Diagnostic accuracy of sentinel node biopsy in non-endometrioid, high-grade and/or deep myoinvasive endometrial cancer: A Turkish gynecologic oncology group study (TRSGO-SLN-006).

INTRODUCTION: This study aimed to evaluate the diagnostic accuracy of the sentinel lymph node (SLN) mapping algorithm in high-risk endometrial cancer patients. METHODS: Two hundred forty-four patients with non-endometrioid histology, grade 3 endometrioid tumors and/or tumors with deep myometrial invasion were enrolled in this retrospective, multicentric study. After removal of SLNs, all patients underwent pelvic ± paraaortic lymphadenectomy. Operations were performed via laparotomy, laparoscopy or robotic surgery. Indocyanine green (ICG) and methylene blue (MB) were used as tracers. SLN detection rate, sensitivity, negative predictive value (NPV) and false-negative rate (FNR) were calculated. RESULTS: Surgeries were performed via laparotomy in 132 (54.1%) patients and 152 (62.3%) underwent both bilateral pelvic and paraaortic lymphadenectomy. At least 1 SLN was detected in 222 (91%) patients. Fifty-five (22.5%) patients had lymphatic metastasis and 45 patients had at least 1 metastatic SLN. Lymphatic metastases were detected by side-specific lymphadenectomy in 8 patients and 2 patients had isolated paraaortic metastasis. Overall sensitivity, NPV and FNR of SLN biopsy were 81.8%, 95% and 18.2%, respectively. By applying SLN algorithm steps, sensitivity and NPV improved to 96.4% and 98.9%, respectively. For grade 3 tumors, sensitivity, NPV and FNR of the SLN algorithm were 97.1%, 98.9% and 2.9%. CONCLUSION: SLN algorithm had high diagnostic accuracy in high-risk endometrial cancer. All pelvic metastases were detected by the SLN algorithm and the isolated paraaortic metastasis rate was ignorable. But long-term survival studies are necessary before this approach becomes standard of care.

Impact of cytoreductive surgery on survival of patients with low-grade serous ovarian carcinoma: A multicentric study of Turkish Society of Gynecologic Oncology (TRSGO-OvCa-001).

BACKGROUND AND OBJECTIVES: The aim of this study was to analyze the factors affecting recurrence-free (RFS) and overall survival (OS) rates of women diagnosed with low-grade serous ovarian cancer (LGSOC). METHODS: Databases from 13 participating centers in Turkey were searched retrospectively for women who had been treated for stage I-IV LGSOC between 1997 and 2018. RESULTS: Overall 191 eligible women were included. The median age at diagnosis was 49 years (range, 21-84 years). One hundred seventy-five (92%) patients underwent primary cytoreductive surgery. Complete and optimal cytoreduction was achieved in 148 (77.5%) and 33 (17.3%) patients, respectively. The median follow-up period was 44 months (range, 2-208 months). Multivariate analysis showed the presence of endometriosis (p = .012), lymphovascular space invasion (LVSI) (p = .022), any residual disease (p = .023), and the International Federation of Gynecology and Obstetrics (FIGO) stage II-IV disease (p = .045) were negatively correlated with RFS while the only presence of residual disease (p = .002) and FIGO stage II-IV disease (p = .003) significantly decreased OS. CONCLUSIONS: The maximal surgical effort is warranted for complete cytoreduction as achieving no residual disease is the single most important variable affecting the survival of patients with LGSOC. The prognostic role of LVSI and endometriosis should be evaluated by further studies as both of these parameters significantly affected RFS.

High-grade endometrial stromal sarcoma versus undifferentiated uterine sarcoma: a Turkish uterine sarcoma group study-001.

OBJECTIVE: Prognostic factors associated with high-grade endometrial stromal sarcoma (HGESS) and undifferentiated uterine sarcoma (UUS) have not been distinctly determined due to the repetitive changes in the World Health Organization (WHO) classification. We aimed to compare clinicopathologic features and outcomes of patients with HGESS with those of patients with UUS. METHODS: A multi-institutional, retrospective, cohort study was conducted including 71 patients, who underwent surgery at 13 centers from 2008 to 2017. An experienced gynecopathologist from each institution re-evaluated the slides of their own cases according to the WHO2014 classification. Factors associated with refractory/progressive disease, recurrence or death were examined using logistic regression analyses. Kaplan-Meier method and log-rank test were used for survival comparisons. RESULTS: The median disease-free survival (DFS) for HGESS and UUS was 12 months and 6 months, respectively. While the median overall survival was not reached in HGESS group, it was 22 months in the UUS group. Kaplan-Meier analyses revealed that patients with UUS had a significantly poorer DFS than those with HGESS (p = 0.016), although OS did not differ between the groups (p = 0.135). Lymphovascular-space involvement (LVSI) was the sole significant factor associated with progression, recurrence or death for HGESS (Hazard ratio: 9.353, 95% confidence interval: 2.539-34.457, p = 0.001), whereas no significant independent factor was found for UUS. CONCLUSIONS: UUS has a more aggressive behavior than HGESS. While no significant predictor of prognosis was found for UUS, LVSI is the sole independent prognostic factor for HGESS, with patients 9.3 times more likely to experience refractory/progressive disease, recurrence or death.

