Is Omentectomy Necessary for Non-Endometrioid Endometrial Cancer.

BACKGROUND: In subtypes of non-endometrioid endometrium cancers (non-ECC), it is not clear whether the omentectomy is a part of debulking if visual assessment is normal. Recently, the ESMO-ESGO-ESTRO Endometrial Consensus Conference Working Group in their report titled "Endometrial Cancer: diagnosis, treatment and follow-up" recommended that omentectomy be performed in the serous subtype, but not in carcinosarcoma, undifferentiated endometrial carcinoma or clear cell. In this study, the question is whether omentectomy should be a part of a staging procedure in patients with non-ECC. Besides, the sensitivity and specificity of the visual assessment of omentum were analyzed. METHODS: Patients diagnosed with non-ECC in 2 gynecological oncology clinics between 2005 and 2015 were retrospectively reviewed. Occult (absence of visible lesions) and gross (presence of visible lesions) omental metastasis rates of histological subtypes were analyzed. RESULTS: We identified 218 patients with non-ECC. Thirty-four of them (15.1%) had omental metastases and 44.1% of these metastases (n = 15) were occult metastases. The sensitivity of the surgeon's visual assessment of an omentum (positive or negative) was 0.55. The highest rate of omental metastasis was found in carcinosarcoma followed by serous, mixed subtypes, and clear-cell (20.4, 17.3, 16.6, 10.0%, respectively). Adnexal metastasis was the only factor associated with occult omental metastasis (p = 0.003). CONCLUSION: Omental metastases occur too often to omit omentectomy during surgical procedures for non-ECC regardless of histological subtypes, and visual assessment is insufficient in recognizing the often occult metastases. Omentectomy should be a part of the staging surgery in patients with non-ECC.

Preoperatively Assessable Clinical and Pathological Risk Factors for Parametrial Involvement in Surgically Treated FIGO Stage IB-IIA Cervical Cancer.

OBJECTIVE: Determining the risk factors associated with parametrial involvement (PMI) is of paramount importance to decrease the multimodality treatment in early-stage cervical cancer. We investigated the preoperatively assessable clinical and pathological risk factors associated with PMI in surgically treated stage IB1-IIA2 cervical cancer. METHODS: A retrospective cohort study of women underwent Querleu-Morrow type C hysterectomy for cervical cancer stage IB1-IIA2 from 2001 to 2015. All patients underwent clinical staging examination under anesthesia by the same gynecological oncologists during the study period. Evaluated variables were age, menopausal status, body mass index, smoking status, FIGO (International Federation of Obstetrics and Gynecology) stage, clinically measured maximal tumor diameter, clinical presentation (exophytic or endophytic tumor), histological type, tumor grade, lymphovascular space invasion, clinical and pathological vaginal invasion, and uterine body involvement. Endophytic clinical presentation was defined for ulcerative tumors and barrel-shaped morphology. Two-dimensional transvaginal ultrasonography was used to measure tumor dimensions. RESULTS: Of 127 eligible women, 37 (29.1%) had PMI. On univariate analysis, endophytic clinical presentation (P = 0.01), larger tumor size (P < 0.001), lymphovascular space invasion (P < 0.001), pathological vaginal invasion (P = 0.001), and uterine body involvement (P < 0.001) were significantly different among the groups with and without PMI. In multivariate analysis endophytic clinical presentation (odds ratio, 11.34; 95% confidence interval, 1.34-95.85; P = 0.02) and larger tumor size (odds ratio, 32.31; 95% confidence interval, 2.46-423.83; P = 0.008) were the independent risk factors for PMI. Threshold of 31 mm in tumor size predicted PMI with 71% sensitivity and 75% specificity. We identified 18 patients with tumor size of more than 30 mm and endophytic presentation; 14 (77.7%) of these had PMI. CONCLUSIONS: Endophytic clinical presentation and larger clinical tumor size (>3 cm) are independent risk factors for PMI in stage IB-IIA cervical cancer. Approximately 78% of the patients with a tumor size of more than 3 cm and endophytic presentation will require adjuvant chemoradiation for PMI following radical surgery. Considering clinical tumor presentation along with tumor size can enhance the physician's prediction of PMI in early-stage cervical cancer.

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.

Prognostic factors and treatment outcomes in surgically-staged non-invasive uterine clear cell carcinoma: a Turkish Gynecologic Oncology Group study.

