Predicting the rate of adjuvant postoperative chemo/radiation in cervical cancer with tumor size ≥2 cm and <4 cm: An Israeli Gynecologic Oncology Group study.

OBJECTIVE: Women with cervical cancer who undergo radical hysterectomy are often treated postoperatively with chemoradiation. Patient selection that minimizes adjuvant treatment is valuable. We compared two methods for predicting postoperative adjuvant treatment of women with tumor size ≥2 cm and <4 cm. STUDY DESIGN: This multicenter retrospective study included 272 women with tumor size ≥2 cm and <4 cm. A receiver operating characteristic curve (ROC) analysis was used to determine the optimal tumor cutoff size to predict adjuvant treatment. A second analysis compared the rate of adjuvant treatment between women with and without lymph vascular space involvement (LVSI). RESULTS: According to the ROC, the optimal cutoff value of tumor size for predicting adjuvant treatment was 2.95 cm (sensitivity 0.70, specificity 0.67). Tumors were ≥3.0 cm in 166 (61.0%) women. The rate of adjuvant treatment was higher in women with larger tumor diameter (73.8% vs. 47.9%, p < 0.0001). Of the 241 women with a LVSI record, LVSI was present in 81 (34%) women. Among women with LVSI, rates were higher of positive lymph nodes (41.0% vs 14.5%, p < 0.0001) and postoperative adjuvant treatment (83.3% vs. 53.7%, p < 0.001). Among women with tumor size ≥3.0 cm and LVSI, the rate of adjuvant treatment was 90.0%. In the multivariate analysis, both tumor size ≥3.0 cm and the presence of LVSI were independently associated with adjuvant treatment (OR 3.9, 95% CI 2.1-7.1; p < 0.0001 and OR 4.9, 95% CI 2.4-10.0; p < 0.0001, respectively). CONCLUSION: In women with cervical cancer who underwent radical hysterectomy, tumors ≥3 cm were associated with a >70% rate of adjuvant treatment, and LVSI was associated with a >80% rate. These data should be weighed in multidisciplinary consultation with radiation oncologists when deciding treatment strategy.

Minimally invasive approach in endometrial cancer with lower uterine segment involvement in stage ≥ II: A retrospective study.

OBJECTIVE: To compare oncological outcomes in women with lower uterine segment involvement (LUSI) in endometrial carcinoma (EC) stage ≥ II - staged by a minimally invasive surgery (MIS) versus laparotomy. STUDY DESIGN: A retrospective multi-center cohort study. Univariate analysis, Kaplan-Meier survival and Cox proportional hazard analysis were performed to compare between women staged by MIS and those staged by laparotomy. RESULTS: Over a median follow-up period of 3 years (interquartile range, 1.5-6 years) 212 women were included, 68 (32.1%) were surgically staged by MIS. Stages of disease did not vary between MIS and laparotomy and were 32.1%, 51.9%, and 16.0%, in stages II, III and IV - respectively. Adjuvant radiation and chemotherapy rate did not differ between groups. Overall recurrence rate was comparable (p = 0.084). Locoregional recurrence rate was higher in the MIS group odds ratio 2.17, 95% confidence interval 1.19-4.20). Overall and progression free survival were similar in both groups (log rank test p = 0.08 and p = 0.912 respectively). In Cox regression model adjusting for age, comorbidities, tumor grade, stage and adjuvant therapy, route of surgery (MIS vs. laparotomy) was not associated with overall survival (p = 0.169). CONCLUSIONS: In women with advanced EC and LUSI, although MIS is associated with locoregional recurrences, survival is comparable to laparotomy.

Anatomical and functional outcomes of uterus preservation and pelvic organ prolapse repair with vaginal trocar-less mesh kit (Endofast): A retrospective study of 239 patients.