Morcellation in gynecology: short review and suggestions from Turkish Society of Minimally Invasive Gynecologic Oncology

Morcellation allows the removal of a large uterus and fibroids through small incisions with minimally invasive surgery. It helps to prevent the complications associated with large incisions in both hysterectomy and myomectomy operations. Currently, there is much debate regarding the use of power morcellation in laparoscopic hysterectomy and myomectomy, mainly due to the risk of peritoneal dissemination of undiagnosed uterine sarcomas. Unfortunately, there is no valid pre-operative diagnostic method that can differentiate sarcomas from myomas, and the currently available scientific literature regarding morcellation is insufficient. As the Turkish Society of Minimally Invasive Gynecological Oncology, we present our consensus opinion and suggestions for the preoperative evaluation and morcellation of fibroids, in line with the recent literature.

Environment-Based Impairment in Mineral Nutrient Status and Heavy Metal Contents of Commonly Consumed Leafy Vegetables Marketed in Kyrgyzstan: a Case Study for Health Risk Assessment.

Leafy vegetables are important components of the human diet for providing mineral nutrients. However, due to the tendency of metal accumulation, metal contents of leafy vegetables need not only to be determined but also estimated health risk for revealing possible health effects on humans. The aims of this study are (I) to examine comprehensive concentrations of trace/heavy metals along with some macroelements including Ca, Cd, Cu, Fe, K, Mg, Mn, Na, Ni, Pb, and Zn in selected leafy vegetables from Kyrgyzstan; (II) to assess recommended dietary allowances (RDA); and (III) to evaluate hazard quotient (HQ) and carcinogenic risk estimation with associated vegetable consumption. For this purpose, B, Ca, Cd, Cu, Fe, K, Mg, Mn, Na, Ni, Pb, and Zn elements were quantified, utilizing an ICP-OES instrument, in 18 samples belonging to 12 different groups of leafy vegetables including celery, Chinese parsley, dill, garden sorrel, lettuce, parsley, purple basil, spinach, and white-red-napa cabbage collected from different bazaars of Kyrgyzstan. Average elemental contents of the analyzed vegetables were determined (in mg kg-1) as follows: B (3.21-64.79), Ca (852.51-17,183.20), Cd (0.015-0.09), Cu (6.08-63.47), Fe (116.52-768.66), K (2347.04-17,305.42), Mg (136.34-1261.11), Na (54.75-526.42), Ni (0.09-1.3), Pb (1.91-9.54), and Zn (29.49-314.93). Estimated daily intake, recommended daily allowance, hazard quotients, and carcinogenic risk values of the vegetables were calculated with the help of these results. In considering HQ values, Chinese cabbage was determined to be safe for the consumption of both genders whereas parsley to be safe for only males. Based on the carcinogenic risk calculation, most of the vegetables examined in this study were categorized as moderately risky. It was inferred from the given results that airborne pollution has impaired/increased the mineral contents of vegetables for both genders. The findings obtained from this study were compared with international standards and will contribute to the data available on a global scale.

Can risk groups accurately predict non-sentinel lymph node metastasis in sentinel lymph node-positive endometrial cancer patients? A Turkish Gynecologic Oncology Group Study (TRSGO-SLN-004).

