEEP. Heavy bleeding was also associated with a larger specimen size. There was no correlation between BMI, age or any other demographical factor.

Patient expectations and experiences with loop electrosurgical excision procedure in inpatient and outpatient settings

BackgroundLoop electrosurgical excision procedure (LEEP) for high‐grade squamous intraepithelial lesion is performed in both an inpatient setting under general anaesthesia and an outpatient setting under local anaesthesia. Efficacy and safety are comparable and outpatient LEEP may save time and cost in the Australian setting.AimsWe aim to compare patient satisfaction with inpatient LEEP compared to outpatient LEEP for Australian best practice.Materials and MethodsThis was a prospective quantitative and qualitative cohort study. An online questionnaire was sent to patients undergoing inpatient and outpatient LEEP to assess satisfaction with the procedure. Further histopathological and demographic data were also collected from the medical records. Groups were compared using Fischer's exact test and pain scores were compared using non‐parametric tests.ResultsNinety‐three outpatients and 52 inpatients responded to the survey. No difference was found between groups with regard to rate of positive histopathological margins or number of passes required. Outpatients found the procedure to be more convenient than inpatients (P = 0.007), and experienced more pain during the procedure than the inpatient group (P < 0.001). There was no significant difference in pain scores following the procedure or post‐procedure anxiety.ConclusionsOutpatient LEEP is an acceptable and well‐tolerated procedure, comparable to inpatient LEEP. Regardless of the option chosen, patients are highly likely to be satisfied with their choice. Increased efforts should be made to reduce pre‐procedural anxiety, which may in turn reduce expectations and experiences of pain.

Subjective Assessment of Adnexal Masses Using Various Ultrasonographic Diagnostic Models: An Analysis of Interobserver Variability

ABSTRACT Objective To investigate the interobserver agreement of the International Ovarian Tumour Analysis (IOTA) ultrasound‐based simple rules risk (SRRisk) score, the logistic regression model 2 (LR2), the Assessment of Different NEoplasias in the adneXa (ADNEX) model and the Ovarian‐Adnexal Reporting and Data System (O‐RADS) in an Australian, population‐based context. Methods A retrospective multi‐centre study was performed between January 2020 and January 2021. The study included 198 women with adnexal masses examined with transvaginal grey scale and power Doppler ultrasound. Participants were recruited from the multidisciplinary oncology meetings (MDT) of two tertiary cancer centres. Two independent radiologists described the adnexal masses according to the SRR, LR2 scores, ADNEX model, and O‐RADS. Values > 30 units different were considered differential and > 50 units were considered highly differential. Results From 198 patients, 128 were diagnosed with benign ovarian masses, 53 with malignant and 17 patients with borderline tumours. There was strong agreement (Cohen's kappa 0.8) for intra‐tumour blood flow, number of cysts locules, and presence of blood flow within solid projections. Interobserver agreement was moderate (Cohen's kappa 0.60–0.79) for the presence of free pelvic fluid/ascites, solid components, unilocular cysts and acoustic shadows. Of the 198 cases, 10 (5%) cases were highly differential and (38/198) 19% were differential for SRRisk, (20/198) 10% highly differential and (36/198) 18% differential for LR2, and (10/198) 5% and (24/198) 12% for ADNEXA model, respectively. Comparison of O‐RADS scores between the two observers showed a moderate agreement with a kappa of 0.65. In 7/198 (4%) cases, the difference between observers was for 2 or more categories when using the O‐RADS score. Conclusions Our results suggested that interobserver variation was present in evaluating adnexal masses using well established ultrasonographic diagnostic models. Implementation of sonographic ovarian cancer risk prediction models will need to consider this issue and ensure examiners have adequate training in the technique, and standard operating procedures are in place to reduce interobserver variability.

Borderline tumours of the ovary: A 37‐year experience at a tertiary referral centre

IntroductionBorderline ovarian tumours (BOT) are a common epithelial ovarian tumours. Typically diagnosed at an early stage with a good prognosis, many BOT are treated conservatively. Recurrence is common. This update to our last audit in 1997 represents one of the largest audits of BOT to date.Materials and MethodsAll patients with BOT managed at ‘the hospital’ from 1984 to 2021 were included. Expert pathology review was available.ResultsThere were 549 cases included. The recurrence rate was 5% (n = 29/549) with 1.4% (n = 8/549) undergoing malignant transformation. Three of the eight women who recurred as cancer died from their disease. Frozen section was predictive of histologic diagnosis in 92% (n = 55/60) of serous tumours (SBOT), but only 62% (n = 54/87) of mucinous tumours (MBOT). In MBOT where the appendix appeared normal intra‐operatively, it was histologically benign in all cases (n = 63). In SBOT, the recurrence rate was 5/23 (22%), 12/52 (23%), 1/29 (3%) and 3% (P = <0.01) for unilateral cystectomy, unilateral oophorectomy ± cystectomy, bilateral oophorectomy, and bilateral oophorectomy with hysterectomy, respectively, as index procedure. In MBOT this correlated to 2/20 (10%), 3/93 (3%), 0 and 1/58 (2%), respectively.DiscussionThis study describes important information correlating first surgical procedure and fertility‐sparing surgery to recurrence and malignant transformation. For all BOT subtypes, fertility‐preserving surgery increased the risk of recurrence and hysterectomy was not superior to removal of both ovaries. In MBOT, frozen section is of limited utility and the macroscopically normal appendix is very unlikely to be anything but benign, if MBOT is the true histologic diagnosis.

