Journal of Obstetrics and Gynaecology Canada

Are Women with Antecedent Low-Grade Cytology and <CIN2 Findings in Colposcopy Being Overmanaged?

To determine the baseline and cumulative risks of cervical intraepithelial lesion grade 3 (CIN3) and invasive cervical cancer in patients with <CIN2 colposcopy findings after a low-grade screening cytology finding (atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion [LSIL]). By linking administrative databases, including cytology, pathology, cancer registries, and physician billing history, a population-based cohort study was performed on participants with <CIN2 initial colposcopy results after a low-grade antecedent cytology finding, between January 2012 and December 2013. Three and 5-year risks of CIN3 and invasive cervical cancer were generated using Kaplan-Meier survival analysis. Among the 36 887 participants included in the study, CIN3 incidence based on referral cytology were as follows at 3 and 5 years, respectively: normal, 0.7% and 0.9%; ASCUS, 4.31% and 5.6%; and LSIL, 5.9% and 7.2%. Three- and 5-year incidence of invasive cancer were 0% and 0.02% for normal cytology, 0.08% and 0.11% for ASCUS, and 0.04% and 0.07% for LSIL, respectively. Stratifying risk by biopsy result at initial colposcopy, 3- and 5-year CIN3 incidences were 2.85% and 3.81% with a negative biopsy, 7.09% and 8.32% with an LSIL biopsy, and 4.11% and 5.2% when no biopsy was done, respectively. Three- and 5-year incidence of invasive cancer was 0% and 0.05% after a negative biopsy, 0% and 0% after LSIL biopsy, and 0.05% and 0.08% when no biopsy was done, respectively. When initial colposcopy is done after a low-grade screening cytology result and <CIN2 is identified, the risk of CIN3 and invasive cancer is low, particularly when biopsies indicate LSIL. Surveillance strategies should balance the likelihood of detecting CIN3 with the potential harms over management with too frequent screening or colposcopic interventions in low-risk patients.

Role of HPV in the Prediction of Persistence/Recurrence After Treatment for Cervical Precancer

(1) To determine the role of human papillomavirus (HPV) testing after excisional treatment of cervical precancer. (2) To determine clinical factors associated with persistence of cervical precancer post-treatment. A retrospective chart review was conducted including patients who had a loop electrosurgical excision procedure (LEEP) for cervical precancer (cervical intraepithelial neoplasia 3/adenocarcinoma in situ/high-grade squamous intraepithelial lesions [HSIL]). All patients treated between 2016 and 2018 at a tertiary centre colposcopy unit were included. Persistence/recurrence of disease was defined as high-grade cytology or histology identified during the time of follow-up. Univariate and multivariate regression models were performed to identify factors associated with persistence/recurrence and HPV positivity at exit testing. A total of 284 patients were included. The median follow-up time was 19 months. Of the LEEP specimens, 90.8% (n = 258) demonstrated HSIL and 3.9% (n = 11) had adenocarcinoma in situ. 28.5% (n = 81) of the LEEP specimens had positive margins. In follow-up, 72.9% had negative cytology, 17.6% had atypical squamous cells of undetermined significance/low-grade SIL, 1.8% had atypical squamous cells, HSIL cannot be excluded/low-grade SIL-H, and 6.7% had HSIL. At the final follow-up, 27.8% (n = 79) were HPV+. Overall rate of persistence/recurrence was 11.3% (n = 32); median time to persistence/recurrence was 6.5 months. Multivariate regression models demonstrated that follow-up HPV positivity (OR = 22.0) and positive margins (OR = 3.7) were significantly associated with persistence/recurrence. Similarly, in univariate regression models, positive margins were significant (OR = 2.2) for predicting HPV positivity in exit testing. Persistence/recurrence of precancer can occur due to incomplete treatment of lesions by local excision and by the persistence of HPV infection. Surveillance strategies for women treated for cervical precancer require a risk-based approach and should rely on HPV testing.

Is There a Survival Advantage in Diagnosing Endometrial Cancer in Asymptomatic Patients? A Systemic Review and Meta-analysis

Data supporting a survival advantage of endometrial cancer diagnosed before the onset of postmenopausal bleeding are lacking. This study sought to compare overall survival and disease recurrence between women who were asymptomatic at diagnosis and women who were symptomatic at diagnosis. A systemic search was conducted in databases using the terms: "asymptomatic," "ultrasound," "screening," and "endometrial cancer." Only original research studies that compared characteristics of tumour advancement and survival measures were included. The six articles included in the meta-analysis comprised 2961 patients. Data were collected on study design and period, number and characteristics of participants, and outcomes in terms of tumour histology and survival measures. Higher rates of stage I tumours were shown among asymptomatic patients (relative risk 1.19). The proportion of high-grade histology did not differ between the two groups (relative risk 0.92). The crude pooled estimate for overall survival did not yield statistical significance, nor did recurrence-free survival (which was reported by three studies). In conclusion, endometrial cancer diagnosed in asymptomatic women is not associated with higher survival than in symptomatic women. Invasive procedures in asymptomatic women with incidental ultrasonographic findings should be carefully weighed because no survival advantage is expected.

Guideline No. 403: Initial Investigation and Management of Adnexal Masses

To aid primary care physicians, emergency medicine physicians, and gynaecologists in the initial investigation of adnexal masses, defined as lumps that appear near the uterus or in or around ovaries, fallopian tubes, or surrounding connective tissue, and to outline recommendations for identifying women who would benefit from a referral to a gynaecologic oncologist for further management. Gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists, radiologists, sonographers, nurses, medical learners, residents, and fellows. Adult women 18 years of age and older presenting for the evaluation of an adnexal mass. Women with adnexal masses should be assessed for personal risk factors, history, and physical findings. Initial evaluation should also include imaging and laboratory testing to triage women for management of their care either by a gynaecologic oncologist or as per SOGC guideline no. 404 on the initial investigation and management of benign ovarian masses. A search of PubMed, Cochrane Wiley, and the Cochrane systematic reviews was conducted in January 2018 for English-language materials involving human subjects published since 2000 using three sets of terms: (i) ovarian cancer, ovarian carcinoma, adnexal disease, ovarian neoplasm, adnexal mass, fallopian tube disease, fallopian tube neoplasm, ovarian cyst, and ovarian tumour; (ii) the above terms in combination with predict neoplasm staging, follow-up, and staging; and (iii) the above two sets of terms in combination with ultrasound, tumour marker, CA 125, CEA, CA19-9, HE4, multivariable-index-assay, risk-of-ovarian-malignancy-algorithm, risk-of-malignancy-index, diagnostic imaging, CT, MRI, and PET. Relevant evidence was selected for inclusion in descending order of quality of evidence as follows: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional articles were identified through cross-referencing the identified reviews. The total number of studies identified was 2350, with 59 being included in this review. The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework (Table A1 of Online Appendix A). See Table A2 of Online Appendix A for the interpretation of strong and weak recommendations. The summary of findings is available upon request. Adnexal masses are common, and guidelines on how to triage them and manage the care of patients presenting with adnexal masses will continue to guide the practice of primary care providers and gynaecologists. Ovarian cancer outcomes are improved when initial surgery is performed by a gynaecologic oncologist, likely as a result of complete surgical staging and optimal cytoreduction. Given these superior outcomes, guidelines to assist in the triage of adnexal masses and the referral and management of the care of patients with an adnexal mass are critical. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Outcome and Management of Serous Tubal Intraepithelial Carcinoma Following Opportunistic Salpingectomy: Systematic Review and Meta-Analysis

Serous ovarian cancer is the most common subtype of epithelial ovarian carcinoma-the most prevalent type of ovarian cancer. High-grade serous ovarian carcinoma (HGSOC) is thought to arise from the distal fallopian tube, with a precursor lesion known as serous tubal intraepithelial carcinoma (STIC). STICs are found in the final pathology of a salpingectomy specimen in 10%-20% of women with a BRCA gene mutation and 1%-7% of women without a mutation. However, there is currently no official guideline and a paucity of data on the management of STICs. We performed a systematic review following PRISMA guidelines. Five databases were searched for relevant studies on STICs. Two independent reviewers performed the abstract and full-text screening and data extraction, with conflicts resolved through discussion with the third reviewer. The risk of bias of each study was assessed using the Newcastle-Ottawa scale. Fourteen articles were included. Ninety-nine patients who were diagnosed with STIC and subsequently followed for a mean period of 55.5 months were included in this analysis. Eighty-three patients (83.9%) were BRCA mutation carriers. After the diagnosis of isolated STIC, 7 patients (7.3%) received chemotherapy and 25 (26%) underwent surgical staging. Three of the 25 patients were diagnosed with HGSOC based on the staging surgery. Nine patients were later diagnosed with HGSOC during follow-up, with an average duration of follow-up of 58.5 months between the diagnosis of STIC and the diagnosis of HGSOC. Based on our review of the literature, there is a 10.7% risk of having concurrent HGSOC at the time of STIC diagnosis, and the risk of developing a subsequent HGSOC is 14.5%. BRCA mutation status should be determined in cases of isolated STIC, as 83.9% of patients included in this study were found to carry BRCA mutations. We believe it is necessary to further investigate the role of surgical staging following the diagnosis of STIC.