OBJECTIVE: To assess the prognosis of surgically-staged non-invasive uterine clear cell carcinoma (UCCC), and to determine the role of adjuvant therapy. METHODS: A multicenter, retrospective department database review was performed to identify patients with UCCC who underwent surgical treatment between 1997 and 2016 at 8 Gynecologic Oncology Centers. Demographic, clinicopathological, and survival data were collected. RESULTS: A total of 232 women with UCCC were identified. Of these, 53 (22.8%) had surgically-staged non-invasive UCCC. Twelve patients (22.6%) were upstaged at surgical assessment, including a 5.6% rate of lymphatic dissemination (3/53). Of those, 1 had stage IIIA, 1 had stage IIIC1, 1 had stage IIIC2, and 9 had stage IVB disease. Of the 9 women with stage IVB disease, 5 had isolated omental involvement indicating omentum as the most common metastatic site. UCCC limited only to the endometrium with no extra-uterine disease was confirmed in 41 women (73.3%) after surgical staging. Of those, 13 women (32%) were observed without adjuvant treatment whereas 28 patients (68%) underwent adjuvant therapy. The 5-year disease-free survival rates for patients with and without adjuvant treatment were 100.0% vs. 74.1%, respectively (p=0.060). CONCLUSION: Extra-uterine disease may occur in the absence of myometrial invasion (MMI), therefore comprehensive surgical staging including omentectomy should be the standard of care for women with UCCC regardless of the depth of MMI. Larger cohorts are needed in order to clarify the necessity of adjuvant treatment for women with UCCC truly confined to the endometrium.

The Effect of Patient Position during Mid-Urethral Sling Operations on the Postoperative Outcomes of Sling Success: A Randomized Clinical Study.

AIMS: To determine and compare the effectiveness, peri- and postoperative outcomes of mid-urethral sling (MUS) operations for urinary incontinence, using 2 different patient positions during surgery. METHODS: In this study, 146 patients underwent MUS surgery in a urogynecology clinic. Of them, 72 patients underwent the intraoperative surgical procedure of reverse trendelenburg patient positioning for tape adjustment (group 1) and the remaining 74 patients had the routine surgical procedure of MUS surgery (group 2). The primary outcome was the evaluation of postoperative urine leaks, using the stress test, and secondary outcomes were quality of life, using the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF, Turkish version) and complication rates. RESULTS: There were no significant differences in demographic variables between the 2 groups. The overall cure rates for incontinence in the lithotomy position was 97.22 and 85.13% for groups 1 and 2, respectively, in which group 1 had a statistically significant decrease in urine leak postoperatively (p < 0.05; OR 3.08, 95% CI 2.78-22.14). The postoperative ICQ-SF scores showed no significant difference between the 2 groups (p = 0.19). CONCLUSION: Applying a 45-degree reverse trendelenburg position for tape adjusting during MUS operation results in a greater objective cure rate compared with the typical dorsolithotomy position; however, there was no difference in the subjective outcome.

Evaluation of hemoglobin A1c levels in endometrial cancer patients: a retrospective study in Turkey.

BACKGROUND: Hemoglobin A1c(HgA1c) is a marker of poor gylcemic control and elevation HgA1c is associated with increased risk of many cancers. We aimed to determine the HgA1c levels in endometrial cancer cases and any relationship with stage and grade of disease. MATERIALS AND METHODS: A retrospective data review was performed between June 2011 and October 2012 at a tertiary referral center in Turkey. The study included 35 surgically staged endometrial cancer patients and 40 healthy controls. Preoperative HgA1c levels drawn within 3 months before surgery were compared. Also the relationships between HgA1c levels and stage, grade and hystologic type of cancer cases were evaluated. RESULTS: The mean HgA1c levels were statistically significantly higher at 6.19 ± 1.44 in endometrial cancer cases than the 5.61 ± 0.58 in controls (p=0.027). With endometrial cancer cases, the mean HgA1c level was found to be 6.62 ± 1.40 for stage I and 6.88 ± 1.15 for stages II-IV (p=0.07). The figures were 6.74 ± 1.65 for endometrioid and 6.63 ± 1.41 for non-endometrioid type tumors (p=0.56). Mean HgA1c levels of 6.72 ± 1.14 for grade 1 and 6.62 ± 1.42 for grade 2-3 were observed (p=0.57). CONCLUSIONS: HgA1c levels in endometrial cancer patients were statistically higher than healthy controls. However, HgA1c did not show any significant correlation with stage, grade and histologic type in endometrial cancer cases.

