Survival outcomes of women with grade 3 endometrioid endometrial cancer: the impact of adjuvant treatment strategies.

AIM: This multicenter investigation was performed to evaluate the adjuvant treatment options, prognostic factors, and patterns of recurrence in patients with grade 3 endometrioid endometrial cancer (G3-EEC). MATERIALS AND METHODS: The medical reports of patients undergoing at least total hysterectomy and salpingo-oophorectomy for G3-EEC between 1996 and 2018 at 11 gynecological oncology centers were analyzed. Optimal surgery was defined as removal of all disease except for residual nodules with a maximum diameter ≤ 1 cm, as determined at completion of the primary operation. Adequate systematic lymphadenectomy was defined as the removal of at least 15 pelvic and at least 5 paraaortic LNs. RESULTS: The study population consists of 465 women with G3-EEC. The 5-year disease-free survival (DFS) and overall survival (OS) rates of the entire cohort are 50.3% and 57.6%, respectively. Adequate systematic lymphadenectomy was achieved in 429 (92.2%) patients. Optimal surgery was achieved in 135 (75.0%) patients in advanced stage. Inadequate lymphadenectomy (DFS; HR 3.4, 95% CI 3.0-5.6; P = 0.016-OS; HR 3.2, 95% CI 1.6-6.5; P = 0.019) was independent prognostic factors for 5-year DFS and OS. CONCLUSION: Inadequate lymphadenectomy and LVSI were independent prognostic factors for worse DFS and OS in women with stage I-II G3-EEC. Adequate lymphadenectomy and optimal surgery were independent prognostic factors for better DFS and OS in women with stage III-IV G3-EEC.

Optimal timing of the loop electrosurgical excision procedure according to different phases of the menstrual cycle.

OBJECTIVE: To determine whether treatment of cervical precancerous lesions in the follicular phase or luteal phase of the menstrual cycle affects perioperative and postoperative blood loss during the LEEP. METHODS: In this randomized trial, 73 patients were assigned to either the follicular phase group (n = 37) or the luteal phase group (n = 36). Ultimately, the conditions of 36 patients in the follicular phase group and 34 patients in the luteal phase group were analyzed. The primary outcome measure was median early postoperative blood loss. Secondary outcomes were median intraoperative bleeding, the rate of late postoperative bleeding, and persistent vaginal bleeding. RESULTS: Baseline demographic data were similar in the two groups. Median intraoperative blood loss was significantly lower in the follicular phase group than in the luteal phase group (32.7 [20.1-78.3] vs. 44.6 [30.4-104.2] mL, respectively; P < 0.001). Median early postoperative blood loss was also lower in the follicular phase group than in the luteal phase group (209.2 [67.7-468.6] vs. 289.0 [120.3-552.8] mL, respectively; P = 0.01). Moreover, the rate of late postoperative bleeding was higher in the luteal phase group than in the follicular phase group (20.6% vs. 2.8%, respectively; P = 0.02). CONCLUSION: Performing LEEP during the follicular phase of the menstrual cycle significantly reduces median intraoperative blood loss, early postoperative blood loss, and the rate of late postoperative blood loss.

A novel preoperative scoring system based on 18-FDG PET-CT for predicting lymph node metastases in patients with high-risk endometrial cancer.

