[The 2019 FIGO classification for cervical carcinoma-what's new?] / FIGO-Klassifikation für das Zervixkarzinom 2019 ­ was ist neu?

Numerous therapeutic and prognostic studies of cervical carcinoma have necessitated a revision of the FIGO classification.For microinvasive carcinomas, the horizontal dimension is no longer considered and diagnosis and staging will solely be made by the depth of cervical stromal invasion. Lymphovascular invasion beyond the deepest point of stromal infiltration by tumor cells does not alter the stage.There will be a new subclassification of macroinvasive carcinoma confined to the uterine cervix, which will be made by largest tumor extension as follows: FIGO IB1/T1b1 - invasive carcinoma >0.5 cm depth of stromal invasion and ≤2 cm in largest dimension, FIGO IBII/T1b2: - invasive carcinoma >2 cm and ≤4 cm, FIGO IBII/T1b3 - invasive carcinoma >4 cm. Pelvic as well as para-aortic lymph nodes will be defined as regional nodes. Pelvic lymph node metastases only will be categorised as FIGO IIIC1/pN1a and para-aortic lymph node involvement with or without concomitant pelvic involvement will be FIGO IIIC2/pN1b. Uterine corpus as well as adnexal involvement are not relevant for staging purpose.

[Endometriosis-related ovarian tumors]. / Endometrioseassoziierte Tumorerkrankungen des Ovars.

Endometriosis is a frequent gynecological disease of unknown etiology and pathogenesis. It affects the gynecological organs and the peritoneum with varying frequency and can lead to severe symptoms, mainly pain and to infertility. Despite the fact that causal therapy is not feasible diagnostic and therapeutic procedures are necessary in many cases. In a small percentage of cases endometriosis is associated with neoplastic disease and in some cases it might develop into a neoplasm via the stage of atypical endometriosis, notably in the ovaries. Tumors which are most frequently associated with endometriosis are endometrioid carcinoma, clear cell carcinoma, and low grade serous carcinoma. According to some authors tumors associated with endometriosis have a better prognosis than those without. Other tumors are Mullerian adenosarcoma, endometrioid stromal sarcoma, and seromucinous borderline tumor. In addition to the morphological findings more recent molecular findings serve to demonstrate the origin of the different types of carcinoma from endometriosis. In both endometrioid and clear cell carcinoma, loss of heterozygosity (LOH) can be found in different gene loci. Mutations in CTNNB1 (beta catenin), PTEN, KRAS and ARID1a genes have been demonstrated in endometrioid carcinoma. Cases of clear cell carcinoma have been characterized by mutations of ARID1a gene, PIK3CA and less frequently PPP2R1A and KRAS.

Implementation of certified endometriosis centers: 5-year experience in German-speaking Europe.

The idea of quality improvement in the management of endometriosis has been brought to attention throughout Europe. This - first and foremost - includes the implementation of centers specialized in treating endometriosis. This leads to qualification of both physicians and other medical staff, enforcement of research efforts, and informing the patients, the public, politicians, healthcare providers, and industry. Given limited budgets, focusing on the existing national commitment may be the first step.

[Current TNM/FIGO classification for cervical and endometrial cancer as well as malignant mixed müllerian tumors. Facts and background]. / Aktuelle TNM/FIGO-Stadieneinteilung für das Zervix- und Endometriumkarzinom sowie maligne Müller-Mischtumoren. Fakten und Hintergründe.

Numerous recent studies of endometrial and cervical carcinomas as well as malignant mixed müllerian tumors (MMMT) of the uterus have made a revision of the FIGO/TNM classification necessary, effective as of January 1st, 2010. There will be a new subclassification of carcinoma of the uterine cervix with proximal vaginal infiltration, using the same cut-off for the tumor extension as used for stage FIGOIB/T1b (≤/>4 cm), resulting in stage FIGO IIA1/T2a1 and FIGO IIA2/T2a2. In endometrial carcinoma, the previous FIGO IA/pT1a and FIGO IB/pT1b will be merged to FIGO IA/pT1a. The former category FIGO IC/T1c will be changed into FIGO IB/T1b. The category FIGO IC/pT1c will not longer been used. Additionally, there will be no separate classification for the involvement of the endocervical glands by endometrial carcinoma. This feature will be incorporated in stage FIGO I/T1 disease. The new category FIGO II/T2 will be defined as endocervical stromal involvement. There will be a new category, termed T3c/IIIC, which includes regional lymph node involvement. Stage T3c1/IIIC1 will be defined as pelvic lymph node involvement and stage T3c2/IIIC2 para-aortal lymph node involvement with or without pelvic lymph node disease. In the TNM system, regional lymph node involvement can alternatively be classified as N1. The MMMT will be staged like endometrial carcinoma.

