Sentinel lymph node mapping and intraoperative assessment in a prospective, international, multicentre, observational trial of patients with cervical cancer: The SENTIX trial

BACKGROUND

SENTIX (ENGOT-CX2/CEEGOG-CX1) is an international, multicentre, prospective observational trial evaluating sentinel lymph node (SLN) biopsy without pelvic lymph node dissection in patients with early-stage cervical cancer. We report the final preplanned analysis of the secondary end-points: SLN mapping and outcomes of intraoperative SLN pathology.

METHODS

Forty-seven sites (18 countries) with experience of SLN biopsy participated in SENTIX. We preregistered patients with stage IA1/lymphovascular space invasion-positive to IB2 (4 cm or smaller or 2 cm or smaller for fertility-sparing treatment) cervical cancer without suspicious lymph nodes on imaging before surgery. SLN frozen section assessment and pathological ultrastaging were mandatory. Patients were registered postoperatively if SLN were bilaterally detected in the pelvis, and frozen sections were negative.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02494063).

RESULTS

We analysed data for 395 preregistered patients. Bilateral detection was achieved in 91% (355/395), and it was unaffected by tumour size, tumour stage or body mass index, but it was lower in older patients, in patients who underwent open surgery, and in sites with fewer cases. No SLN were found outside the seven anatomical pelvic regions. Most SLN and positive SLN were localised below the common iliac artery bifurcation. Single positive SLN above the iliac bifurcation were found in 2% of cases. Frozen sections failed to detect 54% of positive lymph nodes (pN1), including 28% of cases with macrometastases and 90% with micrometastases.

INTERPRETATION

SLN biopsy can achieve high bilateral SLN detection in patients with tumours of 4 cm or smaller. At experienced centres, all SLN were found in the pelvis, and most were located below the iliac vessel bifurcation. SLN frozen section assessment is an unreliable tool for intraoperative triage because it only detects about half of N1 cases.

Central Pathology Review in SENTIX, A Prospective Observational International Study on Sentinel Lymph Node Biopsy in Patients with Early-Stage Cervical Cancer (ENGOT-CX2)

The quality of pathological assessment is crucial for the safety of patients with cervical cancer if pelvic lymph node dissection is to be replaced by sentinel lymph node (SLN) biopsy. Central pathology review of SLN pathological ultrastaging was conducted in the prospective SENTIX/European Network of Gynaecological Oncological Trial (ENGOT)-CX2 study. All specimens from at least two patients per site were submitted for the central review. For cases with major or critical deviations, the sites were requested to submit all samples from all additional patients for second-round assessment. From the group of 300 patients, samples from 83 cases from 37 sites were reviewed in the first round. Minor, major, critical, and no deviations were identified in 28%, 19%, 14%, and 39% of cases, respectively. Samples from 26 patients were submitted for the second-round review, with only two major deviations found. In conclusion, a high rate of major or critical deviations was identified in the first round of the central pathology review (28% of samples). This reflects a substantial heterogeneity in current practice, despite trial protocol requirements. The importance of the central review conducted prospectively at the early phase of the trial is demonstrated by a substantial improvement of SLN ultrastaging quality in the second-round review.

Intraprocedural complications of uterine fibroid embolisation and their impact on long-term clinical outcome

OBJECTIVES

Authors evaluate the impact of intraprocedural complications on successful technical realisation and long-term clinical outcome of the uterine fibroid embolisation.

BACKGROUND

The uterine artery embolisation (UAE) has become an accepted treatment method for uterine fibroids. In general, the unilateral embolisation is considered to be insufficient due to poor clinical effect.

METHODS

Overall, 165 uterine artery embolisations were analysed (retrospectively-prospectively) in 163 female patients. Intraprocedural complications and their impact on the possibility to perform bilateral embolisationwere evaluated. In patients with unscheduled unilateral embolisation, short-term as well as long-term clinical effects were observed with mean follow-up period of 41 months.

