Home > Media Relations > Mercy News Archive

Media Relations: Mercy News Archive

Mercy gynecologic oncologists (left to right) Dr. Neil B. Rosenshein, Dr. Hyung S. Ryu and Dr. Dwight Im were among the keynote speakers at the Women’s Health: 2011 symposium presented by The Weinberg Center for Women’s Health and Medicine at Mercy.

For nearly 15 years, Dr. Neil B. Rosenshein, Medical Director of The Weinberg Center for Women's Health and Medicine at Mercy and Director of The Gynecology Center at Mercy, has led a conference for physicians and other medical professionals throughout the region regarding women's health care issues. The symposium serves as an opportunity for continuing medical education credits for participants.

On March 19, 2011 Dr. Rosenshein served as Course Director for "WOMEN'S HEALTH 2011," held all day at the Marriott Waterfront Hotel.

Doctors and surgeons from Mercy's medical staff as well as guest speakers were on hand to address a variety of topics including obesity, osteoporosis, ovarian cancer, etc., as well as issues like robotic surgery and health care reform.

Here are notes from the conference. To view the entire syllabus, contact Mercy Media Relations at 410-332-9714 or dcollins@mdmercy.com and an electronic copy will be sent to you.

The Obesity Epidemic
Scott I. Kahan, MD, MPH, Instructor, Johns Hopkins Bloomberg School of Public Health, Co-Medical Director, George Washington University Weight Management Program

“Obesity wasn’t that big a problem in 1990, but by note the increase over the years…15-19% prevalence in 1991, 20-25% prevalence in 1997, 25-29% prevalence in 2001, and by 2005, a rise to more than 30 percent prevalence. So in just a generation, obesity went from a problem that most states weren’t paying attention to, to one where everyone is paying attention and obesity is expanding at an epidemic rate,” Dr. Kahan said.

In determining numbers of obese individuals, a Behavioral Risk Factor Surveillance Survey (BRSFS) was conducted, a phone survey, “and most people say they are a bit taller than they really are, and a little bit lighter in weight than they really are, so the rates of obesity are actually higher than indicated by BRSFS.

Medical complications of weight gain and obesity include pulmonary disease (abnormal function, obstructive sleep apnea, hypoventilation syndrome), non-alcoholic fatty liver disease (steatosis, steatohepatitis, cirrhosis), gall bladder disease, gynecologic abnormalities (abnormal menses, infertility, polycystic ovarian syndrome), osteoarthritis, gout, phlebitis (venous stasis), cancer (breast, uterus, cervix, colon, esophagus, pancreas, kidney, prostate), coronary heart disease (diabetes, dyslipidernia, hypertension), idiopathic intracranial hypertension, stroke, and cataracts.

“Of these medical complications, there’s a strong risk factor for diabetes, even in cases of people with just a few BMI (body mass index) points up, even in people with a normal BMI, i.e. below 25, the risk of diabetes rises significantly with even a little bit of weight gain. So if you’re seeing this risk with just a little weight gain, in cases of obesity, it’s almost inevitable that you’ll get diabetes, it just a matter of how long it will take,” Dr. Kahan said.

“When you add in the cases of pre-diabetes, the rate goes through the roof. And diabetes is becoming the coronary heart disease equivalent. Patients with diabetes, we treat them as if they have cardiovascular disease. The number of overweight and obese has been going up for the past several decades, we’re seeing diabetes rates go up so right around the corner, we will have increasing rates in cardiovascular disease,” Dr. Kahan said.

The same thing is happening among children as we see the increase in weight gain/obesity prevalence rates mirroring the increase in adults, “even in children as young as 2-5 years old…we see similar increases in Type 2 diabetes in young children, what has been previously known as ‘adult onset diabetes.’ So we have this significant increase in childhood obesity and now an epidemic of diabetes among adolescents and young children, even seeing cardiovascular disease in young children, with more than 100,000 kids needing lipid-lower hypertension therapy, seeing atherosclerosis in 2-3 year old kids…we’re heading down a path where we’ll be seeing 17 year olds having bypass surgery and heart attacks,” Dr. Kahan said.

Why an obesity epidemic? There’s the usual excuses, too much fatty foods, sodas, no sidewalks, cars, no time, stress, TV, gut microbes, a lack of will power. Is this a disease of will power? Just a matter of not working hard enough, a lack of personal responsibility—it’s a very important issue as we can’t look at someone else to solve our problems.

However, if we blame obesity on lack of will power, that means that 65% of Americans don’t have enough will power given current rates of obesity (NHanes, 1992-2002).

“So if it is willpower, where did the willpower go? Did this mean we all had more willpower when obesity rates were low? Doesn’t make sense. When we look at other health behaviors that are associated with willpower, like smoking, problematic drinking, having unsafe sex, driving without a seatbelt, these rates are all improving, so it’s just the obesity problem that’s going up. And besides, how much willpower does a six year old have? A 2 year old? A six month old? Are we saying that a 2 year old doesn’t have enough willpower? Doesn’t make sense,” Dr. Kahan said.

Why don’t our decisions follow our best judgments? It makes sense to eat healthy, so why are we eating unhealthy foods. Fattening foods, foods with high calories, unhealthy foods are far cheaper than healthy foods. There’s been a 40-50% increase in the cost of healthier foods while the unhealthy foods are cheaper with increasing portion sizes.

“For example, your standard size Coke was 6.5 ounces in 1960 and a “king size” was a 12 ounce can. Now 20 ounce is the default, and you can buy even larger than that. You can’t supersize your healthy salad for 19 cents or get a “buy one, get one free” for an apple or banana. And the fact is, fattening foods are tastier,” Dr. Kahan said.

Food scientists understand our innate love of certain tastes and textures, so it is possible to make these foods almost irresistible—that sets a default that is very hard to overcome, given how the brain processes information.

Fattening foods are also more available; the number of fast food restaurants in 1980, one per every 2,000 people; in 2000, that figure is now one per every 1,000 people.

Fattening foods are heavily marketed, with billions of dollars spent promoting unhealthy food versus virtually nothing for fruits/vegetables/healthy foods. McDonald’s marketing budget approaches $1 billion a year.

So with the unhealthiest, cheapest, largest portions, most accessible, tastier foods being heavily marketed, is it surprising that obesity is going up?