BACKGROUND AND OBJECTIVES: The purpose of this study was to find out the risk factors associated with non-sentinel lymph node metastasis and determine the incidence of non-sentinel lymph node metastasis according to risk groups in sentinel lymph node (SLN)-positive endometrial cancer patients. METHODS: Patients who underwent at least bilateral pelvic lymphadenectomy after SLN mapping were retrospectively analyzed. Patients were categorized into low, intermediate, high-intermediate, and high-risk groups defined by ESMO-ESGO-ESTRO. RESULTS: Out of 395 eligible patients, 42 patients had SLN metastasis and 16 (38.1%) of them also had non-SLN metastasis. Size of SLN metastasis was the only factor associated with non-SLN metastasis (p = .012) as 13/22 patients with macrometastasis, 2/10 with micrometastasis and 1/10 with isolated tumor cells (ITCs) had non-SLN metastasis. Although all 4 metastases (1.8%) among the low-risk group were limited to SLNs, the non-SLN involvement rate in the high-risk group was 42.9% and all of these were seen in patients with macrometastatic SLNs. CONCLUSIONS: Non-SLN metastasis was more frequent in higher-risk groups and the risk of non-SLN metastasis increased with the size of SLN metastasis. Proceeding to complete lymphadenectomy when SLN is metastatic should further be studied as the effect of leaving metastatic non-SLNs in-situ is not known.

Management of gynecological cancers in the COVID-19 era: a survey from Turkey

Objective: This study aimed to investigate how gynecologic oncologists modified their patient management during Coronavirus disease-2019 (COVID-19) in Turkey. Material and Methods: An online survey was sent to gynecologic oncology specialists and fellows in Turkey. It included management questions about strategies for newly diagnosed or recurrent endometrial, cervical, ovarian and vulvar cancer during the pandemic. Participants were asked if treatment of these cancers can be delayed or not and, if yes, the duration of delay. Results: 32.9% of surgeons prescribed oral or intrauterine progesterone for early stage, low-grade endometrial cancer. Conversely, 65.7% and 45.7% of the most surgeons did not change their management for early stage high-grade and advanced stage endometrial cancers respectively, as they perform surgery. 58% and 67.1% of the surgeons continued to prefer standard surgical treatment for microinvasive and early stage cervical cancers, respectively. Radiotherapy was preferred administered with hypofractionated doses for locally advanced cervical cancer (57.1%). While 67.1% of surgeons operated early stage ovarian cancer patients, 50% administered neoadjuvant chemotherapy (NACT) to all advanced stage ovarian cancers and 50% administered more cycles of NACT in preference to interval debulking surgery. 93.7% of the surgeons responded that treatment should not be delayed beyond eight weeks. Conclusion: Most Turkish gynecologic oncologists modified their management of gynecologic cancers due to the COVID-19 pandemic. While chemotherapy was preferred for ovarian cancer, postponement of the surgery, with or without non-surgical options, was considered for early stage, low-grade endometrial cancer. Treatment of gynecologic cancers should be decided on a case by case basis, taking into account local COVID-19 infection rates and availability of health facilities. Prognosis is also an important consideration if delay is contemplated. Standard treatment and normal time-frames should be used if possible. If not, a postponement for a maximum of eight weeks or referral to another center were acceptable alternatives.

Coexistence of uterine adenomyosis is not associated with a better prognosis in endometrioid-type endometrial cancer.

BACKGROUND: Prognostic value of accompanying adenomyosis in endometrial cancer is the subject of interest due to their common etiology and co-occurrence frequency. However, it is still unclear whether adenomyosis has a role in the prognosis of endometrial cancer. AIMS: The aim of this study was to determine the effects of adenomyosis on the prognosis of patients with endometrial cancer. METHODS: In this study, medical records of 552 patients with endometrioid endometrial cancer who underwent surgery between 2007 and 2017 were retrospectively reviewed. The patients were divided into two groups based on the presence or absence of adenomyosis, and these two groups were compared in terms of the clinicopathological factors and survival outcomes of patients. RESULTS: Of these patients, 103 (18.7%) had adenomyosis, and the remaining 449 (81.3%) did not. The endometrial cancer patients with adenomyosis exhibited earlier stages (p < 0.001), lower tumor grades (p < 0.001), tumor sizes ≤ 2 cm (p = 0.002), myometrial invasion < 50% (p < 0.001), and negative lymphovascular space invasion (p < 0.001). The 5-year overall survival rate was comparable between the adenomyosis and non-adenomyosis groups (95 vs. 89.1%, respectively; p = 0.085). The presence of adenomyosis was significantly associated with a higher 5-year disease-free survival rate (95.1 vs. 87.9%; p = 0.047), but adenomyosis did not remain as a prognostic factor in multivariate analysis. CONCLUSION: The results of our study showed that the endometrioid endometrial cancer patients with adenomyosis are significantly associated with smaller tumor sizes, less myometrial invasion, lower tumor grades, less lymphovascular space invasion, and earlier FIGO stages. Nevertheless, adenomyosis was not found to be an independent prognostic factor for endometrioid endometrial cancer.