The use of intraperitoneal chemotherapy for advanced ovarian cancer – The experience of a tertiary referral centre

BackgroundPlatinum‐based chemotherapy is the backbone of the medical management of ovarian cancer. The dose, route and timing of treatment are ongoing areas of debate. Intraperitoneal (IP) chemotherapy is an alternative delivery method treatment to the conventional intravenous (IV) route for patients with epithelial ovarian cancer, with efficacy supported by Level 1 evidence.AimsTo compare the outcomes and feasibility of IP to IV delivery of platinum‐based chemotherapy in patients with advanced epithelial ovarian cancer.Materials and MethodsIn a single institution, patients receiving adjuvant chemotherapy (IP and IV) for Stages III and IV epithelial ovarian cancer over the period January 2006–December 2018 were identified through a prospectively maintained database. All patients with an IP port inserted were included. A control group of patients treated with IV chemotherapy was created using criteria identified during the study and in the randomised trials that tested IP chemotherapy. Assessments were made for relapse‐free survival (RFS) and overall survival (OS) for each cohort.ResultsA total of 639 patients received adjuvant chemotherapy (73 IP and 566 IV) during the study period. Both the IP group and matched IV control group (65 patients) had a median RFS of 26 months. The median OS in the IP group was 63.9 months, and in the IV group was 57.2 months. At ten years, a significantly higher proportion of patients were alive in the IP group cohort (16% vs 3%, relative risk 5.5, 95% CI 1.29–24, P = 0.012). IP chemotherapy was well tolerated by our cohort. In the IP group, 73% had four or more IP cycles and 99% received six or more cycles of chemotherapy.ConclusionsOur cohort had a high rate of completion of IP chemotherapy with excellent rates of completion of six cycles of any treatment. The RFS and OS in the IP chemotherapy group were comparable to each other and reflected those in the published literature. A significantly higher proportion of patients in the IP cohort were alive at ten years than in the IV cohort.

The Demographics and Outcomes of Women With Stage II Endometrial Cancer Diagnosed in Australia 2005–2007

ABSTRACT Background Stage II endometrial cancer comprises 5% to 10% of cases and is pathologically diverse. Retrospective data guides recommendations which suggest surgical staging with adjuvant therapy, but the role of radical surgery and lymphadenectomy is uncertain, due to conflicting outcomes. Treatment decisions are influenced by histopathology, yet a definitive standard of care is still elusive. Objectives To identify prognostic factors affecting stage II endometrial cancer survival and assess the 2009 FIGO staging changes using data from the Australian National Endometrial Cancer Study (ANECS). Materials and Methods Ninety patients were identified between July 2005 and December 2007. Survival data was analysed using Kaplan–Meier estimates and Cox regression models, with ethics approval from QIMR. Results Ninety patients were identified with an average age of 60 and mean body mass index (BMI) of 30. Positive cytology (HR 5.4 [CI: 1.32–22.15]) and chemotherapy alone (HR 17.3) [CI: 2.65–112.6] were identified overall survival (OS) predictors in univariate and age (HR 1.81; [CI: 1.13–2.91]) in multivariate analyses. LVSI was a significant progression free survival (PFS) predictor (HR 4.29; [CI: 1.13–16.26]). There was no significant difference in OS ( p  = 0.9) and PFS ( p  = 0.6) when cases were re‐stratified into the 1988 stage IIA and IIB groups. Conclusions The study supports contemporary management of simple hysterectomy with lymph node assessment and the refined 2009 stage II definition. Current treatment paradigms could also be refined based upon prognostic factors like age and LVSI.

Cystic Spaces in the Endometrium on Ultrasound and Correlations With Pathological Diagnosis: A Contemporary Retrospective Cohort Study in a Tertiary Centre

ObjectivesTo determine the correlation between the ultrasound finding of cystic spaces in the endometrium and endometrial hyperplasia or cancer.Materials and MethodsWe performed a retrospective cohort study at a tertiary teaching hospital in Victoria, Australia, between January 2014 and December 2016. Patients who had a tertiary ultrasound where the endometrium was assessed and underwent endometrial sampling in the subsequent year were included.ResultsThere were 1614 patients who were included, and 154 (9.5%) had endometrial cystic spaces on ultrasound. Sensitivity, specificity, positive predictive value and negative predictive value for a histological finding of polyps were 16.3%, 93.4%, 51.3% and 72.3%, respectively; for endometrial hyperplasia without atypia (EH no A) 40.7%, 91.0%, 7.1% and 98.9%, respectively; for hyperplasia with atypia (EH with A) 25.0%, 90.8%, 5.2%, 98.4%, respectively and for endometrial cancer were 19.5%, 90.7%, 5.2% and 97.7%, respectively. When adjusted for age, endometrial thickness and the presence of polyps on ultrasound, cystic spaces increased the odds of a histologic diagnosis of polyps (adjusted odds ratio (aOR) 2.13 (95% CI 1.41–3.21) P < 0.001) or EH no A (aOR 5.20 (95% CI 2.06–13.12) P < 0.001) and reduced the odds of endometrial cancer (aOR 0.26 (0.08–0.81) P = 0.02).ConclusionCystic spaces on ultrasound are more likely to indicate the presence of EH no A or an endometrial polyp than endometrial cancer. As one in ten patients who had cystic spaces on tertiary ultrasound had a pathologic diagnosis of EH with A or carcinoma, there remains a need for sampling in this group until better data are available.