The purpose of this study was to develop a model predicting the probability of pelvic-paraaortic node metastases in high-risk endometrial cancer patients. This trial included 41 high-risk endometrial cancer patients. All of the patients underwent an 18-FDG PET-CT followed by surgical staging, including a pelvic and paraaortic lymphadenectomy. We developed a useful scoring system combining weighted risk factors derived from a regression model: (3 × presence PET-CT involvement) + (3 × PET-CT maximum standardised uptake value ≥20) + (2 × diabetes comorbidity) + (1 × age ≥60 years) + (1 × body mass index ≥30). The area under the curve of the resulting score was 0.848. There was 75% sensitivity, 89% specificity and a 75% positive predictive value and 89% negative predictive value when a score of 6 was used as the cut-off. Our novel preoperative scoring system is an accurate method for the preoperative evaluation of lymph node metastases, and thus will aid gynaecological oncologists in selecting EC patients who may benefit from a lymphadenectomy. Impact statement What is already known on this subject? Endometrial cancer (EC) is a common gynaecological malignancy. Surgical staging is currently the standard treatment and the gold standard for evaluating lymph node metastases (LNm) is a surgical assessment (Chan et al. 2006 ). Three previous randomised clinical studies failed to find a clear therapeutic role for the lymphadenectomy; thus, the utility of this surgical procedure in high-risk early-stage EC remains under debate (Benedetti Panici et al. 2008 ; Kitchener et al. 2009 ; Signorelli et al. 2015 ). Non-invasive techniques that accurately identify lymph node metastases would reduce costs and complications. What do the results of this study add? Our developed novel scoring system that is based on positron emission tomography-computer tomography (PET-CT) with 2-deoxy-2-(18F) flouro-2-D-glucose (FDG) may facilitate the identification of patients at an increased risk of LNm. What are the implications of these finding for clinical practice and/or further research? This study shows that our novel preoperative scoring system provides an accurate method for the preoperative evaluation of LNm, and thus could guide gynaecologic oncologists in selecting the high-risk endometrial cancer patients who may benefit from a systematic lymphadenectomy. Further larger, prospective studies are needed to confirm the accuracy and the feasibility of our scoring system.

Risk Factors for Recurrence in Low-Risk Endometrial Cancer: A Case-Control Study.

AIM: The aim of this study was to investigate the risk factors for recurrence in patients with low-risk endometrial cancer (EC). PATIENTS AND METHODS: This retrospective study was performed using 10 gynecological oncology department databases. Patients who met the following criteria were included in the study: (a) endometrioid-type histology, (b) histological grade 1 or 2, (c) no or < 50% myometrial invasion, (d) no intraoperative evidence of extrauterine spread, and (e) the patient underwent at least a pelvic lymphadenectomy. Recurrence was detected in 56 patients who were histologically diagnosed with low-risk EC, and these patients made up the case group. A total of 224 patients with low-risk EC without recurrence were selected (control group) using a dependent random sampling method. The case and control groups were match-paired in terms of grade, stage, and operative technique. RESULTS: Lymphovascular space invasion (LVSI) (odds ratio (OR) 5.8, 95% confidence interval (CI) 2.0-16.9; p = 0.001) and primary tumor diameter (PTD) ≥ 20 mm (OR 6.6, 95% CI 2.7-15.8; p < 0.001) were found to be independent risk factors for recurrence in women with low-risk EC. CONCLUSION: The presence of LVSI and PTD ≥ 20 mm seem to be significant risk factors for recurrence in women with low-risk EC.

Are patients and physicians willing to accept less-radical procedures for cervical cancer?

OBJECTIVE: To evaluate the opinions of women who underwent surgery for cervical cancer (CC) and physicians who treat CC about the acceptability of increased oncological risk after less-radical surgery. METHODS: One hundred eighty-two women who underwent surgery for CC and 101 physicians participated in a structured survey in 3 tertiary cancer centers in Czech Republic and Turkey. Patients and physicians were asked whether they would accept any additional oncological risks, which would be attributable to the omission of parametrectomy (radical hysterectomy/trachelectomy vs. simple hysterectomy/trachelectomy) or pelvic lymph node dissection (systematic resection vs. sentinel lymph node sampling). RESULTS: Although 52.2% of patients reported morbidity related to their previous treatment, the majority of patients would not accept less-radical surgical treatment if it was associated with any increased risk of recurrence (50%-55%, no risk; 17%-24%, risk <0.1%). Physicians tended to accept a significantly higher risk than patients in the Czech Republic, but not in Turkey. Patients with higher education levels, more advanced-stage of disease, or adverse events related to previous cancer treatment, and patients who received adjuvant therapy were significantly more likely to accept an increased oncological risk. CONCLUSION: Patients, even if they suffered from morbidity related to previous CC treatment, do not want to choose between oncological safety and a better quality of life. Physicians tend to accept the higher oncological risk associated with less-radical surgical procedures, but attitudes differ regionally. Professionals should be aware of this tendency when counselling the patients before less-radical surgery.

