[Hyperreactio Luteinalis and an Incidentally Detected FIGO IIIB Borderline Tumor of the Ovary in Pregnancy - Diagnostic, Therapy and Review of Literature]. / Hyperreactio luteinalis mit Zufallsbefund eines serösen Borderline-Tumor des Ovars FIGO IIIB im 3. Trimenon ­ Diagnostik, Therapie, Literaturrecherche.

Adnexal masses affect 2-10% of all pregnancies. The highest incidence of 1-6% can be seen in the first trimester, with a high rate of spontaneous remission. Two percent of these masses are malignant neoplasms or borderline tumors. A rare benign mass of the adnexa in pregnancy is hyperreactio luteinalis characterised by bilateral, multicystic ovaries with a frequent occurrence in the 3rd trimester. Clinical signs include maternal hyperandrogenaemia with virilisation, hyperemesis, nonspecific abdominal pain or laboratory findings of hyperthyroidism and elevated ß-HCG. Hyperreactio luteinalis does not require therapy due to complete spontaneous remission postpartum, but is often treated surgically in graviditate. In our case we report a first-time gravida in the 31st week of pregnancy with a symptomatic 25-cm multicystic, partly solid mass. After antenatal corticosteroid therapy, an exploratory laparotomy with right adnexectomy was performed on suspicion of malignancy. Histology revealed a hyperreactio luteinalis with an incidental finding of a serous borderline tumor of the ovary (FIGO IIIB). At 33 weeks of gestation, a pathological CTG was observed, and an urgent secondary caesarean section by re-longitudinal laparotomy was performed. Postpartum completion surgery revealed no further neoplastic cells.

Atezolizumab in combination with bevacizumab and chemotherapy versus bevacizumab and chemotherapy in recurrent ovarian cancer - a randomized phase III trial (AGO-OVAR 2.29/ENGOT-ov34).

BACKGROUND: Improvement in clinical outcomes of patients with platinum-resistant disease is an unmet medical need and trials in this population are urgently needed. Checkpoint-inhibitors have already shown activity in multiple other tumor entities and ovarian cancer, especially in the combination with anti-angiogenic treatment. PRIMARY OBJECTIVE: To test if the activity of non-platinum-based chemotherapy and bevacizumab could be improved by the addition of atezolizumab. STUDY HYPOTHESIS: The addition of atezolizumab to standard non-platinum combination of chemotherapy and bevacizumab improves median overall survival from 15 to 20 months. TRIAL DESIGN: Patients are randomized to chemotherapy (paclitaxel weekly or pegylated liposomal doxorubicin) + bevacizumab + placebo vs chemotherapy + bevacizumab + atezolizumab. Stratification factors are: number of prior lines, planned type of chemotherapy, prior use of bevacizumab, and tumor programmed death-ligand 1 (PD-L1) status. MAJOR INCLUSION/EXCLUSION CRITERIA: Recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer with up to three prior therapies and a treatment-free interval after platinum of less than 6 months. Patients with three prior lines of chemotherapy are eligible irrespective of the platinum free-interval. A de novo tumor tissue sample biopsy for determination of PD-L1 status prior to randomization for stratification is mandatory. Major exclusion criteria consider bevacizumab-specific and immunotherapy-specific criteria. PRIMARY ENDPOINT: Overall survival and progression-free survival are co-primary endpoints. SAMPLE SIZE: It is planned to randomize 664 patients. TRIAL REGISTRATION: NCT03353831.

Predictors for a successful external cephalic version: a single centre experience.