Is It Possible to Develop a Prediction Model for Lymphovascular Space Invasion in Endometrioid Endometrial Cancer?

OBJECTIVE: The purpose of this retrospective study was to define a risk index that would serve as a surrogate marker of lymphovascular space invasion (LVSI) in women with endometrioid endometrial cancer (EC). MATERIALS AND METHODS: Final pathology reports of 498 women who underwent surgery with curative intent for endometrioid EC between January 2008 and June 2018 were retrospectively reviewed. Logistic regression was used to investigate clinicopathologic factors associated with positive LVSI status. Independent risk factors for LVSI were used to build a risk model and "risk of LVSI index" was defined as "tumor grade×primary tumor diameter×percentage of myometrium involved." The scores used in the "risk of LVSI index" were weighted according to the odds ratios assigned for each variable. The risk of LVSI index was noted for each patient. The diagnostic performance of the model was expressed as sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio. RESULTS: According to the "risk of LVSI index," presence of LVSI was correctly estimated in 89 of 104 LVSI-positive women at a cutoff of 161.0 (sensitivity 85.5%, specificity 79.4%, negative predictive value 95.4%, positive predictive value 52.3%, positive likelihood ratio 4.15, negative likelihood ratio 0.18). The area under curve of the receiver-operating characteristics was 0.90 (95% confidence interval, 0.87-0.93) at this cutoff. CONCLUSIONS: It seems possible to predict the presence of LVSI in women with endometrioid EC when the "risk of LVSI index" is calculated. However, external validation of this model is warranted.

SATEN III-Splitting Adjuvant Treatment of stage III ENdometrial cancers: an international, multicenter study.

INTRODUCTION: The purposes of this study were to compare adjuvant treatment modalities and to determine prognostic factors in stage III endometrioid endometrial cancer (EC). METHODS: SATEN III was a retrospective study involving 13 centers from 10 countries. Patients who had been operated on between 1998 and 2018 and diagnosed with stage III endometrioid EC were analyzed. RESULTS: A total of 990 women were identified; 317 with stage IIIA, 18 with stage IIIB, and 655 with stage IIIC diseases. The median follow-up was 42 months. The 5-year disease-free survival (DFS) of patients with stage III EC by adjuvant treatment modality was 68.5% for radiotherapy (RT), 54.6% for chemotherapy (CT), and 69.4% for chemoradiation (CRT) (p=0.11). The 5-year overall survival (OS) for those patients was 75.6% for RT, 75% for CT, and 80.7% for CRT (p=0.48). For patients with stage IIIA disease treated by RT versus CT versus CRT, the 5-year OS rates were 75.6%, 75.0%, and 80.7%, respectively (p=0.48). Negative peritoneal cytology (HR: 0.45, 95% CI: 0.23 to 0.86; p=0.02) and performance of lymphadenectomy (HR: 0.33, 95% CI: 0.16 to 0.77, p=0.001) were independent predictors for improved OS for stage IIIA EC. For women with stage IIIC EC treated by RT, CT, and CRT, the 5-year OS rates were 78.9%, 67.0%, and 69.8%, respectively (p=0.08). Independent prognostic factors for better OS for stage IIIC disease were age <60 (HR: 0.50, 95%CI: 0.36 to 0.69, p<0.001), grade 1 or 2 disease (HR: 0.59, 95% CI: 0.37 to 0.94, p=0.014; and HR: 0.65, 95%CI: 0.46 to 0.91, p=0.014, respectively), absence of cervical stromal involvement (HR: 063, 95% CI: 0.46 to 0.86, p=0.004) and performance of para-aortic lymphadenectomy (HR: 0.52, 95% CI: 0.35 to 0.72, p<0.001). DISCUSSION: Although not statistically significant, CRT seemed to be a better adjuvant treatment option for stage IIIA endometrioid EC. Systematic lymphadenectomy seemed to improve survival outcomes in stage III endometrioid EC.

Comparison of survival outcomes in optimally and maximally cytoreduced stage IIIC ovarian high-grade serous carcinoma: Women with only peritoneal tumor burden versus women with both peritoneal and lymphogenous dissemination.

