The Role of Lymphovascular Space Invasion and Cytology in the Prognosis of Endometrial Cancer.

BACKGROUND: Lymphovascular space invasion (LVSI) and cytology are both independent and strong prognostic factors in endometrial cancer. This study aims to highlight the impact of LVSI and cytology positivity on prognosis, in addition to molecular classification. METHODS: A retrospective review was conducted on the records of 223 patients with endometrial cancer diagnosed between January 2011 and January 2021. The inclusion criteria stipulated that the patients were diagnosed with endometrial cancer by endometrial biopsy and were operated in the clinic. The exclusion criteria included sarcoma in the postoperative pathology report results or synchronous tumor. Staging was performed according to the Fédération internationale de gynécologie et d'obstétrique (FIGO) 2009 criteria. Cytology (using 50 cc saline) was obtained upon entry into the peritoneal cavity. In 20 patients, saline was not used due to the presence of ascites in the abdomen. The Kaplan-Meier method was employed to evaluate overall survival and progression-free survival. Survival rates were compared in terms of cytology and LVSI. RESULTS: After analyzing the postoperative pathology results, it was found that the mean tumor size was 4.03 ± 2.3 cm. The most common histological type was endometrioid carcinoma, with stage IA being the most common stage. Out of 223 patients with endometrial cancer, the overall survival rate was 82.4%, and the progression-free survival rate was 88.3%. For patients negative for LVSI, the progression-free survival rate was 93%, while for LVSI-positive patients, it was 77.3% (p < 0.001). Additionally, the progression-free survival rate for patients negative for cytology was 90.4%, whereas for cytology-positive patients, it was 77.1% (p < 0.05). CONCLUSIONS: In our study, we observed that LVSI positivity and cytology positivity also reduced the overall survival rate. We aimed to highlight that, in addition to molecular classification, cytology positivity and LVSI positivity are still highly significant and independent factors in prognosis.

Relationship between molecular markers and lymphadenectomy and lymphovascular space invasion in endometrial cancer.

PURPOSE: Relationship between pathologic parameters, surgical parameters, or lymph node status with oncologic outcomes is not fully elucidated in endometrial cancer (EC). We want to investigate the molecular classification of uterine cancer in the Turkish population and its relationship between lymphadenectomy and lymph node metastasis. METHODS: In this study, 100 patients' clinical and pathologic data diagnosed with EC were analyzed. Pathologic and molecular parameters were investigated and compared them with clinical parameters. RESULTS: According to the molecular analysis, 16 patients (16%) had p53 mutation, 3 patients (3%) were classified as POLE mutant group, 38 (38%) patients in the MSI group, and the remaining 43 patients (43%) into the no specific mutation profile (NSMP) group. Lymph node metastasis rate was significantly higher in copy number high (CNH) group compared to the others. In the CNH group, 29 of 437 (6.6%) dissected lymph nodes had metastasis. The median OS was the highest in the POLE group (72 months) and lowest in the CNH group (36 months). CONCLUSION: Endometrial cancer patients showed significantly different overall and disease-free survival according to the molecular subtypes and it was consistent with the literature, Lymph node metastasis risk was the highest in CNH group. MSI status is important for the lymph node metastasis risk but not all abnormalities, especially PMS2 and MLH1 expression changes showed the highest risk.

Prognostic value of systemic inflammation response index in patients with persistent human papilloma virus infection.