PURPOSE: The external cephalic version (ECV) is one of the options patients presenting with a breech pregnancy should be offered. Various fetal, maternal and other predictors for a successful ECV have been published in the past. METHODS: This is a retrospective multivariate analysis of our ECV patient database at the Department of Obstetrics and Gynaecology at the University Hospital Ulm. In an outpatient setting, patients with fetal breech position were routinely offered an ECV attempt after 36 weeks of gestation if the patient was willing to consent. Contraindications for ECV were placental abruption, placenta praevia, uterus malformations, regular contractions, premature rupture of membranes, and non-reassuring fetal heart rate patterns. RESULTS: From January 1st 2010 to July 31st 2013, 444 patients with a minimum of 36 weeks gestational age (i.e. >35 + 6 weeks) attended our clinic with a breech presentation. Of those 118 had an ECV attempt and an extended ultrasound examination within 21 days. In 33 patients the procedure was successful (success rate 28 %). A multivariate binary logistic regression analysis revealed that an increased Amniotic Fluid Index (AFI; p < 0.001), at least one prior vaginal delivery (p = 0.002) or a high estimated fetal weight (p = 0.045) were significant independent predictors for a successful ECV. In our series no delivery occurred within 48 h after the ECV. CONCLUSIONS: An ECV is a safe procedure. ECV should be offered as an option for the mother-to-be on the basis of an informed consent. Identified fetal and maternal factors can help to estimate the chances of success and in particular multi-parity and increased amniotic fluid seem to be associated with successful ECV.

The influence of obesity on survival in early, high-risk breast cancer: results from the randomized SUCCESS A trial.

INTRODUCTION: Obese breast cancer patients have worse prognosis than normal weight patients, but the level at which obesity is prognostically unfavorable is unclear. METHODS: This retrospective analysis was performed using data from the SUCCESS A trial, in which 3754 patients with high-risk early breast cancer were randomized to anthracycline- and taxane-based chemotherapy with or without gemcitabine. Patients were classified as underweight/normal weight (body mass index (BMI) < 25.0), overweight (BMI 25.0-29.9), slightly obese (BMI 30.0-34.9), moderately obese (BMI 35.0-39.9) and severely obese (BMI ≥ 40.0), and the effect of BMI on disease-free survival (DFS) and overall survival (OS) was evaluated (median follow-up 65 months). In addition, subgroup analyses were conducted to assess the effect of BMI in luminal A-like, luminal B-like, HER2 (human epidermal growth factor 2)-positive and triple-negative tumors. RESULTS: Multivariate analyses revealed an independent prognostic effect of BMI on DFS (p = 0.001) and OS (p = 0.005). Compared with underweight/normal weight patients, severely obese patients had worse DFS (hazard ratio (HR) 2.70, 95 % confidence interval (CI) 1.71-4.28, p < 0.001) and OS (HR 2.79, 95 % CI 1.63-4.77, p < 0.001), while moderately obese, slightly obese and overweight patients did not differ from underweight/normal weight patients with regard to DFS or OS. Subgroup analyses showed a similar significant effect of BMI on DFS and OS in patients with triple-negative breast cancer (TNBC), but not in patients with other tumor subtypes. CONCLUSIONS: Severe obesity (BMI ≥ 40) significantly worsens prognosis in early breast cancer patients, particularly for triple-negative tumors. TRIAL REGISTRATION: Clinicaltrials.gov NCT02181101 . Registered September 2005.

Treatment cost evaluation of extrauterine gravidity: a literature review of medical and surgical treatment costs.

BACKGROUND: The diagnosis of extrauterine pregnancy is possible very early giving the patient and doctors treatment options. As the risks and success rate of medical and surgical treatment are similar, the decision is increasingly influenced by cost-effectiveness. OBJECTIVE: The following article systematically reviews the known literature regarding cost, decision criteria and possible follow-up. METHODS: Literature review of extrauterine gravity in combination with cost in the online National Library of Medicine since 1.1.1997 following the PRISMA recommendations. RESULTS: Six articles were identified in which the cost of the laparoscopic versus medical treatment is reviewed. In five articles, the medical treatment was shown to be more cost effective and in the sixth article the costs were found to be equal. The cost saving varies between 18 and 88% depending on the consideration of direct and indirect costs. If indirect expenses are considered, the total sum increases with treatment failures. Failure rates are given as up to 27% depending on the type of failure (surgical or medical). These rates seem to be linked indirectly with the ß-HCG levels. Predictive parameters for the successful medical treatment are missing. CONCLUSIONS: The treatment of small extrauterine gravidities in haemodynamically stable patients (defined by HCG levels <1,500 IU/l) is medically successful and cost-effective. With HCG levels between 1,500 IU/l and 3,000 IU/l, the treatment costs are similar. HCG levels >5,000 IU/l favour the surgical treatment as being more cost-effective. A similar cut-off for the sonographic imaging is missing.

