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J M Monaghan

Publications and source records attributed to J M Monaghan.

At least 19 recordsLinked to original sources
PubMed2005

Recurrent smear abnormalities where repeat loop treatment is not possible: is hysterectomy the answer?

OBJECTIVE: The objective of this study was to determine the outcome of women who underwent hysterectomy for recurrent cytological abnormalities where repeat loop treatment was considered not to be technically possible because of insufficient remaining cervical tissue. METHODS: Women undergoing a hysterectomy for the above indication at the Northern Gynaecological Cancer Centre over a period of 10 years (1992-2001) were identified from a prospectively collected database. Case notes were then reviewed and women undergoing hysterectomy for other indications were excluded. Relevant demographic and clinical data were then extracted. RESULTS: 33 patients meeting the above criteria were identified. The overall hysterectomy rate for this indication was 0.73%. 20 out of the 33 women had significant pathology on the hysterectomy specimen. 95% of these had high-grade disease with one having a Stage 1A1 squamous carcinoma. None of the patients required more radical treatment than a simple hysterectomy. There were no major complications following the hysterectomy. Positive endocervical margins on the previous loop specimen (P = 0.05) was an important correlating factor predicting the presence of CIN on the hysterectomy specimen. One out of the thirty hysterectomies (3.3%) performed using the vaginal route had incomplete excision compared to one of three (33%) using the abdominal route. Hysterectomy was successful in treating 85.2% of the women; only 4 women subsequently developed vaginal intraepithelial neoplasia. CONCLUSION: Simple hysterectomy appears to be a suitable diagnostic and treatment option for women with recurrent high-grade cytological abnormalities where further loop treatment is technically not possible. Incomplete excision at the endocervical margin on the previous loop specimen was the main factor associated with the presence of cervical intraepithelial neoplasia at hysterectomy.

Adult↗
PubMed2004

Laparoscopically assisted radical vaginal hysterectomy vs. radical abdominal hysterectomy for cervical cancer: a match controlled study.

OBJECTIVES: The technical feasibility of laparoscopically assisted radical vaginal hysterectomy has been well described, but its advantages over the open technique remain largely unproven. We reviewed and compared our experiences with both approaches. METHODS: All patients undergoing laparoscopically assisted radical vaginal hysterectomy (LARVH) between 1996 and 2003 were identified and matched for age, FIGO stage, histological subtype and nodal metastases using a control group of women who underwent radical abdominal hysterectomy (RAH) during the same time period. RESULTS: Fifty-seven women were listed for LARVH, resulting in five conversions. Fifty cases were matched successfully using the criteria above. The majority of cases were FIGO stage 1B1. Statistically significant differences (P < 0.05) were present when the following were compared for LARVH vs. RAH: duration of surgery (median 180 vs. 120 min), blood loss (median 350 vs. 875 ml), hospital stay (median 5 days vs. 8 days) and duration of continuous bladder catheterisation (median 3 days vs. 7 days). There were no statistically significant differences with regard to nodal yield, completeness of surgical margins or perioperative complication rate. Four major complications (8%, three cystotomies and one enterotomy) occurred in the LARVH group and three in the RAH group (6%, one pulmonary embolism, one ureteric injury and one major haemorrhage). Three women in LARVH group had seen a specialist regarding postoperative bladder dysfunction, versus 12 in the RAH group (P = 0.04). No patients in the LARVH group reported constipation requiring regular laxatives, versus six in the RAH group (P = 0.03). Median follow-up was 52 months for LARVH and 49 months for RAH. There was no significant difference between recurrence rates or overall survival (94% for LARVH vs. 96% for RAH). CONCLUSIONS: Despite the inherent limitations of LARVH and its associated learning curve, the procedure conveys many advantages over the open technique in terms of blood loss, transfusion requirement and hospital stay. In addition, the incidence of postoperative bladder and bowel dysfunction appears low-suggesting improved quality of life-without compromising survival.

