A risk factor analysis of complications after surgery for vulvar cancer.

INTRODUCTION: Despite the less frequent use of surgery in patients with vulvar cancer, the high rates of postoperative complications are still a matter of concern. The aim of the present study was to identify risk factors that influence postoperative complications rates in vulvar cancer and identify specific clinical parameters that may influence their incidence. MATERIALS: Patients who underwent curative-intent surgery for squamous cell carcinoma of the vulva from 2003 to 2018 were selected. All patient characteristics were analyzed as risk factors for the development of postoperative lymphocele, lymphedema, and wound dehiscence. The patients were followed up for 2 years postoperatively. RESULTS: The investigation comprised 121 patients, of whom 18.1% developed wound dehiscence, 17.7% a lymphocele, and 20.4% lymphedema. We found no significant evidence of an association between patient's characteristics and postoperative complications. The depth of tumor invasion and the appearance of lymph-node metastasis were significantly associated with postoperative complications. Free resection margins of 5 mm or more were associated with a reduced risk of postoperative complications compared to resection margins less than 5 mm. No complications were encountered after sentinel node biopsy (SNB). Complication rates were associated with inguinofemoral lymphadenectomy, but not with the extent of lymphadenectomy. The development of a lymphocele or wound dehiscence may be correlated with the development of long-term lymphedema. CONCLUSION: FIGO stage at diagnosis influences the risk of postoperative complications. The use of SNB minimized postoperative complications. Correlations between the free microscopic resection margin distance and the risk of postoperative wound dehiscence must be investigated further.

Accuracy of frozen section at early clinical stage of endometrioid endometrial cancer: a retrospective analysis in Germany.

PURPOSE: The aim of this study was to estimate the accuracy of intra-operative frozen section (FS) diagnosis during hysterectomy for early-stage endometrial cancer (EC). METHODS: At the Department of Obstetrics and Gynecology, University of Luebeck, between 2009 and 2014, the intra-operative FS pathology of 164 patients with pre-operative endometrial curettage, showing G1 or G2 endometrioid EC at an early clinical stage (FIGO I-II), was compared retrospectively with the final paraffin section reports. The accuracy of myometrial invasion (MI) in all patients and separately in stage FIGO I patients was calculated and the under- or overtreatment of the patients was analyzed. A subgroup analysis was performed focusing on the percentage of inadequate staging by FS with clinical consequences. RESULTS: Concordance of FS and final pathology results in terms of FIGO stage was 85.2%, with an under-diagnosis rate of 14% and an over-diagnosis rate of 0.8%. The subgroup analysis rate of patients who were inappropriately operated using FS was 6.6%, while 3.3% underwent a secondary operation. The overall accuracy of FS in predicting MI was 93.3% and in patients with stage FIGO I, 92.7%. Sensitivity, specificity, PPV and NPV were 98.25%, 89.06%, 88.89% and 98.28%, respectively, and in stage FIGO I, 98.25%, 84.62%, 90.32% and 97.06%, respectively. CONCLUSION: The authors consider that intra-operative FS is a reliable diagnostic method to identify the clinical stage of EC and especially MI, to determine the necessity of lymphadenectomy. Further development of diagnostic techniques is essential to maximize diagnostic accuracy.

Correlation between Adenomyosis and Endometrial cancer: 6-year experience of a single center.

INTRODUCTION: Adenomyosis often co-exists in the pathological specimens after surgery for endometrial cancer. The aim of this study is to describe the clinicopathological and oncological characteristics of these patients and further investigate the possibility of malignant transformation in the adenomyotic tissue. METHODS: We retrospectively reviewed the medical records of all patients that underwent hysterectomy for endometrial cancer (January 2012 - December 2017). The pathological reports were studied and when adenomyosis was present, the pathological slides were reviewed in order to discover any malignant change in the adenomyotic tissue. The clinicopathological characteristics and oncological results were described. RESULTS: Out of 229 cases of endometrial cancer, 64 (28%) patients had concurrently endometrial cancer and adenomyosis. Among these 64 patients, 7 (11%) had malignant transformation of adenomyosis. The mean age of patients suffering from both endometrial cancer and adenomyosis was 63.2 years old and 57 (89%) of these patients, had early endometrial cancer. Concerning the patients with malignant transformation of adenomyosis, their mean age was 65 years old with no premenopausal case. DISCUSSION: Adenomyosis has been described in the last decades, but its malignant transformation into endometrial cancer is not fully undercovered. Further investigation is needed in order to clarify the pathologic progression of adenomyotic lesions to endometrial cancer.