Guideline No. 461: The Management of Uterine Fibroids

To provide clinicians with an understanding of the clinical significance of fibroids for individuals with uteruses and provide evidence-based guidance on currently available treatment options. This clinical practice guidelines seeks to improve the lives of individuals with uterine fibroids and fibroid-associated menstrual bleeding or pressure symptoms. Fertility considerations are not discussed in detail, as they are described in the SOGC's Clinical Practice Guideline on The Management of Uterine Fibroids in Women with Otherwise Unexpected Infertility guideline. This clinical practice guideline is intended to facilitate the decision-making process between patients and healthcare providers regarding the assessment and management of symptomatic uterine fibroids. A majority of fibroid patients are asymptomatic and require no intervention. For patients with abnormal uterine bleeding, iron deficiency anemia, or pelvic pain or pressure symptoms, selected treatment should take into consideration fibroid characteristics and be directed towards patient symptoms and fertility goals. The cost of therapy to the healthcare system for individuals with fibroids must be interpreted in the context of the economic burden, lost productivity, and adverse impacts on quality of life that can be associated with untreated disease. This clinical practice guideline is an update of the SOGC's Clinical Practice Guideline No. 318 on The Management of Uterine Leiomyomas. A national panel of patient partners were gathered to provide feedback and perspective on the recommendations and summary statements for this guideline. Patient partners were purposefully selected to ensure representation of Canadian geographic region, racial representation, and fibroid-related symptom and treatment received. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations). Health care providers involved in the assessment and management of individuals with uterine fibroids. Uterine fibroids are very common and can cause uterine bleeding and pressure symptoms. There should be a low threshold for investigation of such symptoms, as a variety of treatment options are available. RECOMMENDATIONS.

Complication Differences Across Elective, Minimally Invasive, Outpatient Hysterectomy and Myomectomy

To examine differences in 30-day complications between minimally invasive myomectomy and minimally invasive hysterectomy in the outpatient setting. This was a retrospective, propensity-matched cohort study using data collected from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files from 2016 to 2021. The American College of Surgeons National Surgical Quality Improvement Program database collects surgical outcome data from over 700 hospitals in the United States. Cases selected for this study were performed in the outpatient setting. Patients aged 18-50 years who had undergone a minimally invasive elective outpatient hysterectomy or myomectomy for a primary indication of uterine fibroids. Patients were stratified by whether they underwent a minimally invasive hysterectomy or minimally invasive myomectomy. The primary outcome was the incidence of 30-day complications, with secondary outcomes including readmissions and reoperation. Among 31 203 patients (median age: 43 years), 14% underwent myomectomy. Based on a matched analysis of 3413 myomectomy-hysterectomy pairs, patients who underwent myomectomy had lower odds of 30-day postoperative complication (OR 0.73; 95% CI 0.59-0.90, P = 0.003), hospital readmission (OR 0.39; 95% CI 0.27-0.57, P < 0.001), and reoperation (OR 0.33; 95% CI 0.17-0.64, P = 0.001). Complication rates across these 2 surgical management options for leiomyomas favour minimally invasive myomectomy for elective outpatient cases.

Implementation of a Frailty Screening Tool Algorithm in Older Patients with Advanced Ovarian Cancer

Cervix Relapses of Lymphoblastic Leukemia Type B

Lichen Sclerosus: Why Do Most Women Struggle With Their Diagnosis?

Excerpts from the World Medical Literature: Obstetrics

Two-Port Laparoscopic Removal of Large Ovarian Cystadenoma

An ovarian mucinous cystadenoma is a common benign tumour of the ovary that tends to reach very large sizes. Although traditional morcellation in the abdominal cavity is largely avoided in gynaecologic surgery, several authors have proposed other systems and techniques for the removal of large masses without resorting to laparotomy. We proposed an extremely minimally invasive technique to remove a large mass with a very low suspicion of malignancy, and created a video demonstration of the procedure. In this short film we illustrate our novel technique using only 2 laparoscopic ports, which maximizes both cosmesis and speed of recovery. The technique is not a completely closed system, therefore the potential for spreading an undiagnosed malignancy still exists. Accordingly, the authors do not suggest this technique for masses with a high potential for malignancy. However, in properly consented patients where there is very little suspicion for malignancy, our technique may be a reasonable option to promote fast recovery and provide excellent cosmesis.

Excerpts from the World Medical Literature

Guideline No. 404: Initial Investigation and Management of Benign Ovarian Masses

To provide recommendations for a systematic approach to the initial investigation and management of a benign ovarian mass and facilitate patient referral to a gynaecologic oncologist for management. Obstetricians, gynaecologists, family physicians, internists, nurse practitioners, radiologists, general surgeons, medical students, medical residents, fellows, and other health care providers. Women ≥18 years of age presenting for evaluation of an ovarian mass (including simple and unilocular cystic masses, endometriomas, dermoids, fibromas, and hemorrhagic cysts) who are not acutely symptomatic and without known genetic predisposition to ovarian cancer. This guideline aims to encourage conservative management and help reduce unnecessary surgery and long-term health complications, maintain fertility, and decrease operative costs and improve overall patient care and outcomes by providing criteria for referral of patients with ultrasound imaging findings suggestive of a malignant mass to a gynaecologic oncologist. Databases searched: Medline, Cochrane, and PubMed. Medical terms used: benign asymptomatic and symptomatic ovarian cysts, adnexal masses, oophorectomy, ultrasound diagnosis of cysts, simple ultrasound rules, surgical and medical therapies for cysts, screening for ovarian cancer, ovarian torsion, and menopause. Initial search was completed by 2017 and updated in 2018. Exclusion criteria were malignant ovarian cystic masses, endometriosis therapies, and other adnexal pathologies unrelated to the ovary. The content and recommendations were drafted and agreed upon by the authors. The Society of Obstetricians and Gynaecologists of Canada's Board of Directors approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework. Implementation of the recommendations could reduce costs due to unnecessary surgeries and hospitalizations and reduce lost work days and the risk of loss of fertility, early menopause, and surgical complications. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Excerpts From the World Medical Literature

Evaluation of the Performance of the IOTA ADNEX Model in Discriminating Adnexal Masses Preoperatively: An Ambispective Study

To evaluate the performance of the International Ovarian Tumour Analysis (IOTA) Assessment of Different NEoplasias in the adneXa (ADNEX) model in discriminating adnexal masses preoperatively. This ambispective observational study included 112 women with at least 1 adnexal mass, from January 2016 to April 2023. Cases underwent pelvic ultrasound and CA125 level assessments prior to surgery. The masses were classified into various subcategories by the IOTA ADNEX model and compared with postoperative histopathological reports. Sensitivity, specificity, negative predictive value, positive predictive value, and diagnostic accuracy were calculated for classifying tumours into various histological subtypes. Among the 112 women, 66 (58.9%) had benign ovarian tumours, 10 (8.9%) had borderline ovarian tumours, 17 (15.2%) had stage I ovarian cancer, 15 (13.4%) had stage II-IV ovarian cancer, and 4 (3.6%) had ovarian metastasis. The area under the receiver operating characteristic curve was 0.852 (0.772-0.912) for distinguishing between benign and malignant tumours using the IOTA ADNEX model at a 50% cut-off, with a sensitivity of 84.78%, specificity of 84.85%, positive predictive value of 79.6%, and negative predictive value of 88.9%. The IOTA ADNEX model is effective in classifying adnexal masses into benign and malignant categories, making it a valuable tool for triaging adnexal masses for further management.

Clinical Conundrum: A Case of Cervical Giant Condyloma Acuminatum

Giant condyloma acuminatum (GCA) is a benign anogenital lesion caused by human papilloma virus. It is rarely found on the cervix and is difficult to differentiate from malignancy. It is associated with a propensity for invasion, recurrence, and malignant transformation. A 35-year-old woman presented with abnormal uterine bleeding and a suspicious cervical mass. After a Pap test revealed high-grade squamous intraepithelial lesion, cervical biopsies revealed cervical dysplasia. A diagnostic loop electrical excision procedure identified a giant condyloma. A total hysterectomy was performed, confirming the diagnosis. This condition should be in the differential diagnosis for a cervical mass suspicious for malignancy. Prompt biopsy of mass is crucial.

Evidence to Support Change of Clinical Pathway Following Colposcopy Treatment for Cervical Intraepithelial Neoplasia in Canada

Human papillomavirus (HPV) testing can be incorporated into the post-treatment pathway of cervical intraepithelial neoplasia (CIN) to confirm disease-free status. To inform a post-treatment strategy based on risk of recurrence, we modelled disease and economic outcomes. The current Alberta, Canada, post-treatment care pathway-cytology testing with colposcopy assessment-was compared with 6 other scenarios incorporating cytology, HPV testing, or both tests at different time points in a modelling study based on a microsimulation program. Input parameter values for the screening participation, screening age groups, and follow-up options and test compliance for HPV, cytology, and colposcopy were varied, based on Alberta cervical cancer screening program data. Health outcomes over the short- and long-term were projected, which incorporated the increasing population-level coverage of HPV vaccination. Lifetime incremental cost-effectiveness ratios (ICERs) were used to evaluate economic outcomes and descriptive statistics compared with numbers of tests, visits, and procedures as well as changes in incidence and mortality rates between the scenarios. At 5 years after implementation of the "HPV testing alone at 6 and 18 months" post-treatment pathway, the number of colposcopies dropped by 36% and the number of pre-cancer treatments, by 6%. Lifetime ICERs were CAD $6170 versus $248,495 per quality-adjusted life-year compared with the status quo pathway. Cervical cancer incidence and mortality rates decreased significantly and similarly in all scenarios. Strategies that involve HPV testing in CIN post-treatment follow-up care are expected to be more cost effective with improved clinical outcomes than traditional cytology and colposcopy-based follow-up.

What Are the Current HPV Types Contributing to Cervical High-Grade Squamous Intraepithelial Lesions, Adenocarcinoma In Situ, and Early Cervical Cancer?