OBJECTIVES: Persistent human papilloma virus (HPV) infection is a risk factor for the progression of cervical neoplasia into invasive carcinoma. Many inflammatory markers obtaining from hemogram parameters as platelets, monocytes, lymphocytes, and neutrophils or their ratios are still under investigation in recent decades, especially in the oncology era. Indeed, there have not been enough data about the relationship between these parameters and cervical cancer in the literature. Our primary aim was to investigate the possible relationship between the persistent HPV, which is one of the significant risk factors of cervical cancer, and these inflammatory markers. Further, we can add an easy follow-up parameter in women with persistent HPV infection. MATERIAL AND METHODS: The study included patients between 30-65 years old, tested positive for HPV, and afterward had an HPV control test between January 2015 and June 2020. RESULTS: The study included 114 HPV DNA-positive patients. The mean age was 43 (standard deviation 8.7), and 41 of them (36%) had persistent HPV, but the remaining 73 (64%) did not. The baseline neutrophil/lymphocyte ratio (NLR) value was 2.1, platelet/lymphocyte ratio (PLR) was 133, monocyte/lymphocyte ratio (MLR) was 0.28, and systemic inflammation response index (SIRI) was 0.9. All the parameters were significantly higher in the persistent HPV group compared to the non-persistent group. Patients who had 0.65 and under this had a significantly lower risk of persistent HPV. CONCLUSIONS: Persistent HPV disease can be predicted with an elevated SIRI, NLR, and other hematologic parameters. So, we can closely follow up with these patients with different algorithms to prevent cervical cancer.

Clinical implication of preoperative psoas muscle area in endometrial cancer patients.

OBJECTIVE: Obesity is a significant risk factor for endometrial cancer. In contrast, sarcopenia describes a loss of the body's muscle mass that is closely related to unfavorable clinical outcomes. Even endometrial cancer patients have high rates of obesity, and they should have a significantly higher risk for undiagnosed sarcopenia or fragile muscle quality. METHODS: This is a retrospective study that included an endometrial cancer database collected from a tertiary gynecologic cancer center. We investigated the relationship between preoperative psoas muscle area by magnetic resonance imaging, surgical outcomes and pathological features. RESULTS: The study included 116 patients, the mean height was 160 cm (Standart deviation 7), weight was 72 kg (Standart deviation 18), and the median duration of hospitalization was 4 days (Interquartile range 2-9) in the whole study group. Sarcopenia was diagnosed in 25 (21.6%) patients, according to the magnetic resonance imaging findings. Three (6.5%) obese patients had sarcopenia, but it was 31.4% in nonobese patients (p=0.026). The median duration of hospitalization was five days (3-9 days) in the sarcopenia group, and it was four days (2-7 days) in the non-sarcopenia group. CONCLUSION: Sarcopenic patients did not have increased surgical complication rates following uterine cancer surgery. We should be aware of hospitalization duration in those patients, and sarcopenic counterparts necessitate longer follow-up after the surgery.

Two-Year Follow-Up Results of Transobturator Tape Procedure with and without Concomitant Vaginal Surgery.

OBJECTIVE: This study aims to evaluate the subjective and objective outcomes of the transobturator tape (TOT) procedure performed to treat stress urinary incontinence and to determine the efficacy and safety of the TOT procedure when used along with vaginal surgery. METHODS: This is a prospective review of 24 women who had the TOT procedure done only due to stress incontinence; 22 women who underwent concomitant TOT and pelvic floor repair; and 20 women who received concurrent TOT, transvaginal hysterectomy, and sacrospinous ligament fixation. RESULTS: When compared to the patients who had TOT with pelvic floor repair, the patients who underwent TOT with hysterectomy declared to have more dyspareunia (p = 0.008) and they were found to have significantly higher post-void residual volume (p = 0.014). When compared to the patients who had only TOT, the patients who underwent TOT with hysterectomy claimed to have more pelvic pain (p = 0.012) and significantly higher post-void residual volume (p = 0.020). CONCLUSION: The TOT procedure results in moderately high objective cure rates, and concurrent application of pelvic floor repair or transvaginal hysterectomy does not affect these rates. The relatively higher incidences for voiding problems and pelvic pain in women who underwent TOT, hysterectomy, and sacropinous fixation simultaneously suggest that the extent of surgery directly correlates with the severity of postoperative complications.

Plasma L-carnitine levels of obese and non-obese polycystic ovary syndrome patients.