Additional surgical risk factors and patient characteristics for mesh erosion after abdominal sacrocolpopexy.

AIM: The aim of this study is to determine the risk factors of mesh exposures following abdominal sacral colpopexy (ASC) in which polypropylene mesh is used. METHODS: This is a retrospective cohort study of patients who underwent ASC and were subsequently followed for development of mesh exposure for vaginal/vault prolapse between 2002 and 2012. Demographics and risk factors of the patients who did develop mesh exposure after ASC and the ones who did not were compared. RESULTS: In 42 months of survey, 19 of the 292 patients who underwent ASC developed mesh exposure. It was found that rates of patients with stage 3-4 prolapse were significantly greater in the mesh exposure group than in the control group (P = 0.04). Rates of mesh exposure were lower in patients with previous hysterectomy (P = 0.03). Also, it was found that concomitant hysterectomy or three or more additional procedures increased the risk of mesh exposure (P = 0.03 and P = 0.02). CONCLUSION: In abdominal sacrocolpopexy operations in which polypropylene meshes are used, stage 3 or 4 prolapse, concomitant hysterectomy and three or more additional procedures increase the risk of mesh exposure development.

Should omentectomy be a part of surgical staging in patients with endometrioid adenocarcinoma of the uterine corpus?

BACKGROUND: The purpose of the study was to determine the prevalence of omental metastasis in endometrioid adenocarcinoma and to correlate risk variables with this spread. METHODS: A retrospective analysis of patients with endometrioid adenocarcinoma who underwent omentectomy in addition to staging laparotomy was performed. RESULTS: Omental metastases were noted in 11 of the 322 patients with endometrioid adenocarcinoma (3.4%). Multivariate analyses showed that there was a significant correlation between omental metastasis and positive peritoneal cytology, adnexal involvement, and grade 3 tumor (p = 0.028, p = 0.001, and p = 0.01, respectively). There was no statistical relationship between omental metastasis and lymphovascular space involvement, deep myometrial invasion, and lymph node metastasis (p = 0.087, p = 0.97, and p = 0.92, respectively). CONCLUSION: Grade 3 endometrioid adenocarcinomas, especially those that are complicated by deep myometrial invasion, have a pattern of intra-abdominal spread similar to more aggressive endometrial cancers, with frequent involvement of the omentum. Overall, we conclude that 37.5% (3/8) of patients who had a grade 3 tumor and omental metastasis stage IV disease would have been missed if a staging operation similar to that employed for ovarian cancer had not been performed.

Lymph node metastasis in patients with epithelial ovarian cancer macroscopically confined to the ovary: review of a single-institution experience.

BACKGROUND: To evaluate the patterns of lymphatic spread in epithelial ovarian cancer (EOC) macroscopically confined to the ovary and to determine risk factors for lymph node metastasis. MATERIALS AND METHODS: All patients with clinically apparent stage IA/B/C EOCs who underwent staging surgery between January 2003 and February 2013 were retrospectively identified. RESULTS: Two hundred and thirty-six (n = 236) consecutive patients were operated for primary epithelial ovarian carcinoma. Sixty-two of these patients (26.2 %) who underwent a comprehensive staging procedure including pelvic and paraaortic lymphadenectomy were diagnosed with tumors confined to one or two ovaries (stage IA/B/C). Of these 62 patients, 17 (27.4 %) had upstaged disease and 8 (12.9 %) had lymph node metastasis. Tumor histology was serous in 25 patients (40.3 %), mucinous in 23 patients (37 %), endometrioid in 9 patients (14.5 %), and clear cell in 5 patients (8 %). Positive lymph node status was found in 20 % (5/25) of those with serous histology while this rate was only 8.1 % (3/37) in those with non-serous disease. Although the presence of ascites was not associated with an increased risk of lymph node involvement (p = 0.24), positive peritoneal cytology (p = 0.001) and grade 3 disease (p = 0.001) were significant predictors of lymph node involvement. CONCLUSION: All patients diagnosed with EOC macroscopically confined to the ovary should be considered for comprehensive staging surgery including pelvic and paraaortic lymphadenectomy.

Ovarian fibroma/fibrothecoma: retrospective cohort study shows limited value of risk of malignancy index score.

