Prognostic significance of Sugarbaker's peritoneal cancer index for the operability of ovarian carcinoma.

INTRODUCTION: This study aimed to investigate Sugarbaker's peritoneal cancer index (PCI) as a prognostic indicator for the resectability of ovarian carcinoma (OC), as depicted in the study using the completeness of cytoreduction score (CCS).Currently, the intraoperative assessment of operability in OC surgery is primarily a subjective measurement that is dependent on the surgeon. METHODS: The retrospective data from 98 patients with OC International Federation of Gynecology and Obstetrics (FIGO) III to IV who had received surgery between January 2010 and December 2011 were analyzed. The PCI and the CCS were determined retrospectively using surgical reports, histological findings, and intraoperative photographic documentation. Receiver operating characteristic curves and ordinal regression were applied to evaluate the predictability of CCS using the PCI. RESULTS: Of 98 patients, 80 (81.6%) were staged FIGO III and 18 (18.4%) FIGO IV. A statistically significant correlation was demonstrated between the PCI and CCS (P < 0.01). A receiver operating characteristic curve with an area under the curve of 0.839 demonstrated the high precision in discrimination with which the PCI could predict the CCS. Using ordinal regression, it was possible to estimate the probabilities of achieving CCS 0, CCS 1, CCS 2, or CCS 3 for a given PCI (pseudo R(2) according to Cox and Snell 0.428, Nagelkerke 0.476, and McFadden 0.244). CONCLUSIONS: The PCI more precisely defined the heterogeneous group of patients with OC FIGO III. The PCI provided objectivity and reproducibility, and it seems to be a possible prognostic indicator for OC resectability.

Characteristics and survival of primary vaginal malignancy: an analysis of the German nationwide cancer registry data.

BACKGROUND: Vaginal neoplasms are rare. To study the survival of patients depending on tumour characteristics and age, the data from the national cancer registries in Germany were analysed. METHODS: In a retrospective analysis, data from 2006 to 2015 on disease stage, survival, and factors that might affect prognosis were analysed. RESULTS: Altogether, out of 4004 datasets, 2194 were deemed adequate to be included in the analysis. Overall survival at 5 years (5YSR) and relative survival (5RSR) were 48.6% (95%CI 45.4-52.1%) and 58.7% (95%CI 55.3-61.2%) for carcinomas, but significantly worse at 20.2% (95%CI 8.3-32.0%) and 24.2% (95%CI 16.4-32.0%) for melanomas and 38.3% (95%CI 23.3-53.5%) and 44.4% (95%CI 31.5-56.8%) for sarcomas. 5YSR and 5RSR correlated significantly with FIGO stages (5YSR: 66.9-10.1%; 5RSR: 81.7-11.9%, p = 0.04). Furthermore, survival depended on the absence of LN metastases (5RSR: 59.1% vs. 38.0%, p < 0.001), and the tumour grading had an influence (5RSR: 83.7-52.1%). We also noted that prognosis was worse for older patients ≥75 years (5RSR:51.2%) than for patients <55 years (62.2%) and 55-74 years of age (61.6%). CONCLUSION: Unless LN metastases, local advanced tumours and G3 grading are associated with a worse prognosis. Relative survival of older patients decreases, perhaps indicating that treatment compromises have been made.

Exenteration in the treatment of Stage III/IV vulvar cancer.

OBJECTIVES AND METHODS: Vulvar carcinomas are rare genital malignancies. While advanced primary cancer chemoradiation is often preferred over pelvic exenteration (PE), PE is often the only therapy available in cases of recurrence. In a retrospective study, we analyzed predictive factors and outcomes of patients who underwent exenteration for vulvar cancer in our department during the past 10 years. RESULTS: We identified 27 patients; 9 of them suffered from primary disease, and 18 had experienced a recurrence. A total of 18 patients presented with stage FIGO III, and 9 patients presented with stage IV. In 10 patients, the disease had spread to the inguinal lymph nodes, and in 3 patients, it had also spread to the pelvic nodes. At the end of surgery, all patients were macroscopically tumor free, which was confirmed microscopically in 20 patients (74%, R0), with the other 7 patients having microscopic tumor remnants. For all patients, median time of survival was 37 months, the five-year survival rate (5YSR) was 62%, and the overall survival (OS) was 59%. Patients with tumor-free lymph nodes had an OS of 76% and a 5YSR of 83% vs. 40% and 36%, respectively, for patients with tumorous spread to the nodes (p=0.03). The 5YSR correlated to the degree of resection (R0 vs. R1, 74% vs. 21%, p=0.01). CONCLUSION: PE is a therapeutic option in advanced primary or relapsed vulvar carcinoma, offering median- to long-term survival for many patients. Carcinomatous spread to regional lymph nodes and complete resection are the most important prognostic factors.