It’s a perfectly rational response to what’s happening in our society. These foods are so dirt cheap, are virtually given away, and last so long, you can put it on your shelf til next year, versus fruits and vegetables that are too expensive and go bad if you don’t eat them right away.

“The environment, the setting, the context in which we live, shapes and often determines what our decisions and health outcomes ultimately are. Just a few years ago, there was excessive marketing using sex, cartoon characters, and even doctors to sell cigarettes. This largely shaped what many of the decisions and behaviors were back then. Now we changed these defaults and have seen smoking rates go down throughout the 20th century.

“In 1948 we learned about the hazards of smoking, told people about it in the Surgeon General’s report, tried educating people to change their behavior, but smoking rates went up. It wasn’t until we combined these efforts to educate people with environmental changes that address the setting and the context…a broadcast ban, for instance, in advertising in print and later broadcast got tobacco out of playgrounds, we increased federal taxes, city and state taxes, to make cigarettes less accessible to young people so now the rate of smoking has gone down and down,” Dr. Kahan said.

It’s time to reconsider our assumption about obesity—don’t be afraid to talk about obesity, stressing HEALTH and NOT APPEARANCE, address BEHAVIORS rather than OUTCOMES to avoid the STIGMA.

People predisposed to weight gain are eating bad things and gaining weight, but skinny people are doing the same thing—they may not gain weight, but they are experiencing heart disease and diabetes. We treat these people with respect, even though in many ways they are the same as those who are gaining weight significantly. These individuals are not caring for themselves, but they wear their disease on the inside, not the outside. This leads to the stigma of obesity and it is unfair in how the medical community addresses these patients.

Don’t be afraid to talk about obesity with patients. Only in about 40% of cases where obese patients met with their physicians did doctors even mention to the patient that he/she is clinically obese and should make life changes, according to a 1990 study. It is important to talk to patients about it and to promote open discussion.

Emphasis should be on HEALTH and NOT appearance. When it’s about appearance, the patient images he/she can achieve his/her high school weight. If you are significantly obese, this is just setting yourself up for failure, to try and reach that idealized BMI value.

Consider a diabetes prevention program that looked at 3,000 patients and randomized them re: lifestyle interventions, i.e. walking 20 minutes a day, dropping 200-300 calories from their daily diet; another group received the medication, Metformin, and the third, placebo.

“These were very minimal lifestyle interventions—not asking people to get down to a 25 BMI, but to lose just 5-7% of body weight. Those who made these changes did much better than those who received the medication or the placebo,” Dr. Kahan said.

To say “you really need to lose some weight” is stigmatizing—it’s like saying to someone with clinical depression, “you really need to cheer up.” Behaviors are actionable, outcomes aren’t—make them specific, measurable, achievable, realistic.

In some cases the behaviors may be more important than the outcome. For example, in cases where people were overweight, but healthy in that they had good cardio fitness levels, as measured by stress test, have a lower mortality rate than those who are lean but are unfit. It’s a fairly consistent finding, so that you’re better off if you eat healthy and gain weight than those who eat poorly and don’t—behaviors are more important than the actual weight gain.

Doctors need to keep in mind that weight gain is an important side effect of many medications that we prescribe. Paxil, many SSRIs, TCAs, some can cause weight gain of 100 or more pounds.

Physicians often view obese patients negatively—call them noncompliant, dishonest, unintelligent, unsuccessful, and offer less intervention and less discussion. One study found that 31% of nurses preferred not to care for obese patients and 24% found obese patients “repulsive.”

One marketing study note that when kids were presented with two cereals, one with a character on the box, like Shrek, the other, also colorful/decorated, but NO character, kids said that the cereal with character on the box tasted better, and they ate more of it, even though the cereals were exactly the same.

Fertility Preservation in Gynecologic Oncology
Gilbert L. Mottla, M.D., FACOG, Anne Arundel Medical Center

“In 2011, counseling patients both male and female on their options for fertility preservation should be an integral part/standard of care in any cancer treatment plan.”

Long term survival rates for many cancers are continually improving; new and highly successful options for fertility preservation now exist; maintaining options for fertility has been shown to have a very positive psychological benefit for patients.

Examining US Cancer Sites in 2009, in women, greatest cancer prevalence is in breast cancer; in men, prostate cancer. The 5-year survival rate for almost all cancers continues to improve as biotechnology improves, hopefully a trend that will continue.

In general, both chemo and radiation therapy treatments are highly gonadotoxic and can effect the hypothalamic-pituitary axis as well. Still, in cancer therapy, SURVIVAL needs to be the primary focus.

Regards male fertility, the degree of testicular damage is agent dose and duration dependent. In some small studies, has been shown that after therapy, sperm integrity is reestablished to age-matched controls after time.

Female fertility is affected by depletion of primordial follicles which drops down to 300,000 between the time of conception to birth (so greatest drop in eggs even before you are born!) Females between the ages of 12 and 40 use about 300 eggs out of that 300,000. A return to menses is NOT a reliable indicator of fertility. As in males, the effects are agent dose and duration dependent. In cases of TBI (Total Body Irradiation), there is 90% gonadal failure. “What we’ve learned over the years is that even in chemotherapy that doesn’t leave a woman in ovarian failure.

Female fertility depletion of primordial follicles, between conception and birth down to 300,000 egg loss is prior to birth, females begin life with primordial follicles between age 12-40 use about 300 eggs out of that 300,000, return of menses is not a reliable indicator of fertility. Effects are agent, dose and duration dependent, total body radiation, 90% gonadal failure. What we’ve learned over years even chemo therapy that doesn’t leave a woman in ovarian failure, if she’s 25, she’ll have a 35 year old’s fertility, and if in her 30s, that of a woman in her 40s, due to chemo,” Dr. Mottla said.

How much reserve does the ovary have and this speaks also to the quality of eggs that are remaining.

Cancer Treatment is Gonadotoxic: chemotherapy and true of radiation, amount dose, field of treatment, all relate to impact on fertility.

Regarding males; sperm banking been going on for 60 plus years; we do get calls requesting surgical sperm retrieval, testicular sperm aspiration, where one can retrieve sperm with men with erectile dysfunction, where a man can’t produce a sample.

In females, the issue is more complicated; age is an issue. Today we can freeze eggs, prior to that we couldn’t do much for a single woman without a partner; with partner, you could freeze embryos. Now only need 2-4 weeks to freeze eggs or embryos and that doesn’t interfere with patient’s therapy . In cases of malignancy, not a good idea to be freezing as if there’s a chance of cancer in the ovaries, this impacts the eggs.

