Prognostic value of isolated tumor cells in sentinel lymph nodes in low risk endometrial cancer: results from an international multi-institutional study.

OBJECTIVE: The prognostic significance of isolated tumor cells (≤0.2 mm) in sentinel lymph nodes (SLNs) of endometrial cancer patients is still unclear. Our aim was to assess the prognostic value of isolated tumor cells in patients with low risk endometrial cancer who underwent SLN biopsy and did not receive adjuvant therapy. Outcomes were compared with node negative patients. METHODS: Patients with SLNs-isolated tumor cells between 2013 and 2019 were identified from 15 centers worldwide, while SLN negative patients were identified from Mayo Clinic, Rochester, between 2013 and 2018. Only low risk patients (stage IA, endometrioid histology, grade 1 or 2) who did not receive any adjuvant therapy were included. Primary outcomes were recurrence free, non-vaginal recurrence free, and overall survival, evaluated with Kaplan-Meier methods. RESULTS: 494 patients (42 isolated tumor cells and 452 node negative) were included. There were 21 (4.3%) recurrences (5 SLNs-isolated tumor cells, 16 node negative); recurrence was vaginal in six patients (1 isolated tumor cells, 5 node negative), and non-vaginal in 15 (4 isolated tumor cells, 11 node negative). Median follow-up among those without recurrence was 2.3 years (interquartile range (IQR) 1.1-3.0) and 2.6 years (IQR 0.6-4.2) in the SLN-isolated tumor cell and node negative patients, respectively. The presence of SLNs-isolated tumor cells, lymphovascular space invasion, and International Federation of Obstetrics and Gynecology (FIGO) grade 2 were significant risk factors for recurrence on univariate analysis. SLN-isolated tumor cell patients had worse recurrence free survival (p<0.01) and non-vaginal recurrence free survival (p<0.01) compared with node negative patients. Similar results were observed in the subgroup of patients without lymphovascular space invasion (n=480). There was no difference in overall survival between the two cohorts in the full sample and the subset excluding patients with lymphovascular space invasion. CONCLUSIONS: Patients with SLNs-isolated tumor cells and low risk profile, without adjuvant therapy, had a significantly worse recurrence free survival compared with node negative patients with similar risk factors, after adjusting for grade and excluding patients with lymphovascular space invasion. However, the presence of SLNs-isolated tumor cells was not associated with worse overall survival.

Safety and feasibility of hyperthermic intraperitoneal chemotherapy during interval cytoreductive surgery in patients with advanced high-grade serous ovarian, fallopian tube, peritoneal cancer in an Australian context.

AIMS: To assess the safety and feasibility of hyperthermic intraperitoneal chemotherapy (HIPEC) during cytoreduction surgery (CRS) in advanced high-grade serous ovarian, fallopian tube and peritoneal cancer within an Australian context. METHODS: Data were collected from 25 consecutive patients undergoing CRS and HIPEC from December 2018 to July 2022 at the Peritoneal Malignancy Service at the Mater Hospital Brisbane, Australia. Data collected included demographics, clinical variables, surgical procedures and complications and intra-operative and post-operative indexes of morbidity. RESULTS: Twenty-five women who underwent CRS and HIPEC from December 2018 to July 2022 were included in analysis. Findings indicate that CRS with HIPEC is associated with low morbidity. CONCLUSION: While judicious patient selection is imperative, HIPEC during CRS was well tolerated by all patients and morbidity was comparable to results from the previously reported OVHIPEC-1 trial. HIPEC appears to be a safe and feasible addition to CRS for the treatment of advanced ovarian cancer in Australian practice.

Discussing diet, nutrition, and body weight after treatment for gynecological cancer: a conversation analytic study of outpatient consultations.

