Annual outpatient hysteroscopy and endometrial sampling (OHES) in HNPCC/Lynch syndrome (LS)

Background: LS women have a 40-60 % lifetime risk of endometrial cancer (EC). Most international guidelines recommend screening. However, data on efficacy are limited. Purpose: To assess the performance of OHES for EC screening in LS and compare it with transvaginal ultrasound (TVS) alone. Methods: A prospective observational cohort study of LS women attending a tertiary high-risk familial gynaecological cancer clinic was conducted. LS women opting for EC screening underwent annual OHES and TVS. Histopathological specimens were processed using a strict protocol. Data of women screened between October 2007 and March 2010 were analysed from a bespoke database. Histology was used as the gold standard. Diagnostic accuracy of OHES was compared with TVS using specificity, and positive (PLR) and negative (NLR) likelihood ratios. Results: Forty-one LS women underwent 69 screens (41 prevalent, 28 incident). Four (three prevalent, one incident) women were detected to have EC/atypical endometrial hyperplasia (AEH), five had endometrial polyps and two had endometrial hyperplasia (EH) on OHES. TVS detected two of four EC/AEH. OHES had similar specificity of 89.8 % (CI 79.2, 96.2 %), but higher PLR 9.8 (CI 4.6, 21) and lower NLR (zero) compared to TVS: specificity 84.75 %(CI 73, 92.8 %), PLR 3.28 (CI 1.04, 10.35) and NLR 0.59 (CI 0.22, 1.58). No interval cancers occurred over a median follow-up of 22 months. The annual incidence was 3.57 % (CI 0.09, 18.35) for EC, 10.71 % (CI 2.27, 28.23) for polyps and 21.4 % (CI 8.3, 40.1) for any endometrial pathology. Conclusions: Our findings suggest that in LS, annual OHES is acceptable and has high diagnostic accuracy for EC/AEH screening. Larger international studies are needed for confirmation, given the relatively small numbers of LS women at individual centres. It reinforces the current recommendation that endometrial sampling is crucial when screening these women. © 2012 Springer-Verlag

Epidemiology of Herpes Zoster Ophthalmicus

PURPOSE: A hospital-based epidemiology study to describe herpes zoster ophthalmicus (HZO) prevalence, and identify risk factors for recurrent and chronic disease. DESIGN: Retrospective, hospital-based cohort study PARTICIPANTS: All patients evaluated in the Broward and Miami VA Healthcare System (MIAVHS) during the study period. METHODS: Retrospective medical record review of patients seen in the MIAVHS from January 1, 2010 and December 31, 2014 with a HZO clinical diagnosis. Assessment of the patient's clinical course was defined by the following: an acute episode of HZO was defined as quiescence of disease within 90 days of initial presentation; HZO recurrence was defined as any recurrent eye disease or rash >90 days after quiescence disease was noted off therapy; chronic HZO was defined as active disease persisting greater than 90 days from initial presentation. MAIN OUTCOME MEASURES: 1) Frequency of HZ involving the V1 dermatome (HZO) with and without eye involvement; 2) HZO recurrence rates 3) Risk factors for recurrent or chronic HZO. RESULTS: 90 patients with HZO were included in the study. The mean age at incident episode of HZO was 68±13.8 years (range, 27-95 years). The majority of patients were white (73%), immune competent (79%), and did not receive zoster vaccination at any time point in their follow up (82%). Patients were followed for a mean of 3.9±5.9 years, (range, 0-33 years). The period prevalence of HZ in any dermatome was 1.1%, the frequency of HZ involving V1 (HZO) was 0.07% and the frequency of HZO with eye involvement was 0.05%. The overall 1, 3, and 5-year recurrence rates for either recurrent eye disease or rash were 8%, 17%, 25%, respectively. Ocular hypertension (HR 4.6, 95% Cl 1.3-16.5; OR 6.7, 95% Cl 1.5-31.2) and uveitis (HR 5.7, 95%CI 1.7-19.0; OR 6.7, 95% C1 1.5-31.2) increased the risk of recurrent and chronic disease. CONCLUSION: This study supports newer data that a significant proportion of patients experience recurrent and chronic HZO. Further study is needed to guide preventative and therapeutic approaches to recurrent and chronic HZO

Sensitivity of transvaginal ultrasound screening for endometrial cancer in postmenopausal women: a case-control study within the UKCTOCS cohort

BACKGROUND: The increase in the worldwide incidence of endometrial cancer relates to rising obesity, falling fertility, and the ageing of the population. Transvaginal ultrasound (TVS) is a possible screening test, but there have been no large-scale studies. We report the performance of TVS screening in a large cohort. METHODS: We did a nested case-control study of postmenopausal women who underwent TVS in the United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) following recruitment between April 17, 2001, and Sept 29, 2005. Endometrial thickness and endometrial abnormalities were recorded, and follow-up, through national registries and a postal questionnaire, documented the diagnosis of endometrial cancer. Our primary outcome measure was endometrial cancer and atypical endometrial hyperplasia (AEH). Performance characteristics of endometrial thickness and abnormalities for detection of endometrial cancer within 1 year of TVS were calculated. Epidemiological variables were used to develop a logistic regression model and assess a screening strategy for women at higher risk. Our study is registered with ClinicalTrials.gov, number NCT00058032, and with the International Standard Randomised Controlled Trial register, number ISRCTN22488978. FINDINGS: 48,230 women underwent TVS in the UKCTOCS prevalence screen. 9078 women were ineligible because they had undergone a hysterectomy and 2271 because their endometrial thickness had not been recorded; however, 157 of these women had an endometrial abnormality on TVS and were included in the analysis. Median follow-up was 5.11 years (IQR 4.05-5.95). 136 women with endometrial cancer or AEH within 1 year of TVS were included in our primary analysis. The optimum endometrial thickness cutoff for endometrial cancer or AEH was 5.15 mm, with sensitivity of 80.5% (95% CI 72.7-86.8) and specificity of 86.2% (85.8-86.6). Sensitivity and specificity at a 5 mm or greater cutoff were 80.5% (72.7-86.8) and 85.7% (85.4-86.2); for women with a 5 mm or greater cutoff plus endometrial abnormalities, the sensitivity and specificity were 85.3% (78.2-90.8) and 80.4% (80.0-80.8), respectively. For a cutoff of 10 mm or greater, sensitivity and specificity were 54.1% (45.3-62.8) and 97.2% (97.0-97.4). When our analysis was restricted to the 96 women with endometrial cancer or AEH who reported no symptoms of postmenopausal bleeding at the UKCTOCS scan before diagnosis and had an endometrial thickness measurement available, a cutoff of 5 mm achieved a sensitivity of 77.1% (67.8-84.3) and specificity of 85.8% (85.7-85.9). The logistic regression model identified 25% of the population as at high risk and 39.5% of endometrial cancer or AEH cases were identified within this high risk group. In this high-risk population, a cutoff at 6.75 mm achieved sensitivity of 84.3% (71.4-93.0) and specificity of 89.9% (89.3-90.5). INTERPRETATION: Our findings show that TVS screening for endometrial cancer has good sensitivity in postmenopausal women. The burden of diagnostic procedures and false-positive results can be reduced by limiting screening to a higher-risk group. The role of population screening for endometrial cancer remains uncertain, but our findings are of immediate value in the management of increased endometrial thickness in postmenopausal women undergoing pelvic scans for reasons other than vaginal bleeding