Ultrasonography, macroscopy, and frozen section: whıch is better for predicting deep myometrial invasıon in endometrial cancer?

OBJECTIVE

The aim of this study was to compare the power of preoperative transvaginal ultrasonography, intraoperative macroscopic examination, and frozen section for predicting deep myometrial invasion in endometrial cancer.

METHODS

This is a retrospective review involving 68 patients who underwent surgical staging for endometrial cancer from 2014 to 2017. Patients with grade 3 endometrial cancer and non-endometrioid tumors were excluded. The findings related to preoperative transvaginal ultrasonography, intraoperative macroscopic examination, and frozen section were compared with definitive histopathological diagnosis.

RESULTS

The mean age, gravidity, and body mass index of the patients were 58.1±8.9 years (range: 30-80 years), 3.2±2.1 (range: 0-9), and 33.5±6.6 kg/m2 (range: 20-52 kg/m2), respectively. Only 11 (16.2%) patients were in the premenopausal period, while 57 (83.8%) were in the postmenopausal period. Grade 1 endometrial cancer was found in 29 patients (42.6%) and grade 2 tumors were specified in 39 patients (57.4%). Stage IA disease was found in 45 (66.2%) patients, while stage IB disease was observed in 23 (33.8%) patients. The 5-year survival rate was 91.2%. The sensitivity of preoperative transvaginal ultrasonography, intraoperative macroscopic examination, and frozen section were 56, 34, and 52%, respectively, for predicting deep myometrial invasion. In contrast, the specificity of preoperative ultrasonography, intraoperative macroscopic examination, and frozen section were 86, 100, and 100%, respectively.

CONCLUSION

Transvaginal ultrasonography and intraoperative frozen section were found to have similar sensitivity and specificity for predicting deep myometrial invasion. Preoperative transvaginal ultrasonography appears as an efficient approach for predicting endometrial cancers with deep myometrial invasion.

Peripartum Hysterectomy: Is There Any Difference Between Emergency and Planned Surgeries?

OBJECTIVE

 To compare the outcomes of emergency and planned peripartum hysterectomies.

METHODS

 The present retrospective cross-sectional study was conducted in two hospitals. Maternal and neonatal outcomes were compared according to emergency and planned peripartum hysterectomies.

RESULTS

 A total of 34,020 deliveries were evaluated retrospectively, and 66 cases of peripartum hysterectomy were analyzed. Of these, 31 were cases of planned surgery, and 35 were cases of emergency surgery. The patients who underwent planned peripartum hysterectomy had a lower rate of blood transfusion (83.9% versus 100%; p = 0.014), and higher postoperative hemoglobin levels (9.9 ± 1.3 versus 8.3 ± 1.3; p < 0.001) compared with the emergency hysterectomy group. The birth weight was lower, although the appearance, pulse, grimace, activity, and respiration (Apgar) scores were higher in the planned surgery group compared with the emergency cases.

CONCLUSION

 Planned peripartum hysterectomy with an experienced team results in less need for transfusion and improved neonatal outcomes compared with emergency peripartum hysterectomy.

Survival outcomes of women with grade 3 endometrioid endometrial cancer: the impact of adjuvant treatment strategies

AIM

This multicenter investigation was performed to evaluate the adjuvant treatment options, prognostic factors, and patterns of recurrence in patients with grade 3 endometrioid endometrial cancer (G3-EEC).

MATERIALS AND METHODS

The medical reports of patients undergoing at least total hysterectomy and salpingo-oophorectomy for G3-EEC between 1996 and 2018 at 11 gynecological oncology centers were analyzed. Optimal surgery was defined as removal of all disease except for residual nodules with a maximum diameter ≤ 1 cm, as determined at completion of the primary operation. Adequate systematic lymphadenectomy was defined as the removal of at least 15 pelvic and at least 5 paraaortic LNs.

RESULTS

The study population consists of 465 women with G3-EEC. The 5-year disease-free survival (DFS) and overall survival (OS) rates of the entire cohort are 50.3% and 57.6%, respectively. Adequate systematic lymphadenectomy was achieved in 429 (92.2%) patients. Optimal surgery was achieved in 135 (75.0%) patients in advanced stage. Inadequate lymphadenectomy (DFS; HR 3.4, 95% CI 3.0-5.6; P = 0.016-OS; HR 3.2, 95% CI 1.6-6.5; P = 0.019) was independent prognostic factors for 5-year DFS and OS.

CONCLUSION

Inadequate lymphadenectomy and LVSI were independent prognostic factors for worse DFS and OS in women with stage I-II G3-EEC. Adequate lymphadenectomy and optimal surgery were independent prognostic factors for better DFS and OS in women with stage III-IV G3-EEC.

Impact of cytoreductive surgery on survival of patients with low-grade serous ovarian carcinoma: A multicentric study of Turkish Society of Gynecologic Oncology (TRSGO-OvCa-001)

BACKGROUND AND OBJECTIVES

The aim of this study was to analyze the factors affecting recurrence-free (RFS) and overall survival (OS) rates of women diagnosed with low-grade serous ovarian cancer (LGSOC).

METHODS

Databases from 13 participating centers in Turkey were searched retrospectively for women who had been treated for stage I-IV LGSOC between 1997 and 2018.

RESULTS

Overall 191 eligible women were included. The median age at diagnosis was 49 years (range, 21-84 years). One hundred seventy-five (92%) patients underwent primary cytoreductive surgery. Complete and optimal cytoreduction was achieved in 148 (77.5%) and 33 (17.3%) patients, respectively. The median follow-up period was 44 months (range, 2-208 months). Multivariate analysis showed the presence of endometriosis (p = .012), lymphovascular space invasion (LVSI) (p = .022), any residual disease (p = .023), and the International Federation of Gynecology and Obstetrics (FIGO) stage II-IV disease (p = .045) were negatively correlated with RFS while the only presence of residual disease (p = .002) and FIGO stage II-IV disease (p = .003) significantly decreased OS.