BACKGROUND: Ovarian fibromas/fibrothecomas are uncommon benign tumours of ovary. Due to their solid structure, these benign tumours are sometimes confused with malignant tumours during clinical evaluation. AIMS: To determine the clinico-pathological characteristics of ovarian fibroma/fibrothecoma and analyse the efficiency of risk of malignancy index (RMI) scoring system to distinguish malignancy among these tumours. METHODS: Between November 2001 and February 2012, women with a pathological diagnosis of ovarian fibroma/fibrothecoma were identified. Depending on the menopausal status, serum CA-125 level and ultrasonographic findings, RMI scores were calculated for each of the patients. RESULTS: During the study period, 43 ovarian fibroma/fibrothecoma (4.7%) were detected among 912 adnexal masses operated. The mean age of the women was 52.2 (range, 21-80 years). Upon calculating RMI scores, 33 women (76.7%) were classified as low risk and 10 women (23.3%) as high risk for malignancy. Sensitivity, specificity, positive predictive value and negative predictive value of the RMI scoring for identification of malignant lesions preoperatively were found as 0%, 76%, 0% and 97%, respectively. Final pathological diagnosis was ovarian fibroma in 13 (30%) women, fibrothecoma in 29 (67%) and fibrosarcoma in one woman (2%). CONCLUSION: There are no specific markers for accurate preoperative diagnosis of ovarian fibroma/fibrothecoma. Moreover, according to our results, RMI scoring system does not aid clinicians in this issue either, with a high false-positive rate and very low sensitivity. Further studies with higher number of cases are needed to state clearly the role of RMI scores in preoperative discrimination of malignancy.

Evaluation of endocervical canal in women with minimal cervical cytological abnormalities.

OBJECTIVE: This study aimed to examine the endocervical canal curettage (ECC) results of patients with atypical squamous cells of undetermined significance (ASC-US) or low-grade intraepithelial lesion (LSIL) and secondarily to explore the features of patients who are at greatest risk for endocervical involvement. MATERIALS AND METHODS: This is a retrospective analysis of 846 women who underwent ECC with ASC-US or LSIL on cervical cytology between January 2003 and April 2011. Records of demographic data and colposcopic impression were evaluated. Histopathological results of biopsies and ECC were classified into 2 categories as less than cervical intraepithelial lesion 2 (CIN 2) and CIN 2+ lesions for comparison. Multivariate analysis was performed using binary logistic regression analysis to identify predictors of ECC results. RESULTS: CIN 1 lesions were detected in 8.9% of patients, and the rates of CIN 2 or 3 and invasive/microinvasive cancers in ECC were 3.8% and 0.7%, respectively. Cervical intraepithelial lesion 2 or worse lesions were detected in 1.6% (7/419) of the patients with normal colposcopic findings. There was no statistically significant difference in the rate of CIN 2+ lesion in endocervical canal between the patients with or without satisfactory colposcopic examination (4.4% vs 4.1% p = .69). A total of 1.7% of the patients who did not have cervical biopsy and also 1.1% of the patients who had less than CIN 2 biopsy results were diagnosed with CIN 2+ lesion by ECC despite the satisfactory colposcopy. Only a positive biopsy result for dysplasia was found to be an independent factor for the detection of a dysplastic lesion in endocervical canal (odds ratio = 0.06; 95% CI = 0.01-0.35; p = .02). CONCLUSIONS: Endocervical canal curettage had minimal diagnostic utility for the detection of CIN 2 or worse lesions in women with ASC-US or LSIL smear result and normal colposcopic findings. In addition to this, the presence or absence of CIN 2+ lesions diagnosed by means of endocervical curettage was independent of a satisfactory or unsatisfactory colposcopic examination.

Combined use of preoperative transvaginal ultrasonography and intraoperative gross examination in the assessment of myometrial invasion in endometrial carcinoma.