Is open surgery the solution to avoid morcellation of uterine sarcomas? A systematic literature review on the effect of tumor morcellation and surgical techniques.

PURPOSE: Today's surgical standard of care for uterine leiomyomas is laparoscopic and/or vaginal surgery with larger specimens requiring morcellation to avoid open surgery. This is often associated with intra-abdominal dissemination of cellular material which in case of a uterine sarcoma might result in iatrogenic seeding of malignant tumor cells. The aim of this systematic literature review is to evaluate the surgical techniques and the impact of accidental tumor morcellation on the outcome of patients postoperatively diagnosed with malignant uterine sarcomas. METHODS: The National Library of Medicine database (pubmed) and Web of science were searched individually using three different search terms ('morcel* sarcoma', 'survival, sarcoma, treatment, Uter*', and 'disease free survival, sarcoma, treatment, uter*'). After excluding duplicates and screening for relevance, 16 articles were left for full-text review, resulting in seven case series with more than 5 patients. RESULTS: The case numbers range from 14 to 123 patients with the majority of cases being leiomyosarcomas. CONCLUSION: There is no reliable diagnostic tool to differentiate a fibroid from a uterine sarcoma preoperatively. Tumor morcellation occurs in various open and closed surgical techniques and is not limited to laparoscopic surgery only. There is an urgent need for a presurgical diagnostic parameter.

Differential prognostic relevance of patho-anatomical factors among different tumor-biological subsets of breast cancer: Results from the adjuvant SUCCESS A study.

OBJECTIVES: In breast cancer, large tumor size, positive nodal stage and a triple-negative tumor subtype are associated with reduced survival, but the interactions between these prognostic factors are not well understood. MATERIAL AND METHODS: Here we re-evaluated the impact of tumor size, nodal stage and tumor subtype on disease-free survival (DFS), overall survival (OS), distant disease-free survival (DDFS) and breast cancer specific survival (BCSS) in a retrospective analysis using data from the adjuvant SUCCESS A trial. Subgroup analyses were conducted to assess whether the effect of tumor size and nodal stage on survival depended on tumor subtype. RESULTS: Increasing tumor size, higher nodal stage and triple negative breast cancer (TNBC) were associated with unfavorable prognosis (all p < 0.001). There was no significant interaction between tumor subtype and tumor size (p > 0.5 for all four survival endpoints), but we found significant interactions between tumor subtype and nodal stage (p < 0.05 for all four survival endpoints), with no differences in survival among tumor subtypes for patients with pN0 tumors (all p > 0.05) and pronounced differences in survival among tumor subtypes for patients with positive nodal stage (all p < 0.001). CONCLUSIONS: This analysis confirms tumor size, nodal stage and tumor subtype as independent prognostic factors in high-risk early breast cancer. Nodal-positive patients with TNBC had a considerably worse outcome compared to nodal-positive patients with another tumor subtype. This underlines the importance for early detection particularly for patients with TNBC. TRIAL REGISTRATION: EudraCT 2005-000490-21; ClinicalTrials.gov Identifier: NCT02181101.

Evaluation of Sentinel Lymph Node Dose Distribution in 3D Conformal Radiotherapy Techniques in 67 pN0 Breast Cancer Patients.

Introduction. The anatomic position of the sentinel lymph node is variable. The purpose of the following study was to assess the dose distribution delivered to the surgically marked sentinel lymph node site by 3D conformal radio therapy technique. Material and Method. We retrospectively analysed 70 radiotherapy (RT) treatment plans of consecutive primary breast cancer patients with a successful, disease-free, sentinel lymph node resection. Results. In our case series the SN clip volume received a mean dose of 40.7 Gy (min 28.8 Gy/max 47.6 Gy). Conclusion. By using surgical clip markers in combination with 3D CT images our data supports the pathway of tumouricidal doses in the SN bed. The target volume should be defined by surgical clip markers and 3D CT images to give accurate dose estimations.