Risk factor analysis in women who underwent trial of labor after cesarean section: a multicenter study in Germany

Objective: Rising caesarean delivery (CD) rates throughout the world are accompanied with high rates of severe maternal complications. The aim of the present study was to analyze the outcome of trial of labor after caesarean section (TOLAC) in a Western population and identify factors associated with the success of vaginal birth after caesarean section (VBAC). Material and Methods: A retrospective study was performed at two large obstetric departments in Germany from 2008 to 2018. Women with singleton pregnancies, a history of only one previous CD with a low transverse incision, a viable fetus in cephalic presentation, and gestational age >32 weeks were included in the study. The characteristics and outcome of successful VBAC and failed TOLAC were compared. A subgroup analysis addressed gestational age, interpregnancy interval, fetal macrosomia, body mass index, and maternal age. Results: Of 1,546 patients, 62.3% achieved VBAC while 37.7% had a secondary CD. Independent factors associated with the success of TOLAC were a history of vaginal birth in previous pregnancies (p<0.001) and the use of oxytocin (p<0.001), whereas preterm birth between gestational week 32 and 37 signified a higher risk of failed TOLAC (p=0.04). The success of VBAC did not differ significantly for patients older than 40 years of age, those with a shorter interpregnancy interval than 12 months, and fetal macrosomia with birth weight exceeding 4000 grams. Maternal and neonatal outcomes were poorer in women with failed TOLAC. Conclusion: Nearly two thirds of women with a history of CD achieve VBAC in Germany. Previous vaginal birth and the augmentation of labor with oxytocin are positively associated with the achievement of VBAC and no major perinatal complications. The decision to have a TOLAC should be encouraged in the majority of patients. Further studies are needed to evaluate the feasibility of TOLAC in preterm delivery.

Do estrogen, progesterone, P53 and Ki67 receptor ratios determined from curettage materials in endometrioid-type endometrial carcinoma predict lymph node metastasis?

AIM: Estrogen receptor (ER), progesterone receptor (PR), and Ki-67 and P53 receptor levels in endometrial curettage material were investigated for their ability to predict lymph node (LN) involvement in patients with endometrioid-type endometrial cancer (EEC). METHODS: This retrospective study was based on a review of the records of patients who were diagnosed with EEC and underwent both hysterectomy and systematic retroperitoneal lymphadenectomy at the Gynecologic Oncology Clinic of Tepecik Training and Research Hospital, Turkey, between January 2008 and August 2017. RESULTS: The curettage materials of 138 EEC patients were analyzed for ER, PR and P53 and Ki-67 receptor levels. According to the pathology results, the median pelvic LN count was 20 (range: 12-49) and the para-aortic LN count was 14 (10-46). Retroperitoneal LN involvement was present in 18 patients (13.0%). The association of LN involvement with all receptors was significant. The combined ratio of the 2 groups of markers ([P53 + Ki67]/[ER + PR]) (≥0.71) was an independent risk factor for LN involvement. In addition, in a univariate logistic regression analysis all receptors were significant predictors of LN involvement. CONCLUSIONS: In the detection of LN involvement, determination of the receptor status in curettage material has a high sensitivity and specificity. In EEC patients, receptor levels in curettage materials can be evaluated to detect LN involvement preoperatively.

Postoperative nomogram for the prediction of disease-free survival in lymph node-negative stage I-IIA cervical cancer patients treated with radical hysterectomy.