Invitro fertilization “does what the body does,” captures and fertilizes and and grows an embryo which is then transferred back into the uterine cavity. All egg retrievals are done transvaginally.

Today, we no longer have the multiple pregnancies that sometimes occurred in the past. Today we see a 90% thaw survival rate and 80% fertilization rate with no apparent loss of fertility potential with vitrification

What is vitrification? Until recently, the only method for freezing oocytes (or unfertilized eggs) was a slow-freezing method. Unlike sperm, which has been successfully frozen and used for years, eggs contain a great deal of water, which makes freezing more difficult. When the eggs are frozen, ice crystals can form within the egg. These ice crystals can destroy the cell's structure.

To help minimize the amount of ice crystals, scientists would remove some of the water as the egg was slowly frozen. But it's impossible to remove all the water, and they couldn't prevent the formation of some ice crystals. The fertilization and pregnancy rates for these slow-frozen eggs, once thawed, is low.

Vitrification is a specialized freezing technique, which freezes the egg so quickly, ice crystals don't have time to form.

Embryo virtification…for patients with partners, good thaw success, virtification freeze at one cell stage and culture to multi-cell fresh embryos…when thaw, it’s like a fresh embryo…success appears to be similar to fresh.

What are the fertility preservation options for women?

They can freeze ovarian tissue for later harvest and transplantation (done in the pelvis and even the forearm); another option is ovarian transposition in cases of pelvic cancer; and third party reproduction, Fertility preservation optiokns for females…can freeze ovarian tissue…harvesting and transplantation of ovarian tissue.

What about Adoption? Costs range from $5,000 to $40,000 and is increasingly difficult both domestic and internationally as some countries, like Guatemala are closed for adoptions. There are restrictions for those undergoing cancer therapy, a five-year survival rate has to be seen before adoption is allowed; adoption is social complex, there are open adoptions where the birth mother is still involved, problems with substance abuse, etc. .

Highly successful fertility preserving options are available to male and females with or without partners. These fertility preserving treatments can be done in 2-4 weeks without impacting the patient’s therapy.

Insurance companies in Maryland do cover invitro fertilization.

Resources: Fertile Hope; American Society for Reproductive Medicine; Lance Armstrong Foundation; Oncofertility Consortium.

No limit with frozen eggs, no aging during freezing process, lasting at least 9 years or so.

Cut off age is about 40 for freezing of eggs. Over 40 fertility even in healthy patient diminishes rapidly and isn’t of value to freeze a few eggs that wouldn’t become a pregnancy.

Thawing takes a couple hours, rehydration of the cells. If they plump up we call them alive. 95% almost as good as fresh.

Evidence Based Treatment of Osteoporosis 2011: Benefits vs. Harms
Marc Hochberg, MD, MPH
Professor of Medicine and Epidemiology and Public Health, University of Maryland School of Medicine

Objectives: review current treatment recommendations for postmenopausal women with osteoporosis, identify the most efficacious currently approved treatments and identify the adverse events of currently approved treatments.

Goals of Therapy: fracture prevention, stabilize or increase bone mass, provide tolerability and long tem safety and optimize adherence. Uncommon for patients to fracture in the short term.

Types of fractures…vertebral fractures, involve both the thoracic and lumbar spine, only about a third are associated with acute back pain. Presence of vertebral deformities is associated with chronic back pain and disability, increased risk of hospitalization, and excess mortality.

Second type is Non-Vertebral fractures (upper extremities like humerus, forearm and writes; lower extremity like femur, lower leg and ankle; pelvis and ribs).

“Most studies involve vertebral fractures and there are differing definitions as to what constitutes a nonvertebral fracture—some include all sites, some all except head, fingers and toes, etc. These differences across studies makes it hard to compare study results directly.

Hip fractures are considered the most series as these are associated with high short term morality; 20% of patients die within one year. Mortality rate is lower than in recent years for women, more like 10-15%.

Morbidity is high with hip fracture patients; about 50% fail to regain their independence and do not regain their previous level of function. Patients who survive are often NOT treated for osteoporosis and are at increased risk for additional fractures.

In 2010 few patients discharged with hip fractures were treated with an anti-osteoporotic agent after hip fracture.

Consider bone mineral density tests for women with “osteopenia,” that’s another way of saying low bone mineral density. “Go to GOOGLE, type in FRAX, hit enter and up comes an URL for a website. Click, get a screen that allows you to enter weight, age, height, race, history of prior fracture, parent history of hip fracture, smoking, alcohol consumption, secondary diseases associated with osteoporosis, the use of certain drugs, etc., and get a result that provides you with a 10-year probability of that person sustaining a hip fracture. If those probabilities are greater, than those women who score accordingly should be treated,” Dr. Hochberg said.

Please note that the FRAX scale does NOT apply to women who have had a vertebral fracture in the past; only use FRAX with women with low bone density but do NOT have osteoporosis.

What steps can you take to reduce fractures?

First, have a home safety evaluation. Advise against the use of throw rugs or area rugs that aren’t fastened to the floor that can slip when people walk on them. Secure electrical cords from floor lamps, and advise that patients get rid of small pets which they can trip over. Avoid excessive alcohol intake; for women, that’s more than one drink per day. Encourage smoking cessation; you can download fall prevention advice from the National Institutes on Aging website. Encourage load-bearing and muscle strengthening exercise, but NO weightlifting as this can result in fractures if patient’s bone mineral density in the spine is low.

Non-pharmaological approaches: Calcium intake

Vitamin D supplementation…at least 1200 mg of calcium with up to 2000 mg with Vitamin D. If you’re going to treat with supplementation, be sure to test Vitamin De levels with a routine blood test.  You are looking for a serum level of less than 10 nanograms per milliliter. Others say that 30-32 is the lower level of normal Vitamin D. Typical supplementation is 50,000 units of Vitamin D administered once a week. Also a 600-800 units of Vitamin D3 per day, that’s the Institute of Medicine (IOM) current recommendation.

What about harms, risks of calcium supplementation? GI intolerance? Upper intestinal distress? According to data from the Women’s Health initiative (WHI) study, there was an increased risk in renal stones, only about 17% increase risk over placebo; so only an increase of about six kidney stone events per 10,000 women.