OBJECTIVE: The aim of the study was to assess safety and long term efficacy as well as short and long term complications of vaginal prolapse mesh repair using single incision trocar-less system while preserving the uterus. STUDY DESIGN: A single-center, retrospective cohort study including all patients who underwent vaginal prolapse mesh repaier surgery with EndoFast Reliant™ kit between October 2010 and January 2015. Outcomes included anatomical changes (POP-Q), overactive bladder symptoms (OAB) stress urinary incontinence (SUI), sexual function and constipation as well as the rate of surgical failure, immediate and long-term complications. RESULTS: 239 women, with an average follow-up period of 1.7 years (range: 6 weeks to 7 years), were included. Uterus was preserved in 87 % of patients (184 out of 211 patients with intact uterus) and concurrent surgery for SUI was performed in 46 %. POP-Q significantly improved as well as OAB and SUI symptoms and remained without significant change during follow-up period. In 11 patients (4.6 %) a new/recurrent prolapse was observed during the follow up period. Immediate complications occurred in 4 patients. One case of bladder perforation, one case of mesh contamination, 2 cases of urinary retention, one of them permanent. Late complications included mesh erosion, de novo dyspareunia, cervical elongation and de-novo SUI, and were observed in 38 cases (16 %). Surgical intervention was required in 20 (8.4 %) cases; 10 cases of de-novo SUI, 2 cases of partial mesh removal because of dyspareunia, 1 case of mid urethral sling removal because of erosion and 7 cases of cervical amputation. CONCLUSIONS: Repair of prolapse with vaginal trocar-less mesh kit while preserving the uterus for the majoroty of women, is a relatively safe and effective surgery,with a low incidence of complications and re-operation rate which was mainly for de novo SUI or elongation of cervix. Randomiesed prospective long term studies are neaded to establish the results.

Age is an independent predictor of outcome in endometrial cancer patients: An Israeli Gynecology Oncology Group cohort study.

INTRODUCTION: Advanced age is considered an adverse factor in endometrial cancers but may be a surrogate for other conditions that impact outcomes. The study objective was to assess the association of age with endometrial cancer features, treatment and prognosis. MATERIAL AND METHODS: In this multicenter cohort study, consecutive women with endometrial cancer treated at 10 Israeli institutions between 2000 and 2014 were accrued in an assimilated database. Postmenopausal women were stratified into age groups with a cut-off of 80. Clinical, pathological and treatment data were compared using t test or Mann-Whitney test for continuous variables, and Chi-square Test or Fisher's Exact test for categorical variables. Main outcome measures included disease recurrence and disease-specific and overall survival; these were plotted using the Kaplan-Meier method and compared using the log-rank test. The association between age and recurrence and survival, adjusted for other clinical and pathological factors, was assessed using multivariable Cox regression modeling. RESULTS: A total of 1764 postmenopausal women with endometrial cancer were identified. Adverse pathological features were more prevalent in older women, including high-risk histologies (35% vs 27%, P = .025), deep myoinvasion (44% vs 29%, P = .001) and lymphovascular involvement (22% vs 15%, P = .024). Surgical staging was performed less frequently among older women (33% vs 56%; P < .001). Chemotherapy was less often prescribed, even for non-endometrioid histologies (72% vs 45%; P < .001). On multivariable analysis, age remained a significant predictor for recurrence (HR = 1.75, P = .007), death of disease (HR = 1.89, P = .003) and death (HR = 2.4, P < .001). CONCLUSIONS: Older age in women with endometrial cancer is associated with more adverse disease features, limited surgery and adjuvant treatment, and worse outcomes. On multivariable analysis, age remains an independent prognosticator in this population.

Increased ultrasonographic endometrial thickness is associated with poor survival in patients with endometrial cancer: An Israel gynecologic oncology group study.

BACKGROUND: We aimed to assess the association of pre-operatively evaluated ultrasonographic endometrial thickness with outcomes of patients with endometrial cancer. METHODS: An Israel Gynecologic Oncology Group multicenter retrospective cohort study of consecutive patients with endometrial cancer who underwent surgery between 2002 and 2014 in one of eleven academic centers. Patients were categorized by endometrial thickness into two groups: ≤20 mm and >20 mm. Clinical and pathological features were compared using Student T-test for continuous variables and Chi-square or Fisher's exact test for categorical variables. Survival measures were plotted with the Kaplan-Meier method and compared using the log-rank test. A Cox proportional hazards model was used for multivariable comparison of associations. RESULTS: 1113 patients in whom endometrial thickness data was recorded were the subject of this study and included 2 groups: ≤20 mm (n = 930), >20 mm (n = 183). The median follow-up was 52 months (range 12-120 months). Patients with endometrial thickness >20 mm had significantly lower recurrence-free survival (log rank, p < .0001), disease-specific survival (log rank, p = .01), and overall survival (log rank, p < .0001). On multivariate Cox proportional hazards analysis, endometrial thickness >20 mm remained independently associated with an increased hazard of recurrence and death (HR = 1.77, 95% CI 1.07-2.96, p = .03 for recurrence; and HR = 1.68; 95% CI 1.07-2.65; p = .03 for overall survival). CONCLUSION: In patients with endometrial cancer, endometrial thickness>20 mm as measured preoperatively by ultrasound, is independently associated with decreased recurrence-free and overall survival. This finding suggests that thick endometrium may be considered as one of the risk factors for poor prognosis.