To determine the prevalence of human papillomavirus (HPV) types by genotyping high-grade squamous intraepithelial lesion (HSIL), adenocarcinoma in situ (AIS), and early-stage invasive cervical cancer (ICC) in patients who have been exposed or are naïve to the HPV vaccine. This was a cross-sectional study. All patients over the age of 18 years who presented to the colposcopy clinic with HSIL, AIS, or ICC who were expected to undergo a cervical biopsy, loop electrosurgical excisional procedure, or cone biopsy were eligible and approached for informed consent. HPV typing was performed to identify the causative HPV types. Between November 2016 and May 2023, 113 patients (34 vaccinated with at least 1 dose, and 79 non-vaccinated) consented to this study. The median ages at coitarche and study entry were 18 (range 14-37) and 34 (range 24-66) years, respectively. Only 3 patients were vaccinated prior to coitarche. Histology was as follows: HSIL = 97, AIS = 9, HSIL and AIS = 2, squamous cell carcinoma = 4, and 1 patient with adenocarcinoma. The causative HPV type was 16 or 18 in 59% of the vaccinated group and in 66% of the non-vaccinated group. Most vaccinated patients (74%) reported receiving 2-3 doses of HPV vaccine. In our cohort, the distribution of causative HPV 16 and 18 in patients presenting with HSIL/AIS/ICC was similar between vaccine-naïve and vaccinated patients. This data suggests cervical screening guidelines should not differentiate between "vaccinated" and "non-vaccinated" women without further details of their vaccination.

The Effect of Self-Sampling or Clinician-Based Sampling on Anxiety in Cervical Cancer Screening Among Women: A Randomized Controlled Trial

This study aimed to determine the effect of self-sampling or clinician-based sampling on anxiety in cervical cancer screening among women. This study was conducted between October 2022 and December 2023 in a family health centre among women aged 30-65 years who had not undergone cervical cancer screening in the last 5 years, were sexually active, and could read and write Turkish. Participants (N = 110) were randomly divided into 2 groups (1:1): the experimental group (n = 55) and control group (n = 55). Women in the experimental group were trained before the procedure and were allowed to take samples from the vaginal area on their own. The women in control group were sampled from cervical region by the clinician. Both groups were pretested before the procedure using the "descriptive information form" and "state anxiety inventory" to measure anxiety. After the sampling procedure, a post-test was administered to the experimental and control groups using the state anxiety inventory. Statistical Package for Social Sciences for Windows 24.0 was used for the analysis and P 0.05), whereas in the post-test, it was observed that anxiety levels of women in experimental group were significantly lower than those in the control group (P < 0.05). This study observed that women's self-sampling during cervical cancer screening reduced their anxiety level.

A Parallel-Group, Randomized Trial Examining Impact of Colposcopy Results Delivery by a Nurse Liaison on Patient-Reported Outcomes and Adherence

Cervical cancer is on the rise in Canada. Addressing patient anxiety and improving patient understanding of colposcopy and results may improve adherence. This randomized controlled trial examined the impact of colposcopy results delivery by a Nurse Liaison versus the referring primary care provider (PCP) on patient anxiety, and secondary outcomes including patient satisfaction, knowledge of diagnosis, and 9-month adherence to follow-up. Patients ≥18 years old presenting for initial appointment at the study colposcopy clinic were randomized 1:1 to an intervention group (Nurse Liaison) versus a control group (PCP). After receiving colposcopy results, participants completed online measures of anxiety (State-Trait Anxiety Inventory), health care satisfaction scales (Patient Satisfaction Questionnaire-18, Health Anxiety Inventory, Visit-Specific Satisfaction Questionnaire-9), self-reported colposcopy diagnosis, and demographics. Chart review at 9 months assessed adherence to recommended colposcopy follow-up. Groups were compared on continuous and categorical variables, controlling for diagnosis severity and trait anxiety. The intervention group had significantly lower state anxiety with State-Trait Anxiety Inventory-state mean scores of 37.3 versus 40.7 in controls (P = 0.03). Intervention group participants were more likely to correctly report their diagnosis (84% vs. 66.3%, P = 0.003). Questionnaire responders were more likely to be in the intervention group and had a higher proportion of cervical intraepithelial neoplasia 2+ pathology. There were no differences in demographics, patient satisfaction, or adherence to follow-up between groups. Direct delivery of colposcopy results by a trained Nurse Liaison was associated with decreased patient anxiety around colposcopy results, and increased patient knowledge regarding diagnosis. This model may be considered to improve patient-centred care.

The Value of Using Patient-Specific 3D-Printed Anatomical Models in Surgical Planning for Patients With Complex Multifibroid Uteri

To compare surgeon responses regarding their surgical plan before and after receiving a patient-specific three-dimensional (3D)-printed model of a patient's multifibroid uterus created from their magnetic resonance imaging. 3D-printed models were derived from standard-of-care pelvic magnetic resonance images of patients scheduled for surgical intervention for multifibroid uterus. Relevant anatomical structures were printed using a combination of transparent and opaque resin types. 3D models were used for 7 surgical cases (5 myomectomies, 2 hysterectomies). A staff surgeon and 1 or 2 surgical fellow(s) were present for each case. Surgeons completed a questionnaire before and after receiving the model documenting surgical approach, perceived difficulty, and confidence in surgical plan. A postoperative questionnaire was used to assess surgeon experience using 3D models. Two staff surgeons and 3 clinical fellows participated in this study. A total of 15 surgeon responses were collected across the 7 cases. After viewing the models, an increase in perceived surgical difficulty and confidence in surgical plan was reported in 12/15 and 7/15 responses, respectively. Anticipated surgical time had a mean ± SD absolute change of 44.0 ± 47.9 minutes and anticipated blood loss had an absolute change of 100 ± 103.5 cc. 2 of 15 responses report a change in pre-surgical approach. Intra-operative model reference was reported to change the dissection route in 8/15 surgeon responses. On average, surgeons rated their experience using 3D models 8.6/10 for pre-surgical planning and 8.1/10 for intra-operative reference. Patient-specific 3D anatomical models may be a useful tool to increase a surgeon's understanding of complex gynaecologic anatomy and to improve their surgical plan. Future work is needed to evaluate the impact of 3D models on surgical outcomes in gynaecology.

Opportunistic Salpingectomy Between 2017 and 2020: A Descriptive Analysis

Opportunistic salpingectomy (OS) is the removal of fallopian tubes during another pelvic surgery for the purpose of ovarian cancer prevention. Herein, we describe the rates of OS at the time of hysterectomy and tubal sterilization between 2017 and 2020. This study uses the Canadian Institute of Health Information's Discharge Abstract Database and National Ambulatory Care Reporting System for all Canadian provinces and territories except for Quebec between the fiscal years 2017 and 2020. A descriptive analysis on all people aged 15 years and older who had hysterectomies or tubal sterilizations was conducted to determine the proportion of hysterectomies that included bilateral salpingectomy (OS) and the proportion of tubal sterilizations that were OS compared to tubal ligation. There were 174 006 people included in the study. The proportion of hysterectomies that included OS increased from 31.7% in 2017 to 39.9% by 2020. With respect to tubal sterilizations, rates of OS increased from 26.3% of all tubal sterilizations in 2017 to 42.5% in 2020. British Columbia remained the jurisdiction with the highest rates of OS, but rates increased significantly in many jurisdictions, particularly at the time of tubal sterilization. The rates of OS have continued to increase in all Canadian jurisdictions following the official Society of Obstetricians and Gynaecologists of Canada recommendation to consider OS in 2015. Assuming that all tubal ligations could have been OS and 75% of hysterectomies with ovarian conservation could have included OS, our data indicate 76 932 missed opportunities for ovarian cancer prevention.

Access to Surgery for Endometrial Cancer Patients During the COVID-19 Pandemic in Ontario, Canada: A Population-Based Study

To assess the impact of the COVID-19 pandemic on endometrial cancer stage and surgical treatment in Ontario, Canada. This descriptive study identified cases from January 1, 2017 to December 31, 2021 from endometrial cancer hysterectomy specimens in the Ontario Health-Cancer Care Ontario, ePath system. Endometrial biopsy records from January 1, 2016 to December 31, 2021 were matched to surgical specimens by provincial health card number. Time to surgery and surgical stage were compared before (2017-2019) and during (2020-2021) the COVID-19 pandemic. There were 10 446 women treated with hysterectomy for endometrial cancer in Ontario from 2017-2021. In April and May 2020, corresponding with the provincial state of emergency, there was a 56% relative reduction in endometrial biopsies. Despite this 2-month reduction in endometrial biopsy volume, there was no change in surgical volume for endometrial cancer treatment. The median time from endometrial biopsy to surgery was 56 days (IQR 40, 80) during the pandemic (2020-2021) compared to 58 days (IQR 43, 82) prior to the pandemic (2017-2019) (P < 0.001). There was no upstaging of endometrial cancer during the COVID-19 pandemic. The Ontario healthcare system continued to prioritize service delivery to endometrial cancer patients during the COVID-19 pandemic, despite the increase in virtual care and decrease in operating room time. There were no significant surgical delays or upstaging of endometrial cancer.

Giant Uterus and Vaginal Bleeding at 18 Weeks Gestation due to Complete Hydatiform Molar Pregnancy Co-Existing With a Healthy Fetus

Uterine Fibroids and Black People: A Call for Targeted Population Approaches to Address Challenges Within the Canadian Health Care System

Submucosal Lipoleiomyoma Mimicking Uterine Rupture During Hysteroscopic Resection

Perioperative Incidence of Venous Thromboembolism in Patients With Ovarian Cancer Using Four Different Data Collection Methods: A Manitoba Ovarian Cancer Outcomes (MOCO) Group Study

To evaluate the incidence of venous thromboembolism (VTE) in 90-day pre-operative period and at 30 and 90 days post surgery in patients who underwent debulking for ovarian cancer, analyze the impact of extended prophylaxis that was initiated in 2012, and examine the influence of data collection technique on reported rates of VTE. This retrospective database and records study examined rates of VTE in epithelial ovarian cancer patients in Manitoba, Canada between 2004 and 2016. Cases of VTE were identified using ICD codes, drug prescriptions, and records reviews; 4 different data collection methods were used. Analysis was performed with analysis of variance, Kruskal-Wallis and χ Data collection identified 823 debulking surgeries, with a final cohort of 779 patients; data were analyzed before and after extended prophylaxis intervention. Overall rates of VTE varied by collection method and were 1.82%-5.47%, 0.36%-3.16%, 0.85%-1.46%, and 1.46%-2.79%, respectively. During this timeframe, we noted a significant increase in the use of neoadjuvant chemotherapy (P = 0.010) and stage migration to stage 3 (P < 0.001). We report the rates of VTE utilizing 4 different data collection methods. We found a low overall rate, with some trends requiring further investigation. This study highlights the importance of data collection method on the reported rates of VTE in research.

