The characteristics of the residual disease after cervical conization: A retrospective analysis from a tertiary gynecological cancer center.

Background: Patients with a biopsy-confirmed cervical intraepithelial neoplasia 2 and 3 have an increased risk of disease progression to invasive cancer and should be treated with an excisional method. However, after treatment with an excisional method, a high-grade residual lesion may remain in patients with positive surgical margins. We aimed to investigate the risk factors for a residual lesion in patients with a positive surgical margin after cervical cold knife conization. Methods: Records of 1008 patients who underwent conization at a tertiary gynecological cancer center were retrospectively reviewed. One hundred and thirteen patients with a positive surgical margin after cold knife conization were included in the study. We have retrospectively analyzed the characteristics of the patients treated with re-conization or hysterectomy. Results: Residual disease was identified in 57 (50.4%) patients. The mean age of the patients with residual disease was 42.47 ± 8.75 years. Age greater than 35 years (P = 0.002; OR, 4.926; 95%CI [Confidence Interval] - 1.681-14.441), more than one involved quadrant (P = 0.003; OR, 3.200; 95% CI - 1.466-6.987), and glandular involvement (P = 0.002; OR, 3.348; 95% CI - 1.544-7.263) were risk factors for residual disease. The rate of high-grade lesion positivity in post-conization endocervical biopsy at initial conization was similar between patients with and without residual disease (P = 0.16). The final pathology of the residual disease was microinvasive cancer in four patients (3.5%) and invasive cancer in one patient (0.9%). Conclusion: In conclusion, residual disease is found in about half of the patients with a positive surgical margin. In particular, we found that age greater than 35 years, glandular involvement, and more than 1 involved quadrant were associated with the residual disease.

Effect of Human Papillomavirus Subtype on the Rate of Positive Surgical Margin After Cervical Conization.

Objective. Human papillomavirus (HPV) infection is a risk factor for cervical carcinoma. Over 100 types of HPV have been identified. The excisional procedures are recommended for women with high-grade cervical intraepithelial neoplasia. Surgical margin status is an important predictor of the risk of relapse. The aim of the current study was to evaluate whether HPV genotype is a predictive factor of positive surgical margin after cervical cone excision. Materials and Methods. The records of 448 HPV-infected patients who underwent loop electrosurgical excision or cold knife conization at a tertiary gynecological cancer center were retrospectively reviewed. The patients were divided into 6 groups according to HPV positivity: HPV 16 only, HPV 18 only, HPV 16/18, other high-risk HPV (hrHPV), HPV 16/hrHPV, and HPV 18/hrHPV. Results. There was no significant difference between the HPV groups in terms of age, parity, menopausal status, endocervical canal involvement, conization method, and the rates of positive margin (P = .15, P = .49, P = .07, P = .20, P = .24, P = .39, respectively). Conclusion. The results show that HPV subtypes might not be associated with endocervical canal involvement and the rates of positive margin. In addition, margin status was not related to the conization method and the number of excised cervical tissue.

Mini-plus percutaneous setting in total laparoscopic hysterectomy.

INTRODUCTION: We aimed to analyze the preliminary experience of a mini-plus percutaneous instrument (MpPc) setting in total laparoscopic hysterectomy (TLH). MATERIAL AND METHODS: Forty-three women who underwent a mini-plus percutaneous total laparoscopic hysterectomy at a tertiary-care university-based teaching hospital and academic affiliated private hospital between May 2017 and 2018 were included. MpPc-TLH was performed through one optical trans-umbilical 5-mm trocar, one 5-mm ancillary port on the right side, either one 2.4-mm percutaneous endoscopic instrument or 3-mm mini-laparoscopic port on the right upper quadrant and if required one 3-mm ancillary port on the left lower quadrant. RESULTS: A total of 43 patients were included, with a median age of 48 years (range, 38-71 years). Indication for surgery included uterine myomas (n = 20), benign adnexal mass (n = 7), endometrial intraepithelial neoplasia (n = 6), endometrial cancer (n = 5), adenomyosis with abnormal bleeding (n = 3), and high-grade cervical dysplasia (n = 2). The median operating time was 100 min (range, 60-180 min), and the median estimated blood loss was 30 ml (range, 20-60ml). The median postoperative abdominal pain Visual Analog Scale score was 3 (range, 0-6). CONCLUSIONS: The preliminary data suggest that MpPc approach is a feasible and safe surgical modality for total laparoscopic hysterectomy.