CONCLUSIONS

The maximal surgical effort is warranted for complete cytoreduction as achieving no residual disease is the single most important variable affecting the survival of patients with LGSOC. The prognostic role of LVSI and endometriosis should be evaluated by further studies as both of these parameters significantly affected RFS.

Evaluation of Clinicopathologic Features of Patients Diagnosed with Atypical Glandula Cells in Cervical Cytology

Objective

In our study we aimed to evaluate the clinicopathologic features of patients diagnosed with atyipcal glandular cells on cervical cytology.

Method

The records of 9375 patients who were examined in the gynecology outpatient clinic between 2010 and 2018 and underwent cervicovaginal smear were retrospectively reviewed. Seventy-three (0.8%) patients were diagnosed as atypical glandular cells. Colposcopic examination, cervical biopsy, endocervical and endometrial curettage were performed in patients diagnosed with atypical glandular cells. Age, gravida, parity, systemic diseases and clinicopathological features of the patients were examined and recorded.

Results

Cervical and endometrial abnormal histological findings were detected in 26 (35.6%) of 73 patients with atypical glandular cells. Of these 26 patients, 14 (19.1%) had cervical intraepithelial lesions, 3 (4.1%) had endometrial hyperplasia and 9 (12.3%) had invasive cancer. Five (6.8%) of the 9 patients with the diagnosis of invasive cancer had adenocarcinoma (endocervical and endometrial), in 3 (4.1%) patients cervical squamous carcinoma, and in 1 patient. endocervical lymphoma was observed.The majority of cancers detected in our study were in the age group of 50 years and older.

Conclusion

Invasive cancer is seen in 12.3% of the patients diagnosed with atypical glandular cells, and most of these patients are 50 years or older. Therefore patients diagnosed with atypical glandular cell in cervicovaginal smear should be carefully evaluated with all clinical features.

CD105 (endoglin) expression as a prognostic marker of angiogenesis in squamous cell cervical cancer treated with radical radiotherapy

Introduction

Increased levels of endoglin may represent a new reagent of active neovascularization and angiogenesis process in various cancer types. The prognostic value of tumor CD105 (endoglin) expression in cervical squamous cell cancer (CSCC) patients treated with radical radiotherapy (RT) ± chemotherapy was investigated.

Materials and Methods

CD105 (endoglin) expression was assessed by immunohistochemical methods in seventy patients, who were treated with radical RT ± chemotherapy for CSCC. The prognostic effects of CD105 on patient and treatment characteristics, local-regional control, and survival were assessed.

Results

The median follow-up was 24 (5-99) months for the whole cohort. The median CD105 microvessel density was 55.5 (range; 12-136). Age (≤61 vs. >61 years; P = 0.015), lymph node metastasis status (absent vs. present; P = 0.028), International Federation of Gynecology and Obstetrics stage (Ib-IIa vs. IIb-IVa; P = 0.036), cycles of concurrent chemotherapy (1-3 vs. 4-6 cycles; P = 0.001), and hemoglobin levels (≤10 g/dL vs. >10 g/dL; P = 0.006) appeared to associate significantly with overall survival on univariate analysis.

Discussion

No correlation was identified between the tumor CD105 (endoglin) expression and survival in CSCC patients treated with radical RT ± chemotherapy.

Risk Factors for Recurrence in Low-Risk Endometrial Cancer: A Case-Control Study

AIM

The aim of this study was to investigate the risk factors for recurrence in patients with low-risk endometrial cancer (EC).

PATIENTS AND METHODS

This retrospective study was performed using 10 gynecological oncology department databases. Patients who met the following criteria were included in the study: (a) endometrioid-type histology, (b) histological grade 1 or 2, (c) no or < 50% myometrial invasion, (d) no intraoperative evidence of extrauterine spread, and (e) the patient underwent at least a pelvic lymphadenectomy. Recurrence was detected in 56 patients who were histologically diagnosed with low-risk EC, and these patients made up the case group. A total of 224 patients with low-risk EC without recurrence were selected (control group) using a dependent random sampling method. The case and control groups were match-paired in terms of grade, stage, and operative technique.

RESULTS

Lymphovascular space invasion (LVSI) (odds ratio (OR) 5.8, 95% confidence interval (CI) 2.0-16.9; p = 0.001) and primary tumor diameter (PTD) ≥ 20 mm (OR 6.6, 95% CI 2.7-15.8; p < 0.001) were found to be independent risk factors for recurrence in women with low-risk EC.

CONCLUSION

The presence of LVSI and PTD ≥ 20 mm seem to be significant risk factors for recurrence in women with low-risk EC.

The Impact of Surgical Staging on the Prognosis of Mucinous Borderline Tumors of the Ovaries: A Multicenter Study

BACKGROUND/AIM

The purpose of this study was to prove the effect of complete surgical staging of patients with mucinous borderline ovarian tumors (mBOTs) especially appendectomy on progression-free survival (PFS) and overall survival (OS).

PATIENTS AND METHODS

The database of 14 gynecological oncology departments from Turkey and Germany were comprehensively searched for women who underwent primary surgery for an ovarian tumor between January 1, 1998, and December 31, 2015, and whose final diagnosis was mBOT.

RESULTS

A total of 364 patients with mBOT with a median age of 43.1 years were included in this analysis. The median OS of all patients was 53.1 months. The majority of cases had Stage IA (78.6%). In univariate and multivariate analyses, radical surgery, omentectomy, appendectomy, lymphadenectomy, and adding adjuvant chemotherapy were not independent prognostic factors for PFS and OS. Furthermore, FIGO stage (≥IC vs. <IC), radical surgery, and staging surgery were not independent risk factors for recurrence of mBOTs. Finally, abnormal macroscopic appendix and FIGO stage (≥IC vs. <IC) were independent risk factors for appendiceal involvement (p=0.032).