Venous Thromboembolism in Patients Receiving Neoadjuvant Chemotherapy for Advanced Ovarian Cancer and Impact on Survival

To determine the incidence of venous thromboembolism (VTE) in patients with ovarian cancer receiving neoadjuvant chemotherapy (NACT), identify risk factors for VTE, and assess the effect of VTE on treatment trajectory and overall survival. This is a retrospective cohort study of patients diagnosed with ovarian, fallopian tube, or primary peritoneal cancer treated with NACT between 2013 to 2016 in Alberta, Canada. The primary outcome was incidence of VTE during NACT. Secondary outcomes were risk factors for VTE and overall survival. Data related to patient demographics, cancer treatment, and incidence of VTE were collected. Statistical analyses included Kaplan-Meier estimates and univariate and multivariate Cox regression analysis. A total of 284 patients were included in this study. Average age at diagnosis was 63.8 years. The incidence of VTE during NACT was 13.3%. Patients with VTE were less likely to undergo interval debulking surgery (58.3%) than patients without VTE (78.6%). Kaplan-Meier estimates demonstrated a decrease in overall survival in patients who had VTE during NACT (15.0 mo; 95% CI 14.5-16.5) compared with patients who did not (26.8 mo; 95% CI 22.8-30.9) (P 30 kg/m The risk of VTE in this cohort was 13.3%, which was associated with decreased overall survival. These findings suggest that thromboprophylaxis may have a role in this patient population.

Acceptability and Feasibility of Early Palliative Care Among Women with Advanced Epithelial Ovarian Cancer: A Randomized Controlled Pilot Study

To evaluate the acceptability of early palliative care (EPC) among patients with advanced ovarian cancer and to determine the feasibility of larger-scale phase III trials. We performed a randomized controlled pilot study of adult women (>18 years) with pathologically confirmed epithelial ovarian cancer that had recurred or progressed on first-line therapy and had no immediate need for palliative care. We randomly assigned patients to either EPC or standard oncologic care (SOC), and collected patient-reported outcomes (PRO) at baseline, 3 months, and 6 months; end-of-life care quality indicators were collected at study completion. Study endpoints were rates of enrollment, EPC adherence, and PRO completion. Of 32 eligible patients approached, 23 enrolled (72%; 95% CI 53-86) and were randomly assigned to either EPC (n = 12) or SOC (n = 11). At baseline, participants had poor physical and emotional wellbeing, high rates of depression (65%), and understood that their disease was not curable (87%). Eleven patients (92%; 95% CI 62-100) attended their EPC consultation, and all visits took place within 4 weeks of enrollment. However, PRO completion was low due to deaths by 3 (5/23) and 6 months (9/23). Patients had accurate perceptions of their disease status, were willing to be randomly assigned to EPC, and attended scheduled appointments. However, a definitive trial in this group is not feasible without major adjustments to eligibility criteria and a multicentre, international effort. We propose that EPC be considered routinely at progression or recurrence given patients' symptom burden and clear acceptance of the intervention, as well as evidence of benefit from adequately powered trials in other malignancies.

Low BRCA1 and BRCA2 Germline Mutation Rates in a French-Canadian Population with a Diagnosis of Epithelial Tubo-Ovarian Carcinoma

Universal genetic testing has become increasingly important in the management of epithelial tubo-ovarian and peritoneal carcinoma. Worldwide, reported incidences of deleterious BRCA mutations vary between 12% and 15%. We sought to evaluate the incidence in our population, given its specific genetic background (French-Canadian ancestry). Mainstream genetic testing was implemented in our service in May 2017 and offered to all patients with epithelial tubo-ovarian or peritoneal carcinomas, except mucinous and borderline tumours. Data were prospectively collected in a database and retrospectively analyzed. We tested 222 patients in our centre, of whom 183 (82.4%) had high-grade serous carcinoma (HGSC). Overall, 139 patients had no identified mutation (62.6%). Deleterious BRCA1 and BRCA2 mutations were found in 12 patients (5.4%): 6 had BRCA1, and 6 BRCA2 mutations; 11 of these patients had HGSC. Other non-BRCA mutations (ATM, RAD51C, RAD51D, BRIP1, CDH1, MRE11, MSH6, MUTYH, PALB2, and PMS2) were observed in an additional 20 patients (9.0%), of whom 18 had HGSC. A total of 63 different variants of unknown significance (VUS) were found, of which 4 were in the BRCA1 and BRCA2 genes. Deleterious mutations were not identified in clear cell carcinomas, and only 1 was found in low-grade serous carcinoma. In our French-Canadian population, the incidence of deleterious germline BRCA mutations was surprisingly low at 5.4%-less than half that reported in the literature. This may affect patient response to poly (ADP-ribose) polymerase (PARP) inhibitor (PARPi) therapy. Mainstream genetic testing was successfully implemented in our service and facilitated access to genetic testing in our patient population.

Unintended Consequences: The Impact of Cervical Cancer Screening Guidelines on Rates of STI Screening in Primary Care

In 2012, cervical cancer screening guidelines in Ontario shifted from recommending yearly Pap testing to recommending Pap tests every 3 years. We sought to investigate how these changes have impacted rates of sexually transmitted infection (STI) screening in young women. We conducted a retrospective cohort study of 600 patients aged 19-25 years who presented to 1 of 2 community family health teams from May 1, 2009 to April 30, 2012 (the annual Pap test group) or from Nov 1, 2012 to Oct 31, 2015 (the triennial Pap test group). The primary outcome was the number of visits at which STI screening was performed. Secondary outcomes were presence/absence of STI screening over a 3-year period and method of screening used. A significant decrease was observed in the number of visits at which STI screening was performed, with the annual group averaging 1.21 visits/patient compared with 0.82 visits/patient for the triennial group (P = 0.001). A decrease in the proportion of patients screened over 3 years was also observed (66.8% vs. 52.8%, P = 0.007). A significant decrease in the use of endocervical culture (1.06 vs. 0.57 tests/patient, P <0.001), and a non-significant increase in urine NAAT (0.09 vs. 0.17, P = 0.07) and serum STI screening (0.37 vs. 0.47, P = 0.16) was observed. The 2012 Ontario cervical cancer screening guidelines were associated with a decrease in STI screening among women aged 19-25 years in the primary care setting. This unintended effect of guideline changes highlights a need for STI screening practices that are independent of routine pelvic examinations.

The Role of Incisional Negative Pressure Wound Therapy in Vulvar Surgical Outcomes

To evaluate the effect of incisional negative pressure wound therapy (iNPWT) on surgical outcomes in patients undergoing wide vulvar surgical excision with simultaneous plastic reconstruction. We conducted a single-centre retrospective cohort study at a São João Local Health Unit. The study included 21 patients diagnosed with vulvar malignancy who underwent wide vulvar surgical excision with immediate reconstruction with flaps between 2017 and 2024. Patients were divided into 2 groups based on postoperative wound management: the iNPWT group (N = 7), who received incisional negative pressure wound therapy, and the conventional care group (N = 14), submitted to standard wound management. The study's primary outcome was the occurrence of postoperative wound complications. Secondary outcomes assessed the occurrence of specific complications, such as wound infection, dehiscence, necrosis and hematoma, and length of hospital stay. Overall wound complications occurred in 12 cases of conventional care patients (85.7%) but in none of the iNPWT group patients (P < 0.001). Compared to those submitted to incisional negative pressure wound therapy, the conventional care group had significantly higher prevalence of wound dehiscence (0.0% vs. 64.3%, P = 0.007) and infection (0.0% vs. 78.6%, P = 0.001). There was no significant difference (P = 0.521) in the necrosis rate. Median hospital stay was similar between groups (21.00 vs. 25.50 days, P = 0.488). Fewer postoperative complications were observed in the iNPWT group compared to the conventional care group, particularly wound dehiscence and infection. These findings suggest that iNPWT may be a valuable tool in improving surgical outcomes and reducing postoperative morbidity in patients undergoing wide vulvar surgical excisions.

Knowledge, Practices, and Acceptability of Vulvar Self-Examination in Patients in Colposcopy and Vulvar Dermatology Clinics

Our study investigated current knowledge, practices, and acceptability of vulvar self-examination (VSE) in a population at higher risk for vulvar cancer. Patients presenting to colposcopy and vulvar dermatology clinics at Women's College Hospital, Toronto, Canada were recruited. Participants received a questionnaire adapted from a similar Italian study conducted in 2021. Statistical analysis was completed using descriptive statistics, chi-square test, Fisher exact test, and linear logistic regression. Research ethics board approval was obtained (#2022-0104-E). From October 2022 to July 2023, 264 participants completed the survey (71% response rate), consisting of 46% colposcopy patients and 54% vulvar dermatology patients. The median age of the participants was 49.5 (range 23-87) years, and 87% of participants had attained a bachelor's degree or higher. Overall, 86% of participants had never been taught VSE before. Only 33% of participants could correctly draw and label a simple sketch of the vulva. Most (95%) were interested in learning more about VSE. Patients who had looked at their vulvas at least once before scored better on 7 out of 9 knowledge-based questions and drawing a vulva sketch (P < 0.05). Patients who had been previously taught VSE were more likely to seek medical attention for vulvar abnormalities (P < 0.05). Sociodemographic characteristics including younger age, non-White ethnicity, and lower education were associated with lower scores on knowledge-based questions and/or a vulva sketch (P < 0.05). Knowledge gaps exist in vulvar anatomy among a sample of highly educated patients at higher risk for vulvar cancer. Knowledge was higher among those who had previously engaged in VSE, and there was high interest in learning VSE. Future directions include further teaching and study of VSE practices and attitudes across Canada.