Is the extent of pelvic lymphadenectomy in the staging of endometrial cancer associated with the yield of metastatic nodes? An Israeli Gynecologic Oncology Group study.

OBJECTIVES: Primary, to explore correlation between the extent of pelvic lymphadenectomy in the surgical staging of endometrial cancer and the number of nodes with metastasis. Secondary, evaluate survival measures in relation to the number of excised nodes. METHODS: A retrospective multi-center study of prospectively collected information of 2014 women with endometrial cancer, 1032 of whom underwent lymph node staging. Spearman's rank correlation was used to assess the correlation between the number of pelvic nodes excised and the number of metastatic nodes. Women's data were dichotomized by the median number of excised pelvic nodes. Kaplan-Meier and log rank tests were used to examine the effect of the number of pelvic nodes excised on survival. RESULTS: There was no significant correlation between the number of pelvic nodes harvested and the number of metastatic lymph nodes (r = 0.301; p = 0.28). The median number of excised pelvic nodes was 9 (range 1-77). There was no difference between women with up to 9 and women with more than 9 lymph nodes excised in the 5-year recurrence-free survival (82.4% vs. 83.9%; p = 0.90), disease-specific survival (83.6% vs. 86.7%; p = 0.37), or overall survival (75.8% vs. 82.8%; p = 0.11). CONCLUSIONS: The extent of pelvic lymphadenectomy in the surgical staging of endometrial cancer is not associated with a higher yield of metastatic nodes or with longer survival. Current focus should be on sentinel node procedures that offer women the benefit of accurate staging without the complications associated with extensive lymphadenectomy.

Assisted Reproductive Technology as a Transcutaneous Route for Bacterial Contamination of Ovarian Endometrioma with Coagulase-Negative Staphylococcus: Case Report and Review of the Literature.

Tubo-ovarian abscess may develop in women with endometrioma following assisted reproductive technology (ART). The infection, though rare, is typically late in onset and may present several months after the procedure, and in pregnancy-with the risks of abortion and premature labor. It is thought that transcutaneous oocyte retrieval during ART is the route for bacterial contamination resulting in infection of the endometrioma. Pathogens reported in the literature include Escherichia coli (E. coli) and Group B streptococcus (GBS) but Staphylococcus lugdunensis (S. lugdunensis), a coagulase-negative staphylococcus (CoNS), and groin and perineal skin commensal was isolated from the endometrioma in this case. We discuss the challenges in diagnosis and treatment of this rare condition and the implications of the discovery that an organism previously dismissed as a contaminant has emerged as a causative organism in severe, deep-seated infections of soft tissues in recent literature.

The oncological safety of hysteroscopy in the diagnosis of early-stage endometrial cancer: An Israel gynecologic oncology group study.

OBJECTIVE: To compare survival measures of women with early-stage endometrial cancer who underwent either hysteroscopy or a non-hysteroscopic procedure as a diagnostic procedure. STUDY DESIGN: An Israel Gynecologic Oncology Group multicenter study of 1324 patients with stage I endometrial cancer who underwent surgery between 2002 and 2014. Patients were divided into two groups: hysteroscopy and non-hysteroscopy (curettage or office endometrial biopsy). Clinical, pathological, and survival measures were compared between the groups. RESULTS: There were 355 patients in the hysteroscopy group and 969 patients in the non-hysteroscopy group. The median follow-up was 52 months (range 12-120 months). There were no differences between the groups in the 5-year recurrence-free survival (90.2% vs. 88.2%; p = 0.53), disease-specific survival (93.4% vs. 91.7%; p = 0.5), and overall survival (86.2% vs. 80.6%; p = 0.22). CONCLUSION: Our findings affirm that hysteroscopy does not compromise the survival of patients with early-stage endometrial cancer.

Is there a survival advantage in diagnosing endometrial cancer in asymptomatic postmenopausal patients? An Israeli Gynecology Oncology Group study.

