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

Background The prognostic significance of oestrogen and progesterone receptors ( ER/ PR) in endometrial stromal sarcoma ( ESS) has conflicting reports in the literature, and the routine use of adjuvant progestogen is of uncertain efficacy. Aims To examine the prognostic significance of ER/ PR positivity and of primary adjuvant progestogen use with outcome in ESS. Materials and Methods All women with a diagnosis of ESS in our tertiary institution and associated private practices over the last 23 years were included. Primary variables were ER/ PR positivity and adjuvant progestogen use. Other variables included high-grade disease and extrauterine disease. The primary outcome was survival, and the secondary outcome was recurrence-free survival (both overall and at 5 years). Survival was calculated using the Kaplan-Meier method. Univariate analyses were performed with t-test for means and chi-squared test for proportions, and multivariate analysis was used to control for age. Results 35 women were included. ER/ PR positivity was associated with a survival benefit ( OR death 0.22, P = 0.02), but primary adjuvant progestogen was not. High-grade disease ( OR 13, P = 0.02) and extrauterine disease ( OR 8.7, P = 0.04) were associated with decreased survival. No variable significantly affected recurrence-free survival. Eight of ten cases of recurrence treated with progestogen have survived more than 3 years. Conclusions ER/ PR positivity appears to be useful for prognosis, but routine administration of primary adjuvant progestogen is not supported. There may be a role for progestogen in ER/ PR positive tumours with recurrence or incomplete surgical clearance, but further research is required. [ABSTRACT FROM AUTHOR]

Background For select women with early endometrial cancer, particularly nulliparous women, nonsurgical options may be considered. There is increasing experience using progestogens, but little is known about the long-term outcomes and safety of such treatment. Aims To present the cancer and pregnancy outcomes of women with greater than five years follow-up after progestogen treatment for early endometrial cancer. Methods Ten women who underwent greater than six months of continuous progestogen therapy for early endometrial cancer were included in the study. All were managed by a gynaecological oncologist at a major tertiary centre in Melbourne, Australia. The histology of each subsequent curette was recorded, as was the timing and histology of hysterectomy (if relevant), and the results of any subsequent pregnancies. Results All ten women showed histological regression of cancer with no cases of recurrence on follow-up curette. Four of ten women have undergone hysterectomy with one case of occult disease persistence in a woman noncompliant with therapy. The mean follow-up time was 89 months (range 62-142 months), there were no deaths and no woman was lost to follow-up. All four women attempting pregnancy were successful. There were eight pregnancies and five live births. Conclusions This form of treatment appears to be successful and safe in the long term with good pregnancy outcomes. However, it is not standard and should be supervised in a specialised gynaecological oncology unit. [ABSTRACT FROM AUTHOR]

Background: Transabdominal cervical cerclage has been performed via laparotomy for over four decades. A laparoscopic approach has recently been developed and offers the potential for lower morbidity. Aims: The experience of one operator with transabdominal cervical cerclage via laparotomy is reviewed to establish a baseline with which to compare results from the laparoscopic approach. Methods: Transabdominal cervical cerclage was performed with Mersilene tape. The pregnancy outcome prior to transabdominal cervical cerclage was compared with the outcomes after its insertion. Results: Prior to transabdominal cervical cerclage, there were 58 pregnancies of which 18 ended with a first trimester pregnancy loss. Twenty-eight of the 36 pregnancies delivering between 13- and 26-week gestation resulted in a pregnancy loss. Three of the four children delivered after 26-week gestation survived. Following transabdominal cervical cerclage, there were no first trimester pregnancy losses. Of the 23 pregnancies after transabdominal cerclage, one was terminated at 18-week gestation for spina bifida and the remaining 22 babies were delivered at a mean gestation of 36.2 weeks. Maternal morbidity was limited to a single wound infection. Respiratory distress was the only significant neonatal morbidity with all babies recovering completely. Conclusions: Transabdominal cervical cerclage via laparotomy is a safe and successful method of treating women who need a cervical cerclage but are unable to have a vaginal suture. A baseline has been established with which to compare the results from laparoscopic transabdominal cervical cerclage in the future. [ABSTRACT FROM AUTHOR]