Risk of Vulvar Squamous Cell Carcinoma in Lichen Sclerosus and Lichen Planus: A Systematic Review

The objectives of this study were to determine: 1) the prevalence of lichen sclerosus (LS) and lichen planus (LP) present in association with vulvar squamous cell carcinoma (VSCC), and 2) the incidence and absolute risk of developing VSCC in LS and LP. A search was performed of MEDLINE, EMBASE and CINAHL databases. Three independent reviewers screened articles published before September 1, 2020, first on title/abstract and then on the full text. Women with a history of VSCC, human papillomavirus, smoking, or autoimmune disease were excluded. Newcastle-Ottawa observational study scales were used to assess the risk of bias and methodological quality of the included studies. Of the 3132 studies assessed, 31 were selected for analysis. Due to study heterogeneity, a qualitative synthesis was conducted. The prevalence of LS and LP in association with VSCC ranged from 0% (95% CI 0-5) to 83% (95% CI 36-100) and 1% (95% CI 0-7) to 33% (95% CI 4-78), respectively. The incidence of VSCC ranged from 1.16 (95% CI 0.03-6.44) to 13.67 (95% CI 5.50-28.17) per 1000 person-years for LS. The absolute risk of developing VSCC in patients ranged from 0.0% (95% CI 0.0-5.52) to 21.88% (95% CI 9.28-39.97) with LS and was 1.16% (95% CI 0.1-4.1) with LP. Incidence was not calculable for LP owing to study characteristics. This review provides evidence that there is an increased risk of developing VSCC in women with LS, while associations with LP are less clear. Early identification, treatment, and long-term follow-up are essential to prevent potential malignant progression of these vulvar dermatoses.

CIN Extension at Colposcopy: Relation to Treatment and Blood Parameters

To determine the colposcopic lesion size that predicts the presence of residual lesion in patients with cervical intraepithelial neoplasia (CIN) 2/3, to aid gynaecologists in selecting conservative management. Data from 51 patients with low- and high-grade squamous intraepithelial lesions were evaluated. Colposcopic images were captured and lesion areas were calculated. Polymerase chain reaction (PCR) for human papillomavirus was performed. Laboratory parameters were evaluated. Receiver operating characteristic (ROC) curves were used to obtain cut-off values for lesion area. The performance of PCR in the detection of high-grade CIN was assessed. A flowchart was created to compare the costs of related procedures in the Brazilian health system. For CIN 2/3 treated with excisional surgery, the best cut-off value for lesion area below which no residual lesion was present was 21 019 pixels CIN reflects systemic alteration, leading to altered NLRs, PLRs, and absolute numbers of leukocytes. Patients with high-grade CIN and colposcopic lesion areas <21 019 pixels

Higher Risk of Wound Complications but No Clinically Significant Increase in Operative Time for Smokers Receiving Myomectomy for Uterine Fibroids

Myomectomy is a common procedure to remove uterine fibroids. Smoking impacts outcomes across various surgeries; however, may limit fibroid growth. We sought to determine if smoking impacts myomectomy for uterine fibroid removal outcomes. Patients with and without a history of tobacco smoking receiving a myomectomy for uterine fibroid removal were compared. Compared to patients with no history of tobacco smoking, tobacco smokers had a significantly increased risk of wound complications. No other variables analyzed demonstrated a clinically significant difference. Future research is needed to examine how different frequency of tobacco smoking impacts outcomes.

Innovative 3-Dimensional Imaging in Preoperative Evaluation for Secondary Cytoreductive Surgery in Recurrent Ovarian Cancer—A Pilot Study

The efficacy of secondary cytoreductive surgery (SCS) in recurrent ovarian cancer remains controversial, necessitating meticulous preoperative planning. While three-dimensional (3D) imaging has transformed surgical approaches in various disciplines, its application in gynaecologic oncology is nascent. This study introduces a novel investigation employing preoperative 3D modelling in SCS preparation. A retrospective analysis was undertaken at a university-affiliated tertiary medical centre, examining patients who underwent SCS for recurrent ovarian cancer between 2017 and 2022. Patients were stratified into 2 cohorts: those with preoperative CT-based 3D imaging (group A) and those without (group B). Demographic profiles, clinical data, and surgical outcomes were compared between the groups. Among the 76 identified patients, 18 were deemed suitable for surgery, with 7 in group A undergoing preoperative 3D modelling. Demographics encompassing age and performance status were consistent across both groups, while Serous histology was more prominent in group B. Although operative metrics and collaborative endeavours exhibited no statistically significant variance, the attainment of optimal debulking with no residual disease (R0) was substantially higher in group A (100%) compared to group B (54%), with a significance level of P = 0.05. CT-based 3D modelling in the preoperative phase of SCS for ovarian cancer shows potential for enhancing surgical planning. While this pioneering research highlights the potential benefits of integrating 3D imaging into gynaecologic oncology, the limitations of this retrospective study imply that these findings are primarily hypothesis-generating. Further prospective studies are necessary to validate the impact.

Preoperative Factors of Endometrial Carcinoma in Patients Undergoing Hysterectomy for Atypical Endometrial Hyperplasia

To identify clinicopathological preoperative factors associated with concurrent endometrial carcinoma in patients undergoing surgical management of atypical endometrial hyperplasia. The records of all patients who underwent hysterectomy for preoperatively diagnosed atypical endometrial hyperplasia at a tertiary care hospital from April 2017 to April 2020 were retrospectively reviewed. Clinicopathological characteristics of patients were extracted. Patients who did not undergo hysterectomy or who had evidence of simple hyperplasia or carcinoma on initial biopsy were excluded. Univariate analysis was performed. A multivariate regression model for progression to endometrial carcinoma was developed. A total of 126 patients were included. Of these patients, 19 (15.1%) had a final diagnosis of endometrial carcinoma, whereas 86 (68.2%) retained the diagnosis of atypical endometrial hyperplasia and 21 (16.7%) were found to have no residual atypical endometrial hyperplasia. The odds of a patient being diagnosed with endometrial carcinoma were 6.1 times higher (95% CI 1.32-27.68) if they had an endometrial stripe thickness >1.1 cm and 13.5 times higher (95% CI 3.56-51.1) if there was histological suspicion of carcinoma. The odds of a patient being diagnosed with endometrial carcinoma were significantly lower if the patient had an initial diagnosis of atypical endometrial hyperplasia in a polyp (OR 0.07; 95% CI 0.02-0.34). Our results suggest that an endometrial stripe thickness >1.1 cm, a histological suspicion of carcinoma on preoperative pathology, and the absence of polyp involvement on initial diagnosis are the strongest predictors of endometrial carcinoma at the time of hysterectomy in patients with atypical endometrial hyperplasia.

Endometrial Carcinoma Molecular Classification and Barriers to Implementation, Possible Solutions, and the Implications for Ongoing Clinical Trials

Molecular classification of endometrial carcinoma provides important prognostic and predictive information and ongoing clinical trials are investigating different treatment paradigms and therapy de-escalation. Despite its benefits, there is variability in the application of molecular classification worldwide, including in Canada. A digital survey was distributed to gynaecologic pathologists in 13 Canadian academic pathology departments, and areas of homogeneity and variability in practice for endometrial carcinoma molecular classification were identified. Perceived barriers to universal application included resource restrictions and ambiguity of management implications. Focused research, knowledge translation, and guideline development will aid in more consistent implementation/application.

Single-Agent Gemcitabine in Heavily Pretreated Ovarian Cancer: Experience from a Canadian Tertiary Centre

There is limited real word data regarding the utilization of gemcitabine as a single agent in ovarian cancer (OC). We aimed to study the outcomes of treating recurrent OC with single-agent gemcitabine. We conducted a retrospective study, including patients with recurrent OC who were treated with single-agent gemcitabine. Patients who received gemcitabine in combination with other agents were excluded. Our primary outcome was the overall survival (OS) of patients treated with single-agent gemcitabine. Overall, 18 patients were included. The median age of patients was 59 years (IQR 49-63). Most patients (67%) had an Eastern Cooperative Oncology Group performance status of 1. The median number of lines of treatments prior to gemcitabine was 4 (IQR 3-5). The median duration on gemcitabine was 2 months (IQR 1-4), and the median OS was 4 months (95% CI 1-6). One patient had a reaction to treatment after the first infusion and treatment was discontinued. Four patients (22%) had at least 1 additional line of treatment following gemcitabine. During gemcitabine treatment, 67% of patients were admitted, and 61% of patients died within 30 days of treatment. Single-agent gemcitabine in heavily pretreated recurrent OC is associated with a median OS of 4 months, and some patients even benefit from further lines of treatment.

Lynch Syndrome Screening of Women with Endometrial Cancer: Feasibility and Outcomes in a Community Program

Universal screening of endometrial cancer for underlying Lynch syndrome (LS) using DNA mismatch repair immunohistochemistry (MMR IHC) has been recommended. The objective of this study was to assess the feasibility and outcomes of using office endometrial samplings in a community LS screening program. A community laboratory adopted Cancer Care Ontario's LS screening recommendations. All new endometrial cancers in women aged 98% of cases. MMR deficiency (MMRd), which includes LS screen-positive cases, was identified in 25.9% of patients (121/467). LS screen-positive tumours comprised 5.9% (27/467) of all cases. Endometrial samplings from community practice are suitable for pre-operative LS screening. This testing can identify MMRd endometrial cancers with significant prognostic implications. Approximately 1 in 20 Ontario women <70 years of age with endometrial cancer screen positive for LS. Pre-operative and/or operative assessment for co-existent colonic neoplasms needs to be considered in this high-risk group. In addition, these women should be referred to genetic counselling.