Adult↗
PubMed2003

Contralateral groin node metastasis following ipsilateral groin node dissection in vulval cancer: a case report.

BACKGROUND: The majority of vulval cancers are of the squamous cell type. Current operative management strategies are based on modifications of radical vulvectomy and groin node dissection, enabling a more individualised and conservative approach to surgery. This has led to interesting dilemmas regarding the most appropriate management in certain individuals. CASE: We describe a case of a contralateral recurrence following unilateral groin node dissection for vulval cancer, with an initial single microscopically positive node. The patient did not receive adjuvant treatment. Evidence regarding the safety of this approach is discussed. CONCLUSION: The subject remains controversial, and further such cases should be recorded in the literature in order to gather more information on this difficult problem.

Aged↗
PubMed2002

The human ovarian surface epithelium is an androgen responsive tissue.

The pathogenesis of epithelial ovarian cancer remains unclear. From epidemiological studies raised levels of androgens have been implicated to increase the risk of developing the disease. The purpose of this study was to determine the responses of normal human ovarian surface epithelium to androgens. We have established primary cultures of human ovarian surface epithelium from patients undergoing oophorectomy for benign disease. Total RNA was isolated from these cultures and expression of mRNA encoding for the androgen receptor was demonstrated using reverse transcriptase polymerase chain reaction. The presence of androgen receptor in sections of normal ovary was also investigated using an antibody against androgen receptor. The effects of androgens on DNA synthesis and cell death were determined. Eight out of eight (100%) cultures expressed mRNA encoding the androgen receptor. The presence of androgen receptor in ovarian surface epithelium of sections of normal ovaries was demonstrated in all sections. Mibolerone, a synthetic androgen, caused a significant stimulation of DNA synthesis in 5 out of 9 (55%) cultures when used at a concentration of 1 nM. Mibolerone also caused a significant decrease in cell death in 2 out of 5 (40%) cultures tested. We have demonstrated that the ovarian surface epithelium is an androgen responsive tissue and that androgens can cause an increase in proliferation and a decrease in cell death. These findings have important implications for the pathophysiology of ovarian carcinogenesis.

Androgens↗
PubMed2001

Inguinal lymph node metastasis: an unusual presentation of fallopian tube carcinoma.

OBJECTIVES: Inguinal metastasis is a hitherto unreported presenting feature of fallopian tube adenocarcinoma. CASE: We describe a case of a 69-year-old patient whose first manifestation of fallopian tube adenocarcinoma was an enlarged inguinal lymph node. This was excised and confirmed to be metastatic adenocarcinoma. She was investigated by diagnostic laparoscopy and subsequently underwent laparotomy with total abdominal hysterectomy, omentectomy, and pelvic and para-aortic lymph node dissection. All but two of the lymph nodes extirpated were negative. CONCLUSIONS: Fallopian tube adenocarcinoma may rarely present with metastatic inguinal lymphadenopathy.

Aged↗
PubMed2001

The role of surgery in invasive squamous carcinoma of the vagina.

OBJECTIVE: The aim of this study was to define the role of surgery in managing patients with a primary squamous vaginal cancer. METHODS: A retrospective review was conducted of patients with primary invasive vaginal cancer managed at one institution over a 25-year period. The results were compared with those of all major publications of the past 20 years. RESULTS: A total of 84 patients were reviewed. Forty-five (66%) were of squamous origin. The median follow-up was 45 months (range: 0.6-268). The patients were primarily treated by surgery in 67% and by radiotherapy alone in 33% of cases. The 5- and 10-year overall survival was, respectively, 74 and 58%. For stage I the figures were 91 and 70%. These survival rates compared favorably with those of published series of cases managed by radiotherapy alone. Univariate analysis showed that age (P = 0.004), size (P = 0.009), site (P = 0.016), lymph node status (P = 0.022), FIGO stage (P = 0.027), and treatment (P = 0.003) were relevant prognostic factors. Multiple regression analysis, however, revealed that only age (P = 0.009) and size (P = 0.037) were independent prognostic variables. CONCLUSIONS: Stage I and II squamous vaginal cancer patients have good outcomes in terms of survival and local tumor control if they are managed by initial surgery followed by selective radiotherapy.