The purpose of this study was to develop and validate a nomogram for individual prediction of recurrence and disease-free survival (DFS) among lymph node (LN)-negative early-stage (I-IIA) cervical cancer (CC) patients treated with Type B or Type C2 hysterectomy. Data were collected from patients diagnosed with CC between 1995 and 2017 at the Gynecological Oncology Department, Tepecik Training and Research Hospital. A total of 194 cases with stage IA2-IIA CC were evaluated retrospectively. Patients with stage IA2-IIA CC who underwent radical (Type C2) or modified radical (Type B) hysterectomy and pelvic ± paraaortic LN dissection with LN negativity were included in the study. The relationships between prognostic factors such as stage, tumour size, parametrial involvement, vaginal cuff margin, endomyometrial infiltration, and lymphovascular space invasion status and DFS were compared using a univariable Cox regression model. When the nomogram was prepared, the scores of the risk factors were collected, and we observed that scores were at least 0 to a maximum of 414 points. The concordance-index for the nomogram was 0.895 (95% confidence interval, 0.79-0.99). The nomogram based on the indicated prognostic factors yielded excellent results in predicting recurrence in early-stage CC patients without LN metastasis who underwent radical hysterectomy.Impact statementWhat is already known on this subject? Pathology of radical hysterectomy specimens in patients with early-stage cervical cancer provides information that has predictive prognostic potential. In addition to FIGO stage, other important prognostic factors are lymph node status, tumour size, parametrial involvement, vaginal cuff margin status, endomyometrial infiltration, histological type, patient age, lymphovascular space invasion, histological grade, and depth of cervical stromal invasion.What do the results of this study add? In this study, patients with early-stage cervical cancer who underwent radical and modified radical hysterectomy without retroperitoneal lymph node involvement were evaluated, and recurrence development and factors affecting disease-free survival were investigated. A nomogram consisting of factors influencing disease-free survival was constructed. The total score was determined according to the status of all risk factors. This allowed clear definition of the risk for each patient. A nomogram predicting recurrence in patients with stages IA2-IIA cervical cancer with radical hysterectomy without lymph node involvement has not previously been published.What are the implications of these findings for clinical practice and/or further research? Our study investigated early-stage cervical cancer (CC) patients without lymph node (LN) metastasis. Cox regression analysis was performed with six prognostic factors: FIGO stage, tumour size, parametrial margin infiltration, vaginal cuff margin involvement, endomyometrial infiltration, and LVSI positivity. The nomogram was constructed based on the results of Cox regression. The C-index for the nomogram was 0.895 (95% CI, 0.79-0.99). These results can be considered excellent. The higher concordance index in our study indicates that these six factors may be more valuable in predicting recurrence development in CC patients.

Evaluation of the optimal laparoscopic method for benign ovarian mass extraction: a transumbilical route using a bag made from a surgical glove versus a lateral transabdominal route employing a standard endobag.

We compared two transumbilical (TU) routes of surgical specimen retrieval in women with ovarian masses treated via laparoscopy: a bag made from a surgical glove and lateral transabdominal (LTA) retrieval employing a standard endobag. A total of 109 women undergoing laparoscopic surgery to treat benign adnexal masses were retrospectively evaluated between 2014 and 2017. In total, 57 masses were removed via the TU route and 52 via the LTA route. We recorded the ovarian mass size; additional postoperative analgesic drug requirements. Postoperative incisional pain scores were assessed using a 10-cm visual analogue scale (VAS), time to discharge and procedure type. The mean VAS scores at 1 h (5.0 ± 1.7 vs. 6.3 ± 1.3; p < .001); 12 h (0.7 ± 0.8 vs. 1.2 ± 1.1; p = .004); and 24 h (0.1 ± 0.3 vs. 0.7 ± 0.6; p < .001) were lower in the TU-removal group. Furthermore, additional postoperative analgesic drug requirements were significantly higher in the LTA-removal group (10 (19.2%) vs. 3 (5.3%); p = .03). During laparoscopic surgery, removal of an ovarian mass via an umbilical port (compared to a lateral port) causes less postoperative pain and does not increase the risk of wound complications such as infection or hernia.Impact statementWhat is already known on this subject? Laparoscopy has been used for the last 30 years. Constant improvement in the technique and equipment has allowed extensive, laparoscopic pelvic and abdominal surgery affording better outcomes than open surgery, an improved recovery, less pain, and fewer postoperative complications. However, mass removal remains a concern. Most laparoscopic specimens are larger than the initial trocar incision. Minimally invasive, adnexal mass surgery usually requires a trocar at least 10 mm wide to remove the mass. Alternatively, adnexal mass extraction from the abdominal cavity can proceed via a suprapubic, umbilical, or vaginal route.What do the results of this study add? During laparoscopic surgery, ovarian mass removal through an umbilical port using an endobag made from a surgical glove is useful due to the method requiring little funds, is easy to do, and results in a lower amount of postoperative pain than a removal via a lateral port using a standard endobag.What are the implications of these findings for clinical practice and/or further research? A transumbilical route using a bag made from a surgical glove is easy, economical, and causes less postoperative pain to the patient than removal via a lateral port employing a standard endobag.

Preoperative predictors of pelvic and para-aortic lymph node metastases in cervical cancer.