Sentinel Lymph Node Sampling as an Alternative to Lymphadenectomy in Patients With Endometrial Cancer and Obesity

Although its use in endometrial cancer staging is relatively new, sentinel lymph node (SLN) sampling has been shown to be highly accurate and is associated with few complications. However, some studies report lower rates of detection with SLN sampling among patients with obesity. The aim of the current study is to evaluate the feasibility of SLN sampling in endometrial cancer for patients with obesity, and to determine whether omitting lymph node dissection (LND) in surgical staging using SLN sampling impacts oncologic outcomes. we conducted a retrospective study of patients with obesity (BMI ≥35 kg/m Out of 223 patients with a median BMI of 40.6 kg/m In patients with obesity, omitting LND from surgical staging with SLN sampling was associated with shorter operative times and less bleeding and did not affect survival at 2 years.

Robotic-Assisted Laparoscopic Hysterectomy for Endometrial Hyperplasia or Grade 1 Endometrial Adenocarcinoma: A 10-year, Single-Centre Experience

To describe the outcomes of patients undergoing robotic-assisted laparoscopic hysterectomy for grade-1 endometroid endometrial cancer or endometrial hyperplasia at our centre. Retrospective chart review was completed for 160 patients who underwent robotic-assisted laparoscopic hysterectomy by 5 general gynaecologists in a tertiary care setting between September 2008 and September 2018. Outcomes collected included operative time, estimated blood loss, length of stay, perioperative complications, readmissions, and recurrences. Subgroup analysis was completed after stratifying by body mass index (BMI; 3 groups: A, <40 kg/m The intraoperative complication rate was 3%. The rate of conversion to laparotomy was 2%, and the rate of bowel injury, 1%. The postoperative complication rate was 8%. The rate of major postoperative complications was 4%, and 3% of patients required readmission postoperatively. The mean BMI was 43 (range 21-71) kg/m Despite this cohort's mean BMI falling within the category of class III obesity, complication and conversion rates were similar to those reported in the literature and did not increase with BMI, despite an increased comorbidity burden. These results suggest that robotic surgery is a safe and effective method for providing minimally invasive surgery to a technically challenging population.

Comparative Survival Outcomes of Total Hysterectomy Versus Radical Hysterectomy in Gastric-Type Endocervical Adenocarcinoma: A SEER Database Analysis

This study aims to assess the efficacy of total hysterectomy versus radical hysterectomy in the treatment of gastric-type endocervical adenocarcinoma (GEA). Patients diagnosed with GEA from 2001 to 2021 were derived from the Surveillance, Epidemiology, and End Results database. Clinicodemographic characteristics, tumour clinicopathological features, and survival outcomes (including vital status and duration of follow-up) of these patients were collected. Kaplan-Meier survival curves were generated to estimate survival probabilities, with between-group differences assessed using log-rank tests for statistical significance. Overall, 114 patients undergoing total hysterectomy, and 129 patients undergoing radical hysterectomy were included for survival analysis. No statistically significant differences in overall survival (OS) were observed between surgical approaches, either in the entire cohort (P = 0.0594) or the International Federation of Gynecology and Obstetrics stage I-IIA subcohort (P = 0.0777). Adjuvant therapy (radiotherapy and/or chemotherapy) was administered to 52.6% (60/114) of patients in the total hysterectomy group and 42.6% (55/129) in the radical hysterectomy group. However, there was no statistically significant difference in OS between the total hysterectomy and radical hysterectomy groups among patients who received adjuvant therapy, and similar results were also found in the subgroup of patients with International Federation of Gynecology and Obstetrics stage Ⅰ-ⅡA disease. Notably, adjuvant therapies failed to demonstrate significant OS benefits in either surgical group for stage I-IIA disease. Total hysterectomy demonstrated comparable survival outcomes to radical hysterectomy in patients with GEA. These findings suggest that less extensive surgery may represent a viable treatment alternative for early-stage disease.

The Association of Vitamin D with Uterine Fibroids in Premenopausal Patients: A Systematic Review and Meta-Analysis

This study aims to consolidate existing literature regarding the association between vitamin D and uterine fibroid presence and growth. A comprehensive search across databases including Medline, Embase, CINAHL, Web of Science, ClinicalTrials.gov, and grey literature was conducted from inception to February 2023, using relevant keywords. Authors were contacted for unpublished data. From 9931 studies screened based on title and abstract, those evaluating serum vitamin D levels or vitamin D treatment effects, using ultrasonography for diagnosis, and involving at least 25 premenopausal participants were included. Case reports, case series, and reviews were excluded. Data were extracted using a predefined form. Methodological quality was assessed through the Newcastle-Ottawa Scale and the Risk of Bias-2 tools. Evidence quality was evaluated using Grading of Recommendations Assessment, Development, and Evaluation. Data from 3 randomised controlled trials (n = 328) and 23 observational studies (n = 5650) were meta-analyzed via random-effects modelling. Patients receiving oral vitamin D supplementation had a significantly different change in fibroid size (standardized mean difference -5.7%; CI -10.63 to -0.76, P = 0.02, I This review underscores the potential of vitamin D in mitigating fibroid development and growth. While promising, further research is warranted to optimise dosage and treatment duration, potentially offering a non-invasive solution for at-risk patients. Continued exploration of vitamin D's role in fibroid treatment is encouraged.

Navigating Pyomyoma in Pregnancy and Postpartum: A Systematic Review

To assess the different presentations of pyomyoma in pregnant and postpartum populations, and review the treatment modalities. This systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. We performed a comprehensive search of PubMed, Scopus, Google Scholar and Embase during the years 1945 to October 2024. Included case reports assessed the types of intervention (hysterectomy, myomectomy, or other forms of treatments) to treat Pyomyoma. All case studies confirming a diagnosis of pyomyoma on either operative and/or histological findings were eligible. A total of 123 studies were initially screened and after a full-text evaluation, 40 articles with a total of 43 cases were included in this systematic review. Pyrexia and abdominal pain were the most common presenting symptoms found in 79% and 77% of patients, respectively. The most common causative organism was E-Coli (23%). Hysterectomy was performed in a total of 13 (30%) patients, myomectomy in 24 (56%) patients and 6 (14%) patients were treated conservatively. Given the considerable morbidity associated with pyomyoma, the benefits of surgical treatment tend to outweigh the potential risks. However, since pregnant and postpartum women are a younger cohort and fertility is a concern, myomectomy is preferred to hysterectomy.

Spontaneous Uterine Rupture of a High-Risk Gestational Trophoblastic Neoplasia

What Is the Future of Radical Hysterectomy? Commentary on the Indication for Minimally Invasive Surgery for Cervical Cancer ≤2 cm

Abdominal Tuberculosis Mimicking Ovarian Malignancy

Non-surgical Fertility Sparing Management of Cervical Embryonal Rhabdomyosarcoma

Perioperative Venous Thromboembolism Risk in Patients Undergoing Hysterectomy for Fibroids: A US Retrospective Cohort Study

Venous thromboembolism (VTE) occurs in 0.4%-0.7% of benign hysterectomies. Pelvic vascular compression secondary to fibroids may elevate VTE risk. We aimed to evaluate the incidence and timing of VTE among individuals undergoing hysterectomy for fibroids and other benign indications. Retrospective cohort study of patients who underwent a hysterectomy for fibroid and non-fibroid indications from January 2015 to December 2021. Main outcome measure was VTE consisting of pulmonary embolism or deep venous thrombosis diagnosed during 3 periods: (1) preoperative (1 year before surgery until day before surgery), (2) early postoperative (surgery date through 6 weeks after surgery), and (3) late postoperative (6 weeks to 1 year after surgery). Demographics, comorbidities, surgical characteristics, and VTE rates were compared by indication. A total of 263 844 individuals with fibroids and 203 183 without were identified. In total, 1.1% experienced VTE. On multivariable regression (adjusted demographic confounders and route of surgery), the presence of fibroids was associated with increased odds of preoperative (adjusted odds ratio [aOR] 1.12; 95% CI 1.03-1.22, P = 0.011) and reduced odds of late postoperative VTE (aOR 0.81; 95% CI 0.73-0.91, P < 0.001). For individuals with fibroids, uterine weight ≥250 g and undergoing laparotomy were independently associated with preoperative (aOR 1.29; 95% CI 1.09-1.52, P = 0.003 and aOR 2.32; 95% CI 2.10-2.56, P < 0.001) and early postoperative VTE (aOR 1.32; 95% CI 1.08-1.62, P = 0.006 and aOR 1.72; 95% CI 1.50-1.96, P < 0.001). Patients with fibroids were at increased odds of having VTE 1 year before hysterectomy. For those with fibroids, elevated uterine weight and laparotomy were associated with greater risk of preoperative and early postoperative VTEs.

First-Line Treatment Use and Survival Outcomes for Patients With Primary Advanced or Recurrent Endometrial Cancer in Alberta, Canada

To describe first-line treatment patterns and factors impacting survival for patients with primary advanced (stage III-IV) or recurrent (A/R) endometrial cancer (EC) in Canada. This retrospective cohort study used health administrative data for patients with primary A/R EC (2010-2020) in Alberta, Canada. Characteristics by receipt of first-line systemic therapy were compared. Factors impacting overall survival (OS) after first-line chemotherapy were evaluated using a multivariable Cox proportional hazards model. Of 1185 patients included, 817 (68.9%) received first-line systemic therapy (advanced, n = 679 of 885; recurrent, n = 138 of 300). Patients in this cohort were generally younger, with fewer comorbidities than those who did not receive first-line systemic therapy. Patients with recurrent disease who received previous chemotherapy and who had a longer time to recurrence were more likely to receive first-line systemic therapy. The median OS was 53.5 months (95% CI 37.8-80.1); the OS was shorter with older age (≥75 vs. <65 years, adjusted hazard ratio [aHR] 1.62; 95% CI 1.18-2.23) and high-grade versus low-grade histology (aHR 1.99; 95% CI 1.59-3.67). The OS was longer in patients in stage III who had surgery (aHR 0.35; 95% CI 0.24-0.51). Characteristics such as age and comorbidities impacted first-line systemic therapy use in primary A/R EC. Patients who were older, with high-grade histology, stage IV without surgery, and receiving platinum monotherapy had the shortest OS. Effective treatment options are needed to prolong survival for primary A/R EC.