There is no increased risk for fatal MI (myocardial infarcation or heart attack) or stroke with calcium supplementation.

Vitamin D has been shown to reduce the risk of fractures in postmenopausal women; Vitamin D good for fracture prevention, reduces 13-17%. 

Vitamin D reduces risk of falling; about a 20-30 percent reduction in risk of falls and 90% hip fractures follow a fall.

No adverse events with Vitamin D supplementation with the exception being renal (kidney) stones with vitamin D and calcium together. No clinically important adverse effects of vitamin D supplementation.

Current FDA approved treatments for postmenopausal osteoporosis.

First line therapy continues to be the Biphosphonates (Alendoronate, Risedronate; Ibandronate Zoledronic acid); followed by Calcitonin, Denosumab, Hormone Therapy, Raloxifene, Teriparatide, Denosumba subcontaneous injections, every six months in the office. Third line therapy though could be potentially first line therapy.

All FDA approved treatments reduce the incidence of vertebral fractures; some, not all, reduce the incidence of non-vertebral fractures.

Regarding Hormone Therapy…systematic review if ALN Trials by George Wells in 2002 in Canada, found reduction of the risk of vertebral fractures to be 30%, 20% for non-vertebral with hormone therapy.

The adverse events that were documented in the Women’s Health Initiative fuel an ongoing debate that’s spanned 10+ years after the publication of WHI results. Questions include, how many of these events are related to estrogen versus the progesterone component, the differences in age in women, how many years in menopause, etc. Hormone therapy is the only treatment show to reduce fractures in post-menopausal women who did not have osteoporosis and have a low risk of fracture.

Four biphosphonates have received FDA approval for reducing incidence of fracture, but Alendronate has NOT been shown to reduce the risk of non-vertebral fractures.

Adverse events involving taking Bisphosphonates:  upper GI complaints, nausea vomiting…most common reason women stop oral bisphosphonates, upper GI complaints…Erosive esophagitis, esophageal cancer, osteonecrosis of the jaw and atypical femoral fractures. Important to take with sufficient water and to be upright at least an hour or more.

Osteonecrosis of the jaw…is a risk…women should have a dental examination, any invasive dental work need to be completed first before starting medication…and this issue becomes of interest to the lawyers.

So what BPs do we have? Aldenontrate, reduces non and regular vertebral and hip fractures; RIS, does the same; Ibandronate, suggests reduction in non and vertebral fractures, but not hip fractures; Z oledronic acid, reduction in vertebral, non-vertebral and hip fractures. How do we compare these BPs?

Found  IV administered Zoledronic acid more effective in reducing vertebral  fractures than oral BPs, and likely same for non-vertebral fractures, but no substantive difference in these drugs to reduce risk of hip fractures.

Denosumab: The Freedom Trial..showed reduction in all fracture types, reduction in spine, hip and non-vertebral fractures, no significant difference in adverse events with placebo; however, there is risk of infection as Denosumab is a biological agent and does inhibit immune function.

Drugs shown to reduce the risk of vertebral fractures: Calcitonin, Raloxifene, Hormone therapy, Alendronate, Risedronate, Ibandronate, Zoledronic Acid, Teriparatide, and Denosumbab.

Drugs shown to reduce the risk of non-spine fractures: Hormone therapy, Alendronate, Risedronate, Ibandonate, Zoledonic Acide, Teriparatide and Denosumab. All of these, except for Ibandonate and Teriparatide also reduce the risk of hip fracture.

Safety and tolerability issues…BPs GI intolerability, osteonecrosis of the jaw, and esophageal cancer for oral agents.

Hormone therapy, can cause cardiovascular thrombotic events, breast cancer

Raloxifene, increase in venous thrombotic events, and hot flashes.

Teriparatide, has hypercalcemia issues

And Denosumab, increased risk of infections.

Dr. Hochberg’s recommendations: for postmenopausal women and men with osteoporosis…
Oral BPs, Alendronate or Risedronate; Zoledronic acid if unable to take orally or intolerant of oral BPs; Teriparatide, in cases of failure of or unable to tolerate BPs; Denosumab as above plus unable to tolerate TPTH.

Hormone therapy and calcitonin and raloxifene are lower on the list.

Gynecologic Ultrasound Update 2011
Ulrike Maria Hamper, M.D., Johns Hopkins Medical institutions

An overview of:
Instrumentation and technique; endometrial evaluation; ovarian/adnexal masses; applications of 3D/4D ultrasound; and conclusions

Pelvic ultrasounds that are transabdominal gives an entire view of the pelvis, requires a distended urinary bladder; provides view of superficial structures and area remote from the vagina.

Endovaginal Pelvic Ultrasound is preferred by patients as a full bladder isn’t necessary. Field of view is limited and usually follows a transabdominal ultrasound. Endovaginal Pelvic Ultrasound provides exquisite detail of the uterus, ovaries and adnexae.

Endometrium
Ultrasound appearance varies during the menstrual cycle in patients with normal endometrium. The superficial functional level thickens during the cycle and shed during menses, so the endometrium changes depending on the menstrual phase the patient is in.

The Junctional Zone, the thin, hypoechoic layer deep in the endometrium, the inner most layer, can be detected in ultrasound.

Postmenopausal uterus/endometrium…Endometrial fluid, small amounts are insignificant but can be associated with cervical stenosis or polyps; if complex fluid, most make sure it not a sign of cancer. A thickened EMS (greater than 5-6 mm) may be caused by hyperplasia, polyps or cancer so exclude any malignancy!

Newer data (Bree et al, RADIOLOGY, 2000) for postmenopausal bleeding, examined 96 women with PMB, 70% had a pathological condition for the bleeding: 47% had endometrial polyps, 11% had fibroids, 8% had hyperplasia, 4% had cancer and 30% were normal.

Endometrial hyperplasia…Is it simple or cystic (“Swiss cheese”)? May be due to prolonged unopposed estrogen stimulation.

Endometrial Carcinoma is the most common gynecological malignancy; there were 423,470 new cases in 2010 with 7,950 deaths. 80% occur after menopause and result in postmenopausal bleeding. Risk factors include unopposed estrogens, obesity, nulliparity, hypertension, diabetes, Tamoxifen, and pelvic radiation.

Endometrial Carcinoma in Ultrasound reveals a thickened, echogenic endometrium with irregular hypoechoic regions. If advanced, you’ll note lobulated enlarged uterus.