AIM: The aim of this study was to analyze the survival outcomes of stage IIIC ovarian high-grade serous carcinoma (HGSC) patients with both peritoneal and lymphatic dissemination (IP+/RP+) who had undergone maximal or optimal cytoreduction followed by intravenous carboplatin/paclitaxel chemotherapy compared to those women with stage IIIC ovarian HGSC with only peritoneal involvement (IP+/RP-) who were treated similarly. METHODS: We performed a retrospective, multicenter study with the participation of five gynecological cancer centers. First, the stage IIIC ovarian HGSC patients were classified into optimally or maximally debulked cohorts. Then, in each cohort, the patients were divided into two groups; the IP+/RP- group included those women with transcoelomic spreading outside the pelvis with no nodal disease, and the IP+/RP+ group included those patients with transcoelomic dissemination outside the pelvis in addition to a positive nodal status. The survival outcomes were compared between the two groups in each cohort. RESULTS: A total of 405 ovarian HGSC patients were analyzed. In the optimally debulked cohort (n = 257), the progression-free survival (PFS) and overall survival (OS) medians for the IP+/RP- group (n = 69) were 24 and 57 months, respectively, compared to 21 and 58 months, respectively, for the IP+/RP+ group (n = 188) (P = 0.78 and P = 0.40, respectively). In the maximally debulked cohort (n = 148), the PFS and OS medians for the IP+/RP- group (n = 55) were 35 and 63 months, respectively, compared to 25 and 51 months, respectively, for the IP+/RP+ group (n = 93) (P = 0.49 and P = 0.31, respectively). CONCLUSION: Our findings indicated no survival differences between the IP+/RP- and the IP+/RP+ groups.

A novel multivariable prediction model for lymphatic dissemination in endometrioid endometrial cancer: The lymph node Metastasis Risk Index.

OBJECTIVE: The purpose of this study was to develop a risk assessment index that could determine which endometrioid endometrial cancer (EC) patients would benefit from a lymphadenectomy. METHODS: The final pathology reports of 353 women who underwent complete surgical staging, including pelvic and para-aortic lymphadenectomy, for endometrioid EC between January 2008 and June 2018 were retrospectively reviewed. A logistic regression was used to investigate the clinicopathological factors associated with a positive nodal status. The independent risk factors for lymphatic dissemination were used to build a risk model and a "Lymph Node (LN) Metastasis Risk Index" was defined as follows: (tumor grade) × (primary tumor diameter) × (percentage of myometrial invasion) × (preoperative serum CA 125 level). The scores used in the LN Metastasis Risk Index were weighted according to the odds ratios assigned for each variable. The diagnostic performance of the model was expressed as the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio. RESULTS: The LN Metastasis Risk Index correctly identified 35 of 40 LN-positive women at a cutoff point of 981.0 (sensitivity: 87.5%, specificity: 86.3%, negative predictive value: 98.2%, positive predictive value: 44.9%, positive likelihood ratio: 6.37, and negative likelihood ratio: 0.14). The area under the receiver operating characteristic curve was 0.90 (95% confidence interval = 0.858-0.947) at this cutoff. The clinical accuracy of the model was 86.4%. When a cutoff point of <981.0 was selected in order to define those women at low-risk for lymphatic dissemination, our prediction model classified 275 women (77.9%) as being at low-risk for nodal involvement. Among these 275 women, 5 actually had positive LNs, which indicated a 1.8% false-negative rate. CONCLUSION: After external validation, the LN Metastasis Risk Index may be a valuable tool for the surgical management of endometrioid EC.

Effect of Adjuvant Therapy on Oncologic Outcomes of Surgically Confirmed Stage I Uterine Carcinosarcoma: a Turkish Gynecologic Oncology Study

Background: Uterine carcinosarcoma is rare neoplasm that mostly presents as metastatic disease. Stage is one of the most important prognostic factor, however, the management of the early stage uterine carcinosarcoma is still controversial. Aims: To evaluate prognostic factors, treatment options, and survival outcomes in patients with surgically approved stage I uterine carcinosarcoma. Study Design: Cross-sectional study. Methods: Data of 278 patients with uterine carcinosarcoma obtained from four gynecologic oncology centers were reviewed, and 70 patients with approved stage I uterine carcinosarcoma after comprehensive staging surgery were studied. Results: The median age of the entire cohort was 65 years (range; 39-82). All patients underwent both pelvic and paraaortic lymphadenectomy. Forty-one patients received adjuvant therapy. The median follow-up time was 24 months (range; 1-129). Nineteen (27.1%) patients had disease failure. The 3-year disease-free survival and cancer-specific survival of the entire cohort was 67% and 86%, respectively. In the univariate analysis, only age was significantly associated with disease-free survival (p=0.022). There was no statistical significance for disease-free survival between observation and receiving any type of adjuvant therapy following staging surgery. Advanced age (<75 vs ≥75 years) was the only independent prognostic factor for recurrence (hazard ratio: 3.8, 95% CI=1.10-13.14, p=0.035) in multivariate analysis. None of the factors were significantly associated with cancer-specific survival. Conclusion: Advanced age was the only independent factor for disease-free survival in stage I uterine carcinosarcoma. Performing any adjuvant therapy following comprehensive lymphadenectomy was not related to the improved survival of the stage I disease.