The Impact of Surgical Staging on the Prognosis of Mucinous Borderline Tumors of the Ovaries: A Multicenter Study.

BACKGROUND/AIM: The purpose of this study was to prove the effect of complete surgical staging of patients with mucinous borderline ovarian tumors (mBOTs) especially appendectomy on progression-free survival (PFS) and overall survival (OS). PATIENTS AND METHODS: The database of 14 gynecological oncology departments from Turkey and Germany were comprehensively searched for women who underwent primary surgery for an ovarian tumor between January 1, 1998, and December 31, 2015, and whose final diagnosis was mBOT. RESULTS: A total of 364 patients with mBOT with a median age of 43.1 years were included in this analysis. The median OS of all patients was 53.1 months. The majority of cases had Stage IA (78.6%). In univariate and multivariate analyses, radical surgery, omentectomy, appendectomy, lymphadenectomy, and adding adjuvant chemotherapy were not independent prognostic factors for PFS and OS. Furthermore, FIGO stage (≥IC vs.

Comparison Of Early-Stage High-Grade Serous Primary Fallopian Tube Cancers and Epithelial Ovarian Cancers: A Multicenter Study.

INTRODUCTION: We compared the disease free-survival (DFS) and overall survival (OS) rates of patients with high-grade serous primary fallopian tube cancer (HG-sPFTC) and high-grade serous epithelial ovarian cancer (HG-sEOC). METHODS: 22 early-stage cancer patients (International Federation of Gynecology and Obstetrics (FIGO) stages I-II) with HG-sPFTC were retrospectively evaluated. In addition, 44 control patients diagnosed with HG-sEOC were matched to these patients with respect to tumor stage at diagnosis. All patients underwent complete surgical staging, followed by adjuvant chemotherapy. Kaplan-Meier curves were used to generate survival data. RESULTS: The mean age of HG-sPFTC patients was 59.4 ± 6.2 years, and that of HG-sEOC patients 55.2 ± 11.0 years (p = 0.002). All patients underwent 6 cycles of platinum-based adjuvant chemotherapy. All operations were optimal. The 5-year DFSs were 77.3% for HG-sPFTC patients and 75% for HG-sEOC patients (p = 1.00).The 5-year OS rates were 81.8% in women with HG-sPFTC and 77.3% in those with HG-sEOC (p = 0.75). CONCLUSION: The DFS and OS rates of patients with early-stage (FIGO stages I and II) HG-sPFTC and HG-sEOC were similar. The surgical and adjuvant therapy management of these malignancies should be similar.

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.

Borderline ovarian tumors: clinical characteristics, management, and outcomes - a multicenter study.

BACKGROUND: The optimal surgical management and staging of borderline ovarian tumors (BOTs) are controversial. Institutions have different surgical approaches for the treatment of BOTs. Here, we performed a retrospective review of clinical characteristics, surgical management and surgical outcomes, and sought to identify variables affecting disease-free survival (DFS) and overall survival (OS) in patients with BOTs. METHODS: A retrospective review of ten gynecological oncology department databases in Turkey was conducted to identify patients diagnosed with BOTs. The effects of type of surgery, age, stage, surgical staging, complete versus incomplete staging, and adjuvant chemotherapy were examined on DFS and OS. RESULTS: In total, 733 patients with BOTs were included in the analysis. Most of the staged cases were in stage IA (70.4 %). In total, 345 patients underwent conservative surgeries. Recurrence rates were similar between the conservative and radical surgery groups (10.5 % vs. 8.7 %). Furthermore we did not find any difference between DFS (HR = 0.96; 95 % confidence interval, CI = 0.7-1.2; p = 0.576) or OS (HR = 0.9; 95 % CI = 0.8-1.1; p = 0.328) between patients who underwent conservative versus radical surgeries. There was also no difference in DFS (HR = 0.74; 95 % CI = 0.8-1.1; p = 0.080) or OS (HR = 0.8; 95 % CI = 0.7-1.0; p = 0.091) between complete, incomplete, and unstaged patients. Furthermore, receiving adjuvant chemotherapy (CT) for tumor stage ≥ IC was not an independent prognostic factor for DFS or OS. CONCLUSIONS: Patients undergoing conservative surgery did not show higher recurrence rates; furthermore, survival time was not shortened. Detailed surgical staging, including lymph node sampling or dissection, appendectomy, and hysterectomy, were not beneficial in the surgical management oF BOTs.