The safety of major gynaecologic cancer surgery without routine preoperative COVID-19 testing in the COVID-19 era: a multicentre, retrospective, case-control study.

Our goal was to address the safety of major gynaecologic cancer surgery without routine preoperative COVID-19 testing in the COVID-19 era. The databases of seven gynaecologic cancer centres were searched in order to identify all consecutive gynaecologic cancer patients undergoing major surgery between March 11, 2020 and May 15, 2020 for this retrospective, case-control study. The case group consisted of patients with histopathologically confirmed gynaecologic cancers, and each case was matched with two counterparts who had undergone primary surgery before the COVID-19 pandemic. The case and the control groups were compared in terms of length of hospital stay, admission to the intensive care unit (ICU), intraoperative and postoperative complications.During the study period, 154 women with gynaecologic cancer undergoing major surgery were identified. Although the case group had more co-morbidities compared to the control group (103/154 vs. 178/308, respectively; p = .04), the median length of hospital stays, the rate of ICU admission, intraoperative complication rates and postoperative complication rates were similar in the two groups. Gynaecologic cancer surgery may be performed safely in the COVID-19 era with similar rates of ICU admission, intraoperative and postoperative complications compared to the patients operated before the COVID-19 pandemic.IMPACT STATEMENTWhat is already known on this subject? Many societies have announced their guidelines about the surgical management of gynaecologic cancer patients during the COVID-19 pandemic. However, most of them are not evidence-based and mostly on expert opinions.What do the results of this study add? The main findings of this retrospective, case-control study indicate that the short-term (30 day) outcomes of gynaecologic cancer patients undergoing major surgery in the COVID-19 era are similar to those who had been operated before the COVID-19 pandemic. The length of hospital stays, the rates of admission to the ICU, intraoperative and postoperative complications were comparable between women undergoing major gynaecologic cancer surgery in the COVID-19 era and the women who had been operated before the pandemic.What are the implications of these findings for clinical practice and/or further research? We can suggest that definitive surgery may be performed for gynaecologic cancer patients in the COVID-19 era if the resources permit and appropriate precautions such as social distancing, isolation and the use of personal protective equipment are taken.

Effect of the coronavirus pandemic on tumor markers.

The new type of coronavirus could cause severe acute respiratory syndrome and injuries in other systems as well. Multiple organ damage can occur rapidly in patients infected with coronavirus disease 2019 (COVID-19). Previous studies have shown that many laboratory biomarkers were not within the normal ranges in COVID-19 patients. We aimed to summarize laboratory parameters and the tumor markers in COVID-19 patients. This is a retrospective cohort study conducted on 53 women between the ages of 19-85 years infected with COVID-19 at a training and research hospital between May 2020 and August 2020. Of the 53 women, 16 (30.2%) had leukopenia. The mean C-reactive protein level was 18.42 ± 59.33 mg/L. The mean procalcitonin level was 0.1 ± 0.21 µg/L. The liver function tests were within normal limits. The mean creatinine level was 0.58 ± 0.37 mg/dl. Elevated levels of α-fetoprotein (AFP) in 1 patient, elevated levels of carcinoembryonic antigen (CEA) in 2 patients, elevated levels of cancer antigen 125 (CA125) in 4 patients, elevated levels of CA19-9 in 2 patients, and elevated levels of CA15-3 in 2 patients were detected. One of 4 patients who were taken to the intensive care unit had elevated levels of AFP. In addition, 2 of 4 patients who were taken to the intensive care unit had elevated levels of CA125 and CA15-3. Except for AFP, levels of all tumor markers of the patient who died were high. We found that COVID-19 had no effect on tumor markers (CA125, CA19-9, CA15-3, AFP, and CEA).

