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Okunade KS, Adekanye TV, Osunwusi B, Soibi-Harry A, Okoro AC, Toks-Omage E, Okunowo AA, Ohazurike EO, Anorlu RI. Survival outcomes following interval versus primary debulking surgery in advanced epithelial ovarian cancer: A retrospective cohort study in Lagos, Southwest Nigeria. RESEARCH SQUARE 2024:rs.3.rs-3834135. [PMID: 38260667 PMCID: PMC10802718 DOI: 10.21203/rs.3.rs-3834135/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background There is conflicting evidence regarding the survival benefit of interval debulking surgery (IDS) compared to conventional treatment with primary debulking surgery (PDS) in women with advanced epithelial ovarian cancer (EOC). Objectives We compared the survivals following PDS followed by adjuvant chemotherapy (ACT) versus IDS after neoadjuvant chemotherapy (NACT) in women with advanced EOC at the gynaecological oncology unit of a tertiary referral centre in Lagos, Southwest Nigeria. Methods The data of 126 women with advanced EOC who had standard treatment with either PDS and ACT or NACT and IDS between January 2008 and December 2017 were analyzed. Kaplan-Meier estimates of progression-free (PFS) and overall survival (OS) time stratified by the types of upfront debulking surgery were calculated and compared by employing the log-rank test statistics. Cox proportional hazard models were then used to estimate hazard ratios of the association between the type of surgical debulking and survivals while adjusting for all necessary covariates. Results We recorded no statistically significant differences in PFS (adjusted hazard ratio=1.28, 95% confidence interval 0.82-2.01, P=0.282) and OS (adjusted hazard ratio=1.23, 95% confidence interval 0.68-2.25, P=0.491) between IDS and PDS among women with advanced EOC. Conclusions There is a need for a larger prospective multicenter study to further compare the impact of upfront surgical debulking types on the survival of women with advanced EOC in our setting. In the meantime, giving interval debulking surgery after a few courses of neoadjuvant chemotherapy should be an acceptable standard of care for women with advanced EOC.
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Ehmann S, Shay K, Zhou Q, Iasonos A, Sonoda Y, Gardner GJ, Long Roche K, Zammarrelli WA, Yeoushoua E, O'Cearbhaill RE, Zivanovic O, Chi DS. Outcomes and long-term follow-up by treatment type for patients with advanced-stage ovarian cancer managed at a tertiary cancer center: A Memorial Sloan Kettering Cancer Center Team Ovary study. Gynecol Oncol 2023; 169:118-124. [PMID: 36565685 PMCID: PMC9928799 DOI: 10.1016/j.ygyno.2022.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess long-term outcomes of patients with advanced-stage ovarian cancer by treatment type. METHODS Patients with newly diagnosed stage III-IV ovarian cancer who underwent primary treatment at our tertiary cancer center from 01/01/2015-12/31/2015 were included. We reviewed electronic medical records for clinicopathological, treatment, and survival characteristics. RESULTS Of 153 patients, 88 (58%) had stage III and 65 (42%) stage IV disease. Median follow-up was 65.8 months (range, 3.6-75.3). Eighty-nine patients (58%) underwent primary debulking surgery (PDS), 50 (33%) received neoadjuvant chemotherapy followed by interval debulking surgery (IDS), and 14 (9%) received chemotherapy alone, without surgery (NSx). Median PFS to first recurrence was 26.2 months (range, 20.1-36.2), 13.5 months (range, 12-15.1), and 4.2 months (range, 1.1-5.8) in the PDS, IDS, and NSx groups, respectively (P < .001). At first recurrence/progression, 80 patients (72.7%) were treated with chemotherapy, 28 (25.5%) underwent secondary cytoreductive surgery (CRS) followed by chemotherapy, and 2 (1.8%) received no treatment. Seven patients (4.6%) underwent palliative surgery for malignant bowel obstruction. Overall, 62.7% received 1-3 lines of chemotherapy. The 5-year OS rates were 53.2% (95% CI: 44.7%-61%) for the entire cohort, 71.5% (95% CI: 60.2%-80%) for the PDS group, 35.2% (95% CI: 22.2-48.5%) for the IDS group, and 7.9% (95% CI: 0.5%-29.9%) for the NSx group. CONCLUSION The longitudinal treatment modalities and outcomes of patients with advanced ovarian cancer described here can be useful for patient counseling, long-term planning, and future comparison studies.
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Affiliation(s)
- Sarah Ehmann
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kelly Shay
- Department of Obstetrics & Gynecology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Qin Zhou
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexia Iasonos
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - William A Zammarrelli
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Effi Yeoushoua
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Roisin E O'Cearbhaill
- Weill Cornell Medical College, New York, NY, USA; Gynecologic Medical Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Weill Cornell Medical College, New York, NY, USA.