CONCLUSION

Patients with conservative surgery do not have higher recurrence rates. Fertility-sparing surgery should be considered in the reproductive age group. Detailed surgical staging including lymphadenectomy, appendectomy, and omentectomy does not have an impact on survival rates.

Factors associated with survival after relapse in patients with low-risk endometrial cancer treated with surgery alone

Objective

To determine factors influencing overall survival following recurrence (OSFR) in women with low-risk endometrial cancer (EC) treated with surgery alone.

Methods

A multicenter, retrospective department database review was performed to identify patients with recurrent “low-risk EC” (patients having less than 50% myometrial invasion [MMI] with grade 1 or 2 endometrioid EC) at 10 gynecologic oncology centers in Turkey. Demographic, clinicopathological, and survival data were collected.

Results

We identified 67 patients who developed recurrence of their EC after initially being diagnosed and treated for low-risk EC. For the entire study cohort, the median time to recurrence (TTR) was 23 months (95% confidence interval [CI]=11.5–34.5; standard error [SE]=5.8) and the median OSFR was 59 months (95% CI=12.7–105.2; SE=23.5). We observed 32 (47.8%) isolated vaginal recurrences, 6 (9%) nodal failures, 19 (28.4%) peritoneal failures, and 10 (14.9%) hematogenous disseminations. Overall, 45 relapses (67.2%) were loco-regional whereas 22 (32.8%) were extrapelvic. According to the Gynecologic Oncology Group (GOG) Trial-99, 7 (10.4%) out of 67 women with recurrent low-risk EC were qualified as high-intermediate risk (HIR). The 5-year OSFR rate was significantly higher for patients with TTR ≥36 months compared to those with TTR <36 months (74.3% compared to 33%, p=0.001). On multivariate analysis for OSFR, TTR <36 months (hazard ratio [HR]=8.46; 95% CI=1.65–43.36; p=0.010) and presence of HIR criteria (HR=4.62; 95% CI=1.69–12.58; p=0.003) were significant predictors.

Conclusion

Low-risk EC patients recurring earlier than 36 months and those carrying HIR criteria seem more likely to succumb to their tumors after recurrence.

The Evaluation of Hydroxyethyl Starch (6% HES 130/0.4) Solution's Potential Preventive Effects on Coagulation Status in Women with Gynecologic Malignancies Using Rotation Thromboelastography

Objective: The aim of this study was to determine the effects of in vitro hemodilution with 6% hydroxyethyl starch (HES) 130/0.4 solution on the coagulation status of women with gynecologic malignancies by using rotation thromboelastogram (ROTEM®).

Materials and Methods: Twenty-two patients with gynecological tumors scheduled for anesthesia were enrolled. Blood samples were diluted by 20% with 6% HES (130/0.4) solution.

Results: In the INTEM assay, clotting time (CT) (p<0.01) and clot formation time (CFT) (p<0.001) were significantly increased and maximum maximum clot formation (MCF) (p< 0.001) was significantly decreased in HES hemodilution compared with the undiluted control samples. In the EXTEM assay, there was a similar significant increase in increase in CFT (p<0.01) and a decrease in maximum a decrease in MCF (p<0.01) in HES hemodilution when compared with control samples.

Conclusion: HES 130/0.4 solution causes significant hypocoagulable changes in the thromboelastographic profile of gynecologic cancer patients in vitro.

Early versus delayed oral feeding after cesarean delivery under different anesthetic methods--a randomized controlled trial anesthesia, feeding in cesarean delivery

OBJECTIVE

The aim of the study was to evaluate the safety and efficacy of early feeding after cesarean delivery under different anesthetic methods.

STUDY DESIGN

Two hundred women with elective cesarean delivery were randomly assigned to early oral feeding (EOF) or routine oral feeding (ROF) groups. EOF patients were informed that they could begin taking fluids orally (regime I) as soon as 2 hours after the delivery and then gradually progress to solid foods (regime III), if tolerated. ROF patients were informed that they could start regime I right after bowel sounds were heard on examination and then gradually move on to regime III. Hospitalization time and total time to ambulation (primary outcomes), gasstool discharge time and onset of bowel sounds (secondary outcomes) were compared in groups A [EOF patients after regional anesthesia (n=49)}, B [EOF patients after general anesthesia (n=48)}, C [ROF patients after regional anesthesia (n=47)} and 0 [ROF patients after general anesthesia (n=48)].

RESULTS

There were significant differences in primary and secondary outcomes between group A and the remaining groups, especially group D. The status of patients from group B was not better than group C. In fact, the latter were discharged home sooner and passage of gas, as well as initiation of regime I occurred earlier as compared to the former

CONCLUSIONS

Cesarean section under regional anesthesia and encouragement of oral feeding 2 hours after the operation should be recommended in order to acnieve postoperative recovery and early hospital discharge. Routine oral feeding (right after bowel sounds are heard on examination) after cesarean section under general anesthesia should be the last choice.

Economic impact of blood transfusions: balancing cost and benefits

Blood transfusions may be lifesaving, but they inherit their own risks. Risk of transfusion to benefit is a delicate balance. In addition, blood product transfusions purchases are one of the largest line items among the hospital and laboratory charges. In this review, we aimed to discuss the transfusion strategies and share our transfusion protocol as well as the steps for hospitals to build-up a blood management program while all these factors weight in. Moreover, we evaluate the financial burden to the health care system.

Uterine extra gastrointestinal stromal tumor presenting as intramural leiomyoma

Extra gastrointestinal stromal tumors (EGIST) are reported in different sites and organs. This tumors are rare in gynecologic apparatus. Here the authors report an uterine unique tumor represented as intramural leiomyoma. Because of different treatment options, clinicians should be aware of this rare tumor which may be located in uterus and confused with a smooth muscle tumor.