AIM: This study investigated potential preoperative predictors of pelvic lymph node (PLN) and para-aortic LN (PaLN) involvement in cervical cancer (CC). MATERIALS AND METHODS: This study retrospectively analyzed 283 patients diagnosed with early (stage IA1-IIA) CC who underwent retroperitoneal LN dissection between January 1992 and February 2015. Several risk factors that are believed to influence PLN and PaLN involvement in CC were analyzed as follows: age >50 years, lymphovascular space invasion (LVSI), tumor size ≥2 cm, hemoglobin <12 g/dL, and nonsquamous cell histologic type. RESULTS: LVSI (odds ratio [OR] = 11.3, 95% confidence interval [CI] = 5.2-24.3) and tumor size (OR = 3.2, 95% CI = 1.4-7.2) were independent predictors of PLN involvement. None of the factors predicted PaLN involvement in a regression analysis. However, all nine patients who had PaLN involvement also had PLN involvement. CONCLUSION: LVSI and tumor size independently increase the risk of PLN involvement.

Isolated pulmonary metastases in patients with cervical cancer and the factors affecting survival after recurrence.

OBJECTIVES: The aim of this study was to assess the treatment options and survival of uterine cervical cancer (UCC) patients who develop isolated pulmonary metastases (IPM) and to establish risk factors for IPM. MATERIAL AND METHODS: Data from patients diagnosed with UCC between June 1991 and January 2017 at the Gynecological Oncology Department, Tepecik Training and Research Hospital, were investigated. In total, 43 cases with IPM were evaluated retrospectively. Additionally, 172 control patients diagnosed with UCC without recurrence were matched according to the International Federation of Gynecology and Obstetrics (FIGO) 2009 stage when the tumor was diagnosed. They wereselected using a dependent random sampling method. RESULTS: Of the 890 patients with UCC, 43 (4.8%) had IPM. The presence of lymphovascular space invasion (LVSI) and a mid-corpuscular volume (MCV) < 80 fL were statistically significant prognostic factors for IPM development in UCC patientsaccording to univariate regression analyses, and the presence of LVSI, a hemoglobin level < 12 g/dL, and an MCV < 80 fLwere statistically significant according to the multivariate regression analyses. We were unable to assess the role of lymph node status (involvement or reactive) as a prognostic factor in the development of IPM, because only seven patients (16.2%) in the case group underwent lymph node dissection. CONCLUSIONS: IPM typically develops within the first 3 years after the diagnosis of UCC, and survival is generally poor. An MCV < 80 fL and the presence of LVSI are significant risk factors for IPM development.

Active management of the third stage of labor: A brief overview of key issues.

Postpartum hemorrhage is a potentially life-threatening, albeit preventable, condition that persists as a leading cause of maternal death. It occurs mostly during the third stage of labor, and active management of the third stage of labor (AMTSL) can prevent its occurrence. AMTSL is a recommended series of steps, including the provision of uterotonic drugs immediately upon fetal delivery, controlled cord traction, and massage of the uterine fundus, as developed by the World Health Organization. Here, we present current opinion and protocols for AMTSL.

Management of Vertebral Metastasis in Patients With Uterine Cervical Cancer.

AIM: We sought to identify risk factors and management options for uterine cervical cancer (UCC) patients with a vertebral metastasis (VM) treated over the course of 23 years. METHODS: Among 844 UCC patients, 18 were diagnosed with a VM. Thirty-six control patients with UCC but without recurrence were matched to these 18 in terms of stage and histological tumor type using a dependent random sampling method. A logistic regression analysis was used to identify factors prognostic of VM; the results are presented as odds ratios with 95% confidence intervals (CIs). RESULTS: The mean survival time after VM treatment commenced was 12.1 ± 2.7 months (95% CI, 5.3-12.6 months) in patients who received chemotherapy (CT) and 15.0 ± 2.3 months (95% CI, 9.7-14.2 months) in those treated via chemoradiotherapy (CRT) (P = 0.566). In patients who underwent CT, the 1- and 2-year survival rates after recurrence were 19.2% and 0%, respectively. However, these figures were 50% and 8.3% in those treated via CRT. Both lymphovascular space invasion and mean corpuscular volume were risk factors for VM. Cox regression analysis showed that these prognostic factors had no effect on survival duration after recurrence. The locations and percentages of vertebra metastasis were as follows: 11.1% lumbar 4, 27.7% lumbar 5, 22.2% lumbar 4-5, 16.7% lumbar 3-4-5, 5.6% lumbar 2-3, 5.6% lumbar 2-3-4, 5.6% lumbar 3-4-5/sacral 1, and 5.6% thoracic 11-12/lumbar 1-2. CONCLUSIONS: We found that patients with lymphovascular space invasion were at high risk of isolated VM and that the survival times after CT and CRT were similar. Because most VMs are seen in the vertebral space within the borders of radiation therapy, borders of external beam radiotherapy should be carefully determined for each patient.