Universal screening for Lynch syndrome in endometrial cancer diagnoses in Auckland, New Zealand: The initial experience

BackgroundUniversal mismatch repair immunohistochemistry (MMR IHC) tumour testing in endometrial cancer (EC) for Lynch syndrome (LS) was introduced in Auckland, New Zealand, in January 2017. Identifying patients with LS allows them and their families to access risk reduction strategies. Universal MMR IHC testing aids in the molecular classification of EC and has prognostic and therapeutic implications.AimWe aimed to determine the incidence of LS in women with EC in Auckland, New Zealand, following the introduction of MMR testing and the impact of universal screening on local genetic services.Materials and methodsThis is a retrospective clinicopathological evaluation of women with a new EC diagnosis referred to the Auckland Gynaecological Oncology Unit from 1/1/17 to 31/12/18. Patient data were extracted from the Gynaecological Oncology Unit database and electronic records, and analysed using descriptive statistics.ResultsDuring the study period, 409 patients were diagnosed with EC, with an over‐representation of Pacific Islanders (32.5%). Of these, 82.6% underwent MMR IHC testing, 20% were MMR‐deficient (MMRd), and 71% had somatic hypermethylation. The Pacific Islander population had a 64% (odds ratio 0.36, P = 0.005) reduction in the odds of having MMRd tumours compared with Europeans. Of the patients who underwent MMR IHC testing, 5.5% were referred to a genetic clinic for germline testing. LS was confirmed in eight patients (2.3%).ConclusionLS was diagnosed in 2.3% of patients. There was an over‐representation of Pacific Islanders in the EC group but not among those diagnosed with LS.

Prognostic value of serum HE4 level in the management of endometrial cancer: A pilot study

BackgroundHuman epididymis protein 4 (HE4) has shown promising utility as a prognostic biomarker in endometrial cancer. Increased serum HE4 levels may be associated with deeper myometrial invasion, extrauterine disease and poorer prognosis.AimTo evaluate the use of serum HE4 level, compared to and alongside other investigations, to accurately guide management in apparent early‐stage endometrial cancer.Materials and MethodsThis is a single‐site prospective study of 100 patients with histologically confirmed endometrial cancer. All patients underwent preoperative measurements of HE4 and CA125 levels and a preoperative magnetic resonance imaging (MRI) to assess the depth of invasion, nodal status and tumour size. Correlation was sought between serum HE4 level, CA125 level, MRI findings and intra‐operative frozen section with tumour type, grade and stage.ResultsWhile both median HE4 and CA125 levels were higher with worsening clinicopathological features, serum HE4 level showed a more consistent association with high‐risk features. Patients with a low‐grade biopsy preoperatively and a low HE4 level (<70 pmol/L) demonstrated an 86.8% likelihood of having low‐risk disease on final histopathology. In comparison, preoperative MRI or intraoperative frozen section alongside a low‐grade biopsy demonstrated a similar likelihood of 86.2 and 87.7%, respectively.ConclusionsWhen used in conjunction with an initial low‐grade endometrial biopsy, serum HE4 level demonstrated a similar likelihood to both preoperative MRI and intraoperative frozen section in identifying low‐risk disease on final histopathology. As a triaging tool this may be significant given that a preoperative, serum‐based assay would likely be the least invasive, least resource‐intensive and most cost‐effective approach.

Determining a threshold measurement of endometrial thickness for asymptomatic postmenopausal women: A tertiary centre case series

BackgroundAn incidental finding of a thickened endometrium on ultrasound in the postmenopausal patient without bleeding is a common presentation to gynaecological services; however there is limited evidence to guide clinical practice as to when hysteroscopic evaluation and endometrial sampling is required.AimsTo determine the endometrial thickness at which endometrial sampling is indicated in asymptomatic postmenopausal women referred with thickened endometrium on ultrasound.Materials and MethodsA single‐centre retrospective case series of postmenopausal women without bleeding undergoing hysteroscopy was conducted. Logistic regression was used to examine the association between a range of variables and pre‐malignant or malignant pathology and endometrial thickness. The optimal endometrial thickness threshold was identified to maximise model sensitivity.ResultsA total of 404 postmenopausal women were included in this study, having undergone a hysteroscopy at the study site between 1 July 2008 and 30 June 2018. The mean (SD) age of patients at presentation was 65 (9.09) years and the mean body mass index was 29.86 kg/m2 (6.52). Of these women, nine (2.2%) were diagnosed with endometrial carcinoma and seven (1.7%) had endometrial hyperplasia with atypia. The most common histopathological finding was of a benign endometrial polyp (153: 37.9%). When including hyperplasia with or without atypia in histopathology of interest, a cut‐off of ≥9 mm provides the greatest sensitivity (83.3%) and specificity (63.8%) for a diagnosis of pre‐malignant or malignant pathology (classification accuracy of 64.8%; area under the receiver operating characteristic: 0.7358, 95% CI: 0.6439, 0.8278) in this cohort.ConclusionsUsing an endometrial thickness of ≥9 mm can be used as a cut‐off for endometrial sampling in postmenopausal women without bleeding.