OBJECTIVE: To evaluate the diagnostic performance of gross examination and transvaginal ultrasonography in the assessment of the depth of myometrial infiltration when they are used alone or together as a combined test. STUDY DESIGN: The data of 219 consecutive patients with a diagnosis of endometrial cancer were evaluated retrospectively. Transvaginal ultrasound was carried out as a part of the routine preoperative work-up within three days of surgical intervention in all cases. All patients underwent hysterectomy with bilateral salpingo-oophorectomy and routine surgical staging and all uterine specimens were examined immediately after hysterectomy. The depth of myometrial invasion was classified into two groups: no or <50% invasion and ≥50% invasion. The findings of ultrasound and intraoperative gross examination were compared with the final histopathological results. The data of these two methods were integrated to evaluate the diagnostic performance of the combined test. If the results of myometrial invasion evaluation were different for the same patient, the deeper one (the depth of invasion ≥50%) was accepted. RESULTS: Sensitivity, specificity, PPV, NPV and accuracy of preoperative ultrasonography in predicting myometrial infiltration ≥50% were 62%, 81%, 60%, 82%, and 75% respectively. The corresponding rates for intraoperative gross examination were 61%, 88%, 70%, 83% and 79%, respectively. For the combined test they were 78%, 76%, 60%, 88% and 70% respectively. There was no statistically significant difference in sensitivity and specificity between ultrasound and gross examination. The sensitivity of the combined test was significantly higher than that of ultrasound and gross examination (p=0.001 and p<0.0001, respectively). The specificity of the combined test was significantly lower than that of TVS and gross examination (p=0.008 and p<0.0001, respectively). CONCLUSION: Combining ultrasonography and intraoperative gross examination may be a good option to assess the depth of myometrial invasion, as it has a higher sensitivity and negative predictive value in comparison to using these methods alone.

Coexisting ovarian malignancy in patients with clinical stage I endometrial carcinoma.

AIM: To evaluate the feasibility of ovarian preservation at the time of operation in patients with clinical stage I endometrial carcinoma. MATERIALS AND METHODS: The data of 499 consecutive patients with clinical stage 1 endometrial cancer operated between January 2001 and December 2011 were retrospectively reviewed. Clinical and pathologic information and the intraoperative inspection findings of ovaries were evaluated to find the factors associated with the coexisting ovarian malignancy. RESULTS: The mean age of patients was 56.8 ± 9.8 years. Coexisting ovarian tumors were detected in 38 patients (7.6 %), and 28 (5.6 %) of them were malignant (12 metastatic and 16 synchronous primaries). Most of the patients were postmenopausal (n = 371, 74.3 %) and 60 (12 %) of the patients were at the age of 45 years or less. Coexisting malignancy was detected in 9 % (n = 11) of the premenopausal patients and in 5 % (n = 3) of the patients aged 45 years or less. Multivariate analysis revealed that serosal invasion, tubal involvement, and positive abdominal cytology were independent risk factors for coexisting ovarian malignancy. The sensitivity, specificity, positive predictive value and negative predictive value of the intraoperative examination for the diagnosis of benign/normal ovary was 99.6, 78.8, 98.5 and 92.9 %, respectively. CONCLUSION: The incidence of coexisting ovarian malignancy in clinical stage I endometrial carcinoma is low. Although occult metastasis cannot be excluded at all, careful intraoperative inspection of ovaries seems valuable for the prediction of co-existing ovarian malignancy.

Influence of body mass index on clinicopathologic features, surgical morbidity and outcome in patients with endometrial cancer.

AIM: To examine the influence of obesity on the patient characteristics and clinicopathologic features of endometrial cancer, and to find how treatment and prognosis were affected by obesity in women with endometrial cancer. METHODS: The data of 370 consecutive women operated for endometrial cancer were retrospectively reviewed. Patients were divided into three categories as <25, 25-29.9 and ≥30 according to BMI. All patients underwent primary surgical treatment including total abdominal hysterectomy, bilateral oophorectomy and peritoneal cytology. Pelvic lymphadenectomy was carried out for all patients except for those with no myometrial invasion regardless of the tumor grade or for whom it was technically impossible. Paraaortic lymphadenectomy was performed when pre- and intraoperative assessments suggested non-endometrioid or grade 3 endometrioid cancer, >50 % myometrial invasion and cervical involvement. RESULTS: Patients with a BMI (body mass index) of <25 were significantly younger. Patients with a BMI of ≥30 were statistically less likely to have >50 % myometrial invasion and more likely to have stage I disease. There were no significant differences in the incidences of positive pelvic and paraaortic lymph nodes and tumor grades between the three groups. Also, there were no differences in surgery type, the mean of removed pelvic and paraaortic lymph node number, hospital stay, blood loss and complications between the groups. The patients with a BMI of ≥30 had significantly longer operating time. There were no statistically significant differences in recurrences, the median number of months at recurrence or the site of recurrence between the three groups, as well as the 5-year overall and disease-free survival of patients. Multivariate proportional hazard models identified stage III and IV disease as significant covariates for mortality rates, while stage III and IV disease, hypertension and pelvic irradiation were identified as significant covariates for recurrence rates. CONCLUSION: Positive peritoneal cytology, deep myometrial invasion and stage II-IV endometrial cancer were significantly more common in patients with a BMI of <25. There were no significant differences in tumor grade, surgical technique, surgical morbidity or adjuvant radiotherapy between the BMI groups. Recurrence and cancer-related mortality rates were not affected by the BMI.