Prognostic significance of lymphovascular space invasion in low-risk endometrial cancer.

OBJECTIVE: The purpose of this study was to assess the prognostic significance of lymphovascular space invasion in women with low-risk endometrial cancer. METHODS: A dual-institutional, retrospective department database review was performed to identify patients with 'low-risk endometrial cancer' (patients having <50% myometrial invasion with grade 1 or 2 endometrioid endometrial cancer according to their final pathology reports) at two gynecologic oncology centers in Ankara, Turkey. Demographic, clinicopathological and survival data were collected. RESULTS: We identified 912 women with low-risk endometrial cancer; 53 patients (5.8%) had lymphovascular space invasion. When compared with lymphovascular space invasion-negative patients, lymphovascular space invasion-positive patients were more likely to have post-operative grade 2 disease (p<0.001), deeper myometrial invasion (p=0.003), and larger tumor size (p=0.005). Patients with lymphovascular space invasion were more likely to receive adjuvant therapy when compared with lymphovascular space invasion-negative women (11/53 vs 12/859, respectively; p<0.001). The 5-year recurrence-free survival rate for lymphovascular space invasion-positive women was 85.5% compared with 97.0% for lymphovascular space invasion-negative women (p<0.001). The 5-year overall survival rate for lymphovascular space invasion-positive women was significantly lower than that of lymphovascular space invasion-negative women (88.2% vs 98.5%, respectively; p<0.001). Age ≥60 years (HR 3.13, 95% CI 1.13 to 8.63; p=0.02) and positive lymphovascular space invasion status (HR 6.68, 95% CI 1.60 to 27.88; p=0.009) were identified as independent prognostic factors for decreased overall survival. CONCLUSIONS: Age ≥60 years and positive lymphovascular space invasion status appear to be important prognostic parameters in patients with low-risk endometrial cancer who have undergone complete surgical staging procedures including pelvic and para-aortic lymphadenectomy. Lymphovascular space invasion seems to be associated with an adverse prognosis in women with low-risk endometrial cancer; this merits further assessment on a larger scale with standardization of the lymphovascular space invasion in terms of presence/absence and quantity.

Recurrence patterns and prognostic factors in lymphovascular space invasion-positive endometrioid endometrial cancer surgically confined to the uterus.

OBJECTIVE: The purpose of this study was to determine the patterns of failure and prognostic factors for lymphovascular space invasion (LVSI)-positive endometrioid endometrial cancer (EC) patients in the setting of negative lymph nodes (LNs). MATERIALS AND METHODS: A multicenter, retrospective department database review was performed to identify LVSI-positive patients with disease surgically confined to the uterus at two gynecologic oncology centers in Turkey. Demographic, clinicopathological and survival data were collected. RESULTS: We identified 185 LVSI-positivewomen with negative LNs during the study period. Fifty-five (29.7%) were classified as Stage IA, 94 (50.8%) as Stage IB, and 36 (19.5%) as Stage II. The median age at diagnosis was 59 years and the median duration of follow-up was 44 months. The total number of the recurrences was 12 (6.5%). We observed 5 (2.9%) loco-regional recurrences, 3 (1.5%) retroperitoneal failures, and 4 (2.0%) distant relapses. The 5-year progression-free survival (PFS) was 86.1% while the 5-year overall survival (OS) rate was 87.7%. Grade 3 histology (Hazard Ratio [HR] 2.9, 95% Confidence Interval [CI] 1.02-8.50; p = 0.04), cervical stromal invasion (HR 4.5, 95% CI 1.61-12.79; p = 0.004) and age ≥ 60 years (HR 5.8, 95% CI 1.62-21.32; p = 0.007) were found to be independent prognostic factors for decreased OS. Adjuvant treatment did not appear as a prognostic factor for OS even in univariate analysis. CONCLUSION: The recurrence rate among LVSI-positive endometrioid EC patients is low in the setting of negative LNs. However, one out of three patients with a recurrence experiences distant relapses which usually portend worse outcomes.