Predictors of endometrial carcinoma in patients with atypical endometrial hyperplasia at a tertiary gynaecological cancer centre in Western Australia

AbstractAimOur objective was to assess clinical and pathological factors associated with a final diagnosis of endometrial carcinoma in patients with atypical endometrial hyperplasia with a particular emphasis on the grading of atypia.Materials and methodsA retrospective review over five years on patients (N = 97) who underwent hysterectomy for a diagnosis of atypical endometrial hyperplasia at a statewide public tertiary gynaecologic oncology centre. Clinical and pathological characteristics were obtained.ResultsThe rate of concurrent endometrial carcinoma was 34% (n = 33) with most being stage 1A endometrioid. A significant group difference was reported for age at diagnosis (t = −2.20 P = 0.031 d = 0.43) with carcinoma patients on average older (Mage = 60.2 (8.9) years) than patients without carcinoma (Mage = 55.5 (12.3) years). No significant group differences were found for body mass index, endometrial thickness or time between diagnosis and treatment. Significantly higher rates of carcinoma were reported in patients with moderate atypical hyperplasia (27.6%) and severe atypical hyperplasia (66.7%), compared to mild atypical hyperplasia (7.1%). Only severe atypical hyperplasia (odds ratio (OR) = 21.5, 95% CI 2.8–163.1, P = 0.003) and postmenopausal status (OR = 13.2, 95% CI 1.3–139.0, P = 0.032) significantly increased the risk of carcinoma in a multivariate model.ConclusionSevere atypical hyperplasia and postmenopausal status were significant predictors of concurrent endometrial carcinoma in patients with atypical endometrial hyperplasia. The grading of atypical hyperplasia may be utilised by gynaecologic oncologists in the triage and referral process of managing these patients; however, the grading system requires external validation in larger prospective studies.

The utilisation of sentinel lymph node biopsy for endometrial cancer in Australia and New Zealand

AimsThe aim of this study was to identify to what extent the sentinel lymph node (SLN) technique is utilised by gynaecological oncologists in Australia and New Zealand, identifying the techniques used, any barriers to uptake, and management of isolated tumour cells (ITCs) and micrometastases.Materials and methodsWe conducted an online survey of all practising gynaecological oncologists in Australia and New Zealand. They were asked whether they utilised SLN biopsy and in what circumstances, how they managed non‐mapping and how their multidisciplinary team managed small volume disease. Those who did not were asked to identify their concerns with the procedure, reasons for non‐uptake and their alternate technique.ResultsWe surveyed 63 gynaecological oncologists of whom 59 were practising, and 48 (81%) responded. Six members (11%) do not utilise SLN biopsy, and 42 (89%) do. Areas where clinicians differ in practice are those areas that are most controversial and include the use of SLN biopsy in complex atypical hyperplasia, the management of ITCs and micrometastases and procedures on unilateral or bilateral non‐mapping. Those who do not utilise the technique cite concerns about the false‐negative rate, equipment and training issues.ConclusionsThe utilisation of SLN biopsy in endometrial cancer is well established in Australia and New Zealand, with similar practices and concerns to those of other international groups.

Malignant extra‐ovarian endometriosis: A case series of ten patients and review of the literature

BackgroundThe malignant transformation of endometriosis within the ovary is a recognised condition. There is less literature surrounding the malignant transformation of extra‐ovarian endometriosis (MEOE).AimsWe report our experience with MEOE in ten patients and present a review of the literature regarding this rare malignancy.Materials and MethodsFor this retrospective case series, patients were identified from a practice‐based database. Where required, operative notes and pathology reports were reviewed.ResultsTen patients diagnosed with MEOE between 1991 and 2014 were identified. In each case, the tumour was localised to the pelvis and centred on the pouch of Douglas, broad ligament, obturator fossa, parametrium and rectovaginal septum. Tumour histology was endometrioid adenocarcinoma (six), clear cell carcinoma (two), and adenosarcoma (two). Five patients had a history of endometriosis and four had received oestrogen‐only hormone replacement therapy after hysterectomy and bilateral salpingo‐oophorectomy. Treatments included surgery (one), surgery and radiotherapy (one), surgery and chemotherapy (one), surgery, radiotherapy and chemotherapy (three), and radiotherapy and chemotherapy (four). Maintenance hormonal therapy was also used in three patients. Curative doses of radiotherapy 45 Gy or more resulted in in‐field control in five patients. Six patients had no evidence of disease at a mean follow up period of 15 years (5.5–24 years). Severe G3 long‐term bladder morbidity occurred in three patients after radical surgery and radiotherapy.ConclusionMEOE is a rare condition for which treatment needs to be individualised. Multicentre studies and registries will hopefully define optimal treatment.

Investigating women with postmenopausal bleeding: The utility of endometrial thickness in transvaginal ultrasound

BackgroundAustralian clinical guidelines recommend further investigation in females with postmenopausal bleeding (PMB) and endometrial thickness (ET) of ≥4 mm on transvaginal ultrasound (TVUS). However, the literature indicates that an ET of ≥3 mm as an upper limit is a more sensitive predictor of endometrial malignancy (EM) in females with PMB.AimsTo assess whether Australian guidelines for PMB with an upper limit of 4 mm ET on ultrasound investigation, is sensitive enough for malignancy detection.Material and MethodsA retrospective study was performed on tissue results in PMB presentations to the Gold Coast Hospital and Health Service between 2011 and 2015.ResultsTwenty point nine percent of women with PMB had a malignancy. With an upper limit of 4 mm in ET on ultrasound, malignancy was present in 22% of participants. [Correction added on 10 July 2020, after first online publication: percentage of women with PMB that had a malignancy has been amended to twenty point nine percent.]ConclusionsA limit of 3 mm for ET in PMB, along with office endometrial biopsy, should be considered to ensure timely diagnoses.