Adult↗
PubMed2001

Do elderly cancer patients care about cure? Attitudes to radical gynecologic oncology surgery in the elderly.

OBJECTIVE: The aim of this study was to address the hypothesis of no difference between elderly and younger patients' desire for optimal surgery and disease cure. METHODS: The new ARGOSE questionnaire with established instruments was administered to 189 gynecologic cancer patients (95 aged <65, 57 aged 65-74, and 37 aged 75+ years). RESULTS: Disease diagnosis differed between the <65 years and 65+ years cohorts (P < 0.001), but treatment modalities were similar (P = 0.28). Influences of family and friends and past experiences of cancer had little influence on treatment decisions. There was no difference between cohorts in desire for surgery offering a chance of disease cure (P = 0.75), except that the elderly desire cure more if treatment is associated with disfigurement than do the young. (P = 0.029). The elderly believe more strongly than the young that the elderly value cure (P < 0.001). Issues of sexuality and femininity associated with gynecologic cancer and treatment are more important to younger patients (P < 0.001). The elderly support equality of care with relation to age more strongly than the young. However, in a situation of resource limitation, inequality favoring the young is opposed less strongly by the elderly than by the young. Social desirability bias may have influenced this finding. All cohorts reported symptom palliation to be of secondary importance to treatments offering a possibility of cure (P = 0.26). The elderly believe more strongly that doctors should make management decisions (P < 0.001). CONCLUSION: The elderly desire radical surgery and disease cure as strongly as the young. They are less likely to question their doctors' decisions and are therefore vulnerable to physicians' age bias. There is no justification for rationing care on the basis of chronological age.

Adult↗
PubMed2001

The feasibility of a one-stop colposcopy clinic in the management of women with low grade smear abnormalities: a prospective study.

OBJECTIVES: To assess the feasibility of a one-stop colposcopy clinic for the management of women with low-grade smear abnormalities. Secondly, to determine whether the approach of immediate information of biopsy results combined with treatment if indicated helps to reduce patient anxiety and improve overall patient satisfaction with the colposcopy process. DESIGN: Prospective study following the introduction of a "one-stop" process for the management of women with low grade smear abnormalities. SUBJECTS: First 118 women managed in a "one-stop" clinic during an 8-month period. METHODS: Assessment of patient anxiety via self-completed questionnaires and comparison of anxiety scores with a control group managed via a standard clinic. RESULTS: The median waiting time for results in the one-stop clinic was 120 min (range: 100-165). All women in both groups felt anxious at the time of the clinic visit. However, after 1 week the majority of patients managed via the one-stop process felt slight anxiety only (P=0.0001) as opposed to those patients in the control group who remained anxious (P=NS). In addition, all women said they would prefer the one-stop approach for further smear abnormalities if a further colposcopic examination was warranted. CONCLUSION: A one-stop colposcopy clinic is feasible for the management of women with low-grade smear abnormalities. In addition, it delivers a quality service, optimises patient management, reduces anxiety and is the patient's choice.

Adolescent↗
PubMed2001

Follow up after LLETZ: could schedules be modified according to risk of recurrence?