It is well-known that plasma L-carnitine concentrations are significantly decreased in obese individuals. A study showed that L-carnitine concentrations are significantly lower in lean PCOS patients than in lean healthy women. Thus, it has been suggested that lowered L-carnitine is associated with PCOS. This study also showed that the women with PCOS had significantly lower L-carnitine levels than those of the healthy controls. In addition, this study hypothesised that low L-carnitine levels in PCOS patients were associated with obesity and/or insulin resistance. Moreover, plasma L-carnitine concentrations were found to be statistically similar in PCOS patients and healthy controls, when controlled for obesity. This study implied that L-carnitine could be used as an adjunctive therapy in the management of insulin resistance or obesity in women who have PCOS. Further research might be planned to clarify the clinical effects of L-carnitine administration in PCOS patients with insulin resistance and/or obesity.

Recurrent uterine leiomyosarcoma: an atypical location.

Leiomyosarcoma (LMS) is a malignant tumor of smooth muscle cells and comprises 5-24% of all soft tissue sarcomas. Although the most frequent symptoms are vaginal bleeding and abdominal pain, the symptoms are generally associated with dimensions and localization of the tumor. The current study presents a case of uterine leiomyosarcoma that metastasized to the rectus abdominis muscle, which has only been previously reported in two cases in the literature. A 57-year-old multigravid patient presented with a palpable mass in her abdomen. The patient's past medical history revealed a hysterectomy performed in another center seven years ago with a postoperative histopathological report of leiomyosarcoma. A myomatous mass was detected, which was localized at the distal part of the right rectus muscle during operation. The mass was completely excised. The case was diagnosed as leiomyosarcoma according to the histopathological findings. Any mass in a skeletal muscle should be suspected to be metastasis in patients with a prior history of aggressive gynecologic malignancy such as LMS.

Comparison of four different pain relief methods during hysterosalpingography: a randomized controlled study.

BACKGROUND: Hysterosalpingography (HSG) is the most commonly used method for evaluating the anatomy and patency of the uterine cavity and fallopian tubes, and is an important tool in the evaluation of infertility. The most frequent side effect is the pain associated with the procedure. OBJECTIVES: To evaluate four analgesic methods to determine the most useful method for reducing discomfort associated with HSG. METHODS: In the present prospective study, 75 patients undergoing HSG for evaluation of infertility were randomly assigned to four groups: 550 mg of a nonsteroidal anti-inflammatory drug (NSAID) (group 1); 550 mg NSAID + paracervical block (group 2); 550 mg NSAID + paracervical analgesic cream (group 3); or 550 mg NSAID + intrauterine analgesic instillation (group 4). A visual analogue scale was used to assess the pain perception at five predefined steps. RESULTS: Instillation of the liquids used for HSG was found to be the most painful step of HSG, and this step was where the only significant difference among groups was observed. When comparing visual analogue scale scores, group 2 and group 3 reported significantly less pain than the other groups. Group 1 reported significantly higher mean (± SD) scores (7.2 ± 1.6) compared with groups 2 and 3 (4.7 ± 2.5 and 3.8 ± 2.4, respectively) (P<0.001). In addition, group 2 reported significantly less pain than group 4 (4. 7 ± 2.5 versus 6.7 ± 1.8, respectively) (P<0.02). CONCLUSIONS: For effective pain relief during HSG, in addition to 550 mg NSAID, local application of lidocaine cream to the posterior fornix of the cervix uteri and paracervical lidocaine injection into the cervix uteri appear to be the most effective methods.

Could the platelet-to-lymphocyte ratio be a novel marker for predicting invasiveness of cervical pathologies?

PURPOSE: To determine whether the preoperative platelet to lymphocyte ratio (PLR) could predict invasiveness of cervical pathologies. MATERIALS AND METHODS: Patients with preinvasive and invasive diseases were reviewed retrospectively, over a nine-year period, 2005-2014. The pathological records and completed blood counts of the patients were collected and recorded in the SPSS program. Patients were divided in two groups, preinvasive and invasive. RESULTS: The median PLR was significantly higher in the invasive group than in the preinvasive group (p=0.03). There was a correlation between invasion of cervical cancer and white blood cell count, red cell distributing width (RDW), neutrophil-lymphocyte ratio (NLR), and PLR. CONCLUSIONS: This study showed that patients with uterine cervical cancer may present with leukocytosis, increased RDW, NLR and PLR. These cheap and easily available parameters, especially PLR, may provide useful information about the invasiveness of cervical lesions.