Prognostic Significance of Retroperitoneal Lymphadenectomy, Preoperative Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio in Primary Fallopian Tube Carcinoma: A Multicenter Study

Purpose

The purpose of this study is to evaluate the prognostic role of preoperative neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) and the need for para-aortic lymphadectomy in patients with primary fallopian tube carcinoma (PFTC).

Materials and Methods

Ninety-one patients with a diagnosis of PFTC were identified through the gynecologic oncology service database of six academic centers. Clinicopathological, surgical, and complete blood count data were collected.

Results

In univariate analysis, advanced stage, suboptimal surgery, and NLR > 2.7 were significant prognostic factors for progression-free survival, whereas in multivariate analysis, only advanced stage and suboptimal surgery were significant. In addition, in univariate analysis, cancer antigen 125 ≥ 35 U/mL, ascites, advanced stage, suboptimal surgery, NLR > 2.7, PLR > 233.3, platelet count ≥ 400,000 cells/mm³, staging type, and histological subtype were significant prognostic factors for overall survival (OS); however, in multivariate analysis, only advanced stage, suboptimal surgery, NLR > 2.7, and staging type were significant. Inclusion of pelvic and para-aortic lymphadenectomy in surgery showed significant association with longer OS, with a mean and median OS of 42.0 months and 35.5 months (range, 22 to 78 months), respectively, vs. 33.5 months and 27.5 months (range, 14 to 76 months), respectively, for patients who underwent surgery without para-aortic lymphadenectomy (hazard ratio, 3.1; 95% confidence interval, 1.4 to 5.7; p=0.002).

Conclusion

NLR (in both univariate and multivariate analysis) and PLR (only in univariate analysis) were prognostic factors in PFTC. NLR and PLR are inexpensive and easy tests to perform. In addition, patients with PFTC who underwent bilateral pelvic and para-aortic lymphadenectomy had longer OS.

Adjuvant treatment modalities, prognostic predictors and outcomes of uterine carcinosarcomas

Purpose

The purpose of this study is to evaluate the clinicopathological characteristics, treatment, and prognosis of uterine carcinosarcoma (UC).

Materials and Methods

A retrospective review of three cancer registry databases in Turkey was conducted for identification of patients diagnosed with UC between January 1, 1996, and December 31, 2012. We collected clinicopathological data in order to evaluate factors important in disease- free survival (DFS) and overall survival (OS).

Results

A total of 66 patients with UC with a median age of 65.0 years were included in the analysis. The median survival time of all patients was 37.5 months and the 5-year OS rate was 59.1%. In early stage patients (I-II) who received adjuvant chemotherapy (CT) with radiation therapy (RT), the median DFS and OS was 44 months and 55 months, respectively, compared to 34.5 months and 36 months, respectively, in patients who received adjuvant RT or CT alone (hazard ratio [HR], 1.4; 95% confidence interval [CI], 0.7 to 3.1 for DFS; p=0.23 and HR, 2.2; 95% CI, 0.9 to 5.3 for OS; p=0.03). In advanced stage patients (III-IV), the median DFS and OS of patients receiving adjuvant RT with CT was 25 months and 38 months, respectively, compared to 23.5 months and 24.5 months, respectively, in patients receiving adjuvant RT or CT alone (HR, 3.1; 95% CI, 0.6 to 16.0 for DFS; p=0.03); (HR, 3.3; 95% CI, 0.7 to 15.0 for OS; p=0.01). In multivariate analysis, advanced International Federation of Gynecology and Obstetrics (FIGO) stage and suboptimal surgery showed significant association with poor OS.

Conclusion

In patients with early or advanced stage UC, adjuvant CT with RT is associated with improved DFS and OS, as compared to CT or RT alone.

Vaginal misoprostol versus a rectal nonsteroidal anti-inflammatory drug to reduce pain during Pipelle endometrial biopsies: a prospective, randomized, placebo-controlled trial

BACKGROUND

To evaluate and compare the efficacy of vaginal misoprostol and a rectal nonsteroidal anti-inflammatory drug (NSAID) on pain relief during Pipelle endometrial biopsies in a placebo-controlled randomized study.

METHODS

One hundred and fifty-one women who had an indication for a Pipelle endometrial biopsy were randomized into three groups as follows: group 1, vaginal misoprostol; group 2, rectal NSAID, and group 3, control. After the procedure, the women were asked to record their pain severity on a visual analog scale. The secondary outcome of the study was patient acceptability, and vasovagal symptoms and analgesic requirements after the procedure were also recorded.

RESULTS

There were no statistically significant differences in the demographic characteristics of the patients. The primary study outcome was the comparison of the median visual analog scale pain scores of groups 1 and 2 versus group 3 (controls); no statistically significant differences were found (p = 0.502). In addition, the patient acceptability (Likert scale), vasovagal symptoms and analgesic requirements after the procedure were similar among the groups (p = 0.204, 1 and 0.546, respectively).

CONCLUSION

Our study did not demonstrate a reduction in pain relief during Pipelle endometrial biopsies for patients receiving vaginal misoprostol or a rectal NSAID when compared to patients receiving placebo treatment.

Vulval pruritus: the experience of gynaecologists revealed by biopsy

Pruritus of the vulva is a common symptom among patients attending to outpatient clinics. In the present study, we aimed to assess pathologies causing vulval pruritus in the reliability of biopsy in a tertiary referral centre. A total of 137 patients undergoing vulval colposcopy because of vulval pruritus were reviewed from the hospital records retrospectively. The mean age of the patients was 47.61 ± 11.88 years and 36.5% of the patients were postmenopausal. In 101 (73.7%) of the patients, macroscopic lesions were present. In 88 (64.2%) of the patients, tolidine-positive stained areas were determined under colposcopy. In total, 68 (49.6%) of the lesions were plain, whereas 51 (37.2%) of them were depigmented. Lichen simplex chronicus, lichen sclerosis and chronic inflammation were the major pathologies associated with vulval pruritus (25.5%, n = 35; 20.4%, n = 28; 14.6%, n = 20). In conclusion, several pathologies out of vulvovaginal candidiasis may lead to vulval pruritus and clinicians should be aware of the importance of biopsy in determining the underlying pathology.