Prevalence of occult leiomyosarcomas and atypical leiomyomas after laparoscopic morcellation of leiomyomas in reproductive-age women.

STUDY QUESTION: What is the prevalence of leiomyosarcomas and atypical leiomyomas after laparoscopic morcellation of fibroids in reproductive age women? SUMMARY ANSWER: No case of leiomyosarcomas but seven atypical leiomyomas were found in 1216 subjects. WHAT IS KNOWN ALREADY: Although uterine sarcoma is a rare entity affecting usually older peri- or post-menopausal women, the Food and Drug Administration discourages use of laparoscopic power morcellation of uterine fibroids. STUDY DESIGN, SIZE, DURATION: Retrospective review of data extracted from a single center database of 1216 consecutive women who underwent laparoscopic morcellation of 2582 unsuspicious leiomyomas between June 2003 and December 2015 and were followed-up until December 2016. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: A total of 1216 women, aged 18-45 years, underwent laparoscopic morcellation of 2582 apparently benign leiomyomas by the same surgeon and all specimen slides were examined by the same experienced pathologist. MAIN RESULTS AND THE ROLE OF CHANCE: The prevalence of leiomyosarcomas and atypical leiomyomas was 0% (95% CI: 0-0.3%) and 0.6% (95% CI: 0.23-1.18%) (six atypical-bizarre and one mitotically active leiomyoma) respectively. In addition, there were identified 34 cases of adenomyomas, 45 leiomyomas with infarcts, 81 cellular leiomyomas and 133 degenerated leiomyomas. No morcellator-associated complication was recorded and none of the patients included in this study required conversion to laparotomy. LIMITATIONS, REASONS FOR CAUTION: Retrospective and single referral center study design. WIDER IMPLICATIONS OF THE FINDINGS: Laparoscopic morcellation of unsuspicious leiomyomas after careful preoperative work up seems to be safe in women of reproductive age. STUDY FUNDING/COMPETING INTEREST(S): None.

Novasure impedance control system versus microwave endometrial ablation for the treatment of dysfunctional uterine bleeding: a double-blind, randomized controlled trial.

PURPOSE OF INVESTIGATION: To compare the efficacy and safety of two different second-generation ablation devices, Novasure impedance control system and microwave endometrial ablation (MEA), in cases of abnormal uterine bleeding (AUB). MATERIALS AND METHODS: This is a randomized controlled trial that took place in a single Gynecological Department of a University Hospital. Sixty-six women with dysfunctional uterine bleeding (DUB), unresponsive to medical treatment, were included in the trial. The ratio of women allocated to bipolar radio-frequency ablation or MEA was 1:1. Follow-up assessments were carried out at three and 12 months post-ablation. The present main outcome measure was amenorrhea rates 12-months post-treatment. RESULTS: The rate of amenorrhea at 12-months post-ablation was significantly higher in women treated by Novasure (25/33; 75.8%) as compared to those treated by MEA (8/33; 24.2%) (rate difference: +51.5%, 95% CI: +27.8 to +67.7). CONCLUSION: In women with DUB, endometrial ablation with Novasure bipolar radiofrequency impedance-controlled system is associated with increased rates of amenorrhea at 12-months post-treatment as compared to the MEA method.

Pregnancy management and outcome in women with chronic kidney disease.