Differences in the ARID-1 alpha expressions in squamous and adenosquamous carcinomas of uterine cervix.

AT-rich interactive domain 1A (ARID1A) is a tumor suppressor gene involved in chromatin remodeling which encodes ARID1A (BAF250a) protein. Recent studies have shown the loss of ARID1A expression in several types of tumors. This retrospective study was designed to evaluate the differences in tissue expressions of ARID1A in a spectrum of cervical neoplasms. Cervical intraepithelial neoplasms, invasive squamous or adenosquamous carcinomas were identified in 100 patients recently diagnosed as cervical neoplasms based on pathology databases. In this series, there were 29 low- and 29 high-grade cervical intraepithelial neoplasms, 27 squamous cell carcinomas, and 15 adenosquamous carcinomas. Mean age of the patients was 47.8 ± 13 years (20-80 years). It was determined that the expression of ARID1A was statistically significantly down-regulated in adenosquamous carcinomas when compared with non-invasive or invasive squamous cell carcinomas (p = 0.015). Lower levels of the ARID1A expression were detected in cases with adenosquamous carcinomas (60%), low- or high-grade squamous intraepithelial lesion (SIL) (31%), and squamous cell carcinomas (18.5%). Our findings have demonstrated the presence of a correlation between ARID1A expression and adenomatous differentiation of uterine squamous cell carcinomas. Therefore, ARID1A gene may suggestively have a role in the pathogenesis of cervical adenosquamous carcinomas.

Does neoadjuvant chemotherapy plus cytoreductive surgery improve survival rates in patients with advanced epithelial ovarian cancer compared with cytoreductive surgery alone?

PURPOSE: The purpose of this study was to compare the outcomes of interval debulking surgery after neoadjuvant chemotherapy (NAC/IDS) with primary debulking surgery (PDS) in patients diagnosed with advanced epithelial ovarian cancer (EOC). METHODS: A total of 292 patients with IIIC and IV disease stages, who were treated with either NAC/IDS or PDS between 1995 and 2012 were retrospectively reviewed. The study population was divided into two groups: the NAC/IDS group (N=84) and the PDS group (N=208). Progression-free survival (PFS), overall survival (OS), and optimal cytoreduction were compared. RESULTS: The mean patient age was significantly higher in the NAC/IDS group (61.5±11.5 vs 57.8±11.1, p=0.01). Optimal cytoreduction was achieved in 34.5% (29/84) of the patients in the NAC/IDS group and in 32.2% (69/208) in the PDS group (p=0.825). The survival rates were comparable. The survival rate of patients who received optimal cytoreductive surgery in either the PDS or the NAC/IDS arm was significantly higher than that of patients who received suboptimal cytoreductive surgery (p<0.01 and p<0.01, respectively). Multivariate analysis confirmed the treatment method, amount of ascitic fluid, and optimal cytoreduction as independent factors for OS. CONCLUSIONS: There was no definitive evidence regarding whether NAC/IDS increases survival rates compared with PDS. NAC should be reserved for patients who cannot tolerate PDS or when optimal cytoreduction is not feasible.