RESULTS

The bilateral uterine artery embolisation was possible in 95.7 % (95 %, CI 91.3-99.4 %) procedures. The unilateral embolisation was reported in 7 procedures (4.3 %, CI 1.2-8.3 %) and reasons were following: resistant arterial spasm in 4 patients (2.5 %, CI 0.7 %-5.3 %) and impossible catheterisation due to unfavourable anatomic situation in 3 patients (1.8 %, CI 0.3-4.1 %). Other complications, such as dissection and perforation, did not affect the successful technical realisation. The long-term clinical effect of unscheduled unilateral embolisation was reported in 5 patients.

CONCLUSION

The results of our series of unscheduled unilateral uterine fibroid embolisation had high long-term clinical success rate. In way of unscheduled unilateral embolisation, we recommend MRI follow-up and reintervention only in way of persistence or recurrence of symptoms with concurrent MRI finding of residual fibroids(Tab. 5, Fig. 3, Ref. 12).

Strumal carcinoid of the ovary - report of two cases and review of literature

OBJECTIVE

Strumal carcinoid (SC) is a rare ovarian germ-cell tumour, which is characterized by a mixture of thyroid tissue and carcinoid. It can be presented as a monodermal teratoma or as a part of mature cystic teratoma (dermoid cyst).

DESIGN

Case report.

SETTING

Department of pathology, St. Elisabeth Cancer Institute, Bratislava.

METHODS AND RESULTS

Hereby the authors describe two cases of this rare tumour in clinically asymptomatic women, 46- and 52-year-old, whom tumours were diagnosed at preventive gynaecological examination. The tumours considered of solid - cystic features, measured 65×45×40 mm and 75×45×40 mm and both contained parts of SC represented by tougher yellowish gelatinous areas. In both cases, SC was a part of the mature cystic teratoma (dermoid cyst), with predominated content. Histologically, both SC had a characteristic composition of intimate mixture of mature thyroid tissue and carcinoid. Immunohistochemically, the thyroid tissue stained positively with cytokeratin7, thyroglobulin and thyroid transcription factor-1, and the carcinoid component exhibited expression of synaptophysin and chromogranin A (only in one case). Tumour cells of both components of SC were negative for calcitonin and carcinoembryonic antigen. Both tumours showed low proliferation activity expressed by Ki-67 (up to 2%). Tumours were diagnosed in stage IA, and up to now are patients without any complications associated with tumours, free of relapse for 3 years and 6 months, respectively.

CONCLUSION

SC represents an interesting form of primary ovarian carcinoid, which is usually asymptomatic and when confined to ovary, mostly has benign behaviour and can be treated by simple one-sided or bilateral adnexectomy. Keywords ovary, germ cell tumours, strumal carcinoid, immunohistochemistry.

[The finding of isolated oligohydramnios after 37th week of gestation and its association with perinatal outcome]

OBJECTIVE

The objective of this study is to determinate the influence of oligohydramnios on perinatal outcome in term pregnancies.

DESIGN

Retrospective case-control study.

SETTING

II. Gynecologic Obstetrics Department, Comenius University, Bratislava.

METHODS

Authors analysed a group of 372 single pregnancies after completed 37th week of gestation in years 2011 to 2015 with sonographic diagnosis of isolated oligohydramnios. A control group was created with matched patients by age and parity with normal amniotic fluid volume.

RESULTS

We found significant differences in number of obstetric intervention between the two groups: patients with oligohydramnios had higher number of cesarean sections (71% compared to 33.9% in control group) and also the number of inductions was significantely higher (27.4% compared to 18.8%). The most common indication for cesarean delivery was presumed fetal hypoxia. We did not find any differences in numbers of neonates with low Apgar score, low umbilical cord pH and admission to neonatal intensive care unit.

CONCLUSION

The finding of isolated oligohydramnios after 37th week of gestations is associated with higher risk of obstetric intervention without any association with adverse perinatal outcome.

Long term follow-up of the patients with pelvic organ prolapse after the mesh implantation using strict indication criteria

OBJECTIVES

Transvaginal polypropylene mesh implantation is one of the techniques used for pelvic organ prolapse (POP) repair. The surgery outcomes depend on the indication criteria used. The aim of our study was to evaluate the outcomes of the mesh implantation using the strict indication criteria.