Is elective cancer surgery feasible during the lock-down period of the COVID-19 pandemic? Analysis of a single institutional experience of 404 consecutive patients.

BACKGROUND: We aimed to assess the feasibility and short-term clinical outcomes of surgical procedures for cancer at an institution using a coronavirus disease 2019 (COVID-19)-free surgical pathway during the peak phase of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. MATERIALS AND METHODS: This was a single-center study, including cancer patients from all surgical departments, who underwent elective surgical procedures during the first peak phase between March 10 and June 30, 2020. The primary outcomes were the rate of postoperative SARS-CoV-2 infection and 30-day pulmonary or non-pulmonary related morbidity and mortality associated with SARS-CoV-2 disease. RESULTS: Four hundred and four cancer patients fulfilling inclusion criteria were analyzed. The rate of patients who underwent open and minimally invasive procedures was 61.9% and 38.1%, respectively. Only one (0.2%) patient died during the study period due to postoperative SARS-CoV2 infection because of acute respiratory distress syndrome. The overall non-SARS-CoV2 related 30-day morbidity and mortality rates were 19.3% and 1.7%, respectively; whereas the overall SARS-CoV2 related 30-day morbidity and mortality rates were 0.2% and 0.2%, respectively. CONCLUSIONS: Under strict institutional policies and measures to establish a COVID-19-free surgical pathway, elective and emergency cancer operations can be performed with acceptable perioperative and postoperative morbidity and mortality.

The meaning of high-risk HPV other than type 16/18 in women with negative cytology: Is it really safe to wait for 1 year?

BACKGROUND: Human papillomavirus (HPV) is a primary risk factor for cervical cancer. HPV 16 and 18 are the two most carcinogenic genotypes and have been reported in the majority of cervical cancer. High-risk HPVs (hrHPVs) other than HPV 16/18 cause approximately a quarter of cervical cancers. We aimed to present the colposcopy-guided biopsy results of non-16/18 hrHPV-infected women with negative cytology. METHODS: This is a retrospective cohort study conducted on 752 patients between the ages of 30-65 years with non-16/18 hrHPV and negative cytology undergoing colposcopy-guided biopsy at a tertiary gynecological cancer center between January-2016 and January-2019. RESULTS: The mean age of the women was 42.35±9.41 years. Cervical intraepithelial neoplasia (CIN) 2+ lesion was detected in 49 (6.5%) women with negative cytology. The rate of CIN 2+ lesions in women with abnormal cytology was 12.8%. Patients with abnormal cytology had about 2.1 and 2.4 times increased the odds of CIN 2+ lesion in cervical biopsy and endocervical curettage specimens, respectively. CIN 3+ lesion was detected in 20 (2.7%) women with negative cytology. One (0.1%) of the patients with HPV 39 and negative cytology had invasive cervical cancer. The two most common HPV subtypes were HPV 31 and HPV 51. CONCLUSIONS: The risk of cervical preinvasive lesions still can be detected and cannot be completely eliminated among hrHPV other than 16/18-infected women with negative cytology. Based on the results of this study, referral of non-16/18 hrHPV-infected women with negative cytology to colposcopy is supported as a credible and feasible strategy.

Vaginal-assisted laparoscopic nerve sparing radical trachelectomy

Fertility-sparing surgery has gained popularity in the last three decades for the management of cervical cancer in women under 40 years of age. Radical trachelectomy is a fertility-sparing surgical technique for women who wish to retain their fertility. Vaginal-assisted laparoscopic radical trachelectomy is feasible in selected patients with early cervical cancer. The aim of this video is to present a nerve-sparing vaginal-assisted laparoscopic radical trachelectomy demonstrating pelvic anatomical structures.

Factors Affecting the Histopathological Outcomes of Atypical Glandular Cells on Pap Test.