In examining the Endometrium, always use intravaginal ultrasound as it provides ean exquisite depiction of endometrial abnormalities.

Adnexal masses..role of ultrasound in evaluating ovarian/adnexal masses:

What is expected of us as imagers? The sinologist who merely measures the size of a mass and offers a differential diagnosis that includes nearly every adnexal abnormality, including malignancy, has failed in his or her opportunity to contribute meaningfully to the care of the patient.

An imager should be able to offer a reasonalb ediangnosis based on age/menopause status, sonographic appearance/pattern recognition and clinical and lab findings. Recommendations would include offer a specific diagnosis in case of a benign mass; the need for MRI or laparoscopy, and if malignant, to refer to a GYN oncologist for staging laparaoscopy.

Sonographer can diagnosis a simple cyst in the pre- and postmenopausal women, hemorrhagic ovarian cysts, endometrioma, ovarian dermoids, etc. Masses that would require further imaging and/or laparoscopy would be predominantly solid masses, complex masses, cystic masses with thick septations, etc.

The ultrasonic features of a benign mass include a cystic, anechoic mass, a thin wall, no flow on color Doppler ultrasound (CDUS) or minimal high resistance flow; the ultrasound appearance is compatible with dermoid (benign typically ovarian tumor), endometrioma or hemorrhagic cysts.

Normal ovary…varying appearance throughout menstrual cycle

Benign cysts, very low rate of malignancy.

Recommendation for simple cysts…less than one centimeter up to 3 cm, no action is needed.

Hemorrhagic Ovarian Cysts…complex cystic mass…typically resolve in about 8 weeks.

Recommendations…less than three cms, leave it alone.

Endometrioma: ultrasound followup warranted if there is no surgical removal; at least a yearly ultrasound followup.

Dermoid…mature cystic teratoma of the ovary..if a classic dermoid is found on ultrasound, no additional imaging is needed; a followup ultrasound in 6-12 month if the dermoid is not removed

See a dermoid, no additional imaging is needed, just followup in 6-12 months to make sure its stable

Hydrosalpinx…tubular cystic mass…these are typically benign cysts…those with indeterminate features, consider MRI or surgical evaluation.

Suspicious Cysts…worrisome for malignancy…thick sepations, nodules with blood flow, focal wall thickening, should receive further imaging (MRI) and strongly consider surgical evaluation.

Solid ovarian and adnexal masses are consider neoplastic, sometimes just an enlarged ovary, use color Doppler ultrasound (CDUS) to delineate the mass; may represent benign lesions like ovarian fibroma; other alternative is ovarian mestastes.

Ovarian mestastases occur in 5-15% of ovarian neoplasms; breast and gastrointestinal tract tumors are most common (e.g. Krukenberg tumor, an ovarian tumor caused by the spread of stomach cancer); usually bilateral solid masses (e.g. breast, stomach, uterus), may be complex (colon and rectum), lymphoma.

In conclusion, GYN ultrasound is an accurate tool to diagnose variety of ovarian and adnexal masses; MRI may be needed. If both ultrasound and MRI are not conclusive, surgical exploration may be necessary.

3D/4D US Imaging has proven clinical applications in obstetrics and gynecology. You can acquire a true volume of the data set at the time of the initial study or in real time. Disadvantage…steep learning curve, not available on all machines, cost of dedicated equipment is very high and most PACS (picture archives communication systems) currently cannot handle the volume data.

3D ultrasound is best for assessment of uterine anatomy and anomalies, assessment of the endometrium (depiction of polyps) with additional findings found in about 30% of patients.

Uterine Abnormalities..3D obviates MRI in most cases

IUDs often incidentally detected on pelvic ultrasound…

Conclusion: 3D/4D is a valuable problem-solving tool in GYN imaging, allows more detailed and comprehensive exam of the uterus and adnexa than 2D ultrasound. Facilitates better communication with referring MD and patient and consulting among networks. Challenges? The need to educate more imagers and there are storage issues in PACS systems.

Pain Management: Challenges and Solutions
David N. Maine, M.D., Director, Center for Interventional Pain Medicine at Mercy

TIME magazine featured “Understanding Pain” as its recent cover story…Chronic pain is forever, it is a disease, and we need to improve our ability to treat and understand it…from a neurophysiological standpoint…

New York Times: Chronic pain affects more than 70 million Americans…more widespread than cancer, heart disease and diabetes combined.

25% of primary care visit are for pain…110 million adults in the U.S. sayt pain affects their participation in some activities…4.5 million patients die in pain each year and about 30% believe there is no solution to their pain, sense of hopelessness.

Opioids
Reasons for disciplinary action re: prescription of opioids includes keeping.inadequate records, self-prescribing, prescribing to addicts without addressing their addiction, sexual activity with patients, incompetence…

Clinician accountability…Federation of State Medical Boards Model policy on Opiood Prescribing..
Obtain full history, perform physical exam and diagnostic studies, utilize referral when needed, offer best treatment possible, followup and DOCUMENT.

Consider case of a 43 year old female with a 6-year history of low abdominal/pelvic pain, present all the time…taking oxycodone, fentanyl, nontriptyline, peppermint oil, lisnopil…diffuse abdominal pain, tenderness in para spinal msucluature..16 out of 21 tender points. Celiac disease negative.

What to do? Opioids, adjunct medications, etc?

Central Sensitization…functional IBS…plasticity in the nervous system…sensitized neuron, get rapid firing, expanse of pain area (C. Nicholas Verne, M.D and Donald D. Price, PhD, study, “Irritable Bowel Syndrome as a Common Precipitant of Central Sensitization”) Loosely defined, Central Sensitization is an increased response to stimulation that is mediated by amplification of signaling in the central nervous system (CNS).

In a study of patients re: Visceral Hypersensitivity…the IBS group experienced higher pain…six times higher than the control group.

Look at temperature sensitivity--a single tip probe--differences are quite remarkable…Foot, hand, control group…very little pain…but IBS group, foot and hand, reaction 3-6 times faster than the control group.

Reversal of visceral and cutaneous hyperagelsia by local rectal anesthesia in IBS patients…reflects central sensitization mechanism.

