The Emerging Role of PET/MR Imaging in Gynecologic Cancers

 INTRODUCTION
This article summarizes the current literature on PET/MR imaging in gynecologic malignancies and outlines the emerging clinical value of PET/MR imaging as an imaging tool in the management of the 3 most common gynecologic cancers: uterine cervical, uterine endometrial, and ovarian epithelial. Our experience with simultaneous PET/MR imaging is used to show the advantages and challenges of this new hybrid imaging modality in patients with gynecologic cancers.
 

partial view (pdf)

In radiology as in medical genomics, patient preferences should guide decisions around incidental findings

Health Imaging

Aug 29, 2016

Incidental and secondary findings are on the rise, thanks largely to advances in diagnostic technologies and adoptions of value-based practice incentives. As such findings increasingly confound patients as well as clinicians—not to mention medical ethicists and malpractice courts—radiology would do well to follow discussions going on in the field of genetic testing.

Stella Kang, MD, of the departments of radiology and population health at NYU and colleagues have done that. Their observations were posted online Aug. 29 in the Journal of the American College of Radiology.

In medical genetics, the authors point out, the current emphasis is on engaging with patient preferences before results are generated and returned to the clinician.
“The rich history and literature of genetic incidental and secondary findings can reveal parallels for handling incidental findings in radiology,” they write, noting that, in exome sequencing and genome sequencing, incidental and secondary findings fall into three major categories:

CBC Oct 6th: First Patients Considering Euthanasia or Medical Assistance in Dying in Canada (Death with Dignity)

CBC-TV
 

SEASON PREMIERE: Road to Mercy Thursday, October 6, 2016 at 9 PM on CBC-TV

 trailer (2:27 min): Episode available within Canada only.

 Road to Mercy follows doctors and their patients as they struggle to identify the limits of the newly granted right to kill to die. In Belgium, we meet bold physicians who are testing those limits – going beyond terminal illness to provide an assisted death for suffering psychiatric patients, a scenario that is legal both in Belgium and under Canada’s recent Supreme Court Carter ruling.

 Visit the filmmaker's website for more on this issue.

#deathwithdignity 

Death With Dignity Canada 

Impact of Body Weight and Body Composition on Ovarian Cancer Prognosis

abstract

Measures of body weight and anthropometrics such as body mass index (BMI) are commonly used to assess nutritional status in clinical conditions including cancer. Extensive research has evaluated associations between body weight and prognosis in ovarian cancer patients, yet little is known about the potential impact of body composition (fat mass (FM) and fat-free mass (FFM)) in these patients. Thus, the purpose of this publication was to review the literature (using PubMed and EMBASE) evaluating the impact of body weight and particularly body composition on surgical complications, morbidity, chemotherapy dosing and toxicity (as predictors of prognosis), and survival in ovarian cancer patients. Body weight is rarely associated with intra-operative complications, but obesity predicts higher rates of venous thromboembolism and wound complications post-operatively in ovarian cancer patients. Low levels of FM and FFM are superior predictors of length of hospital stay compared to measures of body weight alone, but the role of body composition on other surgical morbidities is unknown. Obesity complicates chemotherapy dosing due to altered pharmacokinetics, imprecise dosing strategies, and wide variability in FM and FFM. Measurement of body composition has the potential to reduce toxicity if the results are incorporated into chemotherapy dosing calculations. Some findings suggest that excess body weight adversely affects survival, while others find no such association. Limited studies indicate that FM is a better predictor of survival than body weight in ovarian cancer patients, but the direction of this relationship has not been determined. In conclusion, body composition as an indicator of nutritional status is a better prognostic tool than body weight or BMI alone in ovarian cancer patients.

Clinical Implications of Sarcopenic Obesity in Cancer

 sarcopenia (def.) loss of muscle tissue as a natural part of the aging process

Sarcopenic obesity is a medical condition which is actually a mix of two different ailments. It is a situation wherein a person shows an increase in fat mass and a reduction in lean mass.
                       ~~~~~~~~~~~~~~~~~~~~~~~~~~~

abstract

Sarcopenia has been associated with several negative clinical outcomes in cancer. However, the consequences of sarcopenic obesity, a condition of combined sarcopenia and obesity burden, have been less extensively investigated. The aim of this paper was to review the current evidence on the prevalence and clinical implications of sarcopenic obesity in cancer. A total of 14 studies linking sarcopenic obesity to a clinical outcome in cancer were included. There is considerable inconsistency in methods used to evaluate body composition as well as in the criteria used to define sarcopenic obesity, which limits comparison among studies. Therefore, the prevalence of sarcopenic obesity varied substantially: between 1 and 29 % in studies including individuals from all body mass index categories and between 15 and 36 % for those including obese individuals only. Negative clinical outcomes reported to be associated with sarcopenic obesity included higher risk of dose-limiting toxicity, surgical complications, physical disability, and shorter survival.