Aims: To evaluate the effectiveness of cytology and colposcopy in the follow up of women treated by laser CO2 ablation for cervical intraepithelial neoplasia (CIN). Methods: A retrospective analysis of 1784 patients with CIN treated with laser CO2 ablation from 1998 to 2003 at the Royal Women's Hospital, Melbourne. Data were collected prospectively in a computerised colposcopy database utilised in the Dysplasia Unit. Results: There was equal distribution in the study population treated for low-grade intraepithelial neoplasia (LSIL) and high-grade intraepithelial neoplasia (HSIL), with no significant age difference in both groups (mean 27.6 years). The success rate of treatment of LSIL (94%) was similar to that of HSIL (92%). Fifty-seven per cent of all failures occurred within the first year of treatment. Colposcopy was more sensitive in detecting intraepithelial neoplasia (SIL) than cytology, whereas cytology was more specific. No case of cancer was diagnosed on follow up. Conclusions: CO2 laser ablation was equally effective in treating different grades of CIN. There is a continuing incidence of recurrent CIN, even up to five years after initial treatment, which suggests that it is necessary for patients to adhere to long-term follow up. The combination of cytology and colposcopic assessment is essential for surveillance of SIL in the initial two years after treatment. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine how often patients with complete hydatidiform mole (CHM) who spontaneously achieve normal human chorionic gonadotrophin (hCG) levels subsequently develop persistent or recurrent gestational trophoblast disease. Methods: Four hundred and fourteen cases of CHM registered at the Hydatidiform Mole Registry of Victoria were reviewed retrospectively after molar evacuation. Maternal age, gestational age, gravidity and parity were determined for each patient, as well as the need for chemotherapy. Results: Among the 414 patients, 55 (13.3%) required chemotherapy for persistent trophoblastic disease. None of the patients whose hCG levels spontaneously fell to normal subsequently developed persistent molar disease. Conclusion: Weekly hCG measurements are recommended for all patients until normal levels are achieved. For patients who attain normal hCG levels within 2 months after evacuation, it seems safe to discontinue monitoring once normal levels are achieved. Patients who fail to achieve normal hCG levels by 2 months after evacuation should be monitored with monthly hCG measurements for 1 year after normalisation to assure sustained remission. [ABSTRACT FROM AUTHOR]

Objective: Human chorionic gonadotrophin (hCG) follow-up data were analysed retrospectively in all patients registered in the Hydatidiform Mole Registry at the Royal Women's Hospital, Melbourne from January 1992 to January 2001 to determine the risk of persistent trophoblast disease following partial molar pregnancy and to review the present follow-up protocol of patients suffering from partial hydatidiform molar pregnancy (PHM). Methods: Demographic factors were determined for all 344 cases with a review diagnosis of PHM, included age, history of previous hydatidiform mole, gestation length, hCG levels and compliance with follow-up. Findings: Six of the 344 patients diagnosed with PHM required treatment with single-agent methotrexate and folinic acid rescue. All six patients achieved and maintained a complete biochemical remission after chemotherapy. hCG regression assays were analysed for 235 patients: 225 patients had at least one normal hCG measurement during follow-up, of whom 152 (64.7%) patients obtained normal values within 2 months after evacuation. All patients obtained normal levels within 32 weeks after evacuation of the partial hydatidiform mole. Only 63 (25.6%) patients completed the recommended follow-up program. No patient who achieved normal hCG levels required chemotherapy because of a recurrent gestational trophoblastic tumour. Recommendations: This study indicates that 1.7% of all partial mole pregnancy patients needed treatment for malignant sequelae. In contrast, no patient diagnosed with partial mole had a biochemical or clinical relapse after achieving normal levels of hCG, consistent with previous studies. Patients who have had a partial hydatidiform mole should be followed by hCG assays until normal levels are achieved and then follow-up can be safely discontinued. [ABSTRACT FROM AUTHOR]

Aim: To determine whether there is any benefit in repeating the Pap smear at the time of colposcopy in women referred to a teaching hospital dysplasia clinic. Methods: Analysis of a computerised database, and review of literature. Results: Repeating the Pap smear potentially changed management in 2% of women referred with low-grade lesions, and in 7% of those with high-grade lesions. Conclusion: Although the literature suggests that the repeat smear may directly affect the quality of the colposcopic examination, repeating the smear in women referred with high-grade squamous intraepithelial (HSIL) smears may be beneficial. [ABSTRACT FROM AUTHOR]