The laparoscopic-assisted vaginal approach to early endometrial cancer.

INTRODUCTION: For the surgical treatment of endometrial cancer laparotomy still is regarded as the gold standard. Over the past decade, the laparoscopic approach has gained equivalence in FIGO stage I carcinomas. RESULTS: Laparoscopic-assisted vaginal hysterectomy and bilateral salpingooophorectomy plus pelvic/paraaortic lymphadenectomy have shown short-term advantages such as reduced blood loss and shorter hospitalization without reducing oncological safety or outcome. This has already been confirmed by numerous smaller studies and recent randomized controlled trials with sufficient numbers of patients are being published. CONCLUSION: Further acceptance of the technique is necessary to enable every gynecological oncologist to individualize treatment by offering minimal access options.

[Changes in the TNM classification of gynecological tumors]. / Anderungen der TNM-Klassifikation gynäkologischer Tumoren.

Based on the results of clinical and histomorphological studies in recent years, a revision of the TNM classification of malignant tumours of the female genital organs became necessary. Vulvar cancer saw the most significant changes. In the T1 category the new system recognises tumour size and its relation to the infiltration of adjacent structures by the tumour. The number of positive regional lymph nodes has also been included in the new staging system. For cervical cancer, there is a new subdivision of the category T2a depending on tumour size with a breakpoint of ≤ 4 cm versus > 4 cm and a subdivision into T2a1 und T2a2. In endometrial cancer, the previous pT1a and pT1b were merged to pT1a. The former category T1c has changed into T1b. The category pT1c is no longer used. For the first time, there is a TNM classification system for uterine sarcomas.

"Occult" neuroendocrine component and rare metastatic pattern in cervical cancer: report of a case and brief review of the literature.

Distant metastases in small cell carcinomas of the uterine cervix are rare, and a disseminated manifestation of the disease is uncommon. This is a case report of a 40-year-old woman treated with platin-based radio-chemotherapy for a moderately differentiated squamous cell cervical cancer FIGO Stage IB 1 (with positive paraaortic lymph nodes). One year later she presented with remarkably unusual cutaneous metastases of the left thumb and scalp as the first signs of spread of disease, including kidney, lung and brain metastases. An advanced retrospective immunohistochemical staining of the cervical biopsy discovered a small neuroendocrine component of the carcinoma as the presumably causative factor for the rare metastastic pattern and poor prognosis.

Extracorporeal Circulation During Lung Transplantation Procedures: A Meta-Analysis.

Extracorporeal circulation (ECC) is an invaluable tool in lung transplantation (lutx). More than the past years, an increasing number of centers changed their standard for intraoperative ECC from cardiopulmonary bypass (CPB) to extracorporeal membrane oxygenation (ECMO) - with differing results. This meta-analysis reviews the existing evidence. An online literature research on Medline, Embase, and PubMed has been performed. Two persons independently judged the papers using the ACROBAT-NRSI tool of the Cochrane collaboration. Meta-analyses and meta-regressions were used to determine whether veno-arterial ECMO (VA-ECMO) resulted in better outcomes compared with CPB. Six papers - all observational studies without randomization - were included in the analysis. All were considered to have serious bias caused by heparinization as co-intervention. Forest plots showed a beneficial trend of ECMO regarding blood transfusions (packed red blood cells (RBCs) with an average mean difference of -0.46 units [95% CI = -3.72, 2.80], fresh-frozen plasma with an average mean difference of -0.65 units [95% CI = -1.56, 0.25], platelets with an average mean difference of -1.72 units [95% CI = -3.67, 0.23]). Duration of ventilator support with an average mean difference of -2.86 days [95% CI = -11.43, 5.71] and intensive care unit (ICU) length of stay with an average mean difference of -4.79 days [95% CI = -8.17, -1.41] were shorter in ECMO patients. Extracorporeal membrane oxygenation treatment tended to be superior regarding 3 month mortality (odds ratio = 0.46, 95% CI = 0.21-1.02) and 1 year mortality (odds ratio = 0.65, 95% CI = 0.37-1.13). However, only the ICU length of stay reached statistical significance. Meta-regression analyses showed that heterogeneity across studies (sex, year of ECMO implementation, and underlying disease) influenced differences. These data indicate a benefit of the intraoperative use of ECMO as compared with CPB during lung transplant procedures regarding short-term outcome (ICU stay). There was no statistically significant effect regarding blood transfusion needs or long-term outcome. The superiority of ECMO in lutx patients remains to be determined in larger multi-center randomized trials.

Endometriosis-associated Malignancy.