Immediate colposcopic evaluation in postmenopausal women with low-grade squamous intraepithelial lesion cytology.

OBJECTIVE: To compare the final diagnosis among pre- and postmenopausal women with low-grade squamous intraepithelial lesion (LGSIL) cervical smear results. DESIGN: Retrospective, comparative study. SETTING: Departments of obstetrics and gynecology in two teaching and research hospitals. POPULATION: Data were evaluated on 712 women with LGSIL between April 2005 and April 2011. METHODS: Results from 129 postmenopausal women with LGSIL were compared with 583 premenopausal women with a similar LGSIL result with respect to sociodemographic data and histopathology. MAIN OUTCOME MEASURES: Final clinicopathological diagnosis. RESULTS: The mean age of the pre- and postmenopausal women was 37.2 and 52.5 years, respectively, and lesions of cervical intraepithelial neoplasia grade 2 or worse were detected by biopsy and/or endocervical curettage in 13.6 and 9.3%, respectively. There was no significant difference between the final diagnosis among pre- and postmenopausal women with LGSIL cytology (relative risk 1.43; 95% confidence interval 0.82-2.48; p= 0.19). Invasive cervical cancer was detected in three premenopausal (0.5%) and two postmenopausal women (1.6%). CONCLUSIONS: Cervical pre-invasive and invasive disease rates were similar in pre- and postmenopausal women with LGSIL cytology. For this reason, LGSIL in postmenopausal women should be considered more seriously, and colposcopic evaluation may be as acceptable an option in the management of LGSIL in this group of patients as it is with premenopausal women.

Malignant transformation arising from mature cystic teratoma of the ovary: a report of six cases.

AIM: Malignant transformation of mature cystic teratoma (MCT) is an uncommon complication. Preoperative diagnosis is difficult because of the lack of specific symptoms and signs indicating malignancy. Thus, we retrospectively analyzed the clinical characteristics of patients and the role of surgery in their management. MATERIAL AND METHODS: During a 9-year period (2002-2010), six patients with malignant transformation arising from ovarian MCT were treated at the Gynecologic Oncology Unit of Bakirkoy Woman and Children's Training and Research Hospital. A retrospective chart review and analysis of the patients' data were conducted. RESULTS: Malignant transformation arising from ovarian MCT accounted for 1.9% of all ovarian MCT (6/321). Three cases were stage IA and the other three were stage IC. Histologically, three of six cases had squamous cell carcinoma (50%), two had a carcinoid tumor (33%), and one had mucinous adenocarcinoma (17%). All patients underwent comprehensive surgical staging. Two patients received adjuvant chemotherapy and one received adjuvant chemoradiation. Five of six patients were observed for 16-104 months and no recurrence was detected. One patient with a carcinoid tumor in stage IC died of disease within 34 months following the surgery. CONCLUSION: Early detection of malignant transformation arising from MCT is mandatory for treating patients, but in most patients malignancy was detected intraoperatively. Surgical cytoreduction with a complete staging procedure and adjuvant treatment may be reasonable for stage IC. Additionally, prognosis is better when the tumor is completely excised and does not extend beyond the capsule.

The novel criteria for predicting pelvic lymph node metastasis in endometrioid adenocarcinoma of endometrium.