Bilateral salpingectomy as an option of permanent contraception at time of caesarean section: A survey of practice

BackgroundOpportunistic bilateral salpingectomy during benign gynaecologic surgery is advocated as a risk‐reducing strategy due to the inverse association of epithelial ovarian cancers observed in epidemiological studies in a low‐risk setting. Currently, no formal guidance exists for permanent surgical contraception at time of caesarean section in Australia.AimsOur aim was to survey Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) regarding bilateral salpingectomy compared to other procedures offered for permanent contraception at the time of caesarean section.Materials and MethodsAn online survey was utilised to collect clinician demographics, opinions, barriers, and justifications in regard to options of permanent surgical contraception at time of caesarean section.ResultsBilateral salpingectomy was identified as the most effective method of permanent contraception at time of caesarean section. However, only 62% of respondents offer the procedure as a method of permanent contraception. The two most common reasons for clinicians to offer bilateral salpingectomy at time of caesarean section were evidence suggesting a link between the fallopian tube and gynaecological cancer (80%) and efficacy as a permanent form of contraception (16%). The primary barrier identified by 51% of respondents was perceived increased risk of surgical complications, followed by reasoning that it would not allow the possibility of future tubal reversal.ConclusionThis study identifies diverse opinions on surgical approach to permanent contraception at time of caesarean section and offered by clinicians of RANZCOG. Further research is required to establish safety profiles and short‐ and long‐term risks of bilateral salpingectomy.

Outcomes of patients registered with the Queensland Trophoblast Centre diagnosed with gestational trophoblastic neoplasia who develop resistance to chemotherapy

ObjectivesTo audit outcomes of patients registered in the Queensland Trophoblast Centre (QTC) database who develop resistance to primary chemotherapy. To determine any risk factors that may predict first‐line chemotherapy resistance in patients diagnosed with gestational trophoblastic neoplasia (GTN).MethodsPatients within the QTC who were diagnosed with GTN between January 2012 and December 2020 were reviewed.ResultsOf 138 patients with GTN registered in the QTC, 22 (15.9%) patients developed resistance to first‐line chemotherapy. Three had high‐risk GTN and 19 had low‐risk GTN. Of the three high‐risk patients, one patient died. This patient had an epithelioid trophoblastic tumour (ETT). The remaining two high‐risk patients had complete hydatidiform moles (CHM) with GTN. Both achieved complete remission with salvage therapy. Of the 19 low‐risk patients, one patient had a partial hydatidiform mole (PHM). This patient achieved remission following third‐line treatment. The other 18 low‐risk patients had CHM with GTN. All but two of these 18 patients were successfully treated with second‐line chemotherapy, with the remaining two patients achieving remission with third‐line chemotherapy. Five of the 18 patients received either actinomycin‐D or methotrexate as salvage therapy. Thirteen patients were given multi‐agent chemotherapy for second‐line treatment. One patient in this group died but this was not due to her disease. Initial β human chorionic gonadotropin levels were not predictive of number of chemotherapy cycles or number of lines of chemotherapy required to achieve remission.ConclusionsGTN is a curable condition. If resistance to first‐line chemotherapy occurred, most patients achieved remission with salvage therapy.

‘Kind of scared but happy something was detected.’ Cross‐sectional survey of Let's Test for HPV participants to understand perspectives on an HPV detected result

BackgroundHuman papillomavirus (HPV) testing became the primary cervical screening modality in Aotearoa New Zealand in September 2023. To inform the national roll‐out of HPV primary screening, a multiregion implementation study (‘Let's Test for HPV’) was undertaken in primary care in 2022–2023.AimsTo explore participant perspectives and information needs following receipt of an HPV detected result.Materials and methodsAn online survey completed in 2023 by 921 Let's Test for HPV participants included 95 people with an HPV detected result (10.3%). Data collection included: adequacy of information provision, receipt of results, emotional response, views on HPV primary screening and needing cervical cytology and/or colposcopy, and intent to screen again.ResultsReceipt of an HPV detected result was worrying for most people and many had unanswered questions about HPV, how HPV testing fits with cytology, implications for follow‐up and outcomes. Knowledge gaps and uncertainty appeared to be linked with feeling anxious about possible outcomes and fear of a cancer diagnosis. All survey participants received recommended follow‐up (cytology and/or colposcopy). Having a choice of screening test and the ability to self‐test were welcomed and the majority (88%) expressed intent to screen again.ConclusionsThese survey findings highlight the importance of giving clear information about potential outcomes at the time of screening and again when sharing results. Sensitive delivery of results, providing reassurance and answering questions are also important to mitigate fear and worry. Population‐level education would help improve understanding of key messages about HPV testing and the changes to cervical screening.

High‐grade squamous intraepithelial lesions and adenocarcinoma in situ with a negative HPV cervical screening test. The role of HPV‐ISH testing: A retrospective review

Australia has transitioned to primary Human Papillomavirus (HPV) screening; however, high‐risk HPV (hrHPV)‐negative high‐grade squamous intraepithelial lesions and adenocarcinoma in situ have been reported. HPV in situ hybridisation (ISH) testing has been proposed to reclassify these cases. This study identified hrHPV‐negative lesions and assessed HPV‐ISH. A total of 89 of 1468 patients (6.06%) had hrHPV‐negative lesions, and HPV‐ISH revealed five (5.75%) reclassified positive cases. No demographical differences were found between groups. Current population‐level screening is effective. HPV‐ISH was not effective for reclassification. This small, significant population requires further study to assess the phenomenon and augment detection given the implications of misidentification.