An increasing number of pregnancies occur in the presence of chronic kidney diseases (CKD), mainly including chronic glomerulonephritis (GN), diabetic nephropathy (DN), and lupus nephritis (LN). The most important factor affecting fetal and maternal prognosis is the degree of renal function at conception. In the majority of patients with mild renal function impairment, and well-controlled blood pressure, pregnancy is usually successful and does not alter the natural course of maternal renal disease. Conversely, fetal outcome and long-term maternal renal function might be seriously threatened by pregnancy in women with moderate or severe renal function impairment. The last few years, advances in our knowledge about the interaction of pregnancy and renal function resulted in the improvement of fetal outcome in patients with chronic renal failure and also in the management of pregnant women with end-stage renal disease (ESRD) maintained on dialysis. However, women with impaired renal function and those on dialysis should be carefully counseled about the risks of pregnancy.

Operative treatment of gynaecologic diseases in puberty: seven years of experience.

PURPOSE OF INVESTIGATION: The aim of this study is to present the incidence and surgical management of gynaecologic pathology in adolescence in the 1st Obstetrics and Gynecology Department of Aristotle University of Thessaloniki. METHODS: After a retrospective review of the medical records of over a seven year period (2004-2011), 32 adolescent patients with reported surgical gynaecologic procedures were identified and analysed. RESULTS: Fourteen out of the 16 adolescents with ovarian masses (eight neoplastic and eight non-neoplastic) were treated by laparoscopy. Congenital anomalies were diagnosed in seven patients and only one of them was treated by laparotomy. The rest were surgically treated for uterine leiomyoma (1), ectopic pregnancy (2), pelvic abscess (1), mesosalpingeal cysts (2), mesenterian cyst (1) and investigation of chronic pelvic pain. DISCUSSION: Although benign ovarian cysts and congenital anomalies represent the major indication for operative treatment of gynaecologic diseases in puberty, laparoscopy and/or hysteroscopy should be the gold standard procedure after careful preoperative investigation.

Obstetric outcome in adolescence: a single centre experience over seven years.

PURPOSE OF INVESTIGATION: The aim of this study was to compare the obstetric outcome of adolescent pregnant women (aged < or = 18) with the outcome of adult pregnant women who delivered in a tertiary university hospital. MATERIALS AND METHODS: Delivery files from 2004 to 2011 were reviewed concerning age of the pregnant women, parity, gestational age, mode of delivery and birth weight of the neonates. RESULTS: During the study period 119 (0.94%) out of 10,483 deliveries were performed in adolescent women. Caesarean section was the mode of delivery in 41 adolescent patients (34.45%), while the corresponding rate was 53.6% (5,556 cases) in adult pregnant women. The preterm labour rate in the adolescent group was 13.44% (16 cases) while in the adult group it was 21% (2,201 cases). The most frequent indication of caesarean section in the adults was previous caesarean section (21%). DISCUSSION: In adolescent pregnancies the caesarean section rate was lower than in adult pregnancies. As far as the prevalent cause of caesarean section is concerned, it was repeat caesarean section for adults while in adolescents it was failure of labour to progress.

Galanin in the amniotic fluid and neonatal birth weight: a prospective observational study.

OBJECTIVE: The aim of the present study was to examine whether an association is present between amniotic fluid (AF) galanin and neonatal birth weight (NBW). DESIGN: Prospective observational study. SETTING: Fetal maternal unit in a tertiary teaching hospital. POPULATION: Fifty women of singleton pregnancy who underwent amniocentesis during the second trimester and delivered after the 37th week of gestation. METHODS: Amniocentesis 18th-19th gestational week for genetic indication with the use of a 22G needle under real-time sonographic guidance and measurement of galanin concentration in the AF. MAIN OUTCOME MEASURES: Association between concentration of AF galanin and NBW at term. RESULTS: Galanin was isolated in all samples of AF (median concentration 19.95 pg/mL; range: 19.0-21.7). A strong linear correlation between AF galanin and NBW was detected (τ = 0.928; p < 0.001). Non-parametric linear regression analysis revealed that galanin concentration could explain 72.1% of the variance in the NBW, when controlling for gestational week at birth and mother's body mass index at delivery. CONCLUSIONS: AF galanin during the second trimester seems to have a strong linear correlation with NBW of term deliveries in singleton pregnancies, even when controlling for important confounders.