BACKGROUND: Glandular cell abnormalities may indicate the presence of pre-malignant or malignant lesions. AIM: This study aimed to investigate the relationship between atypical glandular cells (AGC) and patients' demographics, histopathological outcomes, Human Papillomavirus (HPV) test results. MATERIAL AND METHODS: Between January 2015 and December 2019, women with AGC on Pap tests were retrieved from the hospital electronic database. The patients with AGC on cervicovaginal smears who underwent further pathological, laboratory, and imaging diagnostic testing and who were followed up at least 1-year were included in the study, while those who had a history of cervical dysplasia or cancer, lost during follow-up, or had missing data were excluded. RESULTS: Of 85,692 Pap smears, 114 (0.13%) were diagnosed with AGC, of those 88 cases were eligible for final analysis. Gynecological malignancies were detected in 13 (14.8%) patients; including 6 (6.8%) endometrioid endometrial cancers, 3 (3.4%) non-endometrioid endometrial cancers, 2 (2.3%) cervical adenocarcinomas, 1 (1.1%) cervical squamous cell carcinoma, and 1 (1.1%) high-grade tubal serous cancer. Multivariate analysis revealed that presence of concomitant abnormal squamous lesion (P = 0.002), being 50 years and older (P = 0.028), HPV positivity (P < 0.001), and menopause (P = 0.023) were risk factors for significant pathology. CONCLUSION: The diagnosis of AGC may be related to the preneoplastic/neoplastic processes. A further comprehensive histopathological examination is required in women with AGC, aged 50 years and older, postmenopausal, HPV-positivity and concomitant squamous cell abnormality Clinicians should consider ovarian pathologies when there is no pathological finding on endometrial or cervical histopathological examination.

Is cervical cytology testing as a part of co-test unnecessary for HPV 16/18-infected women? A retrospective cohort study of 1647 women.

BACKGROUND: We aimed to present the biopsy results of women with HPV 16/18 infection and investigate whether cytology is necessary as a part of routine cervical cancer screening in women with HPV 16/18. METHODS: This is a retrospective cohort study conducted on 1647 patients between the ages of 30 and 65 years with HPV 16/18 undergoing colposcopy-guided biopsy at a tertiary gynecological cancer center between January-2016 and January-2019. We compared the preinvasive lesion rates and the invasive cervical cancer rates of women with HPV 16/18 between the negative and the abnormal cytology group. RESULTS: Of the 1647 women, 1105 (67.1%) had negative cytology and 542 (32.9%) had abnormal cytology. Among women with initial negative cytology, cervical intraepithelial neoplasia (CIN) 2+ lesion was detected in 205 (18.6%) women. The rate of CIN 2+ lesion in women with abnormal cytology was 28%. There was a significant difference between negative and abnormal cytology group in terms of CIN 2+ lesion rates (P < .001). Among women with initial negative cytology, invasive cervical cancer was detected in 6 (0.5%) women. The rate of invasive cervical cancer in women with abnormal cytology was 8 (1.5%). There was no significant difference between negative and abnormal cytology group in terms of invasive cervical cancer rates (P = .082). CONCLUSIONS: The rate of cervical cancer among HPV 16/18-infected women with negative cytology is similar to women with abnormal cytology. Based on the results of this study, Pap testing could be unnecessary in HPV 16/18-infected women to diagnose invasive cervical cancer who will undergo colposcopy biopsy.

Effect of Lymphadenectomy on Survival in Early-Stage Type II Endometrial Carcinoma and Carcinosarcoma.

PURPOSE: We aimed to investigate whether systematic pelvic and paraaortic lymph node dissection delivers any survival advantage in a subgroup of patients with type II endometrial carcinoma and carcinosarcoma. METHODS: We evaluated 135 patients with clinically early-stage (Stage I-II) type II endometrial carcinoma and carcinosarcoma who underwent systematic pelvic and paraaortic lymph node dissection or who did not undergo any lymph node dissection. RESULTS: Overall survival (OS) and recurrence-free survivals (RFS) were significantly longer in the systematic lymph node dissection group (hazard ratio 0.28, 95% CI 0.13-0.62 p=0.002 for OS and hazard ratio 0.31, 95% CI 0.14-0.69 p=0.004 for RFS). Multivariate analysis showed that lymph node dissection, age, lymph node metastasis, and adjuvant therapy were independent prognostic variables of OS and RFS. CONCLUSIONS: Systematic pelvic and paraaortic lymph node dissection independently and significantly prolongs the survival of patients with early-stage type II endometrial carcinoma and carcinosarcoma.