BACKGROUND: Incidental ultrasonographic findings in asymptomatic postmenopausal women, such as thickened endometrium or polyps, often lead to invasive procedures and to the occasional diagnosis of endometrial cancer. Data supporting a survival advantage of endometrial cancer diagnosed prior to the onset of postmenopausal bleeding are lacking. OBJECTIVE: To compare the survival of asymptomatic and bleeding postmenopausal patients diagnosed with endometrial cancer. STUDY DESIGN: This was an Israeli Gynecology Oncology Group retrospective multicenter study of 1607 postmenopausal patients with endometrial cancer: 233 asymptomatic patients and 1374 presenting with postmenopausal bleeding. Clinical, pathological, and survival measures were compared. RESULTS: There was no significant difference between the asymptomatic and the postmenopausal bleeding groups in the proportion of patients in stage II-IV (23.5% vs 23.8%; P = .9) or in high-grade histology (41.0% vs 38.4%; P = .12). Among patients with stage-I tumors, asymptomatic patients had a greater proportion than postmenopausal bleeding patients of stage IA (82.1% vs 66.2%; P < .01) and a smaller proportion received adjuvant postoperative radiotherapy (30.5% vs 40.6%; P = .02). There was no difference between asymptomatic and postmenopausal bleeding patients in the 5-year recurrence-free survival (79.1% vs 79.4%; P = .85), disease-specific survival (83.2% vs 82.2%; P = .57), or overall survival (79.7% vs 76.8%; P = .37). CONCLUSION: Endometrial cancer diagnosed in asymptomatic postmenopausal women is not associated with higher survival rates. Operative hysteroscopy/curettage procedures in asymptomatic patients with ultrasonographically diagnosed endometrial polyps or thick endometrium are rarely indicated. It is reasonable to reserve these procedures for patients whose ultrasonographic findings demonstrate significant change over time.

A randomized clinical trial of knotless barbed suture vs conventional suture for closure of the uterine incision at cesarean delivery.

BACKGROUND: Knotless barbed sutures are monofilament sutures with barbs cut into them. These sutures self-anchor, maintaining tissue approximation without the need for surgical knots. OBJECTIVE: The hypothesis of this study was that knotless barbed suture could be used on the myometrium to close the hysterotomy at cesarean delivery. The objective was to compare uterine closure time, need for additional sutures, and blood loss between this and a conventional suture. STUDY DESIGN: This was a prospective, unblinded, randomized controlled trial conducted at the Ziv Medical Center, Zefat, Israel. The primary outcome was the length of time needed to close the uterine incision, which was measured from the start of the first suture on the uterus until obtaining uterine hemostasis. To minimize provider bias, women were randomized by sealed envelopes that were opened in the operating room just prior to uterine closure with either a bidirectional knotless barbed suture or conventional suture. Secondary outcomes included the number of additional hemostatic sutures needed and blood loss during incision closure. RESULTS: Patients were enrolled from August 2016 until March 2017. One hundred two women were randomized. Fifty-one had uterine closure with knotless barbed suture and 51 with conventional suture. The groups were similar for demographics as well as number of previous cesarean deliveries. Uterine closure time using the knotless barbed suture was significantly shorter than the conventional suture by a mean of 1 minute 43 seconds (P < .001, 95% confidence interval, 67.69-138.47 seconds). Knotless barbed sutures were associated with a lower need for hemostatic sutures (median 0 vs 1, P < .001), and blood loss measured during incision closure was significantly lower (mean 221 mL vs 268 mL, P < .005). CONCLUSION: The use of a knotless barbed suture is a reasonable alternative to conventional sutures because it reduced the closure time of the uterine incision. There was also less need for additional hemostatic sutures and slightly reduced estimated blood loss.

Team preparation for human uterus transplantation: Autologous transplantation in sheep model.

We performed autologous uterus transplantation using the living-sheep donor model for team preparation before human uterine transplantation. Five sequential operations (in 3 ewes) were prospectively conducted. Surgical technique included uterus retrieval, graft preparation, and uterus transplantation. Anastomoses were performed at the level of the external iliac. At 3-week follow-up, the uterus and anastomoses were checked for strictures and thrombosis. Two successful auto-transplantations were made, and one failed because of undeveloped uterine arteries (< 1 mm in diameter). In the first two ewes, we identified and used a deep, separate uterine vein, which was not described in other publications. In the third ewe, we used the utero-ovarian vein. The team was able to perform safe dissection and auto-transplantation, with no signs of strictures or thrombosis after 3 weeks. Cold ischemic time was 60 minutes, and warm ischemic time was between 40 and 60 minutes, with no need for re-anastomoses. We noticed that using the deep uterine vein in the sheep model can anatomically simulate better the human uterine vein and the difficulty to approach it. To avoid using unsuitable vessels for anastomoses, the uterine transplantation protocol in humans should include imaging of the donor's uterine vessels.