Primary ovarian small cell carcinoma of pulmonary type with enlarged paraaortic lymph node masses: a case report and review of the literature.

INTRODUCTION: Small cell carcinoma of the ovary of pulmonary type, is a rare, aggressive tumour with poor prognosis and its optimal management is unclear. CASE PRESENTATION: A 55-year-old Caucasian woman presented with abdominal discomfort and left lumbar pain within a three-week period. At exploratory laparotomy, a 8 cm solid cystic mass of the left ovary was found infiltrating the sigmoid colon, and a bulky mass (11 x 7 x 4 cm) in the left paraaortic infrarenal region. Histopathological features resembling small cell carcinoma of the lungs and positive immunohistochemical stains provided a definite diagnosis of IIIC ovarian small cell carcinoma of pulmonary type. After six cycles chemotherapy with carboplatin and etoposide, the patient is still alive at 21 months from initial diagnosis. DISCUSSION: In this case, the absence of peritoneal involvement and the extensive paraaortic adenopathy is suggestive of a different pattern of spread of this rare tumour. Optimal treatment seems to be radical primary debulking surgery resulting in no residual disease, maximizing the effect of adjuvant chemotherapy for this biological aggressive tumour.

Laparoscopic management of unexpected borderline ovarian tumors in women of reproductive age.

PURPOSE OF INVESTIGATION: The aim of this study was to review the clinical features of women with unexpected borderline ovarian tumours. METHODS: Between October 1992 and December 2010, 1332 out of 4016 laparoscopies were performed for adnexal masses in women of reproductive age and 1838 cysts were removed. When ultrasonographic findings did not meet the criteria for low risk malignancy, tumour markers, colour Doppler and MRI/CT were applied. At laparoscopy any solid component or papilla was sent for rapid frozen section. RESULTS: Borderline ovarian tumours were found in eight (0.6%) out of 1332 patients, two of which were bilateral. The mean age was 28.75 +/- 9.27 years and the mean diameter of the cysts was 5.1 +/- 1.7 cm. In two cases unexpected malignancy was discovered during the diagnostic and in six cases during the operative phase of the intervention. CONCLUSION(S): Risk of failure to diagnose cancer could be minimised with careful patient selection preoperatively. Adequate training on laparoscopic oncology is the necessary prerequisite for a safe laparoscopic approach.

Obstetric and neonatal outcome after assisted fertilization and spontaneous conception: a comparative study.

PURPOSE: The widespread use of assisted reproduction technology (ART) is accompanied by concerns for potential adverse outcomes. The aim of the present study was to evaluate the impact of ART in obstetric and neonatal outcome. METHODS: Data from labor ward records from 913 consecutive births were analyzed retrospectively, and the obstetric and neonatal outcomes of pregnancies after ART were compared with those after natural conception. RESULTS: No major complications were noted after ART. A higher probability of cesarean section, lower gestational age at birth, lower birth weight and hospitalization in the Neontal Intensive Care Unit (NICU) was noted after ART, as compared with spontaneous conception. However, after exclusion of multifetal pregnancies, there was no significant difference in outcomes, except for cesarean section rates. CONCLUSIONS: The higher proportion of multiple pregnancies after ART is associated with lower gestational age at birth, lower birth weights and higher NICU hospitalization rates.

Comparison of single versus multiple courses of antenatal betamethasone in patients with threatened preterm labor.

PURPOSE OF INVESTIGATION: To compare single versus multiple courses of antenatal betamethasone administration with regards to the morbidity and mortality of preterm neonates. METHODS: One-hundred and twenty-two women with threatened preterm labor were allocated to three different betamethasone schedules: 1) two doses of betamethasone 12 mg, intramuscularly, 24 hours apart (standard treatment) (n = 41); 2) standard treatment plus a third dose of 12 mg after seven days (n = 41); and, 3) standard treatment plus one dose of 12 mg every seven days until delivery (n = 40). Neonatal morbidity and mortality as well as maternal morbidity were evaluated. RESULTS: Neonatal parameters, such as frequency of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis and neonatal mortality were not significantly different among the three groups for both singleton and multiple pregnancies. Similarly, maternal parameters were not significantly different among the three groups. CONCLUSION: The administration of multiple betamethasone courses in threatened preterm labor is not superior to single courses with regards to neonatal morbidity and mortality, as well as to maternal morbidity.

