Can the preoperative Ca-125 level predict optimal cytoreduction in patients with advanced ovarian carcinoma? A single institution cohort study.

BACKGROUND: Preoperative Ca-125 level has been used as a predictor of optimal cytoreduction in advanced ovarian carcinoma. Yet, controversy exists regarding the ability of the tumor marker to predict optimal debulking and moreover of the proper cut-off limit to do so. METHODS: The preoperative Ca-125 levels of 426 patients with Stage III/IV ovarian carcinoma from a single institution were correlated with surgical outcome. Optimal was considered the cytoreduction if the largest residual tumor was < or equal to 1 cm in diameter. Receiver operation characteristic (ROC) curve data were combined with interval likelihood ratios at various Ca-125 levels to determine the cut-off level with the maximum prognostic power. Sensitivity, specificity, positive and negative predictive values and accuracy were also calculated. RESULTS: Preoperative Ca-125 proved to be a reliable predictor for optimal cytoreduction. The area under curve of the ROC curve was 0.89, 98% C.I.=[0.828-0.952], indicating very good discriminating capability. The level of 500 IU/ml was found to have the most predictive power. The sensitivity of Ca-125 at that level was 78.5%, the specificity 89.6%, the positive predictive value 84.2%, the negative predictive value 85.4% and its accuracy 85%. Furthermore, the likelihood ratio for correct discrimination between optimal and sub-optimal cytoreduction, dropped sharply from 6.33, 95% C.I. [5.19-10.91] at the level of 500 IU/ml to 0.58, 95% C.I. [0.21-1.63] at the level of 600 IU/ml. CONCLUSIONS: Our data indicate that preoperative Ca-125 is a good predictor for optimal cytoreduction. the best threshold for this prediction proved to be 500 IU/ml. These patients may be candidates for neo-adjuvant chemotherapy treatment. Nevertheless, all clinical and radiological findings must be co-evaluated.

Determination of the necessary total protein substitution requirements in patients with advanced stage ovarian cancer and ascites, undergoing debulking surgery. Correlation with plasma proteins.

BACKGROUND: Ascites is common in patients with advanced ovarian carcinoma (AOC). Its drainage during surgery affects plasma proteins. We sought to correlate the volume of ascites with the oncological parameters of the disease, calculate its drainage effect on plasma proteins, and determine the necessary substitution requirements and a clinical way of achieving that. PATIENTS AND METHODS: We evaluated 138 patients with AOC and ascites who underwent primary cytoreductive surgery. Intraoperatively found ascites and its postoperative production were evaluated. Its drainage effect on plasma proteins and the substitution requirements were determined using a mathematic formula. Human albumin(HA) and fresh frozen plasma (FFP) were used to cover these requirements. RESULTS: The intraoperative ascites was found to correlate only with the stage of the disease, while its postoperative production correlated with the residual disease. Optimally debulked patients had a mean ascites production of 128 mL on postoperative day 1 compared with 668 mL of the suboptimally debulked. This production required 3 and 5-7 days, respectively, to drop <50 mL. Plasma proteins fell on their minimum level (88.9 versus 80.8%) on the second postoperative day. The protein deficit was calculated to be 379 and 691 g/day, respectively. This deficit was substituted by administering 2 HA and 2 FFP for 3-6 days. CONCLUSIONS: Ascites drainage affects the postoperative homeostasis of plasma proteins. A mean acute drop of 12-20% is monitored on postoperative day 2. This deficit can be managed with HA and FFP for a minimum of 3 days.

The effect of hypertension and anti-hypertensive drugs on endometrial thickness and pathology.