Does neoadjuvant chemotherapy plus cytoreductive surgery improve survival rates in patients with advanced epithelial ovarian cancer compared with cytoreductive surgery alone?

PURPOSE: To compare the outcomes of interval debulking surgery (IDS) after neoadjuvant chemotherapy (NAC/IDS) with primary debulking surgery (PDS) in patients diagnosed with advanced epithelial ovarian cancer (EOC). METHODS: A total of 292 patients with stages IIIC and IV disease who were treated with either NAC/IDS or PDS between 1995 and 2012 were retrospectively reviewed. The study population was divided into two groups: the NAC/IDS group (N=84) and the PDS group (N=208). Progression-free survival (PFS), overall survival (OS), and optimal cytoreduction were compared. RESULTS: The mean age was significantly higher in the NAC/IDS group (61.5±11.5 vs 57.8±11.1 years, p=0.01). Optimal cytoreduction was achieved in 34.5% (29/84) of the patients in the NAC/IDS group and in 32.2% (69/208) in the PDS group (p=0.825). The survival rates were comparable. The mean survival rate of patients who achieved optimal cytoreductive surgery in either the PDS or the NAC/IDS arm was significantly higher than that of patients who achieved suboptimal cytoreductive surgery (p<0.001 and p<0.001, respectively). Multivariate analysis confirmed the treatment method, amount of ascitic fluid, and optimal cytoreduction as independent factors for OS. CONCLUSIONS: No definitive evidence was noticed regarding whether NAC/IDS increases survival compared with PDS. NAC should be reserved for patients who cannot tolerate PDS or when optimal cytoreduction is not feasible.

Lymphovascular space invasion and cervical stromal invasion are independent risk factors for nodal metastasis in endometrioid endometrial cancer.

AIMS: The purpose of this study was to investigate the potential roles of pathological variables in the prediction of nodal metastasis in women with endometrioid endometrial cancer (EC). MATERIALS AND METHODS: Women who underwent surgery for endometrioid EC between 1995 and 2012 were retrospectively reviewed. Those who underwent prior neoadjuvant chemotherapy or radiotherapy and inadequate lymphadenectomy as well as those with nonendometrioid histology, synchronous cancers, International Federation of Gynecology and Obstetrics stage IV disease, gross uterine serosal and/or gross adnexal involvement were excluded. Lymph node dissemination was defined as occurring in the following circumstances: (i) when nodal metastasis with pelvic and/or para-aortic (P/PA) lymph node dissection (LND) was performed or (ii) when there was recurrence in the P/PA lymph nodes after a negative LND or when LND was not performed. Univariate and multivariate logistic regression models were used to identify the pathological predictors of lymphatic dissemination. RESULTS: A total of 827 women with endometrioid EC were assessed; 516 (62.4%) of whom underwent P/PA LND and 205 (24.8%) underwent P LND. Sixty-seven (13%) women in the P/PA LND group and 5 (2.4%) in the P LND group had positive lymph nodes. Multivariate analysis confirmed cervical stromal invasion (OR 4.04, 95% CI 2.02-8.07 (P < 0.001)) and lymphovascular space invasion (LVSI) (OR 110.18, 95% CI 38.43-315.87 (P < 0.001)) as independent predictors of lymphatic dissemination. CONCLUSION: Cervical stromal invasion and LVSI are highly associated with LN metastasis. These markers may serve as a surrogate for nodal metastasis.

Prognostic Significance of Retroperitoneal Lymphadenectomy, Preoperative Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio in Primary Fallopian Tube Carcinoma: A Multicenter Study.