Is the measurement of the size of uterine lesions with positron emission tomography consistent in pre- and postmenopausal periods in endometrioid-type endometrial cancer?

OBJECTIVE: We aimed to investigate the correlation of the size and volume of uterine tumors obtained using positron emission tomography/computed tomography (PET/CT) and pathology specimens in patients with endometrioid-type endometrial cancer (EEC) in the premenopausal period, and to compare the results with those of postmenopausal women. In the premenopausal period, the endometrium uses more glucose than in the postmenopausal period. Therefore, the measurement of uterine tumor size using PET/CT in the premenopausal period may normally be different. MATERIALS AND METHODS: In this retrospective study, we reviewed the records of patients who were diagnosed as having EEC and underwent hysterectomy. Only patients who underwent preoperative PET/CT imaging were included in the study. The thickness and volume of the uterine lesion, and its maximum standardized uptake value as obtained using PET/CT and hysterectomy pathology specimens were recorded. RESULTS: Tumor size (p=0.051) and volume (p=0.404) were not found to be correlated with the imaging method used in premenopausal women and pathologic specimens. However, there was a correlation in postmenopausal women (p<0.001 for tumor size and p<0.001 for tumor volume). PET/CT has higher sensitivity, specificity, and positive predictive value in the postmenopausal period in the detection of >20 mm uterine tumors. CONCLUSION: PET/CT has a limited role in the measurement of the size of uterine lesions in all patients, especially in the premenopausal period; therefore, we recommend that frozen-section examinations be used intraoperatively to decide on lymph node dissection.

MELF Pattern for Predicting Lymph Node Involvement and Survival in Grade I-II Endometrioid-type Endometrial Cancer.

The aim of this study was to examine the associations between microcystic, elongated, and fragmented (MELF) pattern and other prognostic factors and lymph node involvement, disease-free survival, and overall survival (OS) using a case-control group consisting of grade I-II endometrioid endometrial carcinoma (EEC) patients with/without lymph node involvement. The files of the patients were searched electronically for all hysterectomy specimens with a diagnosis of grade I-II EEC of the uterine body from January 1, 2008 to July 31, 2014. Lymph node involvement was detected in 27 patients who were histologically diagnosed with grade I-II EEC, and these patients made up the case group. Using a dependent random sampling method, 28 grade I-II EEC patients without lymph node involvement were selected. According to multivariate regression analysis, lymphovascular space invasion [odds ratio, 23.5; 95% confidence interval (CI), 2.4-223.5] and MELF pattern (odds ratio, 13.3; 95% CI, 1.4-121.8) were significant predictors of lymph node involvement. There was recurrence in 15.8% of cases that showed a MELF pattern and in 19.4% of those that did not (P=0.738). According to Kaplan-Meier analysis, the MELF pattern revealed no significant differences in disease-free survival (hazard ratio, 1.0; 95% CI, 0.1-36.5), whereas the effect on OS was significant (hazard ratio, 2.2; 95% CI, 1.3-4.2). The presence of MELF pattern was a substantial risk factor for detecting lymph node involvement in patients with grade I-II EEC. The MELF pattern may be important for identifying which patients need staging surgery, in addition to its effect on the OS.

Stage IB1 cervical cancer treated with modified radical or radical hysterectomy: does size determine risk factors?

OBJECTIVES: This study was performed to investigate prognostic factors status at smaller tumors in patients with stageIB1 cervical cancer (CC) who underwent modified radical or radical hysterectomy. MATHERIAL AND METODS: Data from patients diagnosed with CC between January 1995 and January 2017 at the GynecologicalOncology Department, Tepecik Training and Research Hospital and Bakirkoy Dr. Sadi Konuk Training and Research Hospital,Istanbul, Turkey, were investigated. A total of 182 stage IB1 CC cases were evaluated retrospectively. RESULTS: Patients were divided into two groups according to tumor size (< 2 cm and ≥ 2 cm). There were no complicationsassociated with the operation in patients with a tumor size < 2 cm. Among patients with a tumor size ≥ 2 cm, however, 0.9% (n = 1) developed bladder laceration, 0.9% (n = 1) rectum laceration, and 0.9% (n = 1) pulmonary emboli (P = 0.583). The rates of intermediate risk factors (depth of stromal invasion and lymphovascular space invasion) were significantly higher and lymph node involvement significantly more frequent in patients with a tumor size ≥ 2 cm. However, there were no significant differences in parametrial invasion or vaginal margin involvement between the two groups. CONCLUSIONS: Intermediate risk factors and lymph node metastasis were significantly less frequent in patients with small tumors measuring < 2 cm. However, although parametrial involvement and vaginal margin involvement were less common in patients with small tumors compared with large tumors (≥ 2 cm), the differences were not significant.