To assess the clinical and economic impacts of the use of liquid based cytology (LBC) in the Australian average risk population from the perspective of the public health care budget. Concerns over the evaluation of medical technologies in Australia, which are assessed by the Medicare Services Advisory Committee (MSAC), have been raised recently. We report on the evaluation of LBC, which although being widely adopted in other parts of the world, has, despite substantial uptake in the private sector in Australia, been rejected for public funding by MSAC. We used the health economic model developed by MSAC, but populated the model with the best available international data, sourced from a published review article. The economic model considered the clinical benefits and the costs arising from a biennial cervical screening programme. Net costs divided by life years saved is the cost per life year saved and this is reported as the incremental cost effectiveness. Populating the MSAC model with data on test performance showed that one type of LBC (ThinPrep) ‘dominates’ the conventional Pap smear in the screening of average risk women in the Australian setting. The health economic model created by MSAC predicts that ThinPrep dominates the conventional Pap as a screening test for cervical cancer. An additional 2240 high-grade lesions could be detected, resulting in 480 life years gained and delivering an expected saving to the health care system of $5 536 000 per annum if liquid based cytology replaced the conventional Pap. [ABSTRACT FROM AUTHOR]

To assess cytological, colposcopic and histological outcomes in women referred to a teaching hospital dysplasia clinic with low-grade changes on screening Pap smear. Analysis of a computerised database. Repeating the Pap test was of little value. Fifteen percent of women with low-grade changes on the referral smear had biopsy proven high-grade change. There was little difference in biopsy proven high-grade change in women referred with an ‘abnormal smear of uncertain significance’ (23%) or ‘an abnormal smear of uncertain significance-possible high-grade change’ (24%). Given these findings and the current medico-legal climate, immediate referral of women with low-grade changes on routine cytology is indicated, and seems a safer option than the more conservative approach of a repeat smear in 6 or 12 months. Further study of the usefulness of separating smears of uncertain significance into high-grade and low-grade categories is warranted. Consumer input into recommendations for management of Pap smear abnormalities is required. [ABSTRACT FROM AUTHOR]

Background: Cervical cancer and its precursors still remain an important cause of morbidity and mortality despite adequate screening programs. It is now established practice in Australia that a Pap smear without an endocervical component, which is otherwise negative, does not warrant an earlier repeat smear. This study aims to determine if the lack of an endocervical component in women with previously treated high-grade abnormalities of the cervix increases the risk of subsequent cytological abnormalities. Method: Data were retrieved from an electronic database in the Oncology and Dysplasia Unit at The Royal Women's Hospital in Melbourne, Australia. Women who underwent treatment for high-grade cervical abnormalities from 2000–2004 were included in the study. Women with negative cytology immediately after their operations were first identified, and the incidence of subsequent cytological abnormalities was calculated and then separated according to their endocervical status. Results: Of the 1260 women in the study population, seven developed high-grade abnormalities (six with an endocervical component and one without) and 107 developed low-grade abnormalities (98 with an endocervical component and nine without). Conclusion: The lack of an endocervical component was not statistically significantly associated with a higher incidence of either high-grade or low-grade abnormalities. Therefore, women who have had previous treatments for high-grade abnormalities do not need to have earlier repeat smears or intervention if the cytology lacks an endocervical component. [ABSTRACT FROM AUTHOR]

This qualitative study investigated women's participation in decisions regarding treatment of gynaecological cancer. Thirty women, receiving health care in two tertiary hospitals in Australia, were interviewed face-to-face. For women with gynaecological cancer, the most influential factors in treatment decisions are still the surgeon's recommendation and fear of dying from cancer. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 49-year-old multiparous premenopausal woman who was diagnosed with menorrhagia and ovarian cyst. In December 1997, the patient showed menopausal signs, and began a trial of continuous combined hormone replacement therapy (HRT) that was stopped due to migraine. She has experienced vaginal bleeding, demonstrating complex hyperplasia with atypia. It discusses the synthetic steroid pro-hormone called tibolone and endometrial hyperplasia.

A response by Munro Neville and Michael Quinn to a letter to the editor about their article "An Alternative Cost Effectiveness Analysis of ThinPrep in the Australian Setting" in the 2005 issue is presented.

Presents a case report of minimal deviation adenocarcinoma (MDA) in an aged woman with cervical adenocarcinoma. Medical history of the woman; Result of the woman's trachelectomy; Characteristics of patients with MDA.