Endometriosis is a common condition in women of reproductive age. According to several epidemiological studies endometriosis may be associated with increased risk of various malignancies. However, endometriosis-associated malignancy (EAM) is defined by certain histological criteria. About 80 % of EAM have been found in the ovary, whereas 20 % are localized in extragonadal sites like intestine, rectovaginal septum, abdominal wall, pleura and others. Some authors suggest that EAM arise from atypical endometriosis as an intermediate lesion between endometriosis and cancer. Moreover, a number of genetic alterations, like loss of heterozygosity (LOH), PTEN, ARID1 A and p53 mutations have been found in both endometriosis and EAM. Endometriosis-associated ovarian cancer (EAOC) is mostly a well or intermediately differentiated tumor of endometrioid or clear cell histological sub-type. Women affected by EAOC are on average five to ten years younger than non-EAOC patients; in most of the cases EAOC is a low stage disease with favorable clinical outcome. Since EAM is a rare condition systematic data on EAM are still missing. A systematic retrospective study on endometriosis-associated malignancies (EAM study) is currently being conducted by the Endometriosis Research Foundation together with the study groups on ovarian and uterine tumors of the working group for gynecological oncology (AGO) (gyn@mlk-berlin.de).

Sarcoma of the Uterus. Guideline of the DGGG (S2k-Level, AWMF Registry No. 015/074, August 2015).

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Due to their rarity and their heterogeneous histopathology uterine sarcomas remain challenging tumors to manage and need a multidisciplinary approach. To our knowledge so far there is no evidence-based guideline on the appropiate management of these heterogeneous tumors. Methods: This S2k-guideline is the work of an representative committee of experts from a variety of different professions who were commissioned by the DGGG to carry out a systematic literature review of uterine sarcoma. Members of the participating scientific societies developed a structured consensus in a formal procedure. Recommendations: 1. The incidence and histopathologic classification of uterine sarcoma. 2. The clinical manifestations, diagnosis and staging of uterine sarcoma. 3. The management of leiomyosarcoma. 4. The management of endometrial stromal sarcoma and undifferentiated uterine sarcoma. 5. The management of adenosarcoma as well as carcinosarcomas. 6. The management of morcellated uterine sarcoma.

Erratum: Sarcoma of the Uterus. Guideline of the DGGG (S2k-Level, AWMF Registry No. 015/074, August 2015).

[This corrects the article DOI: 10.1055/s-0035-1558120.].

Women of reproductive age with endometriosis are not osteopenic.

OBJECTIVE: To determine whether women of reproductive age with endometriosis are osteopenic and whether bone density decreases with higher stages of endometriosis. DESIGN: A multicenter cross-sectional study was performed. SETTING: Thirty-nine gynecological clinics in the United States, Canada, and Puerto Rico. PATIENT(S): Two hundred forty-one women of reproductive age with laparoscopically proved endometriosis. INTERVENTION(S): Diagnostic laparoscopy, bone densitometry. MAIN OUTCOME MEASURE(S): Endometriosis stages according to the criteria of the American Society for Reproductive Medicine, lumbar spine bone mineral density (L2-L4) as measured by dual-energy x-ray absorptiometry. RESULT(S): The mean lumbar spine bone mineral density, as well as the distribution of bone mineral density, of the women with endometriosis was similar to that of a normal population. There were no significant differences between endometriosis stage groups I-IV regarding bone mineral density as well as body weight, body mass index, and height. CONCLUSION(S): Women of reproductive age with endometriosis are not osteopenic. More advanced stages of endometriosis are not associated with a decrease in lumbar spine bone mineral density.

Add-back medrogestone does not prevent bone loss in premenopausal women treated with goserelin.

To investigate the effect of medrogestone on bone mineral density (BMD) and bone turnover under conditions of estrogen withdrawal, premenopausal women with endometriosis were treated with goserelin (Zoladex), combined with either placebo (group A, n = 12) or 10 mg medrogestone (Prothil, group B, n = 11) for six months, and followed for an additional six months. Lumbar spine BMD was measured at 0 and 6 month. Markers of bone turnover were serum bone alkaline phosphatase (sBAP) and osteocalcin (sOC) by ELISA, and urinary total pyridinoline (uPYD) and deoxypyridinoline crosslinks (uDPD) by HPLC. Patients in both groups had a similar and significant decrease in BMD after 6 months (4%, p < 0.01). The time course of changes in bone turnover, in contrast, was different in both groups. In group A, crosslink excretion increased from one month onwards, while no changes were seen in group B. In group A, sBAP levels rose during treatment, while in group B, this rise was delayed until treatment was terminated. Additionally, group B showed an initial suppression of sBAP and sOC. In both groups, sOC increased after treatment was discontinued. Medrogestone at 10 mg/d does not prevent lumbar bone loss in premenopausal women under estrogen deprivation. In the medrogestone add back group, the changes in bone turnover are compatible with low turnover bone loss,as ooposed to a state of high turnover seen in the unopposed goserelin group. This effect may be due to glucocorticoid receptor mediated actions of medrogestone on bone.