OBJECTIVES: To document the pattern of recurrence of disease following large loop excision of the transformation zone (LLETZ) to identify a low risk group of women who might benefit from less intensive cytological surveillance. DESIGN: Analysis of prospectively collected information with retrospective review of follow up smears. POPULATION: Three thousand, five hundred and sixty women who underwent LLETZ (median age 31 years; IQR 12 years). SETTING: Colposcopy clinic at Northern Gynaecological Oncology Centre, Gateshead. METHODS: Women treated with LLETZ from 1988 to 1995 were reviewed. Information on the pathology from LLETZ was collected prospectively and information on the subsequent smears was obtained from the family health authorities. RESULTS: Invasive cancer was detected on the original LLETZ in 134 women who were excluded from the study. Of the remaining 3,426 women, histology of LLETZ showed high grade CIN (II and III) in 2,371 (69%). At least one follow up smear was undertaken in 3,385 women (99%). This constituted 9,765 women years of follow up with a mean duration of 35 months. Four hundred and seventeen women (12.2%) had a dyskaryotic follow up smear. Incomplete excision of the lesion and an age of > or = 50 years at the time of the LLETZ were associated with an increased risk of recurrent CIN. Based on these risk factors the study group was divided into three risk groups: 1. women aged < 50 with no disease at the margins (n = 1680); 2. women aged > or = 50 with disease at the margins (n = 93); and 3. women aged < 50 with positive margins, or aged > or = 50 with negative margins (n = 1653). The cumulative survival without recurrent CIN at five years for these groups were 92%, 57% and 86%, respectively. CONCLUSION: Women aged > or = 50 with CIN at the margins of excision constituted a small minority high risk group (3%). Consideration should be given to repeat treatment of these women rather than surveillance. Women aged < 50 with complete excision of low grade CIN comprised 51% of the study group. These women were at low risk of recurrent CIN and might benefit from less intensive cytological surveillance following LLETZ.

Adolescent↗
PubMed2001

Recurrent Paget's disease of the vulva in a myocutaneous flap: case report and review of the literature.

A 74-year-old patient with recurrent Paget's disease of the vulva in the gluteus maximus island myocutaneous flap 11 years after a hemivulvectomy with reconstruction is presented. This report is only the second case of recurrent noninvasive Paget's disease in a reconstructive flap. The English literature on this subject is reviewed with special attention to the biological behavior of these tumors.

Aged↗
PubMed2001

Primary vaginal melanoma and long-term survivors.

Vaginal melanoma is a rare and highly malignant disease. This report describes the characteristics and clinical course of all patients treated at one institute (Northern Gynaecological Oncology Centre, UK) over the last 25 years. Of a total of nine patients identified with a primary malignant vaginal melanoma, only one patient survived for more than five years. A literature review revealed only 21 reported cases with a survival greater than five years. The most important factor for survival appears to be the tumour size. Treatment modality varied equally within the group of long-term survivors (27% radical surgery, 27% wide local excision, 27% radiotherapy, 14% wide local excision and radiotherapy, and 5% unknown therapy). The prognosis of patients with primary malignant melanoma is poor, regardless of primary therapy (conservative or radical). Conservative treatment and accurate investigation of every discoloured lesion is recommended.

Adult↗
PubMed2001

Prevalence and management of (non-fistulous) urinary incontinence in women following radical hysterectomy for early stage cervical cancer.