The Obesity Paradox in Cancer: a Review - eg. section bias...

bpen access

 There is a common perception that excess adiposity, commonly approximated by body mass index (BMI), is associated with reduced cancer survival. A number of studies have emerged challenging this by demonstrating that overweight and early obese states are associated with improved survival. This finding is termed the “obesity paradox” and is well recognized in the cardio-metabolic literature but less so in oncology. Here, we summarize the epidemiological findings related to the obesity paradox in cancer. Our review highlights that many observations of the obesity paradox in cancer reflect methodological mechanisms including the crudeness of BMI as an obesity measure, confounding, detection bias, reverse causality, and a specific form of the selection bias, known as collider bias. It is imperative for the oncologist to interpret the observation of the obesity paradox against the above methodological framework and avoid the misinterpretation that being obese might be “good” or “protective” for cancer patients.

Working together to shape the endometrial cancer research agenda: The top ten unanswered research questions (Lynch syndrome??)

abstract

Highlights

•

Endometrial cancer (EC) is under-researched and there are many knowledge gaps.

•

We used James Lind Alliance methodology to prioritise unanswered research questions in EC.

•

The top 10 questions span EC risk prediction, diagnosis, treatment and survivorship.

•

Tackling these issues through research will improve the lives of women affected by EC.

Results

Our first online survey yielded 786 individual submissions from 413 respondents, of whom 211 were EC survivors or carers, and from which 202 unique unanswered research questions were generated. 253 individuals, including 108 EC survivors and carers, completed an online interim prioritisation survey. The resulting top 30 questions were ranked in a final consensus meeting. Our top ten spanned the breadth of patient experience of this disease and included developing personalised risk scoring, refining criteria for specialist referral, understanding the underlying biology of different types of EC, developing novel personalised treatment and prevention strategies, prognostic and predictive biomarkers, increasing public awareness and interventions for psychological issues.

Adjuvant chemotherapy does not improve disease-free survival in FIGO stage IC ovarian granulosa cell tumors

Abstract: The MITO-9 study
  

Highlights

•

No clear evidence of benefit from adjuvant therapy in stage I patients has been demonstrated.

•

Surgical staging seems to be an independent prognostic factor.

•

In our study no difference in DFS between stage IC patients administered adjuvant therapy versus no treatment.

---

Objective

Evidence-based management of granulosa cell tumors of the ovary (GCT) has been not yet standardized: surgery, including fertility-sparing procedures for young women, has been traditionally the standard treatment; on the other hand, chemotherapy has been used for treatment of advanced and/or recurrent disease. However, very limited experience, has been selectively focused on the role of adjuvant chemotherapy in stage IC patients. The objective of this retrospective study was to assess the efficacy of first line postoperative chemotherapy in patients with stage IC treated at the Italian Centers involved in the MITO (Multicenter Italian Trials in Ovarian cancer) Group.

Patients and methods

A retrospective multi-institutional review of patients with GCT of the ovary at FIGO stage IC treated or referred to MITO centers was conducted. Surgical outcome, pathological findings and follow-up data were analysed. Kaplan–Meier and Cox proportional hazards analyses were used to determine the predictors factors for disease free survival.

Results

A total of 40 patients with primary GCT of the ovary at FIGO stage IC were identified. The median follow-up period was 96 months (range 7–300). At multivariate analysis, surgical treatment outside MITO centers and incomplete surgical staging were independent poor prognostic indicators for recurrence; adjuvant chemotherapy did not retain significant predictive value for recurrence.

Conclusions

This study raises the question about the value of adjuvant chemotherapy in stage IC GCT: a comprehensive evaluation of a larger series is urgently needed in order to characterize stage IC substages who can be spared treatment toxicity.

