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Concept: Hysterectomy

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 To conduct a nationwide study of associations between removal of all ovarian tissue versus conservation of at least one ovary at the time of hysterectomy and important health outcomes (ischaemic heart disease, cancer, and all cause mortality).

Concepts: Menopause, Hysterectomy, Ovary

171

Late rupture of external iliac artery pseudo-aneurysm is an uncommon complication in patients who undergo extensive gynecologic radical surgeries. A 28-year-old woman with stage IB cervical cancer underwent pelvic lymphadenectomy and extrafascial trachelectomy. Two months after surgery, massive bleeding from ruptured pseudo-aneurysm of the external iliac artery occurred. Endovascular management with covered stent placement was feasible and safe to stop bleeding.

Concepts: Cervical cancer, Surgery, Radiation therapy, Stent, Pelvis, Hysterectomy, External iliac artery, Internal iliac artery

168

INTRODUCTION: Detection of asymptomatic adnexal tumours in postmenopausal women has increased due to wider use of diagnostic ultrasound and imaging quality improvements. Reliable methods to differentiate between benign and malignant tumours are required to avoid delays in treating ovarian cancer and to prevent unnecessary interventions for benign lesions. In the UK, the Royal College of Obstetricians and Gynaecologists has issued guidance for the management of adnexal cysts in postmenopausal women, which is considered standard in routine clinical practice. The protocol utilises the Risk of Malignancy Index to assess the risk of adnexal lesion being malignant. This protocol has a relatively high intervention rate in order to avoid a delay in a cancer diagnosis. The Simple Rules Protocol designed by International Ovarian Tumour Analysis Group reports a low false-positive rate in the diagnosis of ovarian cancer without a loss of sensitivity and therefore has the potential to reduce unnecessary interventions in asymptomatic postmenopausal women with benign cysts. METHODS AND ANALYSIS: 140 postmenopausal women aged 40-80, with incidentally detected adnexal tumours on ultrasound scan will be recruited to this study. They will be randomly allocated, to be assessed and managed according to either of the two protocols under investigation. In both arms of the study the tumours will be classified into three groups: high, intermediate or low risk of malignancy. Women with high risk of malignancy will be referred for management in a tertiary cancer centre, women with low-risk tumours will be managed expectantly, while those with intermediate risk findings have surgery in their local hospital units. Analysis will be on an intention-to-treat basis. ETHICS AND DISSEMINATION: Research ethical approval was granted by the North London Research Ethical Committee 2 (10/H0724/48). Trial results will be published according to the CONSORT statement. TRIAL REGISTRATION NUMBER: Registration at http://www.controlled-trials.com/ISRCTN89034131/. ISRCTN89034131.

Concepts: Cancer, Oncology, Sensitivity and specificity, Hereditary nonpolyposis colorectal cancer, Benign tumor, Ovarian cyst, BRCA2, Hysterectomy

154

Objective To study the strength and validity of associations between adiposity and risk of any type of obstetric or gynaecological conditions.Design An umbrella review of meta-analyses.Data sources PubMed, Cochrane database of systematic reviews, manual screening of references for systematic reviews or meta-analyses of observational and interventional studies evaluating the association between adiposity and risk of any obstetrical or gynaecological outcome.Main outcomes Meta-analyses of cohort studies on associations between indices of adiposity and obstetric and gynaecological outcomes.Data synthesis Evidence from observational studies was graded into strong, highly suggestive, suggestive, or weak based on the significance of the random effects summary estimate and the largest study in the included meta-analysis, the number of cases, heterogeneity between studies, 95% prediction intervals, small study effects, excess significance bias, and sensitivity analysis with credibility ceilings. Interventional meta-analyses were assessed separately.Results 156 meta-analyses of observational studies were included, investigating associations between adiposity and risk of 84 obstetric or gynaecological outcomes. Of the 144 meta-analyses that included cohort studies, only 11 (8%) had strong evidence for eight outcomes: adiposity was associated with a higher risk of endometrial cancer, ovarian cancer, antenatal depression, total and emergency caesarean section, pre-eclampsia, fetal macrosomia, and low Apgar score. The summary effect estimates ranged from 1.21 (95% confidence interval 1.13 to 1.29) for an association between a 0.1 unit increase in waist to hip ratio and risk endometrial cancer up to 4.14 (3.61 to 4.75) for risk of pre-eclampsia for BMI >35 compared with <25. Only three out of these eight outcomes were also assessed in meta-analyses of trials evaluating weight loss interventions. These interventions significantly reduced the risk of caesarean section and pre-eclampsia, whereas there was no evidence of association with fetal macrosomia.Conclusions Although the associations between adiposity and obstetric and gynaecological outcomes have been extensively studied, only a minority were considered strong and without hints of bias.

Concepts: Pregnancy, Childbirth, Systematic review, Obstetrics, Hysterectomy, Caesarean section, Pre-eclampsia

130

Half the epidemiological studies with information about menopausal hormone therapy and ovarian cancer risk remain unpublished, and some retrospective studies could have been biased by selective participation or recall. We aimed to assess with minimal bias the effects of hormone therapy on ovarian cancer risk.