Outcomes of patients with advanced stage ovarian cancer with intestinal metastasis.

OBJECTIVES: The aim of this study is to evaluate the results of advanced stage (stage IIIB-IVB) ovarian cancer (OC) patients with intestinal metastasis, and to investigate the factors that affect survival. MATERIAL AND METHODS: Patients who underwent cytoreductive surgery (CS) for FIGO stage IIIB-IVB OC with metastasis in the intestinal system, at Tepecik Research and Treatment Hospital between 2008-2014, were analyzed retrospectively. Patients with borderline ovarian tumor; those who had previously undergone radiation therapy and/or hysterectomy and patients having secondary or tertiary cytoreduction were excluded and 49 patients were included and analyzed in this study. Hysterectomy, bilateral salpingo-oopherectomy, pelvic and para-aortic lymph node sampling, resection of bulky lymph nodes and omentectomy were performed. Optimal cytoreduction was accepted as that which left residual tumor ≤ one cm maximum size. RESULTS: The risk factors affecting OS interval were investigated according to Cox' regression analysis. Optimality of the primary CS (P = 0.008 and HR = 5.202) and cancer stage (P = 0.016 and HR = 6.083) were found to be statistically significant factors. CONCLUSIONS: Achieving optimal CS is the most important aim for the general surgeon carrying out an intestinal resection procedure. Although resection procedures are superior in providing the desired optimal results when compared to excision surgery, their higher complication rates and subsequent lower quality of life must be taken into consideration when choosing either resection or excision methods; surgical intervention should always be kept to the minimum possible.

Management of Isolated Vaginal Metastasis in Squamous Cell Cervical Cancer: 23 Years' Experience at a Single Center.

AIM: The aim of this study was to investigate the treatment options and survival of cervical cancer (CC) patients who develop isolated vaginal metastasis (IVM), and to establish risk factors for IVM. PATIENTS AND METHODS: A total of 21 cases with IVM were evaluated retrospectively. In addition, 42 control patients diagnosed with CC without recurrence were matched. Tumor size, depth of stromal invasion (DOI), lymphovascular space invasion (LVSI), and size of vaginal and lymph node metastases were analyzed in accordance with the pathology reports. Patients who had IVM were investigated in terms of treatment options (chemotherapy (CT), radiotherapy (RT), or chemoradiotherapy (CRT)) and survival. RESULTS: After detection of IVM, the 1-, 3-, and 5-year survival rates were 57.1, 23.8, and 9.5%, respectively. The mean survival time after metastasis detection was 23.1 ± 31.3 months. LVSI, DOI ≥ 1/2, hemoglobin < 12 g/dl, postmenopausal status, and tumor size ≥ 4 cm were independent risk factors for IVM. The 5-year survival rates were 30.0% for patients receiving RT, 17.1% for patients receiving CRT, and 0% for patients receiving CT. CONCLUSION: IVM typically develops within the first 2 years after the diagnosis of CC, and survival is generally poor. RT was the most effective treatment in patients with IVM.

Effects of maternal obesity on antenatal, perinatal and neonatal outcomes.

OBJECTIVE: Obesity is critically important to maternal and fetal health during the perinatal period. We have detected an increasing prevalence of maternal obesity in recent years and investigated its complications during pregnancy. METHODS: A total of 931 pregnant females were investigated between March 2012 and March 2013. The patients were divided into four groups: body mass index (BMI) < 18.5 kg/m(2) was underweight, 18.5-24.9 kg/m(2) was normal weight, 25-29.9 kg/m(2) was overweight and ≥30 kg/m(2) was obese. The effects of obesity on fetal and maternal outcomes were investigated. RESULTS: Significant increases in pregnancy-induced hypertension, gestational diabetes mellitus, cesarean delivery, premature rupture of membranes, shoulder dystocia, meconium-stained amniotic fluid, abnormal heart rate pattern and postpartum infection rates were found in the obese group during the perinatal period. Adverse maternal effects in obese cases were significantly more frequent than those in normal-weight cases. Preterm birth, perinatal mortality, low APGAR scores, newborn intensive care unit requirement, hypoglycemia and macrosomia rates were significantly higher in obese cases than those in non-obese cases. However, low birth weight infant rate was higher in the low BMI cases than that in the other BMI categories (p < 0.01). CONCLUSION: We conclude that obesity is an important factor associated with pregnancy complications and the increase in maternal-fetal morbidity and mortality.