PURPOSE: To generate direct observational evidence for understanding how diet, nutrition, and weight-related topics are discussed during follow-up after treatment for gynecological cancer, as recommended by survivorship care guidelines. METHODS: Conversation analysis of 30 audio-recorded outpatient consultations, involving 4 gyne-oncologists, 30 women who had completed treatment for ovarian or endometrial cancer, and 11 family members/friends. RESULTS: From 21 instances in 18 consultations, diet, nutrition, or weight-related talk continued beyond initiation if the issue raised was ostensibly relevant to the clinical activity being undertaken at the time. These instances led to care-related outcomes (i.e., general dietary recommendations, referral to support, behavior change counseling) only when the patient identified needing further support. Diet, nutrition, or weight-related talk was not continued by the clinician if it was not apparently related to the current clinical activity. CONCLUSIONS: The continuation of diet, nutrition, or weight-related talk during outpatient consultations after treatment for gynecological cancer, and the subsequent delivery of care-related outcomes, depends on its immediate clinical relevance and the patient indicating needing further support. The contingent nature of these discussions means there can be missed opportunities for the provision of dietary information and support post-treatment. IMPLICATIONS FOR CANCER SURVIVORS: If seeking information or support for diet, nutrition, or weight-related issues post-treatment, cancer survivors may need to be explicit regarding their need for this during outpatient follow-up. Additional avenues for dietary needs assessment and referral should be considered to optimize the consistent delivery of diet, nutrition, and weight-related information and support after treatment for gynecological cancer.

Dietary Practices After Primary Treatment for Ovarian Cancer: A Qualitative Analysis From the OPAL Study.

BACKGROUND: Little is known about the dietary practices of women who have completed primary treatment for ovarian cancer, many of whom will go on to have cancer recurrence and further treatment. Knowledge of dietary practices is needed to optimize care. OBJECTIVE: Our aim was to identify dietary practices after primary treatment for ovarian cancer and evaluate how these practices differ by disease recurrence and treatment status. DESIGN: Women with invasive epithelial ovarian cancer were provided with the following open-ended question after completing a food frequency questionnaire: "Is there anything we haven't asked you about your diet in the last 1 to 2 months that you feel is important?" PARTICIPANTS/SETTING: Participants were from the OPAL (Ovarian Cancer Prognosis and Lifestyle) Study in Australia. MAIN OUTCOMES: The main outcomes were dietary practices after primary treatment for ovarian cancer and factors affecting these practices. ANALYSIS: Participants' responses were analyzed using content analysis. Individual content codes were categorized and reported by recurrence and treatment status at questionnaire completion. RESULTS: Two hundred eighty-six women provided responses on 363 questionnaires. Those undergoing further treatment for recurrence commonly reported dietary regimens with clinical indications (eg, low fiber to avoid bowel obstructions, high energy/protein to minimize nutritional deficits). Those not undergoing further treatment frequently reported "popular" diets (eg, organic, plant-based, and alkaline). For women with cancer recurrence, dietary practices were affected by poor appetite and late effects of treatment. For women without recurrence, other comorbidities, geographical location, family, and friends appeared to influence dietary practices. In both groups, nutrition information sources and personal beliefs informed dietary practices. Participant responses that referenced media or online sources often included misinformation. CONCLUSIONS: After primary treatment for ovarian cancer, women report dietary practices that may not be captured in standard food frequency questionnaires. Dietary practices and factors affecting these practices likely differ by treatment and recurrence status. Improved access to evidence-based dietary information and support is needed.

Information needs of women undergoing gynaecological risk reduction surgery: Applying patient-reported findings to improve service delivery.

BACKGROUND: Women with genetic mutations including BRCA1, BRCA2 and Lynch syndrome are at increased risk of developing gynaecological cancers with management options including surveillance and/or risk reduction surgery. Little is known about the information women require to inform their decisions around having risk reduction surgery, the implication this surgery has for them and the timing preferences to receive this information. AIMS: To identify the information needs of women who are considering or who have had risk reduction surgery due to having a diagnosed or suspected genetic mutation with subsequent increased risk of developing gynaecological cancer. MATERIALS AND METHODS: A pilot survey was undertaken in a tertiary, metropolitan hospital as part of a service improvement project. Women referred to the gynaecology-oncology service for gynaecological risk reduction surgery between January to December 2018 were invited to participate through completing either online or hard copy versions of a 12-item survey. RESULTS: A response rate of 60% (n = 32) was obtained from women between 27 and 77 years of age. Key information topics included sexuality and intimacy (90.6%; n = 29), the surgery itself (87.5%; n = 28) and surgical menopause (87.5%; n = 28). Over 90% (n = 31) of respondents stated they preferred to receive information about surgery pre-operatively and in written format (81.3%; n = 26). The importance of a multidisciplinary approach was recognised with women wanting information from allied health practitioners such as physiotherapists and social workers. CONCLUSIONS: Findings have enabled a better understanding of the type, timing and content of information desired by women making complex decisions about risk reduction surgery. Results have contributed to developing an information resource which will more adequately assist women to meet their information needs when considering gynaecological risk reduction surgery in our hospital.