Clinicopathological analysis of borderline ovarian tumours and risk factors related to recurrence: experience of single institution.

This study was conducted to determine the demographic and clinicopathologic characteristics and evaluate the prognostic value of various factors, such as the extensiveness of surgery, related to the tumour itself and the clinical features in the recurrence of borderline ovarian tumours (BOT). We retrospectively evaluated the data of 103 patients with a borderline ovarian tumours treated at our institution between the years 2000 and 2012. The median age was 37 (16-79) years and the majority of the patients were premenopausal (76.7%). During the follow-up, 16 recurrences were observed (15.5%). The multivariate analysis showed that the micropapillary architecture and fertility sparing surgery were the only significant independent predictors for the development of a recurrence amongst all of the demographic and clinicopathological features. In our study group, we identified that the micropapillary architecture itself and the fertility sparing surgery had a significant impact on the development of a BOT recurrence. The patients who possess these features should be followed up more closely for a long time period. Impact statement What is already known on this subject? A borderline ovarian tumour is known as a recurrent disease. The recurrence rate varies between 5 and 20%. It is well known in the literature that patients treated by an oophorectomy have a relatively lower risk of development of a recurrence compared to the patients treated by cystectomy. What do the results of this study add? Although some of the clinicopathological features are shown to be risk factors for the development of a recurrence in many studies, some of the pathological-clinical and the demographic features have not been described as yet, or have been considered to be equivocal regarding the development of a recurrence. In this study, we investigate all possible demographic, pathological, and clinical factors associated with a recurrence. Not only the well-known pathological characteristics but also the new pathological parameters and clinical approaches have been investigated. For instance, microinvasion architecture and lymphadenectomy speculated in the literature as the risk factors for the development of a recurrence, have not been identified as risk factors in our study. On the other hand, our statistical analyses have revealed that micropapillary architecture should be described as a risk factor for the development of a recurrence. What are the implications of these findings for clinical practice and/or further research? We hope our study becomes influential in the literature on the field of a micropapillary architecture and the development of a recurrence. The patients carrying this feature have to be followed up very closely and carefully. Furthermore, our findings have indicated no significant relation between the performing of a lymphadenectomy and the rate of a recurrence. This result might be encouraging for the gynaecological surgeons to refrain from a lymphadenectomy for the borderline ovarian tumours.

Risk Factors for Lymph Node Metastasis among Lymphovascular Space Invasion-Positive Women with Endometrioid Endometrial Cancer Clinically Confined to the Uterus.

INTRODUCTION: We aimed to assess risk factors for lymph node (LN) metastasis among lymphovascular space invasion(LVSI)-positive women with pure endometrioid endometrial cancer (EC) clinically confined to the uterus. METHODS: Medical records of women who underwent primary surgery for EC between 2007 and 2016 at either of 2 gynecological oncology centers were retrospectively reviewed. Patient data were analyzed with respect to LN involvement, and predictive factors for LN metastasis were investigated. RESULTS: 280 patients with surgically staged endometrioid-type EC with LVSI were identified. LN involvement was detected in 88 patients (31.4%) with a systematic LN dissection. In multivariate analysis, elevated baseline serum CA 125 levels, deep myometrial invasion (MMI), adnexal involvement and positive peritoneal cytology were found to be independent risk factors for LN metastasis. In women without deep MMI and elevated baseline serum CA 125 levels, the rate of LN metastasis was 19%. The presence of solely deep MMI increased this probability up to 29.1%. The rate of LN metastasis was found to be 46.8% for women with both deep MMI and elevated baseline serum CA 125 levels. CONCLUSION: These findings may be useful in the decision-making process for LVSI-positive women who are unstaged.

Colposcopic biopsy findings among women with either HPV-16 only or HPV-18 only who have normal cervical cytology.