OBJECTIVES: 1) to determine the prevalence of urinary incontinence before and after radical surgical treatment for early cervical cancer, 2) to retrospectively analyse the outcome results following the investigation/treatment of incontinence in these women. PATIENTS AND METHODS: 27 women were studied prospectively by questionnaire prior to surgery and six weeks and three months after surgery (group 1). Seventy-seven women who were more than 12 months post-radical surgery were questioned directly at the follow-up clinic (group 2). Three hundred and two satisfactory responses were obtained to questionnaires sent to general practitioners of patients previously treated by radical surgery for early cervical cancer (group 3). RESULTS: 14.8% of women reported regular incontinence prior to surgery, and 48.1% and 29.6% of women, respectively, reported regular incontinence six weeks and three months after surgery; 31.2% of women also reported regular incontinence more than 12 months after post-radical surgery. Of the women in the 12-month post-radical surgery group, 16.6% had considered their symptoms of regular incontinence severe enough to attend their local practice for treatment and 14.6% (44 women) were referred for further management. In six of these 44 patients (13.6%), spontaneous resolution of incontinence occurred at varying intervals within the first 12 months following radical surgery. Twenty-four of the 44 women who were referred underwent urodynamic investigation. Of these 24 women, in 17 cases the diagnosis was genuine stress incontinence (GSI), of which, in seven cases (41%) GSI was the sole urodynamic abnormality. In six of these seven cases (85.7%), the women were cured or very greatly improved following treatment with either physiotherapy or surgery. However, only six of the remaining ten cases (60%) with coexistent abnormalities achieved this result. Patients with coexistent impaired bladder compliance showed the poorest result, as only two of the six cases (33%) achieved satisfactory improvement following treatment. CONCLUSION: Non-fistulous urinary incontinence following radical pelvic surgery for carcinoma of the cervix despite being a common problem shows a significant spontaneous improvement rate within the first 12 months following surgery. Urodynamics should be a mandatory investigation in patients who complain of persisting problems thereafter. Subjective improvement rates for women with genuine stress incontinence alone are in excess of 85%, being comparable to those of women without any prior history of radical pelvic surgery.

Female↗
PubMed2000

Inguinal node status by ultrasound in vulva cancer.

OBJECTIVE: The objective of this study was to determine the value of ultrasound in preoperative assessment of groin node status in vulva cancer. MATERIALS AND METHODS: Women with clinically uninvolved groins who were undergoing groin node dissection for vulva cancer in our department over an 18-month period were recruited into the study. A preoperative scan of each groin to be dissected was performed to identify any suspicious lymph nodes containing metastases. Suspicious nodes were defined by two sonographic criteria: short axis diameter (>8 mm) and a long axis/short axis ratio (L/S </= 2). Each suspicious node was sampled by ultrasound-guided fine-needle aspiration (FNA). RESULTS: Twenty women, with an average age of 70 years, consented to the study. Seventeen had bilateral groin node dissection and three had unilateral groin node dissection. Six (16%) of the seventeen dissected groins contained metastases. Short axis had a better overall accuracy (89%) but failed to detect a singular micrometastasis. The L/S ratio identified all positive groins but had a high false-positive rate (62%) and an overall accuracy of 67%. The combination of both criteria did not improve the overall accuracy when compared with the individual criterion. FNA was not diagnostic in three, representative in two, and falsely negative in one. CONCLUSION: Although L/S ratio has a lower overall accuracy, it correctly identified all groins with metastases. This has a great impact on treatment and prognosis. Its high false-positive rate may be improved by more diagnostic FNA. These sonographic criteria show good potential for segregating those with groin metastases requiring surgical treatment from those with uninvolved nodes. This experience has to be expanded to prove its clinical effectiveness.

Adult↗
PubMed2000

Optimal cytoreductive surgery is an independent prognostic indicator in stage IV epithelial ovarian cancer with hepatic metastases.

OBJECTIVES: The aim of this study was to determine the value of optimal cytoreduction in stage IV epithelial ovarian cancer. METHODS: A retrospective review was performed of 37 women with stage IV epithelial ovarian cancer treated by radical surgery. RESULTS: Optimal surgery to less than 2 cm tumor deposits was performed in 16 of the 37 cases (43%) and tumor debulking to less than 1 cm tumor deposits in 6 cases (16.2%). Twenty-three cases (62%) were designated stage IV because of the presence of liver metastases alone. Although no patients died within 2 weeks of surgery, 7 of the 37 cases (22%) failed to survive more than 50 days after primary surgery. The overall median survival was 11 months with overall 2- and 5-year survivals of 23 and 9%, respectively. On multivariate analysis comparing age, histological type, tumor grade, place of surgery, secondary surgical procedure, performance of bowel surgery, presence of liver metastases, and optimal cytoreduction, only optimal surgery and residual tumor deposits of less than 2 cm, or less than 1 cm, remained highly significant (P = 0.0029 and 0.0086, respectively). Even when assessing only the 27 cases who were designated as having stage IV disease because of the presence of liver metastases, by multivariate analysis, only optimal surgery and residual tumor deposits of less than 2 cm, or less than 1 cm, remained significant (P = 0.023 and 0.036, respectively). Site of metastases designating stage IV status was not associated with a reduced likelihood of achieving optimal debulking (P = 0.18). CONCLUSION: Optimal cytoreduction in women with stage IV epithelial ovarian cancer with or without hepatic metastases is associated with a more favorable outcome survival.