Feasibility of Same-Day Discharge in Patients Undergoing Laparoscopic Gynaecologic Oncology Surgery

To evaluate the safety and feasibility of same-day discharge (SDD) of oncology patients undergoing complex laparoscopic gynaecologic oncology surgery. A retrospective review including patients from October 2019 to July 2023 undergoing surgical staging for endometrial, tubal, or cervical cancer, treatment for endometrial hyperplasia or pelvic masses. Surgeries included a total laparoscopic hysterectomy. Patients accomplishing SDD were compared with those requiring admission. Data collection included clinical, demographic, and perioperative variables up to 6 weeks after surgery. Univariate and multivariate analyses were conducted. A total of 152 patients were included. On multivariate analysis, variables that significantly predicted admission were age ≥61 (OR 0.256; 95% CI 0.102-0.642, P = 0.004), BMI ≥30-34.9 kg/m SDD is safe and feasible for patients. There are few complications, re-admissions, or unscheduled patient contacts postoperatively. Its success can be increased by refining patient selection using predictive variables.

Giant Mucinous Borderline Ovarian Tumor Presenting Alongside Perforated Peptic Ulcers

Similar Overall Survival Using Neoadjuvant Chemotherapy or Primary Debulking Surgery in Patients Aged Over 75 Years with High-Grade Ovarian Cancer

To perform a hypothesis-generating evaluation of patient outcomes following neoadjuvant chemotherapy (NACT) compared with those following primary debulking surgery (PDS) in patients over age 75 with high-grade ovarian cancer. This was a retrospective cohort study of consecutive patients aged 75 years and older, with high-grade ovarian cancer. Data were analyzed in SPSS 25.0 using descriptive statistics to characterize groups based on primary treatment modality, Kaplan-Meier survival curves to estimate overall and progression-free survival, and Cox proportional hazards to analyze confounders. Of 429 patients with stages III and IV high-grade ovarian cancer (endometrioid and serous), 71 were aged older than 75 years and met our criteria for inclusion; 58 were treated with NACT while 13 underwent primary debulking. Sixteen patients did not undergo interval debulking following NACT. There were no significant differences in demographic characteristics between the groups. Following NACT, more patients were completely debulked-36.2% versus 21% (P = 0.000)-and had a shorter length of stay (5 vs. 7 d; P = 0.018). Overall survival was similar between the NACT and PDS groups (58.7 vs. 59.7 mo; LR -0.836; P = 0.361) despite lower progression-free survival in the NACT group (25.9 vs. 47.1 mo; P = 0.042; LR 4.31). Both progression-free and overall survival were significantly higher when patients undergoing NACT achieved complete debulking (21.7 and 102.3 mo, respectively) compared with suboptimal debulking (12.03 and 14.2 mo, respectively). In this select group older patients with stage III and IV high-grade ovarian cancers, neoadjuvant chemotherapy may be considered without compromising outcomes and contributes to complete debulking.

Response to Multi-Line Chemotherapy in Non-Serous Epithelial Ovarian Cancer

To describe the response rate to chemotherapy, rates of recurrence, and overall survival in patients with non-serous epithelial ovarian cancers. This retrospective cohort study used the Manitoba Cancer Registry to identify all women with non-serous epithelial ovarian, fallopian, or peritoneal cancer treated between 1995 and 2010. Chart review entailed extracting information regarding therapy and outcomes. All patients with recurrence were identified and response to chemotherapy was assessed. We identified 392 patients with non-serous ovarian cancers, 192 of whom received chemotherapy in the first-line setting. Optimal debulking resulted in improvements in rates of recurrence and overall survival (P mucinous > clear cell > endometrioid) and in the third-line setting, 33.3%-75.0% of patients (other > mucinous > clear cell > endometrioid) received >6 lines of chemotherapy. Twenty-three percent of patients experienced a recurrence within 2 years of first-line therapy. Two-year survival was 79.4% after first-line treatment, 27.6% after second-line treatment, and 19.5% after third-line treatment. Patients with clear cell ovarian cancer had chemotherapy continuation rates similar to those of previously reported studies. This is one of the first studies reporting response rates for mucinous and endometrioid subtypes. Recurrent disease responds to treatment with second- and third-line therapy, emphasizing the importance of offering patients subsequent lines of chemotherapy for disease management. Further studies are needed to determine the optimal regimen.

Primary Vaginal Carcinoma Arising on Cystocele Mimicking Vulvar Cancer

Primary vaginal carcinoma is a rare gynaecological tumour representing 1%-3% of all gynaecologic cancers. Several studies report increased vaginal cancer risk associated with genital prolapse following the occurrence of inflammatory lesions or decubitus ulcers. We report the rare case of an 82-year-old woman with primary squamous cell carcinoma arising from vaginal wall prolapse. Vaginal carcinoma was suspected during gynaecological examination for vulvar bleeding. A wide local excision was performed and pathologic examination revealed a primary squamous cell carcinoma of the vagina. Persistent genital prolapse may be at risk for vaginal carcinoma, and cytological and a colposcopic assessments are essential to identify patients who require diagnostic biopsy.

Severe Paraneoplastic Dermatomyositis in a Patient With High-Grade Serous Ovarian Cancer

Paraneoplastic dermatomyositis following a diagnosis of ovarian cancer is rare. There are very few cases reported on the management of severe forms. We report the case of a 50-year-old woman diagnosed with stage IIIC high-grade serous ovarian cancer and a severe form of paraneoplastic dermatomyositis requiring mechanical ventilation. She had significant comorbidities further adding to the complexity of the chemotherapy regimen. Intravenous immunoglobulin and corticosteroids were also administered. The dermatomyositis remained poorly controlled, and the patient was ultimately referred to palliative care. The necessity to treat the underlying neoplasia creates a fine balance between the aggressive treatments required and the clinical state of the patient. Multidisciplinary collaboration is warranted to offer best management.

Predictors of Supportive Care in Young Adults Diagnosed With a Gynaecologic Malignancy

In Canada, gynaecologic cancers significantly impact adults aged 18-40 years, who may undergo multiple treatment modalities impacting their overall well-being. The objective of this study was to understand the individual characteristics, supportive care, and informational needs of these persons. A cross-sectional survey of N = 50 adults (aged ≤40 years) receiving treatment (chemotherapy, surgery, and/or radiation) or under surveillance for gynaecologic cancer at a tertiary cancer centre in Toronto, Canada. Unmet supportive care needs were commonly reported, with more than half of the participants indicating unmet needs in all but 1 of the 5 domains (psychological [78%], health system and information [68%], physical and daily living [54%], sexuality [50%], and patient care and support [46%]). Unmet supportive care needs were associated with a host of psychosocial, demographic, and clinical factors. Notably, for psychosocial factors, low resilience was associated with a higher likelihood of unmet supportive care needs (health system and information [OR 2.97, 95% CI 1.06-8.35], physical and daily living [4.95, 1.69-22.66], and patient care and support [5.91, 1.77-40.50] domains and low perceived information and satisfaction [3.11, 1.30-11.60]). Various other socio-demographic (e.g., non-European cultural origins and other ethnicity, further distance to cancer centre) and clinical factors (e.g., number of treatment modalities) were also related to unmet needs. Future studies must examine how to best meet the needs of younger adults affected by gynaecologic cancers to improve client-centred, supportive care through early intervention and adequate resources.

COVID-19 Won't Be the Last (Or Worst) Pandemic: It's Time to Build Resilience Into Our Cervical Cancer Elimination Goals

Cervical Screening and Colposcopy Management of Women Age 24 and Under

In 2012, Ontario's cervical cancer screening program changed the age of initial screening from 18 years of age to 21 and identified women aged 21-24 years as a special population whose cervical squamous intraepithelial lesions should be managed conservatively. In order to provide insight into these changes, we sought to examine patient, provider, and clinical characteristics of cervical cancer screening and colposcopy care in women aged 12-24 years. We conducted a retrospective population-based cohort study of all women in Ontario, aged 12-24 years, who underwent a Pap test between 2012 and 2014. Variables measured included, patient age, cytologic result of the index Pap test; colposcopy and definitive treatment within 1.5 years of the index Pap test; and carcinoma in situ (CIS) and invasive cervical cancer (ICC) 1.5 years after the index Pap test. Descriptive statistics were calculated for variables, and incidence rates per 100 000 women screened were calculated for CIS and ICC. A total of 270 391 index Pap tests were performed. The majority of patients were between 18 and 24 years of age (12-17 y: 5.5%; 18-20 y: 24.3%; 21-24 y: 70.1%). Overall, 87.0% of Pap tests were normal, 6.9% of women underwent subsequent colposcopy, and 1.1% received any treatment. Of women with a high-grade result, 86.6% (n = 1279) underwent colposcopy and 42.8% (n=632) received any treatment. Of women with a low-grade result, 42.3% (n = 13 856) underwent colposcopy, and 6.0% (n = 1955) had any treatment. Age-standardized rates of CIS and ICC in were 161.5 and 1.0 per 100 000 women, respectively. Despite the change in the screening guidelines, women under the age of 21 continue to be screened. This study highlights the low risk of ICC in women under age 25 and lays groundwork for re-examining screening guidelines for women in this age group. Furthermore, colposcopy referrals for women with a low-grade result on an index Pap test, and treatment of women under 24 years of age continue to be high. Future work must address the over-utilization of population-based screening, as well as factors related to adherence to screening guidelines.