Impact of a lung-protective ventilatory strategy on systemic and pulmonary inflammatory responses during laparoscopic surgery: is it really helpful?

Laparoscopic surgery is performed by carbon dioxide (CO2) insufflation, but this may induce stress responses. The aim of this study is to compare the level of inflammatory mediators in patients receiving low tidal volume (VT) versus traditional VT during gynecological laparoscopic surgery. Forty American Society of Anesthesiologists (ASA) physical status 1 and 2 subjects older than 18 years old undergoing laparoscopic gynecological surgery were included. Systemic inflammatory response was assessed with serum IL-6, TNF-alpha, IL-8, and IL-1ß in patients receiving intraoperative low VT and traditional VT during laparoscopic surgery [within the first 5 min after endotracheal intubation (T1), 60 min after the initiation of mechanical ventilation (T2), and in the postanesthesia care unit 30 min after tracheal extubation (T3)]. Additionally, inflammatory response was assessed with bronchoalveolar lavage (BAL) at T1 and T3 periods. An increase in the serum levels of IL-6, TNF-alpha, IL-8, and IL-1ß was observed in both groups during the time periods of T1, T2, and T3. No significant differences were found in the serum and BAL levels of inflammatory mediators during time periods between groups. The results of the present study suggested that the lung-protective ventilation and traditional strategies are not different in terms of lung injury and inflammatory response during conventional laparoscopic gynecological surgery.

L-Carnitine: a new insight into the pathogenesis of endometrial cancer.

OBJECTIVES: The present study aims to specify the role of L-carnitine in the pathogenesis of endometrial cancer by comparing the serum total L-carnitine levels of endometrial cancer patients with those of healthy women. METHODS: Serum total L-carnitine concentrations were measured in patients with endometrioid-type endometrial cancer (n = 20) and healthy controls (n = 20) who were matched with respect to age and body mass index (BMI). RESULTS: Stage I endometrial cancer was diagnosed in 12 women (60.0%) whereas three women (15.0%) had stage II disease, three women (15.0%) had stage III disease and two women (10.0%) had stage IV disease. The healthy controls and endometrial cancer patients were statistically similar in aspect of age, gravidity, parity, BMI, waist-to-thigh ratio, waist-to-hip ratio, menopause, complete blood count parameters, and serum biochemistry. Serum total L-carnitine levels of women with endometrial cancer were significantly lower than those of healthy women (respectively, 5,519.4 ± 2,712.5 vs 7,940.8 ± 3,566.6 ng/dl, p = 0.021). Moreover, serum total L-carnitine levels decreased significantly and progressively with advancing stage (stage I vs II vs III vs IV; 6,294.0 ± 2,885.1 vs 5,800.0 ± 441.2 vs 4,016.0 ± 2,833.3 vs 2,560.0 ± 67.9 ng/dl; p = 0.021). CONCLUSIONS: This is the first study to hypothesize that L-carnitine deficiency participates in the pathogenesis of endometrial cancer by means of a mechanism which is unrelated with obesity and increased amount of fat in human body.

Multicenter analysis of gestational trophoblastic neoplasia in Turkey.

BACKGROUND: To evaluate the incidence, diagnosis and management of GTN among 28 centers in Turkey. MATERIALS AND METHODS: A retrospective study was designed to include GTN patients attending 28 centers in the 10-year period between January 2003 and May 2013. Demographical characteristics of the patients, histopathological diagnosis, the International Federation of Gynecology and Obstetrics (FIGO) anatomical and prognostic scores, use of single-agent and multi-agent chemotherapy, surgical interventions and prognosis were evaluated. RESULTS: From 2003-2013, there were 1,173,235 deliveries and 456 GTN cases at the 28 centers. The incidence was calculated to be 0.38 per 1,000 deliveries. According to the evaluated data of 364 patients, the median age at diagnosis was 31 years (range, 15-59 years). A histopathological diagnosis was present for 45.1% of the patients, and invasive mole, choriocarcinoma and PSTTs were diagnosed in 22.3% (n=81), 18.1% (n=66) and 4.7% (n=17) of the patients, respectively. Regarding final prognosis, 352 (96.7%) of the patients had remission, and 7 (1.9%) had persistence, whereas the disease was mortal for 5 (1.4%) of the patients. CONCLUSIONS: Because of the differences between countries, it is important to provide national registration systems and special clinics for the accurate diagnosis and treatment of GTN.