PATIENTS AND METHODS

In 47 women aged 61.7±8.3 years with pelvic organ prolapse (POP-Q≥2) and a history of other surgery in the pelvic region outcomes of the mesh implantation were evaluated for up to 7 years (range 1-7 years).

RESULTS

Forty six of 47 patients (97.8%) had a successful mesh implantation (10 anterior, 22 posterior, 14 combined). Peroperative complications occurred in 3 of 47 patients (6.4%). The anatomic cure (POP-Q≤1) was achieved in 93.5% patients with mesh at 6 months after surgery. Any of the postoperative complications occurred in 16 of 46 women (34.8%). Significantly lower risk of complications was found in the group aged over 65 years compared to the younger patients (p=0.005).

CONCLUSION

This is the first study on the mesh implantation including women only with the history or other surgery in the pelvic region, achieving high anatomic success rate and low risk of complications. Thus, our data support the use of the strict indication criteria for this procedure (Tab. 2, Fig. 2, Ref. 14).

[Evolution of peripartal hysterectomy at our department - five years evaluations]

The purpose of this study was to determine the frequency, indications, complications and risk factors associated with peripartum hysterectomy carried out at our clinical department between 1st January 2008 and 31th December 2012. Peripartum hysterectomy was defined as a hysterectomy performed less than 48 hours after delivery. Clinical characteristic and obstetric histories were retrospectively reviewed between 5 years. There were 20 emergency peripartum hysterectomies among 13 660 deliveries at our department. The overall rate of peripartum hysterectomy was 1,46 per 1000 deliveries. The primary indications for hysterectomy were uncontrolled bleeding caused by uterine hypotony (45%), followed by placenta praevia (25%). Other indications were placental abruption (15%), pelvic endometriosis (5%), placenta increta (5%) and uterus myomatosus (5 %). The incidence of peripartum hysterectomy increased 2-fold in cases of placental patology, and 17-fold in cases of uterine hypotony. Overall, 95% of hysterectomy patients required transfusions.

[Thrombotic microangiopathy in pregnancy complicated by acute hemorrhagic-necrotic pancreatitis during early puerperium]

OBJECTIVE

Authors in the article describe a case of a patient with thrombotic thrombocytopenic purpurain 37 weeks gestation complicated by acute severe hemorrhagic-necrotic pancreatitis during the early puerperium.

DESIGN

Case report.

SETTING

Ist Department of gynaecology and obstetrics of the Comenius University Bratislava.

CASE-REPORT

33-years-old patient in the 37 weeks gestation was admitted to our department with the signs of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). Due to the worsening clinical status, we have performed caesarean section. After the transient stabilization of the patient's clinical status, the hemolysis with severe thrombocytopenia reappeared. Based on the clinical signs of abdominal pain and computer tomography, the diagnosis of acute hemorrhagic-necrotic pancreatitis was set. The primary diagnosis was thrombotic thrombocytopenic purpura. Therefore, therapeutic plasma exchange was performed with consequent improvement of the patients clinical state. Normalization of the platelet count was achieved after 4.plasma exchanges. Consequently 5 plasma exchanges were performed. However, one month later, the disease relapsed. Therapeutic plasma exchanges were needed again (4x), with anti CD 20 administration. This therapy had good clinical outcome, without the need for further plasma exchanges.

CONCLUSION

Thrombotic thrombocytopenic purpura is highly lethal disease. Early diagnosis, treatment, and multidisciplinary approach are essential.

Is 48 hours enough for Obstetrics and Gynaecology training in Europe?

The European Working Time Directive, implemented by the European Union (EU) in 1993, was adopted in the medical profession to improve patient safety as well as the working lives of doctors. The Directive reduced the average amount of hours trainee doctors worked to 48 hours per week. However, its adoption has varied throughout the EU. Its potential effect on both the quality and total amount of hours of -training has caused concern. This monograph presents data on Obstetrics and Gynaecology training in Europe obtained from several of the European Network of Trainees in Obstetrics & Gynaecology's (ENTOG) surveys. The monograph demonstrates large variations in training and explains the difficulties in ascertaining whether 48 hours of training a week is sufficient to become an Obstetrics and Gynaecology specialist in Europe.