Efficacy of dexamethasone in the management of malignant small bowel obstruction in advanced epithelial ovarian cancer.

INTRODUCTION: Malignant small bowel obstruction (MSBO) occurs in up to 50% of women with advanced epithelial ovarian cancer (EOC) causing symptom burden and distress to women and their families, particularly in the terminal stages of the disease. Corticosteroids are used to promote symptom resolution in malignant small bowel obstruction (MSBO) related to EOC, with little published data on their efficacy, optimal dosing and duration of treatment. OBJECTIVE: To evaluate the efficacy of dexamethasone in achieving symptom control in women with advanced EOC presenting with MSBO, assess dexamethasone dosing and efficacy over subsequent presentations, and examine differences in dexamethasone responsiveness between platinum-resistant and platinum-sensitive patient. METHODS: This is a retrospective cohort study of women presenting with MSBO due to advanced EOC over a 12-year period from January 2005 to December 2016 in a single tertiary hospital. RESULTS: Ninety-one women with MSBO were administered dexamethasone over 154 admissions with 89% of women initially achieving partial or complete symptom control. Dexamethasone responsiveness did not change with recurrent admissions, and platinum responsive patients were more likely to respond to dexamethasone than platinum-resistant patients (OR 3.6 [95%CI 1.1 to 12.2, p = 0.04]). A total of 15.6% of patients required additional measures to control symptoms of MSBO, and 44.8% had adequate symptom resolution to allow them to remain on or commence further treatment for EOC. CONCLUSION: Dexamethasone therapy is a useful adjunctive therapy in the management of symptoms associated with MSBO in women with EOC.

Oncologic outcomes of endometrial cancer in patients with low-volume metastasis in the sentinel lymph nodes: An international multi-institutional study.

OBJECTIVE: To assess oncologic outcomes in endometrial cancer patients with low-volume metastasis (LVM) in the sentinel lymph nodes (SLNs). METHODS: Patients with endometrial cancer and SLN-LVM (≤2 mm) from December 3, 2009, to December 31, 2018, were retrospectively identified from 22 centers worldwide. Patients with International Federation of Gynecology and Obstetrics (FIGO) stage IV, adnexal involvement, or unknown adjuvant therapy (ATx) were excluded. RESULTS: Of 247 patients included, 132 had isolated tumor cell (ITC) and 115 had micrometastasis (MM). Overall 4-year recurrence-free survival (RFS) was 77.6% (95% CI, 70.2%-85.9%); median follow-up for patients without recurrence was 29.6 (interquartile range, 19.2-41.5) months. At multivariate analysis, Non-endometrioid (NE) (HR, 5.00; 95% CI, 2.50-9.99; P < .001), lymphovascular space invasion (LVSI) (HR, 3.26; 95% CI, 1.45-7.31; P = .004), and uterine serosal invasion (USI) (HR, 3.70; 95% CI, 1.44-9.54; P = .007) were independent predictors of recurrence. Among 47 endometrioid ITC patients without ATx, 4-year RFS was 82.6% (95% CI, 70.1%-97.2). Considering 18 ITC patients with endometrioid grade 1 disease, without LVSI, USI, or ATx, only 1 had recurrence (median follow-up, 24.8 months). CONCLUSIONS: In patients with SLN-LVM, NE, LVSI, and USI were independent risk factors for recurrence. Patients with any risk factor had poor prognosis, even when receiving ATx. Patients with ITC and grade 1 endometrioid disease (no LVSI/USI) had favorable prognosis, even without ATx. Further analysis (with more patients and longer follow-up) is needed to assess whether ATx can be withheld in this low-risk subgroup.

Comparison between laparoscopic and robotic surgery for sentinel lymph node mapping in endometrial cancer using indocyanine green and near infra-red fluorescence imaging.