What to do? Opioids?
New Opioids ligands…
Fedotozine, Asimadoline, Seitin

Why wean? If it is not helpful, reduces tolerance, increase anagelsic effect of drugs acting on Mu receptor, improves co-existing GI dysfunction, patient most actively participate in care challenging prognostic value. Must have a plan outside of weaning.

Strongly consider use of opioid agreement re: terms of treatment, goals of therapy, education, additional treatment, patient responsibilities, limitations of prescriptions, prohibited behavior, emergency issues, points of termination.

Gabapentin and Morphine combined achieve a better analgesia (pain relief) at lower doses of each drug than either as a single agent—opioid sparing.

Case 1 now on Tapendetol, Desipramine, Gabapentin, Mexilitene, seeing a pain psychologist

bi- monthly.

Chronic Pelvic Pain: 20% of women between 18 and 50 years of age have chronic pelvic pain of more than one year’s duration ; CPP accounted for up to 10 percent of all outpatient gynecologic consultations; associated with disturbances of mood and energy in 60% of cases.

CPP patients, about 50% are given no formal diagnosis…those who do, typically endometriosis is the diagnosis.

Greater than 70% of all laparoscopic procedure are performed on patients who have endometriosis as either their primary or secondary diagnosis.

Other issues that can cause chronic pain include: interstitial cystitis; urethral syndrome; bladder spasm and stone disease.

Case #2: healthy 42 year old female with progressively worsening bladder pressure, periods of straining to void and diffuse pelvic pain…urethral syndrome, saw 4 specialists in past 14 months.

Oral therapy with antimuscarinic agents (Trospium) with Elmironand even adding Elavil provided very little relief. Patient sent to pain specialist for consideration of stimulation therapy.

Found only relief with Percocet and Ambien. Stimulation consideration…To stim or not to stim…

History of fibromyalgia, straining to void, pelvic floor muscle EMG amplitutde elevation, nerve conduction similar to inflammatory response.

Diagnosis: Chronic pelvic pain due to interstitial cystitis.

Provided form of neurostimulation. Leads placed in small flurosocopy suite. Had tremendous improvement in her pain.

Genetic Cancer Syndrome: BRCA and Beyond
Kathy J. Helzlsouer, M.D., M.H.S., Director, Prevention and Research Center at Mercy

How much breast and ovarian cancer is hereditary? About 10%
About 20% of women have breast cancer history…5-10% hereditary
10% hereditary inherited susceptibility to ovarian cancer

Of those families suspected to have an inherited predisposition to cancer with family history of breast cancer, 50% of families with breast cancer only in the family history and suspected inherited susceptibility are due to BRCA 1/2 mutations. Breast-ovarian, 80-90 percent of families due to BRCA 1/2. Unusual cancer, think genetics, consider multiple syndromes that may be involved.

Other genetic conditions associated with increased breast cancer risk include these syndrome: Li-Fraumeni, Cowden, Peutz-Jeghers, Ataixa-telangiectasia.

When to suspect hereditary cancer syndrome: cancer in two or more close relatives on same side of the family; early age of diagnosis, multiple primary tumors in the same individual; bilateral or multiple rare cancer; constellations of tumors consistent with cancer syndromes like breast and ovary, evidence of autosomal dominant transmission, i.e. multiple affected generations.

Taking a Cancer Family history: Obtain at least three generation pedigree, ask about all individuals in the family and record the family: age at cancer diagnosis; age at and cause of death; distinguish primary from metastatic sites; precursor lesions, bilateral multiple cancers; pertinent prophylactic surgeries; associated congenital abnormalities; record ethnicity and race.

BRCA 1 and BRCA 2 Associated Cancers lifetime risks: breast cancer 40-85% risk, often early age at onset, ovarian cancer, 15-40%. In men, studies show that breast, prostate and pancreatic cancer risks are elevated.

What to do? Increased surveillance, mammography and MRI…risk0reducing surgery as in breast, ovaries and fallopian tubes, discussion re: hysterectomy; chemoprevention more relevant to BRCA2 mutation carriers and other guided family history such as pancreatic cancer, consider screening trials.

Amsterdam Criteria: Research criteria for defining Lynch Syndrome families (Lynch syndrome is a genetic condition that predisposes people to colon cancer and other cancers as well. While most people have about a six percent chance of developing colon cancer at some point in their lives, people with Lynch syndrome have about an 80 percent chance. Women with Lynch syndrome also have about a 10 percent chance of developing ovarian cancer and a 50 percent chance of developing uterine cancer.)

One member diagnosed with colorectal cancer, less than 50%; two affected generations, three affected relatives with one of them a first degree relative of the other two; FAP (Familial adenomatous polyposis) excluded, and tumors verified by pathological exam.

Primary Prevention in Lynch Syndrmoe…Colonosocopy preventive as well as screening…no convincing evidence for chemo-prevention…NSAIDs regress of adenomas…not consistent in pediatric population; risk reducing surgeries include hysterectomy and oophroectomy.

Have to consider other genetic syndromes.

Emphasize the complexity…maternal and paternal inheritance..small family structure..negative test doesn’t not always mean cancer susceptibility is non inherited, patient may still be at high risk…families where affected members are not tested, families where history remains unexplained after testing, multiple syndromes. Population based risk assessment models aren’t appropriate for suspected inherited syndrome families.

Another whole area this emerging…low penetrant genetic mutations that may increase risk…differences in how we repair DNA damages…versus BRCA 1 and 2 where if you have a mutation risk is as high as 85%. Gene environment interaction, genetic alterations in DNA repair pathways and sun exposure. Environment is inherited so families share more than just genes.

Direct to Consumer Genetic Testing…Direct to consumer genetic testing refers to genetic tests that are marketed directly to consumers via TV, print ads or the internet. This form of testing at home genetic testing, provides access to a person’s genetic information without necessarily involving a doctor or insurance company in the process. These consumer kits won’t pick up BRCA 1 and 2 as these are patent protected.

These tests look at everything from cystic fibrosis, cancer genetic testing, sickle cell, etc.

Potential harms to home tests: false positives/negatives; unclear validity, reliability, clinical utility (e.g. accuracy, type and size of studies, interpretation of results).

To order a test kit online may cost between $429-$999; prices vary by test and how it is procured; also a $199 + monthly subscription. Saliva samples are sent back and results are sent via online account in 2-4 weeks. There is a limited level of involvement by health care professionals; additional testing may be warranted and there are privacy/confidentiality matters to consider.