Maternal blood pressure and dominant sleeping position may affect placental localization.

OBJECTIVE: This study investigates whether maternal socio-demographic and clinical characteristics influence the site of placental implantation so that placental localization and associated abnormalities can be predicted. METHODS: This study reviews 500 healthy women with singleton pregnancy that were consecutively admitted to the study center and eventually delivered healthy newborns. RESULTS: The most frequently observed sites of placentation were anterior uterine wall (53.2%), posterior uterine wall (28.8%), lateral uterine walls (10.0%) and uterine fundus (8.0%), respectively. The women with fundal placentation had significantly higher systolic and diastolic blood pressures (p = 0.044 and p = 0.040, respectively). Supine sleeping position was more frequent in women with anterior placenta and (OR: 11.568, 95% CI: 2.720-49.193) and prone sleeping position was more frequent in women with posterior placenta (OR: 15.449, 95% CI: 2.151-52.978) (p = 0.001). The women who favored to sleep in right lateral position were more likely to have lateral placentation, while the women who used to sleep in left lateral position were more likely to have fundal placentation (p = 0.001). CONCLUSIONS: Sleeping position in early pregnancy may influence placental implantation site. The probable mechanism may refer to the alterations in uterine perfusion which is induced by the change in systemic blood pressure and dominant sleeping position.

Transcutaneous electrical nerve stimulation (TENS) for pain control after vaginal delivery and cesarean section.

OBJECTIVE: The present study aims to determine the efficiency and reliability of transcutaneous electrical nerve stimulation (TENS) in the management of pain related with uterine contractions after vaginal delivery and the pain related with both abdominal incision uterine contractions after cesarean section. METHODS: A hundred healthy women who underwent cesarean section under general anesthesia were randomly assigned to the placebo group (Group 1) or the TENS group (Group 2), while 100 women who delivered by vaginal route without episiotomy were randomized into the placebo group (Group 3) or the TENS group (Group 4). RESULTS: The patients in Group 2 had statistically lower visual analog scale (VAS) and verbal numerical scale (VNS) scores than the patients in Group 1 (p < 0.001 for both). The patients in Group 4 had statistically lower VAS and VNS scores than the patients in Group 3 (p = 0.022 and p = 0.005, respectively). The analgesic requirement at the eighth hour of cesarean section was significantly lower in the patients who were treated with TENS (p = 0.006). The need for analgesics at the eighth hour of vaginal delivery was statistically similar in the patients who were treated with TENS and the patients who received placebo (p = 0.830). CONCLUSION: TENS is an effective, reliable, practical and easily available modality of treatment for postpartum pain.

Lowered serum total L-carnitine levels are associated with obesity at term pregnancy.

OBJECTIVE: This study aims to compare the serum total l-carnitine concentrations of obese and non-obese pregnant women and to identify the role of L-carnitine in both maternal and fetal weight gain during pregnancy. METHOD: This study reviews 118 healthy women with singleton term pregnancy (≥37 weeks). The characteristics of the recruited subjects were analyzed according to their pre-pregnancy body mass index (BMI). RESULTS: The women with pre-pregnancy BMI < 18.5 kg/m(2) had significantly higher serum L-carnitine levels whereas the women with BMI > 29.9 kg/m(2) at term pregnancy had significantly lower serum l-carnitine levels (p = 0.001 for both). The neonates born to women with BMI > 29.9 kg/m(2) at term pregnancy had significantly longer height and wider head circumference (p = 0.001 for both). Serum total L-carnitine levels correlated significantly and negatively with pre-pregnancy body weight, pre-pregnancy BMI, pregnancy body weight, pregnancy BMI and serum triglyceride levels (r = -0.397, p = 0.001; r = -0.357, p = 0.001; r = -0.460, p = 0.001; r = -0.463, p = 0.001 and r = -0.216, p = 0.019, respectively). There was a significant and positive correlation between L-carnitine and HDL values (r = 0.243, p = 0.008). CONCLUSIONS: The crucial role of L-carnitine in pregnancy metabolism suggests that nutritional supplementation of this amino acid can be offered to women who are either overweight or obese at the beginning of the pregnancy.