A financial analysis of operating room charges for robot-assisted gynaecologic surgery: Efficiency strategies in the operating room for reducing the costs

OBJECTIVE

To analyse the steps taking place in the operating room (OR) before the console time starts in robot-assisted gynaecologic surgery and to identify potential ways to decrease non-operative time in the OR.

MATERIAL AND METHODS

Thirteen consecutive robotic cases for benign gynaecologic disease at the Department of Obstetrics and Gynecology at University of Texas Medical Branch (UTMB) were retrospectively reviewed. The collected data included the specific terms 'Anaesthesia Done' (step 1), 'Drape Done' (step 2), and 'Trocar In' (step 3), all of which refer to the time before the actual surgery began and OR charges were evaluated as level 3, 4, and 5 for open abdominal/vaginal hysterectomy, laparoscopic hysterectomy, and robot-assisted hysterectomy, respectively.

RESULTS

The cost of the OR for 0-30 minutes and each additional 30 minutes were $3,693 and $1,488, $4,961 and $2,426, $5,513 and $2,756 in level 3, 4, and 5 surgeries, respectively. The median time for step 1 was 12.1 min (5.25-23.3), for step 2 was 19 (4.59-44) min, and for step 3 was 25.3 (16.45-45) min. The total median time until the actual operation began was 54.58 min (40-100). The total cost was $6948.7 when the charge was calculated according to level 4 and $7771.1 when the charge was calculated according to level 5.

CONCLUSION

Robot-assisted surgery is already 'cost-expensive' in the preparation stage of a surgical procedure during anaesthesia induction and draping of the patient because of charging levels. Every effort should be made to shorten the time and reduce the number of instruments used without compromising care. (J Turk Ger Gynecol Assoc 2014; 15: 25-9).

Platelet volume as a parameter for platelet activation in patients with endometrial cancer

The objective of this study was to use mean platelet volume (MPV) as a measure of platelet activation in patients with endometrial adenocarcinoma and healthy controls. There was a total of 310 patients with endometrial adenocarcinoma retrospectively evaluated and 250 healthy controls. Preoperative haemoglobin, platelet counts and mean platelet volume were evaluated and statistical tests were conducted to determine the differences among early and advanced disease groups and controls. Median haemoglobin (13.0 vs 13.3 g/dl) and platelet count (282,000 vs 280,000/μl) values were similar in patients with endometrial adenocarcinoma and healthy controls (p > 0.05). Subjects with endometrial cancer exhibited slightly higher MPV than the control group (8.4 fl vs 8.2 fl) (p = 0.048). In patients with advanced-stage endometrial cancer, haemoglobin was significantly lower (p < 0.05) and MPV was significantly higher (p < 0.05) than in either patients with early-stage endometrial cancer or the control group. It was concluded that MPV was found to be a marker for predicting advanced-stage endometrial cancers.

Borderline ovarian tumors: outcomes of fertility sparing surgery

AIM

Borderline ovarian tumors(BOT) account for ten to 20 percent of all epitelial ovarian carcinomas and often occur in reproductive ages. The aim of this study was to evaluate the clinical and reproductive outcomes of patients who were diagnosed with BOT and underwent fertility sparing surgery.

MATERIALS AND METHODS

Patients younger than 40 years who underwent fertility sparing surgery for BOT from 2004 to 2012 were reviewed retrospectively and were evaluated according to the reproductive and clinical outcomes.

RESULTS

Twenty-eight patients younger than 40 years with BOT underwent fertility sparing surgery. Median follow up time was 42 +/- 28.1 months. During the follow up period, two patients (7.1%) developed recurrence at 35 and 36 months, respectively. Five (17.9%) out of 28 patients became pregnant during the follow up period.

CONCLUSION

Fertility sparing surgery should be the first choice for the treatment of BOT in patients who wish to preserve fertility.

Outcomes of robotic sacrocolpopexy using barbed delayed absorbable sutures

STUDY OBJECTIVE

To evaluate 1-year outcomes of robotic sacrocolpopexy (RSC) for pelvic organ prolapse using barbed delayed absorbable sutures.

DESIGN

Retrospective cohort study (Class II-3).

SETTINGS

University-based hospital in Southeast Texas.

PATIENTS

Patients with symptomatic apical pelvic organ prolapse who underwent RSC using barbed delayed absorbable sutures between January 2011 and August 2012. Patients were examined postoperatively at least twice (after 6 weeks and 1 year).

INTERVENTIONS

RSC procedure.

MEASUREMENTS AND MAIN RESULTS

The study included a total of 20 patients, of them 15 had grades 3 or 4 whereas 5 had grade 2 apical defects according to the Baden-Walker classification system. Fourteen patients (70%) underwent concomitant hysterectomy while 9 (45%) underwent concomitant anti-incontinence surgery. Mesh suturing times were 46.9 ± 12.6 and 20.5 ± 9.3 minutes in the first 10 versus the last 10 cases, respectively (p < .001). The mean follow-up duration was 17.3 months (range, 12-24 months). There were no recurrences of apical defects or mesh/suture exposure/erosion. However, 1 patient developed a grade 2 cystocele, and another developed new-onset urinary incontinence, both after 1 year. A third patient's urine leakage did not improve postoperatively. Lastly, a fourth patient developed port site incisional hernia and underwent repair 5 months later.