PURPOSE: The purpose of this study is to evaluate the prognostic role of preoperative neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) and the need for para-aortic lymphadectomy in patients with primary fallopian tube carcinoma (PFTC). MATERIALS AND METHODS: Ninety-one patients with a diagnosis of PFTC were identified through the gynecologic oncology service database of six academic centers. Clinicopathological, surgical, and complete blood count data were collected. RESULTS: In univariate analysis, advanced stage, suboptimal surgery, and NLR > 2.7 were significant prognostic factors for progression-free survival, whereas in multivariate analysis, only advanced stage and suboptimal surgery were significant. In addition, in univariate analysis, cancer antigen 125 ≥ 35 U/mL, ascites, advanced stage, suboptimal surgery, NLR > 2.7, PLR > 233.3, platelet count ≥ 400,000 cells/mm(3), staging type, and histological subtype were significant prognostic factors for overall survival (OS); however, in multivariate analysis, only advanced stage, suboptimal surgery, NLR > 2.7, and staging type were significant. Inclusion of pelvic and para-aortic lymphadenectomy in surgery showed significant association with longer OS, with a mean and median OS of 42.0 months and 35.5 months (range, 22 to 78 months), respectively, vs. 33.5 months and 27.5 months (range, 14 to 76 months), respectively, for patients who underwent surgery without para-aortic lymphadenectomy (hazard ratio, 3.1; 95% confidence interval, 1.4 to 5.7; p=0.002). CONCLUSION: NLR (in both univariate and multivariate analysis) and PLR (only in univariate analysis) were prognostic factors in PFTC. NLR and PLR are inexpensive and easy tests to perform. In addition, patients with PFTC who underwent bilateral pelvic and para-aortic lymphadenectomy had longer OS.

A novel preoperative scoring system for predicting endometrial cancer in patients with complex atypical endometrial hyperplasia and accuracy of frozen section pathological examination in this context: a multicenter study.

OBJECTIVE: To estimate the accuracy of frozen pathological analysis in patients preoperatively diagnosed with endometrial atypical complex hyperplasia (ACH) and to develop a model predicting the probability of the presence of endometrial carcinoma in ACH. METHODS: Patients (n = 128) who underwent total hysterectomies because of diagnoses of ACH were evaluated at four tertiary centers. RESULTS: Diagnoses made using frozen sections and permanent sections were in good agreement (ĸ = 0.61, p < 0.0001). A useful scoring system combining weighted risk factors derived from a regression model is as follows: (2 × age ≥50 years) + (3 × BMI ≥30) + (2 × menopausal status) + (2 × diabetes comorbidity) + (3 × endometrial thickness >12 mm). The AUC of this score was 0.793, and the score afforded 80.9% sensitivity, 70.3% specificity, a 75.3% positive predictive value, and a 76.4% negative predictive value, when a score of 5 was used as a cutoff. CONCLUSIONS: Patients with ACH should be evaluated by gynecological oncologists and intraoperative frozen section analysis should be performed by pathologists specializing in the evaluation of gynecological malignancies, because ACH is closely associated with endometrial cancer (EC). Our novel preoperative scoring system may aid in the detection of patients at increased risk of EC and thus guide general gynecologists.

Adjuvant treatment modalities, prognostic predictors and outcomes of uterine carcinosarcomas.

PURPOSE: The purpose of this study is to evaluate the clinicopathological characteristics, treatment, and prognosis of uterine carcinosarcoma (UC). MATERIALS AND METHODS: A retrospective review of three cancer registry databases in Turkey was conducted for identification of patients diagnosed with UC between January 1, 1996, and December 31, 2012. We collected clinicopathological data in order to evaluate factors important in disease- free survival (DFS) and overall survival (OS). RESULTS: A total of 66 patients with UC with a median age of 65.0 years were included in the analysis. The median survival time of all patients was 37.5 months and the 5-year OS rate was 59.1%. In early stage patients (I-II) who received adjuvant chemotherapy (CT) with radiation therapy (RT), the median DFS and OS was 44 months and 55 months, respectively, compared to 34.5 months and 36 months, respectively, in patients who received adjuvant RT or CT alone (hazard ratio [HR], 1.4; 95% confidence interval [CI], 0.7 to 3.1 for DFS; p=0.23 and HR, 2.2; 95% CI, 0.9 to 5.3 for OS; p=0.03). In advanced stage patients (III-IV), the median DFS and OS of patients receiving adjuvant RT with CT was 25 months and 38 months, respectively, compared to 23.5 months and 24.5 months, respectively, in patients receiving adjuvant RT or CT alone (HR, 3.1; 95% CI, 0.6 to 16.0 for DFS; p=0.03); (HR, 3.3; 95% CI, 0.7 to 15.0 for OS; p=0.01). In multivariate analysis, advanced International Federation of Gynecology and Obstetrics (FIGO) stage and suboptimal surgery showed significant association with poor OS. CONCLUSION: In patients with early or advanced stage UC, adjuvant CT with RT is associated with improved DFS and OS, as compared to CT or RT alone.