Adenocarcinoma↗
PubMed2000

Complete cytoreduction: is epithelial ovarian cancer confined to the pelvis biologically different from bulky abdominal disease?

OBJECTIVES: The aim of this study was to determine whether site and size of tumor masses prior to complete surgical cytoreduction affect outcome survival. METHODS: A retrospective review was performed of 53 women with stage II and III epithelial ovarian cancer following complete surgical cytoreduction. RESULTS: Fifteen cases (28%) were classified as stage II and the remaining 38 cases (72%) as stage III. The overall median survival was 58 months with overall 2- and 5-year survivals of 76 and 42%, respectively. On univariate analysis, women with well differentiated tumors did significantly better than those with moderately or poorly differentiated tumours (P = 0.0009). FIGO stage did not reach statistical significance (P = 0.066). On multivariate analysis, comparing patient's age, previous history of pelvic surgery, previous history of malignancy, performance of lymphadenectomy for visibly/palpably enlarged nodes, performance of bowel resection, presence of concomitant tumors, positive pelvic and/or para-aortic lymph nodes, histological type, histological grade, and FIGO stage, only histological grade remained an independent variable affecting outcome survival (P = 0.0004; FIGO stage, P = 0.22) (hazard ratio = 6.5: well versus poor differentiation, 95% confidence interval, 1.7-25.5). CONCLUSION: When surgical cytoreduction to no visible disease has been achieved in women with stage II and III epithelial ovarian cancer, FIGO stage, i.e., site and size of tumor masses prior to surgical cytoreduction, does not appear to influence outcome survival. The aggressiveness of the remaining microscopic disease would seem to be determined largely by histological grade. Bearing in mind the retrospective nature of this study and the relatively small cohort of patients, the results would appear to suggest that it is unlikely that there are any other significant parameters (hidden factors) affecting tumor biology which are independent of tumor grade in these patients. A possible implication of this result is that complete surgical cytoreduction confers a survival benefit by producing a biologically more homogeneous tumor.

Abdominal Neoplasms↗
PubMed2000

The role of laparoscopic surgery in the management of endometrial cancer.

OBJECTIVE: To assess the place of laparoscopically assisted vaginal hysterectomy in the treatment of endometrial cancer. DESIGN: A retrospective uncontrolled case series. SETTING: Gynaecological Oncology Department, Queen Elizabeth Hospital, Gateshead. POPULATION: Women with endometrial cancer referred to this centre from August 1992 to August 1997. MAIN OUTCOME MEASURES: Success of laparoscopically assisted vaginal hysterectomy, operative morbidity, and the length of hospital stay. RESULTS: Laparoscopically assisted vaginal hysterectomy was successful in 35 of 40 women (88%). Five women required laparotomy. Two women sustained injury to the inferior epigastric vessels. One sustained injury to the small intestine requiring later laparotomy and three women required a blood transfusion. The mean hospital stay was 3 x 3 days (SD 1 x 5). Three women died of the disease within one year of their operation. CONCLUSION: Laparoscopically assisted vaginal hysterectomy is a feasible treatment for endometrial cancer. It can be performed successfully in high risk population who are medically unfit and overweight. However, a larger randomised study is required to assess the morbidity compared with the traditional open approach.

Endometrial Neoplasms↗