BRCA testing within the Department of Veterans Affairs: concordance with clinical practice guidelines

abstract

Guideline-concordant cancer care is a priority within the Department of Veterans Affairs (VA). In 2009, the VA expanded its capacity to treat breast cancer patients within VA medical centers (VAMCs). We sought to determine whether male and female Veterans diagnosed with breast cancer received BRCA testing as recommended by the National Comprehensive Cancer Network (NCCN) guidelines on Genetic/Familial High-Risk Assessment in Breast and Ovarian Cancer (v. 1.2010–1.2012). Using the 2011–2012 VA Central Cancer Registry and BRCA test orders from Myriad Genetics, we conducted a retrospective study. The outcome variable was a recommendation for genetic counseling or BRCA testing, determined by chart review. Independent variables expected to predict testing included region, site of care, and patient characteristics. We performed descriptive analysis of all patients and conducted multivariable logistic regression on patients who sought care at VAMCs that offered BRCA testing. Of the 462 Veterans who met NCCN testing criteria, 126 (27 %) received guideline-concordant care, either a referral for counseling or actual testing. No BRCA testing was recommended in 49 (50 %) VAMCs that provide cancer treatment. Surprisingly, patients with second primary breast cancer were less likely to be referred/tested (OR 0.39; CI 0.17, 0.89; p = 0.025). For patients under age 51, a yearly increase in age decreased likelihood of referral or testing (OR 0.85; CI 0.76, 0.94; p < 0.001). There were no differences in testing by race. In conclusion, there was significant underutilization and lack of access to BRCA testing for Veterans diagnosed with breast cancer. Our research suggests the need for clinical decision support tools to facilitate delivery of guideline-concordant cancer care and improve Veteran access to BRCA testing.

The effect of time on racial differences in epithelial ovarian cancer (OVCA) diagnosis stage, overall and by histologic subtypes - NCI

abstract: (a study of the National Cancer Database)

Purpose

Previous studies assessing racial and ethnic differences in ovarian cancer (OVCA) diagnosis stage fail to present subtype-specific results and provide historic data on cases diagnosed between 10 and 20 years ago. The purpose of this analysis is to assess non-Hispanic Black (NHB) and non-Hispanic White (NHW) differences in late-stage diagnosis including; (1) factors associated with late-stage diagnosis of invasive epithelial OVCA overall and by histologic subtypes, (2) potential changes across time and (3) current patterns of trends in a national cancer registry in the USA and Puerto Rico between 1998 and 2011.

Methods

NHB and NHW OVCA cases were derived from the National Cancer Database (NCDB). Diagnosis stage was analyzed as a dichotomous and a four level-category variable, respectively; early (stages I and II; localized) versus late (stages III and IV; regional and distant) and stages I, II, III and IV. Diagnosis period was trichotomized (1998–2002, 2003–2007, 2008–2011). Racial differences in stage were tested using ...... Interactions between race and diagnosis period were evaluated.

Results               (OR=odds ratio)

Between 1998 and 2011, 11,562 (7.8 %) NHB and 137,106 (92.2 %) NHW were diagnosed with OVCA. In adjusted models, NHB were significantly more likely diagnosed with late-stage OVCA than NHW (OR_adj 1.26). Interaction between race and diagnosis period was marginally significant, with racial differences in stage decreasing over time (1998–2002: OR_adj 1.36; 2003–2007: OR_adj 1.27; 2008–2011; OR_adj 1.15. NHB were also more likely to be diagnosed with stage 4 high-grade serous (OR_adj 1.46), clear cell (OR_adj 2.71) and mucinous (OR_adj 2.78) carcinomas than NHW.

Conclusions

Racial differences in late-stage OVCA diagnosis exist; however, these differences are decreasing with time. Within NCDB, NHB are significantly more likely diagnosed with late-stage OVCA and more specifically high-grade serous, clear cell and mucinous carcinomas than NHW.

Evaluation of minimal disseminated disease in cryopreserved ovarian tissue from bone/soft tissue sarcoma patients

abstract:
Evaluation of minimal disseminated disease in cryopreserved ovarian tissue from bone and soft tissue sarcoma patients

STUDY QUESTION What is the risk of finding malignant cells in cryopreserved ovarian tissue from sarcoma patients?

SUMMARY ANSWER Minimal disseminated disease (MDD) was not detected in frozen-thawed ovarian tissue from 26 patients by any of the sensitive methods applied.

WHAT IS KNOWN ALREADY In case of leukemia, the risk of malignant cell transmission through the graft is well known and widely documented. However, for bone cancer, like Ewing sarcoma or osteosarcoma, only a small number of case reports, have been published. These cancers often affect prepubertal girls, in whom ovarian tissue cryopreservation and transplantation is the only option to preserve fertility.

STUDY DESIGN, SIZE, DURATION The presence of malignant cells in cryopreserved ovarian tissue from patients with bone/soft tissue sarcoma was investigated with disease-specific markers for each patient, using immunohistochemistry (IHC), FISH and real-time quantitative RT-PCR (qPCR), with the original tumor serving as a positive control.