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Ehmann S, Aviki EM, Sonoda Y, Boerner T, Sassine D, Jones DR, Park B, Cohen M, Rosenblum NG, Chi DS. Diaphragm hernia after debulking surgery in patients with ovarian cancer. Gynecol Oncol Rep 2021; 36:100759. [PMID: 33869713 PMCID: PMC8042427 DOI: 10.1016/j.gore.2021.100759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 11/26/2022] Open
Abstract
Over 80% of patients with epithelial ovarian cancer present with advanced disease, FIGO stage III or IV at the time of diagnosis. The majority require extensive upper abdominal surgery to obtain complete gross resection. This may include splenectomy, distal pancreatectomy, partial hepatectomy, cholecystectomy, and usually diaphragmatic peritonectomy or resection. Following surgery, diaphragmatic hernia-a very rare but serious complication-may occur. We describe four cases of left-sided diaphragmatic hernia resulting after debulking surgery, which included left diaphragm peritonectomy and splenectomy, in patients with advanced ovarian cancer. In association with the current shift towards more extensive debulking surgery for ovarian cancer, more patients may present with postoperative left-sided diaphragm hernia, making the prevention, diagnosis, and management of this complication important to practicing gynecologic oncologists. Intraoperatively the diaphragm should be checked thoroughly to rule out any defects, which should be closed. A diaphragmatic hernia may be easily misdiagnosed because the patient can present with various symptoms. While rare, these hernias require prompt identification, intervention and surgical correction to avoid serious complications.
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Affiliation(s)
- Sarah Ehmann
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emeline M. Aviki
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Thomas Boerner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dib Sassine
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David R. Jones
- Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bernard Park
- Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Murray Cohen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Norman G. Rosenblum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Dennis S. Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
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Ehmann S, Park B, Chi DS. Minimally invasive repair of a left diaphragm hernia after debulking surgery for advanced ovarian cancer. Gynecol Oncol Rep 2021; 36:100713. [PMID: 33732848 PMCID: PMC7941203 DOI: 10.1016/j.gore.2021.100713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 01/23/2021] [Indexed: 11/25/2022] Open
Abstract
Eighty percent of women with ovarian cancer have advanced disease (FIGO stage III or IV) at the time of diagnoses and require extensive upper abdominal surgery to obtain complete gross resection (Minig et al., 2015, Eisenhauer et al., 2006). A diaphragmatic hernia is defined as abdominal contents bulging into the thoracic cavity (Spellar and Gupta, 2020). While rare following primary debulking surgery (PDS), these present with a variety of symptoms and are often misdiagnosed. Computed tomography (CT) is the diagnostic gold standard (Vertaldi et al., 2020). This video demonstrates repair of a left-sided complex diaphragm hernia via robotic video-assisted thoracic surgery in a 45-year-old with stage IVB ovarian cancer. She previously underwent extensive PDS, including modified posterior exenteration, bilateral salpingo-oophorectomy, omentectomy, bilateral pelvic lymph node dissection, appendectomy, bilateral diaphragm peritonectomy, splenectomy, resection of a right mediastinal lymph node, and insertion of a right chest tube. Complete gross resection was achieved. No left-sided diaphragm resection or repair was performed during the initial surgery. She received standard adjuvant chemotherapy with paclitaxel, carboplatin and bevacizumab. Six months postoperatively a surveillance CT scan revealed a small left hemidiaphragm hernia containing parts of the stomach. Although initially asymptomatic, she developed mild symptoms on follow-up, especially with lying supine. Imaging showed an increase in the size of the diaphragm defect. After completion of her maintenance bevacizumab therapy, corrective surgery was performed to prevent incarceration of the stomach. This video demonstrates the complex repair of this 4 × 6 cm defect located in the central tendon of the diaphragm. On two-week follow-up after corrective surgery, the patient's symptoms had resolved.