Is mucinous adenocarcinoma of the endometrium a risk factor for lymph node involvement? A multicenter case-control study.

PURPOSE: The purpose of this multicenter case-control study was to compare the demographic and clinical characteristics of patients with mucinous adenocarcinoma of the endometrium (MAE) and endometrioid endometrial carcinoma (EEC). METHODS: A retrospective review of two cancer registry databases in Turkey was conducted to identify patients diagnosed with MAE between January 1996 and December 2012. Each patient was matched with a control EEC patient by age and tumor grade. Cases and controls were compared in terms of known risk factors for lymph node metastasis, disease-free survival (DFS), and overall survival (OS). RESULTS: The analysis included 112 patients with MAE and 112 with EEC. No significant difference in baseline characteristics was evident between the two groups. Lymphovascular space invasion, deep myometrial invasion, cervical involvement, and tumor diameter did not differ significantly between the mucinous and endometrioid cases. Multivariate analysis confirmed that only mucinous histology (OR 2.2, 95 % CI 1.1-4.5; P = 0.02) was an independent predictor of lymph node involvement. Although the median DFS and OS tended to be better in the endometrioid group, the differences were not statistically significant. Routine appendectomy was performed in 52 (46.2 %) patients with MAE. No mucinous tumor of the appendix was identified. CONCLUSION: Routine appendectomy is not necessary when the appendix is grossly normal at the time of surgery for MAE. Although the DFS and OS of EEC and MAE patients were similar, the risk of nodal metastasis in MAE patients was greater than that in ECC patients, and we thus suggest to perform retroperitoneal lymphadenectomy (both pelvic and para-aortic) for patients with MAE during the initial operation.

Does lubrication of the vaginal speculum reduce pain during a gynecologic oncology examination?

OBJECTIVE: To evaluate the effectiveness of lubricant gel for reducing pain during a vaginal speculum examination (SE) in patients with gynecologic cancers. STUDY DESIGN: This non blind randomized controlled trial included 200 women who underwent SE for post-treatment surveillance. One-hundred patients each were allocated to the water and lubricant gel groups. All patients were asked to score their pain during speculum insertion, dilatation, and extraction using a visual analog scale (VAS). Pain intensity during speculum insertion was the primary outcome measure. RESULTS: There were no statistically significant differences in demographic characteristics between the water (n = 97) and lubricant gel (n = 98) groups. The VAS pain scores obtained during all phases of the SE were significantly lower in the lubricant gel group compared with the water group during the insertion (3.95 ± 1.57 vs. 5.28 ± 1.71, P < 0.001), dilatation (5.96 ± 1.48 vs. 6.74 ± 1.69, P < 0.001) and extraction phases (2.60 ± 1.17 vs. 3.50 ± 1.25 P < 0.001). When a separate analysis was performed for the patients who underwent radiation therapy, the mean VAS pain scores were significantly lower in the lubricant gel group during the insertion (4.46 ± 1.45 vs. 6.22 ± 1.79, P < 0.001), dilatation (6.31 ± 1.66 vs. 7.52 ± 1.61, P = 0.002) and extraction phases (2.68 ± 1.31 vs. 3.66 ± 1.06, P = 0.001). CONCLUSION: The use of speculum lubricant gel significantly decreased pain during the SE in gynecologic oncology patients.