PARTICIPANTS/MATERIALS, SETTING, METHODS Forty-eight sarcoma patients were enrolled in the study, 12 of whom subsequently died. In each case, tissue from the primary tumor was investigated in order to identify markers (immunohistochemical and/or molecular) to analyze the ovarian tissue case by case. Ovarian tissue from osteosarcoma (n = 15), liposarcoma (n = 1) and undifferentiated sarcoma (n = 5) patients could not be evaluated, as no specific markers were detected by FISH or sensitive IHC in any of their primary tumoral tissue. One patient with Li-Fraumeni syndrome was also excluded from the study. IHC analyses were therefore performed on ovarian tissue from 26 patients and qPCR on 19. The primary tumors involved were Ewing sarcoma family of tumors (n = 14), rhabdomyosarcoma (n = 7), synovial sarcoma (n = 2), clear cell sarcoma (n = 2) and a malignant peripheral nerve sheath tumor (n = 1).

MAIN RESULTS AND THE ROLE OF CHANCE MDD was not detected in any of the 26 analyzed samples using sensitive techniques in this largest reported series, even from patients who subsequently died and/or those who presented with metastasis (11/26), hence the most aggressive forms of bone cancer. Indeed, anti-CD99 IHC and PCR performed on patients presenting with Ewing sarcoma family of tumors (n = 14) was negative in all cases. In patients with soft tissue sarcoma (n = 12) primitive tumor markers were detected by IHC and were negative in ovarian tissue. PCR could only be performed in 6/12 of these patients, again proving negative.

LIMITATIONS, REASONS FOR CAUTION Cryopreserved ovarian fragments to be transplanted cannot be tested, so this analysis of malignant cells cannot guarantee that all cryopreserved fragments will not contain any disseminated disease. Moreover, molecular markers are not readily available for all types of tumors.

WIDER IMPLICATIONS OF THE FINDINGS These results are reassuring regarding the risk of malignant cells in the ovary for transplantation, as the study involves a large series including different types of sarcomas. We believe this will help clinicians in their patient counseling for fertility preservation and restoration.

many events: September is Ovarian Cancer month

search (past week)

Antibacterial Soaps Have Phased Out Controversial Ingredients, But Concerns Remain About New Ones

Forbes
 

The Food and Drug Administration has washed its hands of antibacterial soaps that contain certain active ingredients because manufacturers have not demonstrated their long-term safey and effectiveness.
Instead of conducting the research requested by the FDA nearly three years ago, most antibacterial soap makers simply replaced the ingredients in question. The problem is that the new ingredients also lack evidence of safety and effectiveness, according to the agency.....

                                          ~~~~~~~~~~~~~~~~~~~~~~~~~

Scientific America news - eg.Triclosan/hormones

 Even though triclosan and the other chemicals on the FDA’s list are now outlawed, products probably will not be free of antibacterials anytime soon. DeLeo says companies have substituted triclosan with three other chemicals that are unapproved by the FDA: benzalkonium chloride, chloroxylenol and benzethonium chloride.

ovarian cancer - YouTube sundry videos (sort: past week/events/patients/clinical)

Blogger's Note: search results are not exact

ovarian cancer - YouTube

Michael Birrer on Predicting Outcomes in Ovarian Cancer - OncoLive/you tube (1:17 min)

YouTube
   
Michael Birrer on Predicting Outcomes in Ovarian Cancer(video)

OncLiveTV

1,830

25 views

Published on Sep 1, 2016

Michael Birrer, Harvard Medical School, discusses what he hopes to discover as factors that influence long-term survival in patients and survivors with ovarian cancer.

worth reading (for everyone): Exploring experiences of cancer care in Wales (gyn cancer patients included)

open access:
Exploring experiences of cancer care in Wales: a thematic analysis of free-text responses to the 2013 Wales Cancer Patient Experience Survey (WCPES)

Navigate This Article

• Top
• Abstract
• Introduction
• Methods
  • Study design
  • Cohort identification
  • Questionnaire and design content
  • Survey process
  • Ethics and governance
• Analysis
• Findings
  • Communication
    • Communication between patients and staff
    • Communication between staff and/or institutions
  • Waiting during the treatment and post-treatment phase
    • Waiting on the day
  • Staffing and resource levels
    • Availability of aftercare
    • General comments about staffing levels (nursing and medical staff)
    • Availability and quality of staff on hospital wards at evening and weekends
    • Availability of specialist nursing staff
  • Speed and quality of diagnostic care
    • GP role in diagnosis
    • Investigations and diagnostic services
• Discussion
• Study limitations
• Future research
• Conclusion
• Acknowledgments
• Footnotes
• References