Very rare cause of vaginal mass in pregnancy: cavernous hemangioma.

Vaginal cavernous hemangioma is a considerably rare condition during pregnancy. There has only been one reported case to date. A multiparous, 24-year-old woman in the 32nd week of pregnancy was admitted with a mass prolapsed from the vagina, which had suddenly increased in size over the previous few days. A necrotic mass obstructing the vaginal canal and originating from the posterior wall was observed in a pelvic physical examination and carefully excised. The patient had contractions after the intervention and was administered tocolytic treatment with bed-rest and fluids. Her obstetric clinical status was stable after treatment and she gave birth without complication at 37 weeks and 5 days from the vaginal canal. The main approach to these very rare tumors of pregnancy, especially in the presence of necrosis, infection and/or obstruction, should be excision. But the potential for increased blood loss that may occur due to the hypervascular structure of the tumor should be taken into account.

Efficacy of transcutaneous electrical nerve stimulation for pain relief in women undergoing office endometrial biopsy.

AIM: To evaluate the efficacy of transcutaneous electrical nerve stimulation (TENS) for decreasing pain related with office endometrial biopsy. METHODS: In this prospective study, 65 women undergoing office endometrial biopsy were randomly allocated to receive 550 mg oral naproxen sodium plus active TENS (Group I, n = 33) or 550 mg oral naproxen sodium plus placebo TENS (Group II, n = 32). The intensity of pain perceived by the patients was measured using a 10-cm visual analog scale (VAS) before insertion of the speculum, when the cervix grasped, immediately after biopsy, and 15 min after the procedure. The effect of anxiety (Spielberger's state anxiety inventory) on pain scores was also investigated. RESULTS: There were no statistical significant differences between groups in age, weight, body mass index, gravidity, parity, education, and menopausal status (p > 0.05). The pain scores before insertion of the speculum, when the cervix grasped, and immediately after biopsy were similar in both groups (p > 0.05). But at 15 min after the procedure, there was a significant reduction of the mean VAS pain score in naproxen sodium plus TENS group, compared with the naproxen sodium plus placebo TENS group (0.14 ± 0.47, 1.44 ± 1.37, respectively, p < 0.0001). The mean anxiety scores were 48.19 ± 6.71 and 45.85 ± 6.22 in Group I and Group II, respectively. We did not find any significant correlation between anxiety and VAS pain scores (p > 0.05). CONCLUSIONS: TENS appears to be successful in decreasing pain only after the procedure undergoing office endometrial biopsy. It can be used as a simple, cheap, safe, and effective pain relief method.

Maternal and fetal leptin and ghrelin levels: relationship with fetal growth.

PURPOSE: In our study, we investigated the influence of plasma levels ghrelin, leptin and other metabolic hormones (ILGF-1 and ILGF-2) in pregnants in regulating fetal body weight and mode of delivery. METHODS: A total of 36 appropriately healthy pregnants 19-36-year-old were involved in the study. Demographic characteristics, serum ghrelin, leptin, IGF-1 and IGF-2 levels of the pregnants were studied. RESULTS: Plasma ghrelin and leptin levels did not differ significantly among trimesters and delivery, in contrast to IGF-I and IGF-II concentrations were significantly higher in the first half of the pregnancy (P < 0.05). Serum leptin was significantly associated with mode of delivery (r = 0.231; P = 0.008), BMI (r = 0.462; P = 0.004). CONCLUSION: Metabolic factors are associated with fetal growth, but in AGA babies, there were no differences between any parameter and clinical factor.