Benefits include accurate tests results (true positives and true negatives); individuals may take preventive measures as a result, seeking medical advice and undergoing lifestyle changes.

Genetic testing… 23andMe website..$199, requires $5 monthly subscription…can link you to relatives in other places who get the testing.

“The $1,000 Genome” --get your whole genome sequenced for $1,000.

Gestational Trophoblastic Disease
Dr. Hyung S. Ryu, M.D., The Gyencology Center at Mercy

Gestational Trophoblastic Disease (GTD) is a group of rare tumors that involve abnormal growth of cells inside a woman's uterus. GTD does not develop from cells of the uterus like cervical cancer or endometrial (uterine lining) cancer do. Instead, these tumors start in the cells that would normally develop into the placenta during pregnancy. GTD begins in the layer of cells called the trophoblast that normally surrounds an embryo.

GTD involves a disorder of t-cells, It’s an internal tumor form a gestational tissue, a potential cancer. Incidence to 1 per 1,000 to 1500, whereas higher in Asian populations.

Incidence of molar pregnancy varies in different parts of the world, one in 600 in Asian, and one in 1200 in Europeans.

Molar pregnancy, example of GTD. Molar pregnancy occurs when tissue that normally becomes a fetus instead becomes a growth, called a mole, in the uterus. Even though it is not an embryo, a mole triggers symptoms of pregnancy. A molar pregnancy should be treated right away. This will make sure that all of the mole tissue is removed. This tissue can cause serious problems in some women. About 1 out of 1,000 women with early pregnancy symptoms has a molar pregnancy.

Age is most important factor in the developing of molar pregnancy. Whereas the incidence for women aged 25-29 is standardized as one, the risk is 6-400X incidence increase if occurs at age less than 15, greater than 50.

Maternal age, greater than 40, less than 15; paternal age, greater than age 45; if previous mole, one to two percent, 15-28% with a second; and male be associated with a Vitamin A deficiency.

Cure is possible by hysterectomy or chemotherapy. Can cause uterine rupture and be life threatening. Does not have metastatic potential.

Choriocarcinoma: most cases discovered by bloody brownish discharge…

Hysterectomy is treatment of choice. Small number of patients treated with intensive chemotherapy have achieved good results.

Most common presentation of patient with GTD is vaginal bleeding at end of first trimester, nausea and vomiting, a uterus larger for dates than for a normal pregnancy.

Vaginal bleed, large uterine size, ovarian cysts, preeclampsia, hypermesis, hyperthyroidism, trophoblastic embolization to lungs causing respiratory distress, most to least in this order of incidence, all distinguishing marks of GTD.

Ultrasound findings…increasing performance of ultrasound examination, either toruintinein the first \trimester or for management of early pregnancy complications allows evaluation of most.

Increasing use of ultrasound in early pregnancy has led to earlier diagnosis of molar pregnancy. Diagnostic accuracy is 60-80%.

If there is one viable fetus and the other pregnancy is molar the pregnancy could be allowed to proceed if the mother wishes, following appropriate counseling. Probability of achieving a viable baby is 20%. Risks have miscarriage 50%, still birth, 30% for GTD in twin pregnancy.

How to manage GTD? Suction cutteage is the method of choice of evaluation for complete molar pregnancies.

Persistent GTD can occur after non-molar pregnancies…vaginal bleeding is common, symptoms from metastic disease, such as dyspena or abnormal neurology.

Treatment: women with persistent GTD should be treated at a specialist center with appropriate chemotherapy. Obtain a CT of head chest abdomen and pelvis due to high risk of metasis to other organs. Need for chemotherapy following a mole is 15%, following partial mole, .5%.

Stage One, confined to uterus; stage two, outside of uterus, but limited to genital structures.

Five year survival: non metastatic: 100%; low risk: 97-100% high risk, 75%

Future pregnancy…women should be advised not to conceive until their HCG (a hormone, human chorionic gonadotropin) levels have been normal for six months. Women who undergo chemo are advised not to conceive for one year after completing treatment. Risk for further molar pregnancy is low, 2%.

Approximately 90% of patients who want to become pregnant after chemo have succeeded with no sign of fetal abnormalities.

• Complete molar pregnancy. An egg with no genetic information is fertilized by a sperm. The sperm grows on its own, but it can only become a lump of tissue. It cannot become a fetus. As this tissue grows, it looks a bit like a cluster of grapes. This cluster of tissue is called a mole, and it can fill the uterus.
• Partial molar pregnancy. An egg is fertilized by two sperm. Normally this creates twins. But in a partial molar pregnancy, something goes wrong. The placenta grows into a mole instead. Any fetal tissue that forms is likely to have severe defects.

In a few cases, trophoblastic disease turns into cancer. Fortunately, almost all women who get this cancer are cured with treatment.1

In rare cases, the abnormal tissue can spread to other parts of the body.

When you have a molar pregnancy, you need treatment right away to remove all the growth from your uterus. Then you will have regular blood tests to look for signs of trophoblastic disease. These blood tests will be done over the next 6 to 12 months.

If you do get trophoblastic disease, there's a small chance that it will turn into cancer. But your doctor will likely find it early so it can be cured with chemotherapy. In the rare case when the cancer has had time to spread to other parts of the body, additional chemotherapy is needed, sometimes combined with radiation treatment.

Robotic Surgery in Gynecology
Dwight Im, M.D., Director, The Gynecologic Oncology Center at Mercy

Minimally invasive surgery (MIS) offers reduced blood loss, fewer complications, shorter LOS, faster recovery, less scarring.

Regards conventional laparoscopy…Drawbacks include greater surgeon fatigue, makes complex operations more difficult, accentuation of tumors, surgeon operates from a 2D images, use of straight, rigid instruments; instrument tips are controlled at a distance and in a counter-intuitive fashion, reduced dexterity, precision and control; unsteady camera must be controlled by assistant; dependent on assistant for surgical support through accessory port, etc.

How to overcome these drawbacks? You want better visualization, better instrument control, better dexterity for technically challenging aspects of the procedure, better ergonomics.

Consider the da Vinci surgical system—uses state of the art robotic technical, surgeon is in control and assist has direct access.

Surgeon immersed in 3D image of the surgical field; surgeon directs precise movements of the instruments using console controls.

Conventional laparoscopic instruments are rigid with no wrists. The EndoWrist instrument tips move like a human wrist which allows the surgeon to operate with increased dexterity and precision.