Comparison of single- and dual-energy quantitative computed tomography for therapy control under antiosteoporotic treatment.

Lumbar spine bone mineral density was determined in 50 female patients (mean age: 55.4 +/- 12.3 years), who were treated because of osteoporosis or osteopenia. Bone mineral density was assessed using single-energy QCT with 80 and 120 kV tube voltage and with dual-energy QCT. Compared to single-energy QCT, dual-energy QCT showed much higher variability of the bone density values obtained. Therefore we conclude that single energy QCT is a method that allows precise and reproducible determination of spinal bone mineral content under clinical conditions which cannot be further improved by the use of dual-energy QCT.

["On the abdominal wall visible limit between the uterine body and cervix in labor". In memory of Ludwig Bandl (100th anniversary of his death)]. / "Ueber die an den Bauchdecken sichtbare Grenze zwischen Uteruskörper und Cervix bei der Gebärenden". In memoriam Ludwig Bandl (100. Todestag).

Ludwig Bandl, who is nearly forgotten today, was one of the most active gynaecologists in the 70s and 80s of the last century. We owe him the observation and the description of the uterine contraction ring at birth. After a promising start of his career in Vienna he was professor in Prague for only 20 days. He died mentally ill in Döbling, Vienna in 1892.

[Clinical and endocrine effects of laparoscopic ovarian surgery in patients with polycystic ovary syndrome]. / Klinische und endokrine Effekte laparoskopischer Ovarchirurgie bei Patientinnen mit polyzystischem Ovar-Syndrom (PCO).

OBJECTIVES: Is minimal invasive ovarian surgery an alternative infertility treatment for patients with polycystic ovary (PCO) syndrome? METHODOLOGY: 52 anovulatory patients with the clinical and endocrine characteristics of PCO syndrome were treated with laparoscopic Nd: YAK (n = 11) or CO2 (n = 41) laser surgery to drain atretic follicles and destroy the ovarian stroma. RESULTS: Following surgical reduction of serum androgen and estrogen levels (p < 0,01), 83% of the PCO patients ovulated spontaneously or following ovulation induction; pregnancies occurred in 38%. At re-laparoscopies, 86% of patients had no periovarian adhesions. CONCLUSIONS: Since laparoscopic laser surgery is capable of inducing profound clinical and endocrine effects, it may represents a feasible alternative for infertility treatment in PCO patients.

[Development of rust stains on the skin due to contact with a gun]. / Zur Entstehung von Rostmarken der Haut beim Kontakt mit einer Schusswaffe.

In order to study the conditions for the formation of so-called rustmarks on the skin after contact with weapon steel tests to provoke rustmarks were performed on corpses and living bodies. These tests were only successful under the condition of a firm contact with the weapon steel and a certain minimum contact time between the weapon and the skin. The experiments showed that the critical parameters for the appearance of rustmarks are, first, the humidity of the skin and the environment, respectively, as well as the contact time, and second, the state of the weapon surface (greased or ungreased). Both the ambient temperature and the pH value of the skin (alkaline or acid) are irrelevant to the formation of rust. The longest time period until rustmarks appeared was observed on dry skin in contact with a greased weapon, namely 22 hours on a corpse and 170 min on a living subject. When using a greased gun humidity accelerated the formation of rust. An ungreased surface of the weapon also resulted in faster rust formation. The minimum time necessary for the formation of rust determined under the most favourable circumstances was 135 min for a corpse and 27 min for a living person. During the early postmortal interval the rustmark may therefore be another piece in the jigsaw towards determining the time of death on suicides committed with firearms.

Current and Future Status of Laparoscopy in Gynecologic Oncology.

Laparoscopy is playing an increasingly important role in gynecologic oncology. The benefits of minimally invasive surgery for oncology patients and the quality of this treatment are well documented. Outcomes and quality of minimally invasive surgical procedures to treat cervical cancer were evaluated based on retrospective and case-control studies; outcomes and quality after minimally invasive treatment für early-stage low-risk endometrial cancer were also assessed in prospective randomized studies. If indicated, laparoscopic lymphadenectomy is both technically feasible and oncologically safe. Adipose patients in particular benefit from minimally invasive procedures, where feasible. The potential role of laparoscopy in neoadjuvant therapy for ovarian cancer and in surgery for early-stage ovarian carcinoma is still controversially discussed and is currently being assessed in further studies. Using a minimally invasive approach in gynecologic oncology procedures demands strict adherence to oncological principles and requires considerable surgical skill.