Indocyanine green (ICG) and near infra-red fluorescence imaging in minimally invasive surgery is an option to map sentinel lymph nodes (SLN). The aim of this study was to compare the outcomes of SLN mapping between laparoscopic and robotic surgery. One-hundred-and-forty women with histologically confirmed endometrial cancer, were treated with a minimally invasive hysterectomy, bilateral salpingo-oophorectomy and SLN mapping. After anaesthetic induction, ICG was superficially injected into cervical submucosa and deeply injected into the cervical stroma at the 3 and 9 o'clock positions (1.25 mg/site). Eleven cases were abandoned after ICG injection (laparoscopic surgery seven cases and robotic surgery four cases) because of obesity, technical difficulty and peritoneal disease. One-hundred-and-eleven patients were analysed. Seventy-six patients had a laparoscopic procedure and 33 patients had robotic surgery. The overall and bilateral detection rates were 97% and 83% for laparoscopic surgery and 88% and 73% for robotic surgery. Laparoscopic surgery was superior to robotic surgery in terms of overall detection (p-value .046). There was no significant difference in the intra-operative SLN identification time or SLN dissection time between laparoscopy and robotic surgery (p-value .247 and .145, respectively). Further research is required to compare laparoscopy and robotic surgery in terms of SLN detection.Impact StatementWhat is already known on this subject? Sentinel lymph node (SLN) mapping aims to avoid complications and provide useful staging information for endometrial cancer. ICG has been shown to improve the detection rate and NPV compared with other tracers (blue dye and technetium 99). No data exists comparing SLN mapping rates using ICG in laparoscopy and robotic surgery.What do the results of this study add? The overall and bilateral detection rates were 97% and 83% for laparoscopic surgery and 88% and 73% for robotic surgery. Laparoscopic surgery was superior to robotic surgery in terms of overall detection. There was no significant difference in the intra-operative SLN identification time or SLN dissection time between laparoscopy and robotic surgery.What are the implications of these findings for clinical practice and/or further research?: This study confirms that laparoscopy and robotic surgery are not different in terms of bilateral detection rate and SLN operating time; the study population is small.

Survival outcomes after delayed cytoreduction surgery following neoadjuvant chemotherapy in advanced epithelial ovarian cancer.

OBJECTIVE: Interval cytoreduction following neoadjuvant chemotherapy is a well-recognized treatment alternative to primary debulking surgery in the treatment of advanced epithelial ovarian cancer where patient and/or disease factors prevent complete macroscopic disease resection to be achieved. More recently, the strain of the global COVID-19 pandemic on hospital resources has forced many units to alter the timing of interval surgery and extend the number of neoadjuvant chemotherapy cycles. In order to support this paradigm shift and provide more accurate counseling during these unprecedented times, we investigated the survival outcomes in advanced epithelial ovarian cancer patients with the intent of maximal cytoreduction following neoadjuvant chemotherapy with respect to timing of surgery and degree of cytoreduction. METHODS: A retrospective review of all patients aged 18 years and above with FIGO (2014) stage III/IV epithelial ovarian cancer treated with neoadjuvant chemotherapy and the intention of interval cytoreduction surgery between January 2008 and December 2017 was conducted. Overall and progression-free survival outcomes were analyzed and compared with patients who only received chemotherapy. Outcome measures were correlated with the number of neoadjuvant chemotherapy cycles and amount of residual disease following surgery. RESULTS: Six hundred and seventy-one patients (median age 67 (range 20-91) years) were included in the study with 572 patients treated with neoadjuvant chemotherapy and surgery and 99 patients with chemotherapy only. There was no difference in the proportion of patients in whom complete cytoreduction was achieved based on number of cycles of neoadjuvant chemotherapy (2-4 cycles: 67.7%, n=337/498); ≥5 cycles: 62.2%, n=46/74). Patients undergoing cytoreduction surgery after neoadjuvant chemotherapy had a median 5-year progression-free and overall survival of 24 and 38 months, respectively. No significant difference in overall survival between surgical groups was observed (interval cytoreduction: 41 months vs delayed cytoreduction: 43 months, p=0.52). Those who achieved complete cytoreduction to R0 (no macroscopic disease) had a significant median overall survival advantage compared with those with any macroscopic residual disease (R0: 49-51 months vs R<1: 22-39 months, p<0.001 vs R≥1: 23-26 months, p<0.001). CONCLUSIONS: Survival outcomes do not appear to be worse for patients treated with neoadjuvant chemotherapy if cytoreduction surgery is delayed beyond three cycles. In advanced epithelial ovarian cancer patients the imperative to achieve complete surgical cytoreduction remains gold standard, irrespective of surgical timing, for best survival benefit.