Prevalence of abnormal Pap smear results in inflammatory bowel disease: a prospective study.

PURPOSE: Development of malignancy is a pending threat for patients with inflammatory bowel disease (IBD). Aim of this study was to analyze cervical dysplasia and infection with human papilloma virus (HPV) in patients with IBD. METHODS: This was a prospective, single center cohort study in Germany. Consecutive IBD patients admitted to the Department of Gastroenterology were sent to Gynecology, where a questionnaire was answered and gynecological examinations including a smear for cytology and HPV were taken. Participants of a general screening program constituted controls. Descriptive statistics, 95% confidence intervals and odds ratios were calculated. RESULTS: A total of 101 patients were recruited of which 99 patients participated. Analysis showed a significant (p = 0.05) difference between the prevalence of abnormal smears in patients with (22%) and without (6%) immunosuppressive therapy, while the latter had cervical abnormalities comparable with healthy controls (5%). All immunosuppressants showed similarly high risks for abnormal smear results. Only 11/99 (11%) patients had positive high-risk HPV tests, which is comparable with general population. CONCLUSION: The prevalence of abnormal cervical smears is higher in IBD patients compared to healthy individuals, but the difference is confined to patients with IBD and immunosuppressive therapy. Annual screening is advisable.

Risk for Pelvic Metastasis and Role of Pelvic Lymphadenectomy in Node-Positive Vulvar Cancer-Results from the AGO-VOP.2 QS Vulva Study.

The need for pelvic treatment in patients with node-positive vulvar cancer (VSCC) and the value of pelvic lymphadenectomy (LAE) as a staging procedure to plan adjuvant radiotherapy (RT) is controversial. In this retrospective, multicenter analysis, 306 patients with primary node-positive VSCC treated at 33 gynecologic oncology centers in Germany between 2017 and 2019 were analyzed. All patients received surgical staging of the groins; nodal status was as follows: 23.9% (73/306) pN1a, 23.5% (72/306) pN1b, 20.4% (62/306) pN2a/b, and 31.9% (97/306) pN2c/pN3. A total of 35.6% (109/306) received pelvic LAE; pelvic nodal involvement was observed in 18.5%. None of the patients with nodal status pN1a or pN1b and pelvic LAE showed pelvic nodal involvement. Taking only patients with nodal status ≥pN2a into account, the rate of pelvic involvement was 25%. In total, adjuvant RT was applied in 64.4% (197/306). Only half of the pelvic node-positive (N+) patients received adjuvant RT to the pelvis (50%, 10/20 patients); 41.9% (122/291 patients) experienced recurrent disease or died. In patients with histologically-confirmed pelvic metastases after LAE, distant recurrences were most frequently observed (7/20 recurrences). Conclusions: A relevant risk regarding pelvic nodal involvement was observed from nodal status pN2a and higher. Our data support the omission of pelvic treatment in patients with nodal status pN1a and pN1b.

Exenteration as a primary treatment for locally advanced cervical cancer: long-term results and prognostic factors.