Incitation à participer à une campagne de dépistage du cancer du col de l'utérus : expérience d'un centre de soins tertiaires au Canada

The main objective of this study was to determine the most cost-effective communications strategy for National Cervical Cancer Awareness Week. The secondary objectives were to identify the reasons women were not screened by their primary care provider and to determine the number of abnormal cytology results obtained as a result of the awareness week screening. As part of an evaluation of the quality of care, we reviewed the medical records of all patients who underwent cervical cancer screening at a Québec teaching hospital during National Cervical Cancer Awareness Week. A total of 202 women underwent screening during the national awareness week, held in October 2018. For 180 of the women, we were able to identify the communications strategies that led them to get screened and to obtain information on their follow-up care with their primary health care provider. No-cost marketing channels (including Facebook, the hospital website, and a news report and interview) led to 66 women (36.7%) participating, making these channels the most cost-effective. While 59% of the women had a family physician, 41% of them reported that their family physician did not perform pelvic exams. Abnormal cytology results were reported for 2.8% of the women. No-cost communications channels were the most effective for raising awareness. The majority of participants had a family physician. Efforts to raise awareness of cervical cancer must continue in order to increase screening rates. In addition, strategies must be put in place to improve access to Pap tests.

Performance Indicators for Colposcopy in Ontario

This study sought to evaluate the delivery of colposcopy assessments and treatments in Ontario from 2009 to 2017 according to specific performance measures, derived from guidelines on colposcopy use. This population-based descriptive analysis included screen-eligible women ages 21 to 69 in Ontario who underwent cervical screening between 2009 and 2017. Performance measures that describe the quality of colposcopy services in the province were calculated. Five performance measures were used to assess the use of colposcopy in Ontario from 2009 to 2017. From 2013 to 2017, the percentage of women seen for colposcopy after a first diagnosis of atypical squamous cells of undetermined significance (ASCUS), without evidence of repeat cytology, remained stable, ranging from 5.9% to 6.3%. The median wait time to colposcopy for atypical glandular cells (AGC), atypical squamous cells (ASC-H), cannot rule out high-grade squamous intraepithelial lesions, and high-grade squamous intraepithelial lesions (HSIL), remained relatively stable from 2013 to 2017. In addition, the percentage of women with high-grade Pap test results who were seen in colposcopy within 6 months increased from 74.7% to 83.5%. The percentage of women who were not seen in follow-up within 12 months after treatment for cervical dysplasia remained stable, as did the percentage of women who discontinued colposcopy after three normal Pap test results following treatment for cervical dysplasia. This study developed five performance indicators and used them to assess the delivery of colposcopic services in Ontario from 2009 to 2017. Performance indicators have previously been used effectively in the field of colorectal cancer screening to identify strengths and weaknesses in the delivery of healthcare services. This had never previously been done in colposcopy.

Risk of Cervical Dysplasia After Colposcopy Care and Risk-Informed Return to Population-Based Screening: A Systematic Review

This systematic review examined the risk of cervical dysplasia among women who have undergone a colposcopy episode of care to inform their return to population-based cervical screening. PubMed, Embase, and grey literature were searched between January 2000 and 2018. One reviewer screened citations against pre-defined eligibility criteria. A second reviewer verified 10% and 100% of exclusions at title and abstract and at full-text screening, respectively. One reviewer extracted data and assessed methodological quality of included articles; a second reviewer verified these in full. The primary outcome was incidence of cervical intraepithelial neoplasia grade 2 or greater (CIN2+) subsequent to initial colposcopy evaluation. Secondary outcomes included incidence of CIN2+ after negative follow-up test results and performance of follow-up strategies. Results were synthesized narratively. A total of 48 studies were included. The 1- to 5-year CIN2+ risks after colposcopy evaluation ranged from 2.4% to 16.5% among women treated for CIN2+ and from 0.7% to 16.8% among women untreated for CIN grade 1 or less (≤CIN1). Follow-up strategies included single or repeat cytology, human papillomavirus (HPV) testing, or combined HPV/cytology co-testing at various intervals. After negative follow-up test results, risk varied by follow-up strategy for both groups and by referral cytology severity for untreated women. Performance of follow-up strategies varied among treated women. Among untreated women, co-testing demonstrated greater sensitivity than cytology alone. In conclusion, women treated during colposcopy for CIN2+ and women with ≤CIN1 who were referred to colposcopy for low-grade cytology and who did not receive treatment may be able to return to population-based screening after negative co-testing results. Current evidence does not suggest that women untreated for ≤CIN1 who are referred for high-grade cytology be returned to screening at an average risk interval. The optimal strategy for colposcopy discharge needs ongoing evaluation as implementation of HPV testing evolves.

Giant vulvar fibroepithelial stromal polyp

Giant Superficial Angiomyxoma of the Vulva – A Bizarre Presentation

Hysteroscopic Endometrial Resection in Women Treated With Tamoxifen for Breast Cancer Provides Definitive Diagnosis and Effective Long-Term Therapy

We evaluated resectoscopic surgery for definitive diagnosis and long-term therapy in 16 symptomatic tamoxifen-treated women with breast cancer who presented with abnormal uterine bleeding and/or intrauterine anomalies. Seven pre-menopausal women had benign pre- and post-operative endometrial biopsy, and 4 had benign polyps. At a median of 7 years of follow-up (range 2-8 y), all remained amenorrheic. Of 9 post-menopausal women, pre-operative biopsy was inadequate in 4, benign endometrium was found in 4, and non-atypical endometrial hyperplasia was found in 1. Post-operatively, all had benign pathology, 8 having polyp and 1 leiomyoma. At a median follow-up of 7 years (range 2-13 y), all were amenorrheic, with no recurrence of breast cancer or uterine pathology.

Guideline No. 451: Asymptomatic Endometrial Thickening in Postmenopausal Women

To formulate strategies for clinical assessments for endometrial thickening on ultrasound in a postmenopausal woman without bleeding. Postmenopausal women of any age. To reduce unnecessary invasive interventions and investigations in women with asymptomatic endometrial thickening while selectively investigating women at risk for endometrial cancer. It is anticipated that the adoption of these recommendations would save postmenopausal women unnecessary anxiety, pain, and risk of procedural complications. It is also expected to decrease the cost to the health care system by eliminating unnecessary interventions. English language articles from Medline, Cochrane, and PubMed databases for relevant peer-reviewed articles dating from 1995 to 2022 (e.g., asymptomatic endometrial thickness, endometrial cancer, postmenopausal bleeding, transvaginal ultrasound, endometrial biopsy, cervical stenosis, hormone therapies and the endometrium, tamoxifen, tibolone, aromatase inhibitors). Results were restricted to systematic reviews and meta-analyses, randomized controlled trials/controlled clinical trials, and observational studies. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). Physicians, including gynaecologists, obstetricians, family physicians, radiologists, pathologists, and internists; nurse practitioners and nurses; medical trainees, including medical students, residents, and fellows; and other providers of health care of the postmenopausal population. Postmenopausal women often have a thickening of the lining of the uterus found during ultrasound. Without bleeding, an endometrium <11 mm is rarely a serious problem but should be evaluated by a health care provider. RECOMMENDATIONS.

Guideline No. 447: Diagnosis and Management of Endometrial Polyps

The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the diagnosis and management of endometrial polyps. All patients with symptomatic or asymptomatic endometrial polyps. Options for management of endometrial polyps include expectant, medical, and surgical management. These will depend on symptoms, risks for malignancy, and patient choice. Outcomes include resolution of symptoms, histopathological diagnosis, and complete removal of the polyp. The implementation of this guideline aims to benefit patients with symptomatic or asymptomatic endometrial polyps and provide physicians with an evidence-based approach toward diagnosis and management (including expectant, medical, and surgical management) of polyps. The following search terms were entered into PubMed/Medline and Cochrane: endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy, female infertility. All articles were included in the literature search up to 2021 and the following study types were included: randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Gynaecologists, family physicians, registered nurses, nurse practitioners, medical students, and residents and fellows. Uterine polyps are common and can cause abnormal bleeding, infertility, or bleeding after menopause. If patients don't experience symptoms, treatment is often not necessary. Polyps can be treated with medication but often a surgery will be necessary. RECOMMENDATIONS.

Recognizing Endometrial Cancer Risks in Perimenopausal and Postmenopausal Experiences: Insights From Community Qualitative Interviews and Workshop

To evaluate the experiences of perimenopausal and postmenopausal women in British Columbia, their perceptions of expected reproductive aging, and potential concerns about endometrial cancer (EC). We interviewed 31 midlife community women of diverse backgrounds and hosted a workshop for more in-depth discussion. We summarized relayed experiences and beliefs through a thematic and descriptive analysis of participant stories and workshop feedback. Participants demonstrated a somewhat simplistic understanding of midlife changes, facing this phase of life with a "tough-it-out" attitude rather than seeking medical help for arising symptoms. Awareness of EC and EC-specific risk factors, such as obesity, was low. Confusion between cervical and EC was common. Although abnormal bleeding was seen as potentially of concern, many opted to wait before seeking medical help. Workshop participants stressed the need to include awareness about EC in a broader conversation about perimenopause and menopause and suggested strategies for disseminating EC awareness. Community women in British Columbia demonstrated low awareness of EC-associated symptoms and risk factors. There is little information to help distinguish when perimenopausal abnormal uterine bleeding is of concern and when to seek help. This highlights the need to enhance knowledge of EC and its risk factors in perimenopause among the public and among health care providers.

Carboplatin Hyperthermic Intraperitoneal Chemotherapy in the Management of Primary Stage IVB Endometrial Cancer

Endometrial cancer presenting with peritoneal metastases carries a poor prognosis. The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to the surgical management of these patients has been studied in recent years, but only with cisplatin. This is a series of 3 patients presenting with endometrial cancer and synchronous peritoneal metastases who underwent cytoreductive surgery and carboplatin HIPEC as primary treatment. Complete cytoreductive surgery was achieved for each patient. No grade 3-5 complications were observed. Two patients died at 12 and 18 months, respectively, and 1 patient was alive with disease at 29 months. This case series suggests that the addition of carboplatin HIPEC to the surgical management of peritoneal metastases from endometrial cancer is safe as primary treatment. However, long-term survival remains poor.