[ALLEN-MASTERS SYNDROME AS A CAUSE FOR CHRONIC PELVIC PAIN: DIAGNOSIS, TREATMENT AND LONG TERM FOLLOW-UP].

Chronic pelvic pain is one of the main causes for repeated ambulatory and hospital visits. The main findings on exploratory laparoscopy performed for these complaints are endometriosis and adhesions, while in more than 50% of cases, no cause for the pain is found. In 1955, Allen and Masters reported pain associated with traumatic labor. They reported retroverted and hyper-mobile uterus in all women and during operation, tears in the posterior serosa of the broad igament. A few therapeutic options have been discussed, including repair of the tears, but without long term follow-up and significant relief of symptoms. Tightening of the utero-sacral ligaments following peritoneal resection of the Douglas as a long effective treatment was initially suggested in France in 1972. In 1997, von Theobald showed that it could be conducted by laparoscopy with long term follow-up. We report 3 cases of women diagnosed with Allen-Masters Syndrome, the surgical treatment performed and the long follow-up of these patients. We also discuss the ways to diagnose the syndrome and the preferred modality of treatment.

Early wound dressing removal after scheduled cesarean delivery: a randomized controlled trial.

BACKGROUND: Following cesarean delivery, wound dressings are typically left over the incision for 24-48 hours. OBJECTIVE: The objective of this study was to determine if early removal of the wound dressing at 6 hours postsurgery has any effect on wound complications. STUDY DESIGN: This was a randomized, controlled study from August 2013 through January 2015 in which 320 low-risk women aged 18-44 years having scheduled primary, first repeat, or second repeat cesarean delivery were randomized for wound dressing removal at either 6 or 24 hours postsurgery. Skin closure was with staples in all cases. The primary outcome was postoperative wound complications, defined as infection, disruption (skin dehiscence or deeper), or seroma/hematoma. Also examined was patient satisfaction with timing of their ability to wash or shower after wound dressing removal. A sample size of 160 women in each group was needed to show a 100% increase in the wound complication incidence from 12-24%. RESULTS: A total of 320 women were randomized, 160 in the 6-hour group and 160 in the 24-hour group. The proportion of primary and repeat cesarean deliveries was similar. The incidence of wound complications was not significantly different between the groups, 13.8% in the 6-hour group and 12.5% in the 24-hour group (odds ratio, 1.16; 95% confidence interval, 0.58-2.14). More women were pleased and satisfied with their ability to wash or shower soon after wound dressing removal in the 6-hour group (75.6%) compared to the 24-hour group (56.9%; odds ratio, 2.35; 95% confidence interval, 1.46-3.79). CONCLUSION: Early removal of the wound dressing at 6 hours following cesarean delivery has no detrimental effect on incision healing. Early removal permits the woman to attend to personal hygiene earlier, making her more satisfied with her postoperative recovery.

The effect of chart speed on fetal monitor interpretation.

OBJECTIVE: Electronic fetal heart monitor chart speeds vary between countries, and it is unclear whether differing chart speeds affect physician tracing interpretation. METHODS: Twenty-minute segments of 19 tracings were displayed on both 1 and 3 cm/min strips and interpreted by 14 physicians at the particular speed they were accustomed to reading. Interpretations of tracing characteristics were compared between groups using free margin kappa, a measure of interobserver agreement. RESULTS: Compared to 3 cm/min tracings, 1 cm/min tracings were significantly more often identified as having absent than minimal variability, and minimal than moderate variability. Accelerations were significantly more often identified in 1 versus 3 cm/min strips. There were no significant differences between groups with respect to baseline fetal heart rate, prolonged or repetitive decelerations, or American College of Obstetricians and Gynecologists tracing category. Neither chart speed had substantial interobserver agreement in tracing variables; however, agreement was consistently higher in 3 versus 1 cm/min tracings (all p < 0.05). CONCLUSIONS: Tracing interpretation is significantly affected by fetal monitor chart speed with regards to variability, acceleration and deceleration. Further studies are required to determine if differences in chart speed interpretation affect clinical management.