EndoWrist instruments fit through dime-sized incisions; there’s a wide range of instruments available.

Robotic surgery is appropriate for a broader range of gynecologic conditions and patient situations compared to conventional laparoscopy, including treatment of uterine fibroids, endometriosis, vaginal or uterine prolapse obese patients, complex pelvic mass, endometrial and cervical cancers.

What are the benefits of performing hysterectomy robotically? Enables the physician to offer the potential benefits of MIS to more patients—shorter hospital stay, less blood loss, fewer complications, less risk of infection, less pain, faster recovery, improved cosmesis, and equivalent or better outcomes.

Why robotics in GYN? Overcomes the limitations of conventional laparoscopy. May allow more complex cases to be performed minimally invasively.

Goals: more precise meticulous dissection around uterus and bladder. Increased ability to visualize and dissect compromised anatomy and tissues (e.g. endometriosis, prior pelvic surgery like C-sections), can suture more easily and quickly.

Cancer patients…precision, dexterity and control…OR times drop significantly with robotic proficiency.

As proficiency rises, robotic procedures become more faster than laparoscopy, 146 vs. 213 minutes respectively in clinical study.

Robotic surgery… Typical complaints: Just a fad…It takes too long…I already do minimally invasive laparoscopic surgery…

1980s…laparoscopic laser surgery…but where is it now?

Argon beam coagulator…1990s…how many using it today?

Given the complaints, why switch? Conventional laparoscopy is inadequate—too much dependency on first assistant…not great for complex cases, lymph node dissection or suturing of vaginal cuff, bowel and bladder.

It does NOT have to take long….with proper training, continuing education, reviewing videos, etc.

I’m already an MIS surgeon…but are you really?

Ovarian Remnant Syndrome, Pelvic Adhesive Disease, Retroperitoneal Hysterectomy…all viable procedures performed by robotic surgery.

Robotic surgery is here to stay, can be done fast and efficiently and offers patients more options with greater outcomes.

Future? Ovarian cancer: tumor debulking…Single Incision, Single Port.

Ovarian Cancer 2011: Management of the Adenxal Mass Prevention
Neil B. Rosenshein, M.D., FACOG, Mercy Medical Center

(An adnexal mass is a lump in tissue of the adnexa of uterus, usually in the
ovary or fallopian tube. Adnexal masses can be benign or cancerous)

Ovarian cancer is the most feared and most mysterious of gynecologic cancers.

Ovarian is fifth most common cancer in women…about 22,000 cases, 3% of all new cancer cases.

But 13,850 women will die of ovarian cancer, or 5% of all female cancer cases.

New cancer cases in 2010, 43,470 endometrial followed by 21,880 ovarian and 12,200 cervix. But more die from ovarian (13,850 deaths) than these others (7,950, endometrial; 4,070 cervix).

Epithelial ovarian cancer, the most lethal gynecologic cancer…typically diagnosed at advanced stage; few early target symptoms; no effective screening test, no identifiable precursor lesion…85-90% mortality rate.

Various types of epithelial ovarian cancers…many types (e.g. Serous, Endometrioid, Clear Cell, Mucinous, Transitional, Mixed, Undifferentiated, Unclassified).

Most lethal gyneoclogic cnacer…its advanced stage at diagnosis…few early target symptoms…no prospective randomized control trials showing a decrease in mortality with screening and no identifiable precursor lesions.

Ovarian cancer presentation…75% are advanced disease. How to reduce this to early stage?

There are 169,000 to 289,000 will be hospitalized for ovarian cysts and pelvic masses, so a large number of patients to be evaluated.

No physician wants to miss an early ovarian cancer…

Early involvement by the gynecologic oncologist improves outcomes due to comprehensive staging, optimal cytoreductive surgery, and improved survival studies show that when a gynecologic oncologist is involved in the management of an adenxal mass known to be malignant there is significant improvement in patient survival.

Regards management of the Adnexal Mass…Media age is 63; lifetime risk is 1.5% (one in 68) versus 14% for breast (1 in 7) , 1.429 percent or 1 in 71 for ovarian cancer.

Ovarian cancer while lethal is rare disease and age dependent.

Under age 15…80% cases are malignant; age 16-50, 20% malignant, over 50, 30-60% percent malignant.

Low grade, Type One ovarian cancer, slowing developing;;; high grade type II serous carcinoma no precursor lesion and is rapidly progressive.

Low grade tumor less responsive to chemotherapy.

High grade, rapidly growing tumors are relatively chemo sensitive, but don’t have a precursor lesion.

Contraceptives do not affect existing cysts.

DETECTION

Can occur clinically and radiologically as via pelvic ultrasound, CT scan, MRI, or PET scan

How accurate is the physical examination? Sensitivity 45% and specificity is 90%.

Sensitivity is the probability that diagnostic test will detect a disease given that it is present.

Less than one percent with pelvic examination…Because ovarian cancer is rare so will have a high negative value.

Primary…concerned about something, order a test…

Secondary…somebody has MRI for a back problem and a pelvic mass is picked up.

Ultrasonography was to evaluate adnexal mass; it’s an accurate method.

PREVENTION

30% risk reduction with use of oral contraceptives

Primary prevention: to identify the etiologic factors and eliminate/correct; remove the organ at risk.

Lifetime risk of ovarian cancer with a negative family history, 1.5%; BRCA2, 10-30%;

BRCA1, 35-70%.

Surgical indication is only a risk reduction for ovarian cancer. Risk reducing Salpingo-oophorectomy (surgical removal of ovaries) only for consideration in high risk individuals.

Ovarian cancer risk for those with BRCA 1/2 gene—incidence rises dramatically in late 30s; average age, 51.2 years.

Ovarian cancer risk with BRCA 1/2, risk is higher in women with a prior history of breast cancer.

Patients with Lynch Syndrome have ovarian cancer risk of 10-12% (40-60% for colo-rectal and endometrial cancers).

Primary prevention of ovarian cancer: key factor is TIMING. The earlier the RRSO (Risk Reducing Salpingo-Oophorectomy) the greater the reduction of risk of breast cancer.

Recommendations for RRSO: age 35 with patient with BRCA1; BRCA2, can consider an older age (completion of childbearing years).

Managing the adnexal mass remains “a still challenging clinical problem.”

.

.