OBJECTIVE: Whereas pelvic exenteration is an established therapy for the treatment of recurrent cervical carcinoma, it is not often performed for primary locally advanced cervical cancer (LACC). STUDY DESIGN: This retrospective study analyzed survival data and prognostic factors of 35 patients with LACC who were treated by pelvic exenteration. RESULTS: After surgery, 33 patients (97%) were macroscopically free of tumor. In 20 patients, pelvic lymph nodes (LN) were involved, and in 6 of these, metastatic tissue had reached the paraaortal nodes. Overall, the patients' mean 5 year survival was 43%, and the median survival time was 30 months; these values ranged from 15% to 70% and from 15 to 44 months, respectively, depending on LN involvement (P=.006). Pelvic LN involvement was the only significant factor for overall survival found in the multivariate analysis (P=.02). CONCLUSION: In LACC with free LNs and no distant metastases, pelvic exenteration has good long-term results.

Ileal conduit and continent ileocecal pouch for patients undergoing pelvic exenteration: comparison of complications and quality of life.

OBJECTIVES: Creating a continent urinary pouch has become an alternative to the ileal conduit for patients undergoing exenteration for advanced gynecologic malignancies. The objective of this study was to compare clinical outcomes for the 2 methods. METHODS: In this retrospective study, we compared intraoperative and postoperative complications and quality-of-life scores for the modified ileocecal pouch and the ileal conduit in anterior or total pelvic exenteration. RESULTS: In 33 of 100 patients, an ileal pouch (IP) was created; the other 67 were treated by an ileal conduit (IC). Creating an IP prolonged the exenterative procedure by 97 minutes compared to an IC (IC, 453 minutes vs. IP, 550 minutes; P = 0.009). Overall complication rates were similar, but patients with an IP had significantly more complications of urinary diversion (48%) than patients with an IC (31%; P = 0.03). Follow-up showed urinary loss and frequency of micturition to be comparable, but in patients with an IP, surgery for stomal complications (n = 2) and treatment of bladderstones were necessary more frequently (n = 3). Quality of life according to the 12-item Short Form Health Survey questionnaire was similar in both groups. CONCLUSION: A continent IP is an alternative to the IC in cases of pelvic exenteration. Early complications are more frequent with an IP than with an IC. The mode of urinary diversion has little influence on the quality of life in patients with advanced genital cancer.

Ileal conduit and continent ileocecal pouch for patients undergoing pelvic exenteration: comparison of complications and quality of life.

OBJECTIVES: Creating a continent urinary pouch has become an alternative to the ileal conduit for patients undergoing exenteration for advanced gynecologic malignancies. The objective of this study was to compare clinical outcomes for the 2 methods. METHODS: In this retrospective study, we compared intraoperative and postoperative complications and quality-of-life scores for the modified ileocecal pouch and the ileal conduit in anterior or total pelvic exenteration. RESULTS: In 33 of 100 patients, an ileal pouch (IP) was created; the other 67 were treated by an ileal conduit (IC). Creating an IP prolonged the exenterative procedure by 97 minutes compared to an IC (IC, 453 minutes vs IP, 550 minutes; P = 0.009). Overall complication rates were similar, but patients with an IP had significantly more complications of urinary diversion (48%) than patients with an IC (31%; P = 0.03). Follow-up showed urinary loss and frequency of micturition to be comparable, but in patients with an IP, surgery for stomal complications (n = 2) and treatment of bladderstones were necessary more frequently (n = 3). Quality of life according to the 12-item Short Form Health Survey questionnaire was similar in both groups. CONCLUSION: A continent IP is an alternative to the IC in cases of pelvic exenteration. Early complications are more frequent with an IP than with an IC. The mode of urinary diversion has little influence on the quality of life in patients with advanced genital cancer.

Intestinal complications after pelvic exenterations in gynecologic oncology.