Integration of PET/CT into the preoperative evaluation of patients with early cervical cancer does not decrease the proportion of patients with positive lymph nodes found after surgery.

PURPOSE: The aim of this study was to evaluate whether preoperative positron emission tomography/computed tomography (PET/CT) in patients with early-stage cervical carcinoma reduced the proportion of patients with metastatic lymph nodes identified after surgery. PATIENTS AND METHODS: This is a multicenter case-control study of 599 patients with early cervical cancer who underwent radical hysterectomy and pelvic lymphadenectomy at 1 of 10 gynecological oncology units in Israel. The patients were divided into 2 groups according to whether or not they underwent a preoperative PET/CT. The primary outcome was the proportion of patients with nodal involvement. The 2 groups were compared with regard to the clinical and histological variables. RESULTS: Of the 599 patients who underwent surgery, 180 (36%) had preoperative PET/CT study. There were no significant differences between the PET/CT and control groups with regard to clinical and histological risk factors. The proportion of patients with involved nodes was similar in the control and PET/CT groups (20.8% vs 19%; P = 0.73) as well as the proportion of patients receiving adjuvant radiotherapy/chemoradiation (58.3% vs 55.1%; P = 0.55). CONCLUSIONS: Preoperative PET/CT in patients with early cervical cancer does not reduce proportion of patients with metastatic nodal involvement and the employment of multimodality treatment. Prospective clinical trials comparing management based on PET/CT findings are warranted.

Acute urinary retention in an adolescent as the presenting symptom of lichen sclerosus et atrophicus.

BACKGROUND: A rare case of acute urinary retention caused by labial fusion in an adolescent is described and the possible causes are discussed. CASE: A 17-year-old girl, not sexually active, presented to our emergency service for acute urinary retention. Genital examination revealed labia minora fusion from the clitoris to the vaginal fourchette; urethra, and clitoris were not visualized. Sexual abuse and trauma were excluded. The labia minora were manually separated in the operating room revealing a normal vagina and urethral meatus. Skin biopsies taken from the fused labia minora revealed Lichen Sclerosus et Atrophicus. SUMMARY AND CONCLUSION: Urinary retention may be seen in the face of complete adhesion of the labia minora, a rare event in postpubertal individuals. In such cases, a suspicion of underlying pathology such as asymptomatic Lichen Sclerosus should be raised and be confirmed by a biopsy.

Uterine sarcoma: prognostic factors and treatment evaluation.

BACKGROUND: Uterine sarcoma constitutes a highly malignant group of uterine tumors. It accounts for 2-6% of uterine malignancies and its incidence is 1.7 in 100,000 women. The three most common variants of uterine sarcoma are endometrial stromal sarcoma, leiomyosarcoma and carcinosarcoma. Based on relatively small case series, the literature provides little information on the risk factors, the natural course of the disease and the preferred treatment. OBJECTIVES: To evaluate uterine sarcoma patients treated in a tertiary referral center in Israel over a 20 year period (1980-2005). METHODS: We conducted a retrospective review of the charts of 40 uterine sarcoma patients, including their tumor characteristics, stage at diagnosis, treatment modalities, follow-up and survival. RESULTS: The patients' mean age was 53 years (range 32-76); 30% of the patients had carcinosarcoma, 55% had leiomyosarcoma and 15% had ESS. Half of the patients presented with stage I disease, 23% stage II, 10% stage III and 15% stage IV. Thirty-nine patients were treated with surgery. Adjuvant radiotherapy was administered to 39% of the patients, adjuvant chemotherapy to 21% and combined radiotherapy and chemotherapy to 9%. The mean follow-up period was 44 months, at which time disease had recurred in 44% of the patients. The disease stage was correlated with the 5-year survival rate, which was 73.1% for stages I-II and 22.2% for stages III- IV. CONCLUSIONS: In accordance with other larger studies our data show that the only prognostic factor that was significantly correlated with prognosis was the stage of the disease at diagnosis. Despite advances in diagnosis and treatment, survival has not improved over the last 25 years.

Fertility in women after surgical treatment of nonepithelial ovarian tumors.

Conservative treatment is an acceptable option for women with nonepithelial ovarian tumors who wish to preserve fertility.