CONCLUSION

Our study suggests that barbed delayed absorbable sutures are safe and effective in RCS procedures over 1 year. Larger, comparative, and randomized trials are recommended for definitive conclusions.

Sonographically guided core biopsy: a minimally invasive procedure for managing adnexal masses

OBJECTIVES

We hypothesized that sonographically guided core biopsy is an effective method for the differential diagnosis of adnexal masses and evaluated patients who underwent core biopsies in our gynecologic oncology department.

METHODS

We reviewed the medical records of 55 patients who underwent sonographically guided core biopsies in our gynecologic oncology department between 2010 and 2013. Patients with suspected ovarian malignancies who were unsuitable for optimal debulking surgery and patients at risk for higher morbidity and mortality because of a poor performance status, suspected nongynecologic tumors, and peritoneal tuberculosis were indicated for sonographically guided biopsy.

RESULTS

The indications for sonographically guided core biopsy were candidacy for suboptimal cytoreduction (n = 32 [58.2%]), a poor performance status (n = 11 [20.0%]), and suspected nongynecologic tumors (n = 12 [21.8%]). Histopathologic evaluations revealed primary ovarian tumors in 36 patients (65.5%). Tuberculosis was found to be the second most common disease (n = 8 [14.5%]) among the patients who underwent core biopsies. In 2 patients (3.6%), histologic examination revealed metastatic colorectal cancer.

CONCLUSIONS

Sonographically guided core biopsy may be preferred as a minimally invasive procedure for managing adnexal masses, particularly in patients with advanced ovarian cancer and high comorbidities who might benefit from neoadjuvant chemotherapy and in cases of suspected nongynecologic tumors, including pelvic tuberculosis.

Gestational trophoblastic diseases in Turkey

OBJECTIVE

To evaluate epidemiological data, staging, prognostic scoring system and immunohistochemical reports as well as the management and outcome of hydatidiform mole (HM) in Turkey.

STUDY DESIGN

All published data in the Turkish literature from 1932-2011 were evaluated retrospectively.

RESULTS

The incidence of HM was 0.3-16 per 1,000 pregnancies and 1.0-24.5 per 1,000 deliveries. Of a total number of 929,323 pregnancies during a 68-year period, 2,227 HM cases were encountered, to give an average incidence of 2.39 per 1,000 pregnancies and 1.87 per 1,000 deliveries. Although there were big differences in reported incidences, the overall incidence is also very high, and the main reason for the differences was thought to be related to the origin of the studies: all were hospital based. An epidemiological field study of HM in the rural part of Turkey identified 4 HM cases and 6,274 pregnancies in 2,032 women aged 15-49. The frequency of HM per 1,000 live births and per 1,000 pregnancies was 0.8 and 0.6, respectively.

CONCLUSION

Multicenter, community-based studies are needed to present the real incidence, and it is vital that women with gestational trophoblastic disease be followed by a multidisciplinary team, and ideally in trophoblastic disease centers and national case registry systems for gestational trophoblastic disease.

Hydatidiform mole in Turkey: results from six centers

OBJECTIVE

To evaluate the clinical profile of gestational trophoblastic disease and to determine the incidence of hydatidiform mole (HM) from six centers in Turkey.

STUDY DESIGN

A retrospective analysis of patients diagnosed with HM in six medical centers in Turkey from 2000 to 2010 was undertaken. Patients' age, gravidity, parity and abortion, presenting signs, histopathological results and their follow-up were recorded.

RESULTS

From 2000 to 2010, 351,650 deliveries were recorded in six centers in Turkey, and 263 cases were diagnosed as HMs. Of the 263 patients the mean age was 28.2 years. The mean numbers of gravidity, parity and abortion were 2.6, 1.3 and 0.3, respectively. According to the medical histories, 3 (1.1%) patients had molar pregnancy previously and the presenting symptom was vaginal bleeding in symptomatic cases. After evacuation, histopathologic examination revealed complete mole in 175 (66.5%) patients and partial mole in 86 (32.6%) patients, and methotrexate was given as a prophylactic chemotherapy in 17 patients (6.4%) while 6 (2.2%) patients underwent hysterectomy procedure.

CONCLUSION

According to the results the incidence of molar pregnancy is 0.7/1,000 deliveries. Because of its rarity, multicenter, community-based studies are needed to determine the real incidence.

HPV DNA and Pap smear test results in cases with and without cervical pathology

OBJECTIVE

The aim of the study was to determine the HPV prevalance and its relation to Pap smear, colposcopy and colposcopy directed biopsy in our region of Eskisehir, Turkey.

MATERIAL AND METHODS

A total of 615 women who applied to the outpatient clinic between December 2009 and December 2010 constituted our study population. All patients underwent pelvic examination and Pap smear sampling. Patients who had pathological cervical appearance or Pap smear results of ASCUS, AGUS, LSIL or HSIL were referred to colposcopy. Cervical samples for HPV DNA were taken from the patients before Pap smear sampling during the routine examination or before the colposcopic evaluation.

RESULTS

Twenty six of 615 patients (4%) were HPV positive. Of these 26 patients, 12 were positive for HPV type 16, 3 for type 18, 3 for type 51, 2 for type 6, 1 for type 52, 1 for type 33, 1 for type 16 and type 31, 1 for type 6 and 52, 1 for type 56 and 90, 1 for type 39 and 66. In 4 patients with cervical cancer, and in 3 of 4 CIN III cases both HPV DNA and Pap smear were positive. In the Pap smear examination of 615 patients, cytology revealed 35 ASCUS (5.6%) 4 AGUS (0.6%), 2 CIN I (0.3%) results who were negative for HPV DNA. These patients with abnormal cytology (n=41) underwent colposcopy directed biopsy, there were 3 CIN I and 1 CIN III and all the other cervical biopsy results of these patients were benign (inflammation, chronic cervicitis).