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Affiliation(s)
- Sarah Ehmann
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bernard Park
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
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Raś R, Barnaś E, Magierło JS, Drozdzowska A, Bartosiewicz E, Sobolewski M, Skręt A, Gutkowski K. Preoperative colonoscopy in patients with a supposed primary ovarian cancer. Medicine (Baltimore) 2019; 98:e14929. [PMID: 30896654 PMCID: PMC6709016 DOI: 10.1097/md.0000000000014929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The final diagnosis of ovarian cancer is based on surgery and pathological verification. Therefore patients who are presented to surgery may be described only as supposed ovarian cancer. According to the literature the diagnosis of ovarian cancer is confirmed only in 2/3 of them. The rest are that which mimic ovarian cancer. One of them is colorectal cancer. Colonoscopy is a gold standard in its diagnostics. On the other hand, ovarian cancer may disturb the bowel patency and makes the bowel resection or stoma necessary.The main aim was to find out the distribution of bowel patency disturbances in ovarian cancer patients during preoperative colonoscopy and to assess their predictive value with respect to the bowel resection or stoma and the additional aim to identify the pathologies which mimic the ovarian cancer.In a prospective study among 104 patients with supposed ovarian cancer, primary ovarian cancer was diagnosed in 68 patients. The rest of them suffered from colorectal cancer found at colonoscopy (N = 6), ovarian benign pathology (N = 8), ovarian borderline tumor (N = 5), and other nonandexal malignant diseases (N = 17). In ovarian cancer group dominated serous carcinoma and fedération international de gynécologie et d'obstétrique stage 3 (N = 33).During preoperative colonoscopy in ovarian cancer patients, the complete obstruction was found in 27.9%, and relative risk of bowel resection or stoma was in them 4.29 and 4.38, respectively. Another colonoscopic finding was limited patency caused by extrinsic compression (29%) which is connected with relative risk of bowel resection or stoma 3.16 and 3.21 accordingly. The last colonoscopy finding was described as moderate limited patency of unknown origin (20.6%) and the relative risk of bowel resection or stoma was 5.14 and 4.17, respectively.Colonoscopy enables the diagnoses of colorectal cancer one of the diseases which mimic ovarian cancer in patients supposed to have this diseases.Bowel patency disturbances found at colonoscopy are a potential risk factor to intestine resection or ostomy.Colonoscopy is not fully noninvasive procedure and its obligatory use in patients supposed to have ovarian cancer should be limited to the cases with specific symptoms, and tumor marker pattern. Preoperative computed tomography, dedicated to bowel examination, candidates as an alternative to colonoscopy, but not completely.
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Affiliation(s)
- Renata Raś
- Obstetrics and Gynecology Clinic, Clinical Hospital No1 Rzeszow, University of Rzeszow
- Department of Physics, Rzeszow University of Technology
| | | | - Joanna Skręt- Magierło
- Obstetrics and Gynecology Clinic, Clinical Hospital No1 Rzeszow, University of Rzeszow
- Medical Faculty, University of Rzeszow
| | - Anna Drozdzowska
- Obstetrics and Gynecology Clinic, Clinical Hospital No1 Rzeszow, University of Rzeszow
| | - Ewelina Bartosiewicz
- Department of Gastroenterology and Hepatology with the Internal Diseases Unit, Clinical Hospital No.1
| | - Marek Sobolewski
- Department of Quantitative Methods, Rzeszow University of Technology, Rzeszow, Poland
| | - Andrzej Skręt
- Obstetrics and Gynecology Clinic, Clinical Hospital No1 Rzeszow, University of Rzeszow
| | - Krzysztof Gutkowski
- Medical Faculty, University of Rzeszow
- Department of Gastroenterology and Hepatology with the Internal Diseases Unit, Clinical Hospital No.1
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Neoadjuvant chemotherapy versus primary debulking surgery in advanced epithelial ovarian cancer: A meta-analysis of peri-operative outcome. PLoS One 2017; 12:e0186725. [PMID: 29059209 PMCID: PMC5653345 DOI: 10.1371/journal.pone.0186725] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 10/08/2017] [Indexed: 11/19/2022] Open
Abstract
Objective To assess whether neoadjuvant chemotherapy (NACT) is superior to primary debulking surgery (PDS) with regard to optimal cytoreduction, peri-operative morbidity, mortality, and quality of life (QOL) in advanced epithelial ovarian cancer (EOC). Methods We searched the PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Registers of Clinical Trials for randomized controlled trials (RCTs) comparing NACT to PDS in women with Federation of International Gynaecologists and Obstetricians stage Ⅲ-Ⅳ EOC. RevMan 5.3 software was utilized for statistical analysis. Results Four RCTs involving 1,607 women with advanced EOC were included. Compared with PDS, NACT provided a higher rate of complete cytoreduction (risk ratio [RR], 1.95; 95% confidence interval [CI], 1.33 to 2.87), optimal cytoreduction (RR: 1.61 [95%CI: 1.05 to 2.47]), but there was no significant difference in residual disease 0–1 cm (p = 0.49). NACT was associated with lower peri-operative morbidity with respect to infection (RR: 0.30 [95% CI: 0.16 to 0.56]), gastrointestinal fistula (RR: 0.24 [95% CI: 0.06 to 0.95]), any grade 3 or 4 adverse event (RR: 0.29 [95% CI: 0.11 to 0.78]), and less post-surgical death within 28 days (RR: 0.14 [95% CI: 0.04 to 0.49]). NACT provided better QOL in terms of fatigue (weight mean difference [WMD], -3.28; [95% CI: -3.99 to -2.57]), role functioning (WMD: 5.29 [95% CI: 4.44 to 6.14]), emotional functioning (WMD: 6.19 [95% CI: 5.57 to 6.82]), and cognitive functioning (WMD: 1.02 [95% CI: 0.43 to 1.61]) at 6-month follow-up compared with PDS. Conclusions NACT is associated with superior optimal cytoreduction, lower peri-operative morbidity as well as post-surgical mortality, and better QOL compared to initial surgery in patients with advanced EOC. Future research should focus on improving the efficacy of NACT.