Concepts: Hormone replacement therapy, Epidemiology, Hormone, Menopause, BRCA2, Hysterectomy

50

The objectives of this study were to determine the age-standardized and age-specific annual US cervical cancer mortality rates after correction for the prevalence of hysterectomy and to evaluate disparities by age and race.

Concepts: Human papillomavirus, Cervical cancer, United States, Hysterectomy, Race, European American, Nationalism, Indigenous peoples of the Americas

28

We report a case of a 35-year-old woman who underwent uterine artery embolization (UAE) for symptomatic multiple uterine fibroids with collateral aberrant right ovarian artery that originated from the right external iliac artery. We believe that this is the first reported case in the literature of this collateral uterine flow by the right ovarian artery originated from the right external iliac artery. We briefly present the details of the case and review the literature on variations of ovarian artery origin that might be encountered during UAE.

Concepts: Uterus, Hysterectomy, External iliac artery, Internal iliac artery, Uterine fibroids, Uterine artery embolization, Uterine artery, Ovarian artery

28

Borderline ovarian tumor with the initial presentation of pseudo-Meigs' syndrome is rare. A 52-year-old postmenopausal woman presented with a large ovarian tumor, ascites, and right hydrothorax. We found elevated serum carcinoembryonic antigens (44.4 ng/mL), carbohydrate antigen (CA)-125 (269.8 U/mL), and CA-199 (7942 U/mL). The frozen section pathology revealed a mucinous borderline ovarian tumor, and a staging operation was performed. Final pathologic examination confirmed the diagnosis of intestinal type ovarian mucinous borderline tumor with non-invasive cul-de-sac implants. Her pleural effusion and ascites resolved after surgery, and she remained tumor-free after 3 years' follow up. Physicians should be cautious for the rare possibility of pseudo-Meigs' syndrome in patients with pelvic tumors having the features of advanced ovarian cancer.

Concepts: Cancer, Hereditary nonpolyposis colorectal cancer, BRCA2, Ovarian cancer, Pleural effusion, Hysterectomy

28

Objective: To evaluate results of expectant management of sonographically benign ovarian cysts in selected asymptomatic premenopausal women. Study design: Prospective cohort study comprising premenopausal women diagnosed as having a persistent adnexal cyst. Patients were selected according to complaints (asymptomatic), ultrasound cyst’s appearance (benign) and size (< 8 cm). Patients underwent a follow-up protocol with transvaginal scan at 6 months interval for two years and then annually for at least 3 years. Results: The study comprises 166 women (mean age: 40 years) with 192 masses present at inclusion. Twenty-two women (29 masses) were lost to follow-up. Seventy-four masses (38.7%) resolved spontaneously (median time from diagnosis to resolution: 40 months). Forty-nine masses (25.1%) persisted without changes (median time follow-up time: 88 months, range: 36-192 months). Forty masses (20.9%) were surgically removed (12 cases because of increasing size, four cases because of a second lesion appeared during follow-up, three cases because of changing aspect and increasing size, five cases because of surgery for uterine benign or malignant disease, two case because of changing aspect without increasing size, one patient because of ovarian torsion clinical and 13 cases because of patient's decision with no change on the mass). Histology was benign in all but in two cases (stage Ia mucinous ovarian carcinoma and stage Ia mucinous borderline tumor). During follow-up 40 new masses in 31 women were diagnosed (21 resolved spontaneously, 5 were surgically removed -all benign histology- and 14 are persisting) Conclusions: Expectant management of cysts with benign ultrasound morphology is a management option in selected asymptomatic premenopausal women. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Concepts: Cohort study, Cancer, Oncology, Medical terms, Observational study, Ovarian cyst, Ovarian cancer, Hysterectomy

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The majority of symptomatic uterine fibroids are currently treated by surgical interventions (myomectomy or hysterectomy) or radiological treatments (uterine artery embolisation or focussed ultrasound surgery). None of these treatments is a panacea, and what is conspicuous is the lack of an effective long-term medical therapy for a disorder so common among women of reproductive age. It has been known for some time that progesterone and its receptors enhance proliferative activity in fibroids and this has raised the possibility that anti-progestins and (PRMs) could be useful in the medical management of fibroids. Some of the compounds which have produced promising results in recent clinical trials or research studies include mifepristone, CDB-4124 (telapristone), CP-8947, J-867 (asoprisnil) and CDB-2914 (ulipristal acetate or UA). UA has recently completed Phase III clinical trials with very encouraging results, and has now acquired a licence for clinical use in Europe. While considerable research has yet to be done on the long-term safety and efficacy of UA there is nevertheless good reason for optimism on the emergence of effective medical therapy in the form of UA and possibly other PRMs.

Concepts: Medicine, Clinical trial, Uterus, Hysterectomy, Uterine fibroids, Uterine artery embolization, Selective progesterone receptor modulator, Myomectomy