CONCLUSION

HPV positivity in our hospital setting is low which is compatible with other studies in Turkey. In positive HPV cases there is a good correlation between HPV type and positive cervical biopsy results.

Analysis of uterine rupture cases in Agri: a five-year experience

INTRODUCTION

We attempted to establish the frequency of uterine rupture and to address etiological factors, complications, management and maternal and perinatal outcome of complete versus incomplete rupture, with the aim of proposing preventive measures.

METHODS

The clinical records of uterine rupture cases managed at the Obstetrics and Gynecology Department of Agri Maternity and Children's Hospital in Turkey from June 2004 to June 2009 were analyzed retrospectively.

RESULTS

There were 44 cases of ruptured uterus. Among 24,554 deliveries the total incidence of uterine rupture was 1/558 or 17%. The most common site for the location of rupture was the fundal region (36.36%) followed by the lower segment, isthmic and mixewd types, respectively.

DISCUSSION

Prevention must necessarily include regular antenatal care and meticulous screening of high-risk patients. Improved organization and access to maternal care, decentralization of obstetric services into peripheral care units in villages to prevent home deliveries and good supervision during labor can reduce the incidence of this preventable obstetric catastrophe.

Is placebo as effective as estrogen regimens on vasomotor symptoms in women with surgical menopause?

OBJECTIVE

To evaluate the short-term effects of two hormone therapy (HT) regimens and placebo on the Greene Climacteric Scale (GCS) of women with surgical menopause following six months of treatment.

METHODS

This 6-month, prospective, randomized, parallel-group, masked evaluator study compared the efficacy of once daily administration of 0.625 mg conjugated equine estrogen (group I), 3.9 mg transdermal 17beta-estradiol patch applied every week (group II) and placebo (group III). Mean GCS before and after six months of treatment in each group was compared.

RESULTS

In groups I and II, vasomotor symptoms (p < 0.005, p < 0.05), somatic symptoms (p < 0.05, p < 0.05) and total score (p < 0.005, p < 0.01) significantly reduced from baseline values respectively, while the other subscores revealed no statistically important differences following six months of HT. In group III, vasomotor (p < 0.05), subscore and total score (p < 0.05) decreased significantly while other subscore reductions were not significant.

CONCLUSIONS

Estrogen regimens and placebo seem to be effective in alleviating vasomotor symptoms. Additional larger prospective randomized studies need to be conducted in an aim to look at not only short-term but also long-term effects on climacteric symptoms, in comparison to both placebo arms and different dose and mode of HT use.

Case report: sacral parasitic twins

INTRODUCTION

Sacral parasitic twins originate from one fertilized ovum and they have one placenta and the same sex.

CASE REPORT

A 23-year-old woman was referred to our clinic. Examination by touch revealed a mass that was in the sacral region but the borders could not be fully examined. The solid mass, which was conjoined to the sacrum, had a soft texture. The infant's appearance was macroscopically normal. When the mass was examined by palpation, there were structures which felt like extremities. The mass was 20 x 11 x 9 cm in size.

CONCLUSION

The differential diagnosis should include sacrococcygeal teratoma. In our case the differential diagnosis was done by histopathologic findings. This case, which involved a tumoral formation at the sacral region in the antenatal period, was detected during delivery. A sacral parasite is a rarely seen phenomenon and as such the diagnostic information of this case could be useful.

Pelvic abscess in intrauterine device users

OBJECTIVE

To assess the causality between pelvic abscess formation and intrauterine device (IUD) use through a clinical study in a hospital.

METHOD

Sixty-two pelvic abscesses were retrospectively evaluated over a 7-year period. Patient records retrieved for the women enrolled in this study consisted of demographic characteristics, duration of IUD use and clinical management details.

RESULTS

All the women were monogamous Muslim women without any suspicious sexual contacts, immunosupressive states, or drug use at the time of IUD insertion. In 10 cases (16.1%), a history of pelvic surgery was present. The mean age of the women was 36.1 +/- 2.3 years (range 19-50 years). Of the 62 women, 14 (22.6%) were current IUD users. The mean time interval for women using IUD prior to the diagnosis of pelvic abscess was 5.7 +/- 1.2 years (range 1-14 years). In all cases, a pelvic mass and abdominal pain constituted the referral signs and symptoms. All women received an initial antibiotic regimen comprising penicillin (24 mU/day), clindamycin (900 mg/day) and gentamycin (240 mg/day) in divided doses. In 38 cases (61.3%), medical treatment yielded a satisfactory clinical outcome, defined as a decreas in mass volume together with pain relief and a decrease in leukocytosis. Twenty-four cases (38.7%) underwent a subsequent surgical procedure, either laparotomy (n = 19) or laparoscopy (n = 5). The type of surgery ranged from abscess drainage to more radical approaches such as total abdominal hysterectomy and/or unilateral or bilateral salpingo-oophorectomy. There were no differences between those women responding to medical therapy and those who did not respond in terms of mean age, percentage of past pelvic surgery, gravidity, parity and the size of pelvic abscess.

CONCLUSIONS

A substantial number of women with an IUD were diagnosed as having a pelvic abscess within a 7-year period at the university clinic. Despite current knowledge that pelvic inflammatory disease and pelvic abscess are rarely encountered in long-term IUD users, the presence of an IUD should be investigated in cases with an initial diagnosis of pelvic abscess based on clinical and ultrasonographic evaluation, demonstrating mostly acquisition via sexually transmitted disease.