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Terzioğlu SG, Kılıç MÖ, Çetinkaya N, Baser E, Güngör T, Adıgüzel C. The outcomes of intestinal resection during debulking surgery for ovarian cancer. Turk J Surg 2017; 33:96-99. [PMID: 28740958 DOI: 10.5152/ucd.2016.3515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/14/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the clinical and surgical outcomes of intestinal resection during primary debulking surgery for ovarian cancer. MATERIAL AND METHODS This retrospective study was conducted at Zekai Tahir Burak Women's Health Training and Research Hospital between 2009 and 2013. The patients who underwent intestinal resection during debulking surgery for stage 3 ovarian cancer were included in the analysis. Data regarding patient age, body mass index, tumor histology, disease stage, the site of intestinal resection, all postoperative complications, duration of intensive care unit admission and hospital stay were collected and analyzed. RESULTS A total of 22 patients with a mean age of 53.4 years were included in the study. Optimal cytoreduction was achieved in 14 (63%) patients. Transverse colectomy was the most common type of intestinal resection (63%). The most common postoperative complication was transfusion of blood products (63%). No postoperative mortality was observed. CONCLUSION Intestinal resection is a crucial part of debulking surgery for advanced ovarian cancer, with acceptable complication rates. Despite the limited number of patients, the results obtained from the present study are comparable with previous reports.
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Affiliation(s)
| | - Murat Özgür Kılıç
- Clinic of General Surgery, Numune Training and Research Hospital, Ankara, Turkey
| | - Nilüfer Çetinkaya
- Clinic of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Ankara, Turkey
| | - Eralp Baser
- Clinic of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Ankara, Turkey
| | - Tayfun Güngör
- Clinic of Gynecologic Oncology, Zekai Tahir Burak Women's Health Training and Research Hospital, Ankara, Turkey
| | - Cevdet Adıgüzel
- Clinic of Gynecologic Oncology, Numune Training and Research Hospital, Adana, Turkey
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Dahm-Kähler P, Palmqvist C, Staf C, Holmberg E, Johannesson L. Centralized primary care of advanced ovarian cancer improves complete cytoreduction and survival - A population-based cohort study. Gynecol Oncol 2016; 142:211-6. [PMID: 27238084 DOI: 10.1016/j.ygyno.2016.05.025] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/06/2016] [Accepted: 05/20/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate centralized primary care of advanced ovarian and fallopian tube cancers in a complete population cohort in relation to complete cytoreduction, time interval from surgery to chemotherapy and relative survival. METHODS A regional population-based cohort study of women diagnosed with primary ovarian and fallopian tube cancers and included in the Swedish Quality Registry (SQR) during 2008-2013 in a region where primary care of advanced stages was centralized in 2011. Surgical, oncological characteristics, outcomes, follow-ups and relative survivals were analyzed. RESULTS There were 817 women diagnosed with ovarian and fallopian tube cancers during 2008-2013 and 523 were classified as FIGO stage III-IV and further analyzed. Primary debulking surgery (PDS) was performed in 81% and neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) in 11%. Complete cytoreduction at PDS was performed in 37% before compared to 49% after centralization (p<0.03). The chemotherapy protocols were identical in the cohorts and they received and completed the planned chemotherapy equally. The time interval between PDS and chemotherapy was 36days (median) before compared to 24days after centralization (p<0.01). The relative 3-year survival rate in women treated by PDS was 44% compared to 65% after centralization and the estimated excess mortality rate ratio (EMRR) was reduced (RR 0.58; 95% CI 0.42-0.79). Comparing the complete cohorts before and after centralization, regardless primary treatment, the relative 3-year survival rate increased from 40% to 61% with reduced EMRR (RR 0.59; 95% CI 0.45-0.76). CONCLUSION Centralized primary care of advanced ovarian and fallopian tube cancers increases complete cytoreduction, decreases time interval from PDS to chemotherapy and improves relative survival significantly.
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Affiliation(s)
- Pernilla Dahm-Kähler
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of clinical sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Regional Cancer Center Western Sweden, Gothenburg, Sweden.
| | - Charlotte Palmqvist
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of clinical sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Christian Staf
- Regional Cancer Center Western Sweden, Gothenburg, Sweden
| | - Erik Holmberg
- Institute of clinical sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Regional Cancer Center Western Sweden, Gothenburg, Sweden
| | - Liza Johannesson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of clinical sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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