OBJECTIVES AND METHODS: The present study reviews the frequency of intestinal complications in patients having undergone pelvic exenteration in our department between July 1999 and June 2008. RESULTS: Ninety patients with pelvic exenteration were included. R0 resection was achieved in 61 patients (67.8%), R1 in 20 patients (22.2%), and R2 in 9 patients (10.0%). Sixty-four patients had a rectal resection, all less than 7 cm from the anal verge. Forty-two of them had a rectal anastomosis; in 23 cases, with a protective colostomy. The other 22 patients had a terminal colostomy. Fifty-three patients had an ileal anastomosis for bladder reconstruction by ileal conduit, and 29 patients had an ileo-ascendostomy for an ileocecal pouch.Twenty-three patients (25.6%) needed surgical intervention for complications; anastomotic dehiscence being most frequent with 7 cases (7.8%). Three leakages appeared in ileal anastomoses (3/53, 5.7%) and 4 in rectal anastomoses (4/42, 9.5%). Although not significantly, the risk of symptomatic leakage was lower for patients with a protective colostomy (1/23, 4.3%) than for those without (3/19, 15.7%). We found no correlation between the preceding radiotherapy or chemotherapy and the frequency of breakdown of rectal anastomosis. CONCLUSIONS: The risk of intestinal complications in exenterative surgery is moderate and not higher than in surgery for rectal cancer. Clinical appearance and, hence, relevance of anastomotic leakage may be reduced by a temporary diverting stoma.

The Impact of Age on the Prognosis of Vulvar Cancer.

INTRODUCTION: Younger women are particularly affected by the increase in the incidence of vulvar cancer. The purpose of this study was to investigate how clinical characteristics differ depending on the patient´s age and what role the age of initial diagnosis plays in the prognosis. Patients andMethods: Included patients were divided into groups aged below or above 50 years. The disease-free survival (DFS) was calculated and a multivariate discriminant analysis was conducted. RESULTS: Of the 300 patients, 79 were ≤50 years and 221 were >50 years. The median age was 64 years (19-96 years). There were no differences between the groups regarding lymph node (LN) status and distant metastasis, but T1 tumours were more frequent in patients ≤50 years (77% vs. 62%, p = 0.02). The DFS only differed between the groups when there were no LN metastases. The nodal status was the predominant prognostic factor for the DFS regardless of age. In node-free patients, the 5-year DFS was 49% for the ≤50 years group and 89% for the >50 years group (p = 0.008), whereas there was no difference if a LN was involved. CONCLUSION: In node-free patients, the risk for recurrence is lower for patients older than 50 years.

Neoadjuvant and definitive chemotherapy or chemoradiation for stage III and IV vulvar cancer: A pooled Reanalysis.

OBJECTIVES AND METHODS: A number of publications study the treatment of advanced vulvar cancer by neoadjuvant or definitive chemotherapy (CT) or chemoradiation (CRT); however, the reported survival rates vary widely. In a pooled reanalysis of the published data, we studied the factors influencing patients' survival. RESULTS: We included 97 patients with stage III and IV vulvar cancer of publications in our study. In the pooled reanalysis we found that neoadjuvant therapy plus surgery lead to significantly better 5YSR (73%) than definitive CRT (43%) alone. No significant difference was found between CRT (5YSR: 69%) and CT (77%, p=0.11) in the neoadjuvant setting. In addition, patients showing a positive response to CT or CRT had a better 5YSR (67% vs. 20%, p=0.001). CONCLUSION: Neoadjuvant therapy plus surgery can improve survival of patients with advanced vulvar cancer.

Can clitoris-conserving surgery for early vulvar cancer improve the outcome in terms of quality of life and sexual sensation?

OBJECTIVES: Vulvar carcinomas (VC) and vulvar in situ cancers (VCIS) are rare genital malignancies. Total vulvectomy as the standard of care has been replaced by local excision during the early stages of the disease. We studied whether conservation of the clitoris in vulvar surgery has a positive effect on either the quality of life (QoL) or the sexual sensation of the patient. STUDY DESIGN: In a retrospective study, patients with and without clitoris-sparing surgery were interviewed using the Female Sexual Function Index questionnaire (FSFI) and the Short Form 12(®) questionnaire (SF-12). The frequencies of high and low levels and the medians were compared using the Cox-Mantel, Chi(2) and Fisher's exact tests. RESULTS: We identified 24 patients who had surgery in our department for VCIS or VC stage I/II, between 2006 and 2008. Ten of these patients required total inguinal lymphadenectomies and another five required sentinel node biopsies. In twelve patients, the clitoris had been spared, whereas in the remaining twelve, the clitoris had needed to be removed. These groups did not differ in terms of tumor size, stage, type of surgery or age of the patients. The evaluation of the SF-12 indicated high satisfaction in the physical scores for 33% of patients with clitoris-sparing surgery vs. 67% after clitoris resection (n.s.). For the mental domain, the rates were 58% and 67% (n.s.), respectively. In the FSFI, both groups showed comparable values <18 (n = 7) and >18 (n = 5) in sexual sensation. CONCLUSION: Reducing the surgical resection is oncologically acceptable, but improvement in the patients' quality of life or sexual sensation is not achieved solely by conserving the clitoris.