Dermatofibrosarcoma protuberans of the vulva: a case report

Dermatofibrosarcoma protuberans (DFSP) is a low-grade to intermediate-grade well-differentiated sarcoma of dermal origin. Local recurrence rates are high but distant metastases are rare. This report describes a case of vulvar DFSP requiring four resections for primary clearance. A 56-year-old woman referred after excision of a vulvar tumour and histology had DFSP extending to the resection margins. Two more extended excisions again yielded a specimen with positive margins. The last excision was performed with intraoperative frozen section analysis of the margins. Frozen section analysis of the resected specimen revealed clear margins and this was confirmed by final pathology. The postoperative course was uneventful. The patient has been without recurrence for 15 months. A wide and deep local excision is recommended for both primary and recurrent lesions. The patient had three resections before clear surgical margins were achieved. Intraoperative frozen section analysis is helpful in assessing resection margins.

Actin bundling protein fascin expression in ovarian neoplasms: comparison of histopathologic features of tumors obtained by the first and secondary cytoreduction surgeries

PURPOSE OF INVESTIGATION

The aim of the study was to compare the fascin expression pattern and histopathologic features of malign epithelial ovarian tumors obtained by the primary and secondary surgeries.

METHODS

The samples of 94 epithelial ovarian carcinomas, 35 secondary surgeries for ovarian carcinomas, 13 borderline epithelial ovarian tumors, 25 cystadenomas and four normal ovarian tissues were stained by means of fascin immunohistochemistry. Secondary surgeries included in the study were secondary cytoreduction at the time of second-look laparotomy (SLL), interval debulking surgery after neoadjuvant chemotherapy or secondary cytoreductive surgery in patients with recurrent epithelial ovarian carcinoma.

RESULTS

Mean rank value of the stromal fascin score was higher in 94 cases of malign epithelial ovarian carcinomas than borderline epithelial tumors, cystadenomas and normal ovaries (.000, p < 0.001). There was no significant difference in terms of total epithelial fascin score (.685, p > 0.05) and total stromal fascin score (.572, p > 0.05) between the primary and the secondary surgeries of epithelial ovarian carcinomas.

CONCLUSIONS

Regarding the results of stromal fascin expression in 94 epithelial ovarian carcinomas, we hypothesized that cell-matrix interaction was an important step in the progression of malign epithelial ovarian neoplasms. Our study showed that the initial tumorigenic phenotype did not change with time and use of cisplatinum-based combination chemotherapy. Further studies with close follow-up of patients are necessary to reveal the role of fascin on matrix degradation mechanisms which might be the cause of the recurrences in ovarian neoplasms.

Possible factors affecting the age at menopause among women in the central anatolian region of Turkey

OBJECTIVE

We aimed to investigate the age at menopause and possible related factors in a Turkish population.

STUDY DESIGN

In a three-year period, a retrospective analysis of 541 spontaneous menopause cases were evaluated. All postmenopausal women with spontaneous cessation of menses for > or = 12 months and serum FSH levels > 40 IU/l were included in the study. Sociodemographic status, reproductive and medical history, menopausal symptoms, and previous contraceptive and hormonal therapy use were assessed based on an interview using a standardized information system. Age at menarche, parity, menopausal age of mother and sister, history of lactation, physical activity, cigarette smoking, oral contraceptive use and body mass index (BMI) were assessed.

RESULTS

Menopausal age of the enrolled cases was positively correlated with mothers and sisters' ages at menopause. Postmenopausal smokers had an earlier age at menopause compared to non-smokers.

CONCLUSION

Cigarette smoking results in earlier menopause in the Turkish population. Menopausal ages of mothers and sisters clearly correlated with the age at menopause.

Associated factors with urogenital score in natural and surgical menopause

OBJECTIVE

To anticipate the factors associated with urogenital symptoms in both natural and surgical menopause.

METHODS

A retrospective analysis was performed comprising 267 cases with spontaneous menopause and 87 surgical menopause cases without any use of hormone replacement therapy. Sociodemographic characteristics, reproductive and medical history, urogenital scale and psychological subscale of Greene Climacteric Scale were assessed and correlated with the age of menopause, time past since last menstrual period, parity, body mass index (BMI), mode of delivery among two groups.

RESULTS

Mean age of women enrolled to the study were 46.8+/-0.3 years and 44.4+/-0.25 years, for natural and surgical menopause cases, respectively. Mean parity had no correlation with urogenital scale in two groups. However, a positive correlation was apparent between the time since last menstrual period, psychological subscore of Green Climacteric Scale and urogenital score in both women with natural and surgical menopause. BMI was negatively correlated with urogenital score among two groups (r(p)=-0.85, p=0.04).

CONCLUSIONS

Intensity and frequency of urogenital symptoms and climacteric complaints as expressed in the Greene Climacteric Scale increase during menopausal transition. Care should be taken to ameliorate the quality of life (QOL) and to confront these problems in post-menopausal women.

Related factors in bone mineral density of lumbal and femur in natural postmenopausal women

OBJECTIVE

To assess possible factors affecting the bone mineral density (BMD) in postmenopausal women.

METHODS

A retrospective analysis of 267 cases with spontaneous menopause within 3 years of period was performed. None of the enrolled cases were taken any hormone replacement therapy and/or treatment for osteoporosis. BMD measurements were done in lumbal vertebral (L1-L4) and left femur (neck, intertrochanteric and ward triangle) via dual energy X-ray absorbtiometry (DEXA) method, yielding corresponding T-scores of above-mentioned areas. In addition, age at menarche, parity, menopausal age, duration of postmenopausal state, lactation, physical activity, cigarette smoking, dietary calcium intake, oral contraceptive use and body mass index (BMI) were determined.

RESULTS

There were no relationships between BMD and age at menarche, parity, menopausal age, lactation, physical activity, smoking, dietary calcium intake and oral contraceptive use. Two associated factors with BMD were BMI and time since menopause. BMI was found to be positively and time since menopause was negatively correlated with BMD of both lumbal region and femur.

CONCLUSIONS

BMD changes and its related factors should be kept in mind during postmenopausal years. Therefore, adequate peak bone mass and related life style measures should be achieved to confront osteoporosis-related symptoms and its consequences.