OBJECTIVE: To compare colposcopic biopsy results among women with normal cervical cytology who had positive test results for either HPV-16 only or HPV-18 only. METHODS: A cross-sectional study was conducted at Zekai Tahir Burak Women's Health Research and Training Hospital, Ankara, Turkey, between July 1, 2015, and October 31, 2017. Colposcopic biopsy results were compared among women in the HPV-16 only (n=185) and HPV-18 only (n=43) groups. RESULTS: Women who had HPV-16 only were more likely to be smokers than women with HPV-18 only (P=0.003). By contrast, women with HPV-18 only were more likely to be aged at least 45 years than women who had HPV-16 only (P=0.038). High-grade squamous intraepithelial lesions were detected more frequently in the HPV-16 only group (51 [27.6%]) than in the HPV-18 only group (4 [9.3%]; P=0.010). By contrast, no between-group difference was found for the rate of invasive cervical cancer, which was detected in 1 (0.5%) woman in the HPV-16 only group and 1 (2.3%) woman in HPV-18 only group (P=0.342). CONCLUSION: Although the risk of high-grade squamous intraepithelial lesions was increased among women with HPV-16 only, this finding did not influence the rate of invasive cervical cancer when compared with women in the HPV-18 only group.

Does the primary route of spread have a prognostic significance in stage III non-serous epithelial ovarian cancer?

BACKGROUND: The purpose of this retrospective study was to determine the prognosis of non-serous epithelial ovarian cancer (EOC) patients with exclusively retroperitoneal lymph node (LN) metastases, and to compare the prognosis of these women to that of patients who had abdominal peritoneal involvement. METHODS: A multicenter, retrospective department database review was performed to identify patients with stage III non-serous EOC at 7 gynecologic oncology centers in Turkey. Demographic, clinicopathological and survival data were collected. The patients were divided into three groups based on the initial sites of disease: 1) the retroperitoneal (RP) group included patients who had positive pelvic and /or para-aortic LNs only. 2) The intraperitoneal (IP) group included patients with > 2 cm IP dissemination outside of the pelvis. These patients all had a negative LN status, 3) The IP / RP group included patients with > 2 cm IP dissemination outside of the pelvis as well as positive LN status. Survival data were compared with regard to the groups. RESULTS: We identified 179 women with stage III non-serous EOC who were treated at 7 participating centers during the study period. The median age of the patients was 53 years, and the median duration of follow-up was 39 months. There were 35 (19.6%) patients in the RP group, 72 (40.2%) in the IP group and 72 (40.2%) in the IP/RP group. The 5-year disease-free survival (DFS) rates for the RP, the IP, and IP/RP groups were 66.4%, 37.6%, and 25.5%, respectively (p = 0.002). The 5-year overall survival (OS) rate for the RP group was significantly longer when compared to those of the IP, and the IP/RP groups (74.4% vs. 54%, and 36%, respectively; p = 0.011). However, we were not able to define "RP only disease" as an independent prognostic factor for increased DFS or OS. CONCLUSIONS: Primary non-serous EOC patients with node-positive-only disease seem to have better survival when compared to those with extra-pelvic peritoneal involvement.

Is the presence of endometriosis associated with a survival benefit in pure ovarian clear cell carcinoma?

BACKGROUND: The purpose of this study was to compare the prognoses of women with pure ovarian clear cell carcinoma (OCCC) arising from endometriosis to those of women with pure OCCC not arising from endometriosis treated in the same manner. METHODS: A dual-institutional, retrospective database review was performed to identify patients with pure OCCC who were treated with maximal or optimal cytoreductive surgery (CRS) followed by paclitaxel/carboplatin chemotherapy between January 2006 and December 2016. Patients were divided into two groups according to the detection of cancer arising in endometriosis or not, on the basis of pathological findings. Demographic, clinicopathological, and survival data were collected, and prognosis was compared between the two groups. RESULTS: Ninety-three women who met the inclusion criteria were included. Of these patients, 48 (51.6%) were diagnosed with OCCC arising in endometriosis, while 45 (48.4%) had no concomitant endometriosis. OCCC arising in endometriosis was found more frequently in younger women and had a higher incidence of early stage disease when compared to OCCC patients without endometriosis. The 5-year overall survival (OS) rate of the patients with OCCC arising in endometriosis was found to be significantly longer than that of women who had OCCC without endometriosis (74.1 vs. 46.4%; p = 0.003). Although univariate analysis revealed the absence of endometriosis (p = 0.003) as a prognostic factor for decreased OS, the extent of CRS was identified as an independent prognostic factor for both recurrence-free survival (hazard ratio (HR) 8.7, 95% confidence interval (CI) 3.15-24.38; p < 0.001) and OS (HR 11.7, 95% CI 3.68-33.71; p < 0.001) on multivariate analysis. CONCLUSION: Our results suggest that endometriosis per se does not seem to affect the prognosis of pure OCCC.