Myoma expulsion after uterine artery embolization

Uterine artery embolization (UAE) has become a standard therapy in the treatment of symptomatic uterine myomas. The procedure is associated with a few complications. One of them is myoma expulsion. A 32-year-old woman was sent to our hospital with diagnosed intramural myoma with dysmenorrhea and pressure symptoms. UAE was performed since the patient preferred conservative treatment. The procedure was without any complications. Three weeks after embolization, she was readmitted because of vaginal discharge and minor bleeding. We diagnosed expulsion of necrotic myoma and performed transvaginal resection. Four months later, the patient is symptom free. Expulsion of intramural myoma can be thus considered as definite treatment and not a complication of embolization therapy.

An alternative management for growth retarded fetus with absent end-diastolic velocity in umbilical artery and normal cardiotocography

OBJECTIVES

Intrauterine growth retardation (IUGR) is associated with fetal adverse conditions. The most important cause of growth restriction and poor perinatal outcome is chronic fetal hypoxemia (CFH). Adaptation to CFH can be studied by Doppler velocity waveform on umbilical and fetal arteries and cardiotocography (CTG).

METHODS

Preterm delivery, as an elimination of CFH, has to be confronted with the risks of prematurity. A special situation may occur when CTG is normal at the absence of end-diastolic velocity (AEDV). AEDV in the umbilical artery precedes the onset of abnormal CTG, whose duration differs considerably among the fetuses. The time after the onset of AEDV in pregnancy may be utilized for performing exact diagnosis by fetal blood analysis.

CASE

Primigravida at 30 gestational weeks was referred because of IUGR. IUGR, AEDV, oligohydramnion, and normal fetal anatomy were revealed. CTG was normal. Indication for cordocentesis was to perform cord blood gases analysis and to obtain fetal caryotype. Cordocentesis revealed normal caryotype, values of pH, and fetal blood gases were considered satisfactory. Continuation of pregnancy was decided in spite of persistent AEDV. At 33 gestational weeks pathological CTG was an indication for induction of labor. Labor, delivery, umbilical blood gases, postpartal and neonatal outcome were normal.

CONCLUSION

In the case of fetal monitoring controversy assessment of umbilical blood analysis may be crucial. This examination is significant and independent of the interval between cordocentesis and the onset of CTG pathology. This interval may be utilized for intrauterine treatment and for optimizing obstetric management.

[DNA analysis in gestational trophoblastic disease]

OBJECTIVE

DNA analysis of different forms of gestational trophoblastic disease.

DESIGN

Retrospective clinical study.

SETTING

Slovak Center of Trophoblastic Disease, Bratislava, Slovak Republic.

METHODS

In the period of September 1993 to April 2003, eighty-nine cases of gestational trophoblastic disease were analysed. There were 22 cases of partial hydatidiform moles, 58 cases of complete hydatidiform mole, 5 cases of invasive mole and 4 cases of gestational choriocarcinomas. Southern hybridization and polymerase chain reaction were used for DNA analysis.

RESULTS

From 22 analyzed cases of partial hydatidiform moles 19 (86.4%) were triploid and 3 (13.6%) diploid ones. There were 58 cases of complete hydatidiform mole and out of them 29 (50%) were homozygous, 28 (48.3%) heterozygous, and in one case (1.7%) both paternal and maternal genome was detected. In 8 cases of heterozygous and in one case of homozygous complete hydatidiform mole occurred a malignant transformation to gestational choriocarcinoma.

CONCLUSIONS

Molecular analysis can determine the nuclear DNA origin of complete hydatidiform mole and allow us to define the patients with higher risk of malignant transformation usually to gestational choriocarcinoma.

Management of intracavitary left atrium tumors during pregnancy - two case reports

OBJECTIVE

Authors documented an individual management of intracavitary left atrium tumors diagnosed during pregnancy.

SUBJECT

Two case reports were presented. Brain embolisation was supposed in the case one of intracavitary left atrium tumor. An urgent cardiosurgery at 24 weeks' gestation was performed on the cardiopulmonary bypass. In case two (multiple pregnancy - twins) cardiac tumor in left atrium was detected in third trimester of pregnancy. The mother was without any serious cardiac and systemic complications during the last trimester. Surgical approach was different - removal of tumor after delivery.