Umbilical stalk elevation technique for safer Veress needle insertion in obese patients: a case-control study.

OBJECTIVE: The purpose of this retrospective study was to compare our umbilical stalk elevation (USE) technique with the classic Veress needle (VN) technique in obese patients. STUDY DESIGN: The USE technique was performed on 40 patients. One control per case was randomly selected from among those undergoing the classic VN technique using a random number table. In USE technique, a 12 mm skin incision was created at the superior crease of the umbilical fold, and the underlying subcutaneous adipose tissue was bluntly dissected using the tip of a fine clamp until the umbilical stalk was isolated at the inferior and central part of the incision. Next, the umbilical stalk was covered and held by a towel clip, and the abdominal wall was elevated by upward traction. The VN was then inserted nearly perpendicular to the incision and turned toward the pelvis immediately after resistance to the needle had been lost. A post-hoc power analysis was performed. RESULTS: The number of attempts was significantly lower in the USE laparoscopy group than in the classic laparoscopy group (1.2 ± 0.4 vs. 2.1 ± 0.7, respectively; P<0.001). The USE technique group had a slightly shorter abdominal entry time than did the classic technique group (328.52 ± 63.71 vs. 434.95 ± 124.10s; P<0.001). Six (7.5%) failed insufflations occurred in our study (5 patients in the classic group vs. 1 patient in the USE group (P=0.10). CONCLUSION: Our novel USE technique can be an effective means of establishing pneumoperitoneum in obese patients undergoing gynecologic laparoscopic procedures.

Immunolocalization of ERK1/2 and p-AKT in normal endometrium, endometrial hyperplasia, and early and advanced stage endometrioid endometrial adenocancer and their prognostic significance in malignant group.

OBJECTIVE: To analyze the expression patterns of extracellular signal-regulated kinase (ERK1/2) and phosphorylated (p)-AKT in the tissues of non-pathologic endometrium, endometrial hyperplasia, and early and advanced stage endometrioid endometrial adenocancer using indirect immunohistochemistry, and also to investigate the effect of ERK1/2 and p-AKT expression patterns on prognosis in endometrioid adenocancer. STUDY DESIGN: Immunolocalization of ERK1/2 and p-AKT was examined in six different types of endometrial tissues: proliferative endometrium (PE; n=10, 11.2%), secretuar endometrium (SE; n=10, 11.2%), simple hyperplasia (SH; n=15, 16.9%), complex hyperplasia (CH; n=3, 3.4%) and atypical complex hyperplasia (ACH; n=10, 11.2%), which were obtained from endometrial biopsies, curettage materials, and hysterectomy specimens and classified as the benign group; and both early stage endometrioid (n=21, 23.6%) and advanced stage endometrioid adenocancer (AC; n=20, 22.5%), which were obtained from complete surgical staging materials and classified as the malignant group. All specimens were fixed in 10% formalin and processed using routine paraffin protocols. Immunostaining intensities were evaluated as negative or weak (assigned as low expression) and moderate or strong (assigned as high expression). RESULTS: In the malignant group, 23 of 41 patients (56.1%) had high ERK1/2 and p-AKT expression, whereas only three of 48 patients in the benign group (6.3%) had high ERK1/2 and p-AKT expression (P<0.0001 and P<0.0001, respectively). p-AKT expression was significantly higher in women with positive lymph nodes (OR 9.0; 95% CI: 1.2-100.0; P=0.03). Higher expression of p-AKT was significantly associated with poor progression-free survival (PFS) and overall survival (OS). In contrast, ERK1/2 expression was not associated with PFS or OS.Conclusions ERK1/2 and p-AKT can be useful in the differential diagnosis of benign vs. malignant endometrial lesions, as well as early vs. advanced stage endometrioid endometrial adenocancer. Additionally, higher p-AKT expression could be used as a marker of poor prognosis in the management of patients with endometrioid endometrial adenocancer.