Sentinel lymph node detection with indocyanine green and patent blue dye in cervical cancer: A single‐centre feasibility study

BackgroundSentinel lymph node (SLN) dissection has been established as standard of care in many tumours. Its use in early cervical cancer is an area of increasing interest and some studies suggest a high detection rate.AimTo explore feasibility of SLN dissection and establish the patient detection rate in women with early cervical cancer.Materials and MethodsAll patients with early cervical cancer, International Federation of Gynaecology and Obstetrics (FIGO) 2018 Stage 1, of any histology who underwent SLN dissection from January 2017 to March 2023 were included. Patients were eligible if they had pelvic confined disease; no suspicious lymph nodes on pre‐operative imaging or intra‐operatively; tumours <4 cm at the time of surgery and no contra‐indications to surgery. Patients were excluded if there was a known allergy to dye or less than six months follow‐up data.ResultsSixty‐two patients were included in the study and 53% had FIGO stage 1b1 disease. The overall bilateral SLN detection rate was 89%, and the side‐specific rate was 94%. Where indocyanine green (ICG) was used alone, the bilateral detection rate was 87% and the side‐specific rate was 93%. Where ICG was used with patent blue dye (PTB) the bilateral detection rate was 92% and the side‐specific rate was 96%. Where PTB was used alone the bilateral detection rate was 85% and the side‐specific rate was 92%. The node positive rate was 6% (7/124) which included isolated tumour cells in four patients.ConclusionSLN dissection with ICG or PTB is feasible in early‐stage cervical cancer.

Colposcopy performance in the new primary HPV screening in Australia: How to determine colposcopy competency?

AimsTo assess colposcopic performance and determine indicators for competency within the new Australian primary human papillomavirus (HPV) cervical screening program.Materials and methodsA retrospective observational study of 4542 women seen at The Royal Women's Hospital Colposcopy Clinic in Melbourne, from 1 December 2017 to 31 July 2020 after a higher‐risk cervical screening test (CST) result.ResultsHistological CIN2+ was detected in 25.1% up to two years from first colposcopy visit (FCV). The majority (86.7%) of CIN2+ was detected early within the first six months of presentation. Biopsy rate overall was 96.1% with abnormal colposcopic impression. Of four colposcopists with a lower biopsy rate, only one was able to achieve this early detection rate. Biopsy was also taken in over 30% of cases with negative reflex cytology and normal colposcopy, with CIN2+ detected in 5.0% among positive HPV16/18 and 3.8% with non‐16/18 HPV. Positive predictive value of high‐grade colposcopic impression at FCV averaged 66.4% (range: 54.9–81.6% among our colposcopists) and is poorly correlated with early detection rate of CIN2+. Overall accuracy of colposcopy is 84.5% (range: 78.7–90.3%), buoyed by high true negative colposcopic predictions secondary to high rates of negative reflex cytology referral with the new screening algorithm and is also unlikely to be a useful colposcopy indicator.ConclusionsEarly detection rate of CIN2+ within the first six months of presentation is a useful measure of colposcopy competency and we would encourage our National Cancer Screening Register to explore this with the participating colposcopists.

Perfusion magnetic resonance imaging in Asherman syndrome

AbstractBackgroundMicrovascular scarring compromises the functionality of the endometrium, and vascular flow at the junctional zone (JZ) may be the key to understanding poor reproductive outcomes in women with Asherman syndrome (AS).AimsTo investigate whether vascular perfusion of the uterus, measured by dynamic contrast‐enhanced magnetic resonance imaging (DCE‐MRI) is impaired in women with intrauterine adhesions (IUA) and AS.Materials and MethodsA prospective observational cohort pilot study of 23 women with IUA treated with hysteroscopic synecholysis and a control group of two patients with cervix cancer were subject to DCE‐MRI with gadolinium to assess uterine vascularity. Twelve regions of interest (ROIs) were allocated on the DCE‐MRI image incorporating the JZ, with control ROI placed at the psoas muscle. Individual ROIs were compared to the mean total perfusion (TP) in the same uterus. Pre‐ and post‐operative perfusion analyses were performed on five women. Receiver operator curves (ROC) were used to analyse MRI as a predictor of IUA.ResultsThere was no significant difference in perfusion; a trend toward reduced perfusion was observed in women with IUA compared to the controls. The ROC was predictive of higher‐grade and inoperable IUA.ConclusionsReduced perfusion on DCE‐MRI as assessed by ROC predicted higher‐stage AS. The results of this study support further investigation of DCE‐MRI as a prognostic tool for AS prior to surgical intervention to assist in providing prognostic guidance for women suffering from AS.