Disruption of Glycogen Utilization Markedly Improves the Efficacy of Carboplatin against Preclinical Models of Clear Cell Ovarian Carcinoma.

High stage and recurrent ovarian clear cell carcinoma (OCC) are associated with poor prognosis and resistance to chemotherapy. A distinguishing histological feature of OCC is abundant cytoplasmic stores of glucose, in the form of glycogen, that can be mobilized for cellular metabolism. Here, we report the effect on preclinical models of OCC of disrupting glycogen utilization using the glucose analogue 2-deoxy-D-glucose (2DG). At concentrations significantly lower than previously reported for other cancers, 2DG markedly improves the efficacy in vitro of carboplatin chemotherapy against chemo-sensitive TOV21G and chemo-resistant OVTOKO OCC cell lines, and this is accompanied by the depletion of glycogen. Of note, 2DG doses-of more than 10-fold lower than previously reported for other cancers-significantly improve the efficacy of carboplatin against cell line and patient-derived xenograft models in mice that mimic the chemo-responsiveness of OCC. These findings are encouraging, in that 2DG doses, which are substantially lower than previously reported to cause adverse events in cancer patients, can safely and significantly improve the efficacy of carboplatin against OCC. Our results thus justify clinical trials to evaluate whether low dose 2DG improves the efficacy of carboplatin in OCC patients.

The shift toward neo-adjuvant chemotherapy and interval debulking surgery for management of advanced ovarian and related cancers in a population-based setting: Impact on clinical outcomes.

OBJECTIVES: The aim of this study was to determine the proportion of patients with advanced ovarian and related cancers (EOC+RC), treated with neoadjuvant chemotherapy and interval debulking surgery (NACT - IDS), and to determine if there was any relationship with optimal cytoreduction rates and overall survival (OS) in a state-wide gynaecologic oncology service over time. METHODS: A retrospective review was undertaken using a population-based database of patients with stages 3 and 4 EOC+RC treated from 1982 till 2013 at the Queensland Centre for Gynaecological Cancer (QCGC). The proportion of patients treated with NACT - IDS compared with primary debulking surgery (PDS) was determined and compared with debulking rates and with the moving five-year OS probability. RESULTS: From 1982-2013, 2601 patients with advanced EOC+RC were managed at QCGC. No patients received NACT - IDS till 1995 when the first two patients received this treatment, rising to 55% of patients in 2013. Surgical cytoreduction rates to no macroscopic residual (R0) were achieved 32% of the time by 2006, rising to 48% in 2009, and 62% in 2013. Despite the increase in utilisation of NACT - IDS, our unit has noted a continued rise in the OS probability at five years to 45%. CONCLUSIONS: The increasing utilisation of NACT - IDS in the setting of a large centralised clinical service has been associated with increasing rates of optimal cytoreduction and survival rates have continued to rise in excess of those achieved in the trials reported to date.

Are endometrial nerve fibres unique to endometriosis? A prospective case-control study of endometrial biopsy as a diagnostic test for endometriosis in women with pelvic pain.

STUDY QUESTION: Can the presence of endometrial nerve fibres be used as a diagnostic test for endometriosis in women with pelvic pain? SUMMARY ANSWER: Endometrial fine nerve fibres were seen in the endometrium of women both with and without endometriosis, making their detection a poor diagnostic tool for endometriosis. WHAT IS KNOWN ALREADY: Laparoscopy and biopsy are currently the gold standard for making a diagnosis of endometriosis. It has been reported that small density nerve fibres in the functional layer of the endometrium are unique to women with endometriosis and hence nerve fibre detection could function as a less invasive diagnostic test of endometriosis. However, it may be that other painful conditions of the pelvis are also associated with these nerve fibres. We therefore focused this prospective study on women with pelvic pain to examine the efficacy of endometrial nerve fibre detection as a diagnostic test for endometriosis. STUDY DESIGN, SIZE, DURATION: This prospective case-control study conducted between July 2009 and July 2013 included 44 women with pelvic pain undergoing laparoscopic examination for the diagnosis of endometriosis. Immunohistochemical nerve fibre detection in endometrial curettings and biopsies using anti-protein gene product 9.5 was compared with surgical diagnosis. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Paired endometrial biopsies and curettings were taken from patients with (n = 22, study group) and without (n = 22, control group) endometriosis. Tissue was analysed by immunohistochemistry and nerve fibres were counted whenever they were present in the functional layer of the endometrium. MAIN RESULTS AND THE ROLE OF CHANCE: Fine nerve fibres were present in the eutopic endometrium of patients both with and without endometriosis. The presence of nerve fibres in curettings was not effective for either diagnosing or excluding endometriosis; sensitivity and specificity were 31.8 and 45.5% respectively, positive predictive value was 36.8% and negative predictive value was 40.0%. Few endometrial biopsy specimens were found to have nerve fibres present; sensitivity and specificity for endometrial biopsy were 13.6 and 68.2% respectively, positive predictive value was 30.0% and negative predictive value was 44.1%. LIMITATIONS, REASONS FOR CAUTION: This was a relatively small sample size and studies like this are subject to the heterogeneous nature of the patient population and tissue samples, despite our best efforts to regulate these parameters. WIDER IMPLICATIONS OF THE FINDINGS: Our results demonstrate that fine nerve fibres are present in women with and without endometriosis. Future work should focus on the function of endometrial nerves and whether these nerves are involved with the subfertility or pain that endometriosis sufferers experience. Our study does not support the detection of endometrial nerve fibres as a non-invasive diagnostic test of endometriosis in women with pelvic pain.