Borderline tumours of the ovary: A cohort study of the Arbeitsgmeinschaft Gynäkologische Onkologie (AGO) Study Group.

BACKGROUND: Borderline ovarian tumours (BOTs) are recognised as a unique entity of ovarian tumours that do not exert infiltrative destructive growth or stromal invasion. Prognosis of BOT is much better compared to the more common invasive epithelial ovarian cancer. Information regarding prognostic factors is inconclusive and no prospective studies exist that evaluate therapeutic strategies. We therefore started a retrospective-prospective cohort study to better understand BOT and identify scenarios in which future studies could be developed. METHODS: Consecutive patients with BOT treated between 1998 and 2008 in 24 German centres were analysed. The retrospective part of the study retrieved patients' data from hospital records and clinical tumour registries while active follow-up and an independent central pathology review were carried out prospectively. FINDINGS: BOT was confirmed in 950 patients, two thirds had serous BOT and 30.5% mucinous BOT. Most were diagnosed in stage I (82.3%); 7.6% and 10.1% had stages II and III, respectively. Overall, 74 patients (7.8%) experienced relapse and 43 (4.5%) died within the observation period. Multivariate analysis revealed higher stage, incomplete staging, tumour residuals, and organ preservation as independent prognostic factors for disease recurrence. Neither microinvasion nor micropapillary growth pattern showed any significant impact. Of 74 relapsed patients, 30% had malignant transformation to invasive ovarian cancer with five-year progression-free survival and overall survival of 12% and 50%, respectively. INTERPRETATION: Prognosis of BOT correlates with tumour-related as well as surgery-related factors. The balance between recurrence risk and organ preservation and fertility-sparing surgery is an important issue deserving further research.

Preoperative assessment of complete tumour resection by magnetic resonance imaging in patients undergoing pelvic exenteration.

OBJECTIVES: To evaluate whether preoperative magnetic resonance imaging (MRI) allows prediction of complete tumour resection in patients planned for pelvic exenteration (PE). STUDY DESIGN: Data of all patients treated by PE at a gynaecologic cancer centre between 6/1999 and 5/2005 were studied retrospectively. Preoperative MRI scans were re-analysed blindly with respect to invasion of neighbouring organs, muscular pelvic side wall, vessels and lymph nodes by an experienced team of radiologist and gynaecologic oncologist, finally also giving estimation whether complete removal of tumour would be feasible. RESULTS: 43 patients were identified: all of them underwent PE. The histopathological investigation of the exenteration specimen demonstrated microscopic complete resection status in 20 cases (46.5%). None of the investigated parameter showed a correlation to complete resection of tumour. Sensitivity for final microscopic results relative to preoperative prediction by radiographic findings was 85%, specificity was 52%. The positive predictive value for tumour-free status was 60% (17/28), the negative 80% (12/15). CONCLUSIONS: Preoperative MRI cannot predict the surgical outcome with sufficient accuracy, hence on its own is inappropriate for prediction of complete tumour resection and final histological margin status in patients undergoing PE.

Pelvic cyst: renal or ovarian?

Ovarian cyst is a common gynecologic finding. Renal cysts develop in 15% of women older than 70 years, and nephroptosis in 20% of the population, primarily in women. Herein, we review these conditions and present a case in which the patient had a cystic kidney in combination with nephroptosis. At vaginal ultrasound performed with the patient in an upright position, the kidney slid down into the pelvis, thus imitating an ovarian mass. At laparoscopy, the patient was positioned head down, and the kidney, lying near the diaphragm, was not seen.