Post-conization follow-up of patients with CIN 2/3 with different amount of distance to negative cone biopsy margin: a retrospective cohort study.

The aim of this study was to investigate whether patients with CIN 2/3 with different amount of distance to negative cone biopsy margin differ in terms of post-conization follow-up results. Cold-knife cone specimens with a negative surgical margin with a diagnosis of CIN-2/3 were selected. The minimum distance between the margin and lesion was categorised as less than 2 mm (Group-1), 2-5 mm (Group-2), or more than 5 mm (Group-3). There were no statistically significant differences between groups in terms of postoperative cone-biopsy results (p = .61). Furthermore, there were no statistically significant differences between groups in terms of cytology at 6 months and 12 months (p = .33 and p = .80, respectively). Results of the present study indicate that the amount of distance of lesion to cone biopsy margin seems to have no effect on follow-up results in patients with negative surgical margin.Impact StatementWhat is already known on this subject? Negative surgical margins on conization are associated with lower rates of lesion recurrence. Only the efficacy of volume and size of cone biopsy specimens have been analysed on lesion recurrence. However, there is no clear definition of the minimum distance of a negative margin during cone biopsy.What do the results of this study add? To the best of our knowledge, this is the first study describing the post-conization follow-up of patients with CIN 2/3 with different amount of distance to negative cone biopsy margin. Patients who underwent surgical treatment with a wider cone biopsy margin and narrower cone biopsy margin demonstrated similar follow-up results.What are the implications of these findings for clinical practice and/or further research? The present study provides valuable information to guide physicians performing conizations with an appropriate amount of negative surgical margin. Future studies investigating the effect of different amount of distance to negative cone biopsy margin on gynaecologic and obstetrics complications such as stenosis, bleeding, and preterm labour, low birth weight, and perinatal mortality are needed to show the benefits of a narrower distance to negative cone biopsy margin.

Failure of sentinel lymph node mapping in a patient with endometrial cancer with chronic lymphocytic leukemia: A case report.

We aimed to report a detection failure of sentinel lymph node (SLN) mapping via indocyanine green in a patient with endometrial cancer with a previous history of chronic lymphocytic leukemia (CLL), which is a potential risk factor to obstruct lymphatic channels. A 64-year-old woman with a 12-year history of CLL presented to the clinic with grade 2 endometrioid carcinoma. The patient underwent laparoscopic surgical staging. Indocyanine green was used intraoperatively to locate the SLN. No lymph node or lymphatic vessels were identified during SLN mapping. At the final pathology, the morphological findings of CLL were detected in the lymph nodes without metastasis of endometrial cancer. Sentinel lymph node mapping failure due to obstruction of lymphatic channels in a patient with CLL was demonstrated in this study. This is the first report to the best of our knowledge showing SLN mapping failure in the presence of lymphoproliferative diseases.

Cervix human papilloma virus positivity: Does it cause sexual dysfunction?

OBJECTIVE: To investigate whether testing positive for human papilloma virus (HPV) in cervical screening has an impact on female sexual functioning. MATERIALS AND METHODS: This study was designed as a single-center, prospective, descriptive-cross-sectional study and 300 women who received HPV testing in our hospital [HPV-positive (n=187) or HPV-negative (n=113)]. The Arizona Sexual Experiences (ASEX) scale and Female Sexual Functioning index (FSFI) were administered to study participants during face-to-face interviews. RESULTS: No significant differences were found between women who were HPV-positive and HPV-negative in sexual functions as assessed using the ASEX and FSFI scales (p=0.343 and p=0.604, respectively). In addition, the analyses addressing whether sexual functioning was affected by a positive test result, at diagnosis or during the follow-up (before 2 weeks, 2 weeks-1 month, 1-3 months, 3-6 months, 6 months-1 year and over 1 year) revealed no significant differences between HPV-positive and HPV-negative women in sexual functioning (p>0.05). Sexual dysfunction was less common in married women than in the ASEX scale (p=0.03), and this difference was not detected when the FSFI scale was applied. The incidence of dysfunction was more frequent in working women than in retirees (p=0.006, p=0.01). CONCLUSION: Educational attainment, socioeconomic status, age, employment status, and marital status were found to have statistically significant effects on sexual functioning. Sexual functioning was affected by neither HPV test results (positive/negative) nor time from diagnosis.