OBJECTIVES: We sought to clarify if hypertension has a direct effect on endometrial pathology. Furthermore, we wanted to evaluate the effect of possible differences among the various antihypertensive drugs on the clinico-pathological findings. PATIENTS AND METHODS: The records of 228 patients who underwent D&C at our tertiary cancer hospital were examined. All other aetiopathogenic factors (DM, tamoxifen, obesity, etc.) for endometrial pathology were excluded, as well as endometrial carcinoma cases. We compared the differences in the clinical symptoms and signs between hypertensive and normotensive women, as well as differences in their histological findings. Furthermore, we carried out a subgroup analysis of the above with respect to the antihypertensive agent(s) the patients used. RESULTS: One hundred and twenty-three patients (54%) were hypertensive and 105 (46%) were normotensive. Vaginal spotting was present in approximately 75% of patients in both groups, but sonographic endometrial thickening was significantly more prevalent among hypertensive women (52.8% versus 34.3%, p=0.004). Hyperplasia was the commonest positive histological finding among hypertensive women (44.7%), compared with polyps for the normotensives. Furthermore, atypia was censored in 4.1% of hypertensive patients only. The subgroup analysis with respect to the various antihypertensives was similar to the above histological distribution, with the exception of the combination b-blocker plus calcium antagonist, which had a significantly more favourable histological profile with over 60% normal endometria. CONCLUSIONS: Hypertensive patients tend to require D&C more frequently. Sonographic endometrial thickening is significantly more frequent among them. Hyperplasia with or without atypia occurs in approximately 50% of hypertensive women. No differences in the above were justified depending on the different antihypertensive agents used, with the exception of the b-blocker plus calcium antagonist (+/-ACE inhibitor) combination, which requires further evaluation.

Diagnostic accuracy of prehysterectomy curettage in determining tumor type and grade in patients with endometrial cancer.

OBJECTIVES: We sought to determine the reliability of tumor typing and grading at the prehysterectomy curettage biopsy in patients with endometrial carcinoma. We also wanted to evaluate the overall rate of false-negative diagnosis in the detection of the disease. METHODS: The final pathologic reports of 263 patients whose diagnosis was endometrial carcinoma were compared with their prehysterectomy curettage reports. We searched for discrepancies between the 2 diagnoses. We also evaluated whether discrepancies varied with respect to the histologic type and tumor grade (endometrioid vs aggressive variant tumours). RESULTS: Although the statistical analysis predicted accuracy rates of DC diagnosis that exceeded 90%, the true figures proved to be more limited. DC pathology accurately predicted the final histologic result in 67.3% (177/263) of patients and the final tumor grade in 55.5% (146/263). Regarding the latter, we found 37.3% (98/263) of patients with undergraded tumors and 7.2% (19/263) with overgraded ones. The histologic type of the carcinoma crucially affected the diagnostic reliability of DC. Nevertheless, the overall false-negative rate in establishing the diagnosis of carcinoma was 7.6% (20/263). CONCLUSIONS: DC is a reliable procedure for establishing the diagnosis of endometrial cancer. Its capability to correctly characterize the final histologic type varies significantly but is satisfactory overall and captures approximately three quarters of the patients; however, the procedure significantly underestimates tumor grade. The limitations of DC are due to the blindness of the sampling procedure.

Intraoperative gross examination of myometrial invasion and cervical infiltration in patients with endometrial cancer: decision-making accuracy.

OBJECTIVES: We sought to determine the accuracy of gross evaluation of the depth of myometrial invasion and the involvement of the cervix, and its value in determining the need for extensive surgery in patients with endometrial carcinoma. METHODS: The intraoperative records of 256 patients operated for endometrial cancer were used to compare the gross evaluations with the final microscopic histopathological findings. In the theater, the uterus was opened and inspected after its removal. The depth of myometrial invasion was noted as less or greater than 50% using a full-thickness incision through the tumor, while cervical involvement was noted as positive or negative, based on extension of the tumor below the internal cervical os. Standard statistical calculations were used to determine accuracy, sensitivity, specificity, positive and negative predictive values, and false-positive and false-negative rates of the method. RESULTS: Regarding the depth of myometrial invasion, gross evaluation could accurately predict the final result in 88.2% of patients. Sensitivity, specificity, positive, and negative predictive values were 83.7, 90.6, 82.8, and 91.1%, respectively. False-positive results were noted in 9.4% of cases and false-negative in 16.3%. Analysis of the characteristics of the false-negative patients showed that they had aggressive variant tumors, tumors of advanced grade, and tumors that more frequently had developed from an atrophic endometrium. With respect to cervical involvement, gross evaluation had an overall accuracy of 98.5%, 0% false-positive rate, 11.5% false-negative rate, 88.5% sensitivity, 100% specificity, 100% positive predictive value, and 98.3% negative predictive value. CONCLUSION: Our data suggest that visual gross examination of the uterus provides safe and reliable estimates of both myometrial invasion and cervical infiltration. So, the surgeon can rely on the procedure to decide the need for further operative manipulations.