Participation in the National Cervical Screening Program Among Women Who Gave Birth in New South Wales, Australia by Place of Maternal Birth: A Data Linkage Analysis

ABSTRACT Objective High participation rates in the National Cervical Screening Program (NCSP) by all groups of women are required to ensure the equitable elimination of cervical cancer in Australia. In this study, we examine screening participation of overseas‐born women compared to Australian‐born women who gave birth. Design Population‐based retrospective cohort study using linked health datasets. Setting and Participants Women who gave birth in New South Wales between January 1, 2000 and June 30, 2017. Main Outcome Measures Participation in the NCSP (≥ 1 cytology test) in the 3‐ and 5‐year periods prior to delivery by place of maternal birth, adjusted for multiple socio‐demographic and health characteristics. Results Among the 1 332 669 mothers who gave birth over the study period, overall cervical screening participation in the 3‐ and 5‐year periods prior to delivery was 67.0% and 75.7%, respectively. Participation was lower for overseas‐born mothers compared to Australian‐born mothers for both the 3‐year (57.8% vs. 71.7%; adjusted odds ratio [aOR]: 0.51, 95% confidence interval [CI]: 0.50–0.51) and 5‐year (64.9% vs. 81.2%; aOR: 0.40, 95% CI: 0.40–0.40) participation periods. All groups of overseas‐born women had substantially lower screening participation compared to Australian‐born women, with the lowest relative 3‐year participation in mothers born in Southern/Central Asia (aOR: 0.30, 95% CI: 0.30–0.31), Oceania (aOR: 0.31, 95% CI: 0.30–0.32), North‐East Asia (aOR: 0.49, 95% CI: 0.48–0.50), and New Zealand (aOR: 0.49, 95% CI: 0.48–0.51). Conclusions Overseas‐born women had around half the cervical screening participation in the period prior to birth compared to Australian‐born women. It is likely that opportunities to screen these under‐screened groups during the antenatal period, typically a time of repeated health services contact, are missed.

‘I was able to make a better decision about my health.’ Wāhine experiences of colposcopy at a marae‐based health clinic: A qualitative study

BackgroundEquitable access to colposcopy services is required if we are to realise the benefit of the introduction of human papilloma virus (HPV) screening in Aotearoa New Zealand. We piloted a community colposcopy clinic, co‐located at an urban marae health clinic.AimTo describe the experiences of wāhine (women) attending the marae‐based colposcopy clinic.MethodsAn in‐depth reflexive thematic analysis from 34 people's accounts was undertaken.ResultsFive themes were identified from the experiences of wāhine attending the clinic. Three themes related to how having a local clinic supported access: everyone was welcoming and friendly, the environment was familiar and non‐clinical and the clinic was accessible. The fourth theme related to how this contributed to agency. A fifth theme relates to wāhine views about informing the ongoing provision of colposcopy services. The experiences reflected the principles and values practised at the marae health clinic. Wāhine described feeling cared for as soon as they entered the clinic. As the clinic was local, and for some based at their marae, it was a known space where they knew the experience would be safe. Whānau were welcome with spaces for children to play. Being local meant there were fewer logistics to manage, all of which supported access.DiscussionPrioritising wāhine through the provision of culturally safe and accessible colposcopy is feasible. It has the potential to contribute to the elimination of cervical cancer in Aotearoa, New Zealand.

‘It's not a solution to keep telling me to lose weight!’ Exploring endometrial cancer survivors’ experiences of nutrition and well‐being advice: A qualitative study

AimsThe aim was to explore Endometrial cancer (EC) survivors' experiences of being offered nutrition and well‐being advice.MethodsThis qualitative study was conducted at two tertiary centres in Aotearoa New Zealand. Semi‐structured conversations with people who had completed treatment for EC in the past 12 months were undertaken to explore how they were offered nutrition and well‐being advice as part of standard follow‐up care. Interviews were analysed using reflexive thematic analysis.ResultsFifteen people of Pacific, Māori and European ethnicity participated. Five themes were derived: (i) isolation and vulnerability, (ii) importance of language, (iii) inconsistent availability and relevance of nutrition and well‐being information, (iv) competing priorities and influences and (v) holistic and culturally responsive support. People often experienced judgement associated with their weight as part of their care, with limited understanding of their lived realities. Nutrition and well‐being advice was not widely available or accessible, and people had to explicitly ask for it. Social and environmental factors were barriers to making changes to health behaviours. A need for culturally safe holistic care was identified.ConclusionEnhancing survivorship after EC is ultimately premised on providing culturally safe and responsive care. Expanding workforce training in communication around high weight as well as education and self‐assessment of cultural safety could enable aspects of this. A holistic care program could facilitate wider access to nutrition and well‐being advice and better meet the needs of this population.

Increasing incidence of endometrial cancer in Aotearoa New Zealand: Health professionals' perspective

BackgroundThe incidence of endometrial cancer is globally increasing. Aotearoa New Zealand is no exception with a 59% increase in cases over that last ten years.AimsWe report a sub‐set of themes which pertain to provider reflections of rising endometrioid‐type endometrial cancer incidence in individuals with high weight.Materials and MethodsFifteen semi‐structured interviews with healthcare professionals experienced in providing care to women with endometrial cancer were audio‐recorded and transcribed. Interviews were analysed using reflexive thematic analysis.ResultsTwo main themes emerged: (1) concerns for the future; and (2) impact on fertility and treatment options. Healthcare professionals discussed rising incidence in younger people and a need for increased awareness about the association of excess weight as a risk factor for developing the disease. The concern extended to workforce and equipment shortfalls of meeting the needs of individuals with higher weight, which subsequently influenced treatment options, health outcomes and survivorship.ConclusionsRising incidence of endometrial cancer in individuals with high weight presents multiple chances for inequitable access and health outcomes over the care continuum for endometrial cancer. Action is required to address incidence, awareness, access to equitable and inclusive treatment, and survivorship.