 Conclusion

This study has illustrated the value of free-text analysis for exploring patient experiences of cancer care, and for complementing and extending findings from closed questions. As the first systematic analysis of free-text data from a national sample of experiences of patients with cancer, it has presented specific areas of concern for patients with cancer, as well as areas of good practice, and revealed themes present across the cancer journey. The volume of comments within specific themes, as well as ratios of negative-to-positive comments, indicate areas of potential concern. Our work on the WCPES has also highlighted an area of potential significance with regard to the reliability of survey data at greater levels of specificity (ie, the site level). These findings have been discussed in the context of existing issues in cancer care, and in doing so have presented areas of specific attention for policymakers and further research.

Are Indirect Benefits Relevant to Health Care Allocation Decisions?

Abstract

When allocating scarce healthcare resources, the expected benefits of alternative allocations matter. But, there are different kinds of benefits. Some are direct benefits to the recipient of the resource such as the health improvements of receiving treatment. Others are indirect benefits to third parties such as the economic gains from having a healthier workforce. This article considers whether only the direct benefits of alternative healthcare resource allocations are relevant to allocation decisions, or whether indirect benefits are relevant too. First, we distinguish different conceptions of direct and indirect benefits and argue that only a recipient conception could be morally relevant. We analyze four arguments for thinking that indirect benefits should not count and argue that none is successful in showing that the indirectness of a benefit is a good reason not to count it. We conclude that direct and indirect benefits should be evaluated in the same way. 

DNA Analysis in Samples From Younger Patients With Germ Cell Tumors and Their Parents or Siblings

ClinicalTrials.gov

 Conditions:

	Childhood Malignant Ovarian Germ Cell Tumor;   Childhood Malignant Testicular Germ Cell Tumor;   Ovarian Choriocarcinoma;   Ovarian Embryonal Carcinoma;   Ovarian Mixed Germ Cell Tumor;   Ovarian Teratoma;   Ovarian Yolk Sac Tumor;   Testicular Choriocarcinoma;   Testicular Embryonal Carcinoma;   Testicular Seminoma;   Testicular Teratoma;   Testicular Yolk Sac Tumor
Interventions:	Other: laboratory biomarker analysis;   Other: questionnaire administration

Pancreas Registry and High Risk Registry - Full Text View

ClinicalTrials.gov

 ClinicalTrials.gov Identifier:

	NCT02775461
Study Title:	Pancreas Registry and High Risk Registry
First Received:	May 13, 2016
Last Updated:	May 16, 2016

Condition Pancreas Cancer Pancreatitis Chronic Pancreatitis Pancreatic Cyst Family History of Pancreas Cancer Genetic Mutations Study Type: Observational [Patient Registry] Study Design: Observational Model: Case-Only Time Perspective: Prospective Target Follow-Up Duration: 10 Years Official Title: Pancreas Disease and High Risk Registry

Primary Anastomosis vs. Ostomy after Colon Resection during Debulking of Ovarian Carcinomatosis

abstract

Ovarian carcinomatosis poses a dilemma for the surgeon. When resecting colon for tumor invasion, one must decide between diversion and primary anastomosis (PA). We examined the National Surgical Quality Improvement Program to determine whether PA associated with more complications than ostomy. The National Surgical Quality Improvement Program dataset was queried for patients with ovarian carcinomatosis between 2007 and 2012. Current Procedural Terminology codes were used to further identify patients undergoing colectomy with PA or ostomy. Logistic regression was used to evaluate 30-day morbidity and mortality. The 1013 ovarian carcinomatosis patients who underwent elective colon surgery were divided into primary repair (n = 453, 43.5%) or ostomy (n = 586, 56.5%) groups. Preoperative demographics were similar; however, ostomy patients had more severe preoperative laboratory derangements. The 30-day mortality and postoperative transfusion requirements were higher in the ostomy group. On multivariate analysis controlling for confounders, the differences were no longer significant. In conclusion, 30-day mortality and postoperative complications were increased in the ostomy group. Given the laboratory derangements in this group, this may reflect tendency to allocate ostomies to more ill patients. Primary repair in a selected population does not worsen outcomes. Prospective evaluation would help determine the impact of PA in the ovarian carcinomatosis population.