OBJECTIVE: To identify clinicopathological risk factors for pelvic lymph node metastasis, and to evaluate the clinical validity of these factors in selecting patients who need pelvic lymph node dissection. METHODS: The data of 466 patients who had lymphadenectomy for endometrioid adenocarcinoma of the endometrium between January 2002 and December 2010 were reviewed retrospectively. RESULTS: All patients underwent pelvic lymphadenectomy and 192 (41.2%) patients also underwent paraaortic lymphadenectomy. The median number of pelvic lymph node was 16 (range: 2-46) and of paraaortic lymph node was 5 (range: 2-16). 10.1% (47/466) of all patients had pelvic lymph node involvement and 7.8% (15/192) of the patients had paraaortic lymph node involvement (LNI). Pelvic LNI was significantly more common in the presence of higher grades of tumor, LVSI, deep myometrial invasion, positive peritoneal cytology and cervical involvement. The logistic regression analysis revealed that LVSI, cervical glandular invasion and cervical stromal invasion remained to be the independent risk factors for LNI. When the LVSI and/or cervical involvement were considered as high risk for pelvic lymph node metastasis, NPV and specificity were found to be 96.3% and 68.4%, respectively. LNI was correctly estimated in 323 women (69%), overestimated in 132 women (28%) and underestimated in 11 women (2%). CONCLUSION: LVSI, cervical glandular and stromal involvement were independent risk factors for pelvic LNI. These variables can be assessed pre- or intraoperatively with a high rate of accuracy, the model which uses these variables may be successfully used in the prediction of pelvic lymph node metastasis.

Preoperative assessment of myometrial and cervical invasion in endometrial carcinoma by transvaginal ultrasound.

OBJECTIVE: To evaluate the diagnostic accuracy of transvaginal ultrasound (TVS) in preoperative assessment of the depth of myometrial infiltration and the presence of cervical invasion in endometrial carcinoma. METHODS: 298 consecutive patients with a diagnosis of endometrial cancer were evaluated by TVS within 3 days of surgical intervention. The depth of myometrial invasion was classified into two groups: no or <50% invasion and ≥50% invasion. Invasion of cervix was diagnosed when the neoplastic tissue distended the cervix and showed ill-defined borders with the cervical stroma. RESULTS: The sensitivity, specifity, positive predictive value (PPV), negative predictive value (NPV) and overall diagnostic accuracy of TVS in evaluation of the depth of myometrial infiltration were 68.4%, 82%, 65.1%, 84.1% and 77.5%, respectively. While the sensitivity and PPV were significantly higher among grade 3 tumors, the specifity, NPV and accuracy were significantly higher among grade 1 tumors. The sensitivity, specifity, PPV, NPV, and overall diagnostic accuracy of TVS in assessment of the presence or absence of neoplastic tissue in cervix were 76.5%, 99.3%, 86.7%, 98.2% and 98%, respectively. While the sensitivity and PPV were significantly higher among grade 1 tumors, the NPV and accuracy were significantly lower among grade 3 tumors. CONCLUSION: TVS can be considered as a feasible, economical and simple imaging modality with a high diagnostic accuracy for the prediction of cervical involvement. However, it is not a reliable method in estimating the depth of myometrial infiltration.

Benign cystic mesothelioma: a case series with one case complicated by pregnancy.

Benign cystic mesothelioma (BCM) is a rare tumor of unknown origin, most frequently encountered in women of reproductive age and with unknown etiology. Most patients have a history of previous pelvic operation, endometriosis, or pelvic inflammatory disease. Preoperative diagnosis is difficult. We report the cases of three patients, with one case complicated by pregnancy, and discuss the diagnostic evaluation and treatment of this rare disease. Complete surgical resection is recommended if feasible. However, recurrent disease is not uncommon. Clinical positive effects of different adjuvant medical treatments are also discussed.

Uterine adenosarcoma with ovarian sex cord-like differentiation: a case report and review of the literature.

OBJECTIVES: To determine the prognosis of uterine adenosarcoma with ovarian sex cord like-differentiation after treatment and to review the literature. CASE REPORT: A 47-year-old premenopausal unmarried woman presented with irregular menstrual bleeding and uterine mass. Sonographic examination, suggested two uterine fibroids located in the uterine fundus and cervix measuring 4 × 3 cm and 3 × 3 cm, respectively. Total abdominal hysterectomy with bilateral salpingo-oopherectomy was performed and the histopathology report confirmed the diagnosis of uterine adenosarcoma with ovarian sex cord like-differentiation. The patient received neither chemotherapy nor other adjuvant therapy because the tumor had low malignant potential, and the extent of myometrial invasion was less than half of the whole myometrium. The patient had an uneventful recovery, and no recurrence was detected for 2 years in the follow-up period. CONCLUSION: Uterine adenosarcomas mostly have relatively low malignant potential. Surgery is the optimal standard treatment for patients. Although there is not enough data in the present literature, benign epithelial differentiations, such as sex cord-like elements may reflect the behaviour of the tumour and shows the tendency to have a benign course in most of cases.