CONCLUSION

The surgical approach should be determined by clinical behavior of left atrial cardiac tumors.

[Laparoscopic findings in women with chronic pelvic pain]

Chronic pelvic pain afflicts 5-10% of women. The diagnosis of its cause is predominantly assessed by means of laparoscopy which in 60-70% reveals various organic causes of pain. The retrospective study analyses the results of 43 laparoscopic examinations indicated due to chronic pelvic pain. The average age of patients was 29.97 years. Organic findings on internal genitals were found in 36 cases (83.7%). Endometriosis was diagnosed in 11 cases (25.6%). According to the criteria of American Fertility Society, 4 patients (36.4%) suffered from stage I, 6 patients (54.5%) suffered from stage II, and only one case (9.1%) was caused by stage III. Chronic inflammatory process was diagnosed in 12 cases (18.6%), adhesions without any other pathologic findings in 8 cases (18.6%), and ovarial cysts in 3 cases (7.0%). Varicose pelvic veins and uterine myoma occurred in one case (2.3%), respectively. In 7 cases, no pathological change was revealed. Laparoscopy in coincidence with chronic pelvic pain is a significant examination which helps to reveal the organic origin of disturbance. An early decision of applying this invasive examination contributes to fast assessment of the diagnose and commencement of treatment. (Tab. 2, Fig. 1, Ref. 32.)

[Fertility after chemotherapy of gestational trophoblastic disease]

OBJECTIVE

To evaluate subsequent pregnancy experience in patients following chemotherapy for malignant form of gestational trophoblastic disease.

DESIGN

Retrospective clinical study.

SETTING

Slovak Center of Trophoblastic Disease, Bratislava, Slovak Republic.

METHODS

There were evaluated subsequent pregnancy experiences in 38 patients after chemotherapy for malignant form of gestational trophoblastic disease registered in Slovak center of gestational trophoblastic disease. Histological and cytogenetical analysis of all placentas after deliveries and material from curettage specimens after miscarriages, abortions and ectopic pregnancies were performed.

RESULTS

11 women conceived following successful chemotherapy of gestational trophoblastic disease became pregnant a total 19 times. Out of them there were 9 full-term deliveries, 2 spontaneous abortion, 1 ended in ectopic pregnancy and 7 pregnancies were terminated in therapeutic abortion. Cytogenetical analysis was successful in 7 to 10 reproductive losses with normal karyotype in all analysed cases.

CONCLUSION

Patients after successful chemotherapy of gestational trophoblastic disease have a normal reproductive outcome.

[Papillomavirus infection of the uterine cervix in women using contraception]

OBJECTIVE

The authors analyze the prevalence of the anogenital form of HPV infection as one of the most frequent STD, in the female population using different types of contraception.

METHODS

Using the method of DNA hybridization, the authors examined for HPV infection of the uterine cervix 245 users of contraception, incl. 127 women using hormonal contraception and 118 women with IUD. 112 women of this group were examined before they started to use contraception and one year after started to use it. The control group was formed by 143 using no contraception.

RESULTS

The authors found a significantly higher incidence of HPV infection of the uterine cervix in the group of women using contraception (24.1%) than in the control group (15.4%). On analysis of the group of women using contraception, as compared with the control group, they found a significantly higher incidence of HPV in women with hormonal contraception (26.0%) while the higher prevalence of HPV (by 6.6%) in women with IUD as compared with the control group was not significant. However the differences in the incidence of HPV (4%) between the two groups of women taking hormonal preparations (26.0%) or having a IUD (22%) were not significant. On examination of women before the onset of contraception and after one year of its use the authors found that candidates of contraception had as compared with the control group an insignificantly (by 3.3%) higher prevalence of HPV already before the beginning of contraception. After one year of contraception it increased by another 3.6%.

CONCLUSION

With regard to the higher incidence of HPV in women using contraception and with regard to the oncogenic effect of HPV the authors emphasize the importance of regular detailed gynaecological examinations of these women focused on early diagnosis of precancerous conditions of the uterine cervix.