Endometriosis: Does the menstrual cycle affect magnetic resonance (MR) imaging evaluation?

PURPOSE: To determine if the menstrual cycle affects MR interpretation in patients with pelvic endometriosis. MATERIALS AND METHODS: Thirty-one patients with either laparoscopically proven endometriosis, or a high clinical suspicion of deep infiltrative endometriosis, were prospectively recruited from May 2008 to October 2009 and January to June 2012. Two pelvic MR scans were performed for pre-operative planning; during menses and the other mid-cycle. Two experienced radiologists independently assessed image quality and disease extent. Both were blinded to patient identity, previous imaging and menstrual status. Interobserver agreement was assessed using the Kappa (k) test. Descriptive statistics were prepared using chi-squared (or Fishers' exact) tests and Mann-Whitney (rank sum) tests to assess for significant differences between menstrual and non-menstrual imaging. RESULTS: Interobserver agreement for image quality was moderate for T2 weighted imaging (k=0.475, p-value <0.001) and substantial for T1 fat saturated imaging (k=0.733, p-value<0.001), with no significant difference in image quality between menstrual and non-menstrual scans (all p-values>0.255). Readers demonstrated at least moderate interobserver agreement for certainty level of endometriosis at site-specific locations, with median k 0.599 (IQR 0.488-0.807). No significant difference in disease extent was observed between menstruating and non-menstruating scans (all p-values>0.05). CONCLUSION: Findings suggest no significant differences in image quality, disease extent or disease severity between menstruating and non-menstruating MR; thus, timing of pelvic MR for assessment of endometriosis need not be influenced by the menstrual cycle.

Ultrasound-guided hysteroscopy to remove a levonorgestrel intrauterine system in early pregnancy.

BACKGROUND: Correctly placed levonorgestrel-releasing intrauterine systems (LNG-IUSs) are rarely associated with intrauterine pregnancy when pregnancy occurs. LNG-IUS retrieval, termination of pregnancy and conservative management if retracted strings prevent ready removal are the usual clinical options given to women. The conservative course raises concerns about teratogenesis related to high local progestin exposure for the developing fetus. STUDY DESIGN: This case report describes combined saline hysteroscopy and ultrasound to retrieve an LNG-IUS at less than 9 weeks of gestational age. A systematic review of the literature was performed to identify similar case reports by contacting the manufacturer and searching Pubmed from 1900 through November 2011 using the terms ((levonorgestrel AND intrauterine) OR mirena) AND (pregnan* OR fetal OR fetus OR teratogen*) NOT (menorrhagia OR hyperplas* OR ectopic OR malig* OR cancer). RESULTS: We identified 37 cases of LNG-IUS pregnancy exposures in the absence of spontaneous expulsion or myometrial or intraperitoneal placement of LNG-IUS. Given the presence of two congenital anomalies reported in the group, the anomaly rate is 5.4%, 95% confidence interval 0% to 11.5%. CONCLUSIONS: Intrauterine LNG-IUS exposure is associated with a low frequency of congenital anomalies. Combining hysteroscopy with ultrasound facilitates surgically precise LNG-IUS removal despite retracted strings.