Comparison of Nerve Fiber Density between Patients with Uterine Leiomyoma with and without Pain: a Prospective Clinical Study.

INTRODUCTION: We aimed to compare the presence and the amount of nerve fibers in endometrial, myometrial and leiomyoma tissues using protein gene product 9.5 (PGP 9.5) and neurofilament (NF) immunohistochemical staining in uterine leiomyoma patients with and without pain complaint. METHODS: Patients undergoing hysterectomy for uterine leiomyoma were prospectively enrolled in the study. Twenty-five uterine leiomyoma patients without pelvic pain complaint (visual analog scale (VAS) < 5) were assigned to Group 1; 23 uterine leiomyoma patients with pelvic pain complaint (VAS ≥ 5) were assigned to Group 2. Endometrial, myometrial and leiomyoma tissues obtained from hysterectomy specimens were stained immunohistochemically using PGP 9.5 and NF dyes. The presence and density of nerve fibers were compared between the two groups. RESULTS: None of the endometrial samples in either groups stained with PGP 9.5 and NF dyes. There was no statistically significant difference in the number of nerve fibers in myometrial and leiomyoma tissues between the two groups with either of the stains (PGP 9.5: p = 0.39 and p = 0.29; NF: p = 0.83 and p = 0.65, respectively). There was agreement between PGP 9.5 and NF immunohistochemical staining for nerve fiber detection in myometrial and leiomyoma tissues (p < 0.05/κ = 0.622 and p < 0.05/κ = 0.388, respectively). CONCLUSION: This study demonstrates that the quantity and density of nerve fibers in myometrial and leiomyoma tissue in patients with pain were similar to that in patients without pain.

WISP1 is a novel adipokine linked to metabolic parameters in gestational diabetes mellitus.

OBJECTIVE: To investigate Wnt1-inducible signaling pathway protein-1 (WISP1) levels and their correlation with metabolic parameters in pregnant women with gestational diabetes mellitus (GDM) and non-GDM healthy pregnant women. MATERIALS AND METHODS: In this prospective cross-sectional study, the study group was composed of 62 women with GDM and 73 healthy pregnant women matched for age, body mass index (BMI) and gestational age. Blood samples were collected at 25-29th gestational week. Serum WISP1, betatrophin, glucose, fasting insulin, glycosylated hemoglobin A1c, total cholesterol, triglyceride, high density lipoprotein cholesterol, low density lipoprotein cholesterol, C reactive protein, alanine aminotransferase and creatinine levels were measured. Homeostasis model assessment of insulin resistance (HOMA-IR) values was calculated. The level of significance was accepted as p < 0.05. RESULTS: Circulating WISP1 in the GDM group was significantly higher than the control group (p <0.001). Further, WISP1 was positively correlated with BMI, HOMA-IR values and fasting glucose, fasting insulin, triglyceride, betatrophin levels. BMI, HOMA-IR and betatrophin independently and positively predicted WISP1 levels. CONCLUSION: These results demonstrate a relationship between WISP1 and the metabolic parameters of GDM. And, WISP1 might be involved in the pathophysiology of GDM. As a part of this pathophysiological mechanism, the activation of WISP1 and betatrophin might take place through several ways; WISP1 and betatrophin might either use same signaling pathways and potentiate each other or they might also constitute the sequential steps of a common pathway.