Hormone therapy for postmenopausal endometrial cancer survivors: a survey among Greek obstetricians-gynaecologists.

PURPOSE OF INVESTIGATION: In this study we evaluated the prescription attitude of Greek obstetricians-gynaecologists towards hormone replacement therapy (HRT) for endometrial cancer survivors. METHODS: An anonymous questionnaire was sent to 900 members of the Hellenic Society of Obstetrics and Gynaecology, presenting a hypothetical case of an endometrial cancer survivor with indications for HRT, followed by a series of relevant questions. RESULTS: Three hundred and three valid responses were received and analysed according to age, gender and practice setting. HRT would be prescribed by 30.4% of gynaecologists; as far as type of regimen is concerned, 67.4% would prescribe tibolone, 22.8% estrogen-only and 9.8% estrogen plus progestagen. In contrast, 69.6% would not prescribe HRT due to the fear of endometrial cancer recurrence (88.2%), development of breast cancer (2.8%) or both (4.7%); among them, 28.4% would prescribe central nervous system (CNS) medications, selective estrogen receptor modulators (SERMs), phyto-oestrogens or biphosphonates, as alternates. CONCLUSIONS: One out of three Greek gynaecologists would prescribe HRT to endometrial cancer survivors. Alternative therapies, mainly CNS medications, would be suggested by the opposers.

Diaphragmatic surgery during primary debulking in 89 patients with stage IIIB-IV epithelial ovarian cancer.

OBJECTIVES: The aim of this study was to describe the role of diaphragmatic surgery in achieving optimal debulking in patients with advanced ovarian cancer and the assessment of the relative post-operative complications. METHODS: Retrospective review was performed of medical records of 89 patients with epithelial ovarian cancer who underwent diaphragmatic surgery during their primary debulking surgery between September 1993 and December 2007. Four different approaches were performed: coagulation (group 1), stripping (group 2), combination stripping with coagulation (group 3) and diaphragm full thickness resection (group 4). Cytoreductive outcome, morbidity, overall survival (OS) and disease-free survival (DFS) were analysed. RESULTS: Eight (8.9%) patients had FIGO stage IIIB, 64 (72%) stage IIIC and 17 (19.1%) stage IV disease. In 20 patients (22%) the diaphragmatic disease was coagulated, in 31 patients (35%) was only stripped, in 31 patients (35%) a combination of these techniques was applied and in 7 (8%) the disease was resected with the adjacent infiltrated part of the diaphragm muscle and the pleura above it. Debulking to no residual tumor was achieved in 90%, 86%, 86% and 100% for groups 1, 2, 3 and 4 respectively. Median DFS was 15, 15, 17 and overall survival OS for groups 1, 2, and 3 was 40, 42, and 50 months respectively and was not yet reached for group 4. Minor and major complications were comparable among the groups. Pleural effusion was the most frequent associated complication and chest tube placement (17%) or thoracocentesis (12%) was necessary for the relief of respiratory distress. The perioperative mortality rate was 0%. The majority of cases were treated in the last five years of our 15-year experience. CONCLUSIONS: Diaphragmatic surgery increases the rates of optimal primary debulking surgery and improves survival with an acceptable and manageable morbidity rate. In patients with thick (>0.3 cm) or large (>4 cm) lesions stripping the diaphragm or full thickness resection of the diaphragmatic muscle is preferred.

Mucocele of the appendix mimicking an adnexal mass: a case report.

Mucocele of the appendix is a rare entity usually mimicking an adnexal tumour. There is no specific imaging or screening method to determine the diagnosis with certainty preoperatively. Appendiceal malignancy can be the underlying cause, although it is not common. We present a case of an appendiceal mucocele mimicking an ovarian tumour by both clinical and imaging (TVS and MRI) methods. This pathological condition should be considered by all the gynaecologists in the differential diagnosis of a right-sided pelvic mass.