Barriers to salpingectomy for permanent contraception: A qualitative study with obstetricians and gynaecologists

Consideration of risk‐reducing bilateral salpingectomy has been recommended instead of tubal occlusive procedures for female sterilisation due to the role of the Fallopian tubes in the aetiology of serous ovarian malignancies. This study identified barriers to performing salpingectomy for permanent contraception. Twenty‐two semi‐structured interviews were conducted with Australian gynaecologists, and transcripts analysed qualitatively. Barriers to performing bilateral salpingectomy included: (a) patient factors (younger age and risk of regret); (b) operative complexity and complications (particularly risk of bleeding); (c) surgeon factors (lack of awareness of guidelines supporting salpingectomy; less comfort with laparoscopic surgery); and (d) practical system challenges (including cost and equipment availability).

Recurrence patterns identify aggressive form of human papillomavirus‐dependent vulvar cancer

BackgroundVulvar cancer is rare and, as a result, is understudied. Treatment is predominantly surgery, irrespective of the type of vulvar cancer, and is associated with physical, emotional and sexual complications. A cluster of human papillomavirus (HPV)‐dependent vulvar cancer patients was identified in Arnhem Land Northern Territory (NT), Australia, in which young Indigenous women were diagnosed at 70 times the national incidence rate.AimsTo assess whether women from the Arnhem Land cluster differ from women with vulvar squamous cell carcinoma (VSCC) and vulvar intraepithelial neoplasia (VIN) resident elsewhere in the NT in recurrence after treatment, disease progression and mortality.Materials and methodsA retrospective cohort study of NT‐resident women diagnosed with VIN or invasive vulvar cancer (VSCC) between 1 January 1993 and 30 June 2015 was undertaken. Time to recurrence was assessed using cumulative incidence plots and Fine and Gray competing risk regression models. Mean cumulative count was used to estimate the burden of recurrent events.ResultsIndigenous women from Arnhem Land experienced more recurrences after treatment than non‐Indigenous women, the cancers recurred faster, and Indigenous women have worse survival at five years.ConclusionsIn characterising the epidemiological features of this cluster, we have identified a particularly aggressive form of vulvar cancer. This provides a unique opportunity for elucidating the aetiopathological pathways driving vulvar cancer development that may ultimately lead to preventive and therapeutic targets for this neglected malignancy. Further, these findings have important implications for clinical practice and HPV vaccination policy in the affected population.

Compliance with follow‐up Test of Cure and outcomes after treatment for high‐grade cervical intraepithelial neoplasia in Victoria, Australia

BackgroundTest of Cure (ToC), a combination of testing for oncogenic human papillomavirus (HPV) and cytology, at 12 months post‐treatment and annually thereafter, was approved in Australia in 2005 for follow‐up of women treated for high‐grade squamous intraepithelial lesions (HSIL) of the cervix.AimsTo determine among women resident in Victoria, Australia, the compliance with ToC and the incidence of recurrence up to five years after successful ToC.Materials and MethodsA retrospective analysis of women with HSIL (diagnosed at pre‐treatment punch biopsy or at excision) who had excisional treatment between 1 January 2007 and 31 December 2011. De‐identified data were retrieved from the Victorian Cervical Cytology Registry in Melbourne as at 24 April, 2015. Successful ToC is defined as the occurrence of two consecutive normal (negative) co‐tests. Recurrence after treatment is defined by histologically detected HSIL or greater.ResultsThere were 8478 women who had excisional treatment for HSIL, with 448 (5.5%) experiencing recurrence. Only 2253 (26.6%) women successfully completed ToC, with a decreasing likelihood of ToC completion by time since year of treatment (32.0% in 2007 compared with 20.9% in 2011). Only one (0.08%) woman had HSIL on histology after successful ToC. From the 2007 cohort, 555 (32.0%) women completed ToC successfully and no HSIL recurrence occurred thereafter (median subsequent follow‐up period of 4.7 years).ConclusionsOur study confirmed that women who successfully complete ToC can be returned to five‐year routine screening. However, more concerted efforts are needed to ensure that all women treated complete ToC.

Resecting Beyond the Central Pelvic Compartment in Pelvic Exenterations for Gynaecological Malignancies: Outcomes From a Tertiary Unit

ABSTRACT Background Pelvic exenterations (PE) in solid organ gynaecological malignancies have historically been confined to the central pelvic compartment but an expansion of resection extent to include the lateral compartment is now technically feasible. There remains uncertainty about its influence on outcomes. Methods Retrospective study of consecutive patients undergoing PE for non‐ovarian gynaecological malignancies in a tertiary referral unit. Two groups were assessed and compared: standard resections including but not beyond the pelvic sidewall (SR); and extended resections beyond the pelvic side wall (lateral compartment excisions; internal iliac vessels and/or obturator internus/piriformis resection and/or bone resection) (ER). Results Thirty‐one patients underwent 32 PE: of these, 21 patients underwent SR (65.6%) with 11 who underwent ER (34.4%). Clear microscopic resection margins (R0) were achieved in 72.7% for ER versus 90.5% for SR. The overall 30‐day major complication rate (≥Clavien‐Dindo III) was 45.5% for the ER group versus 19.9% for SR. Median length‐of‐stay for ER was longer than for SR (38 vs. 18.5 days). The 1‐year DFS for ER was 66.7% versus 77.8% for SR. The 2‐year DFS for ER group was 60% versus 57.1% for SR. Conclusions In this study of contemporary patients, the short‐term patient outcomes of ER were consistent with other similar cohorts in the literature and comparable to SR in this cohort. There is an urgent need for larger multicentre studies to clarify the influence of PE resectional extent on resection margin status, patient outcomes and survival.