Influence of Intraoperative Fluid Management on Postoperative Outcome and Mortality of Cytoreductive Surgery for Advanced Ovarian Cancer-A Retrospective Observational Study.

Background: The surgical treatment of advanced ovarian cancer is associated with extensive tissue trauma, prolonged operating times and a considerable volume shift. It, therefore, represents a challenge for anaesthesiological management. Aim: The aim of this single-centre, retrospective, observational study was to investigate whether intraoperative extensive volume supply influences postoperative outcomes and long-term survival. Methods: The study included 73 patients with a mean (SD) age of 63 (13) years who underwent extensive tumour-reducing surgery for ovarian cancer between 2012 and 2015. The effect of the intraoperative fluid balance on postoperative complications, such as anastomotic insufficiency or pleural effusions, was investigated using logistic regression. Further, the influence of fluid balance, lactate and creatinine levels on 5-year survival was analysed in a Cox regression model. Associations between anaesthesia time and the intraoperative fluid balance were examined using Spearman's rank correlation coefficients. Results: The mean (SD) postoperative fluid balance in the considered patient cohort was 9.1 (3.4) litres (l) at a mean (SD) anaesthesia time of 529 (106) minutes. Cox regression did not reveal a statistically significant effect of the fluid balance, but it did reveal a statistically significant association between the lactate level 24 h following surgery and the 5-year survival (HR [95%-CI] fluid balance: 0.97 [0.85, 1.11]; HR [95%-CI] lactate: 1.79 [1.24, 2.58]). According to logistic regression, the intraoperative fluid balance was associated with an increased chance of postoperative complications in the considered patient cohort (OR [95%-CI] 1.28 [1.1, 1.54]). Conclusions: We could not detect a negative impact of an increased fluid balance on 5-year survival, but a negative impact on postoperative complications was found in our patient cohort.

No evidence to support the impact of migration background on treatment response rates and cancer survival: a retrospective matched-pair analysis in Germany.

BACKGROUND: Immigration has taken the central stage in world politics, especially in the developed countries like Germany, where the continuous flow of immigrants has been well documented since 1960s. Strikingly, emerging data suggest that migrant patients have a poorer response to the treatment and lower survival rates in their new host country, raising concerns about health disparities. Herein, we present our investigation on the treatment response rate and cancer survival in German patients with and without an immigrant background that were treated at our comprehensive cancer center in Germany. METHODS: Initially, we considered 8162 cancer patients treated at the Center for Integrated Oncology (CIO), University Hospital Bonn, Germany (April 2002-December 2015) for matched-pair analysis. Subsequently, the German patients with a migration background and those from the native German population were manually identified and catalogued using a highly specific name-based algorithm. The clinical parameters such as demographic characteristics, tumor characteristics, defined staging criteria, and primary therapy were further adjusted. Using these stringent criteria, a total of 422 patients (n = 211, Germans with migration background; n = 211, native German population) were screened to compare for the treatment response and survival rates (i.e., 5-year overall survival, progression-free survival, and time to progression). RESULTS: Compared to the cohort with migration background, the cohort without migration background was slightly older (54.9 vs. 57.9 years) while having the same sex distribution (54.5% vs. 55.0% female) and longer follow-up time (36.9 vs. 42.6 months). We did not find significant differences in cancer survival (5-year overall survival, P = 0.771) and the response rates (Overall Remission Rate; McNemar's test, P = 0.346) between both collectives. CONCLUSION: Contrary to prior reports, we found no significant differences in cancer survival between German patients with immigrant background and native German patients. Nevertheless, the advanced treatment protocols implemented at our comprehensive cancer center may possibly account for the low variance in outcome. To conduct similar studies with a broader perspective, we propose that certain risk factors (country-of-origin-specific infections, dietary habits, epigenetics for chronic diseases etc.) should be considered, specially in the future studies that will recruit new arrivals from the 2015 German refugee crisis.

Risk Factors for Severe Complications in Ovarian Cancer Surgery.

Backround: Due to extensive surgical intervention for macroscopic complete cytoreduction in epithelial ovarian cancer (EOC) patients, severe complications in the postoperative course are possible. PATIENTS AND METHODS: A total of 345 EOC patients who underwent cytoreductive surgery were retrospectively evaluated regarding risk factors for an unfavorable postoperative course. Possible pre-, intra- and postoperative risk factors were statistically analyzed performing multivariate ordinal logistic regression. RESULTS: A total of 345 EOC patients underwent cytoreductive surgery. There were no complications in 114 patients, mild complications in 114 patients and severe complications in 117 patients. The risk factor evaluation identified age (p=0.049), smoking (p=0.032) and duration of surgery (p<0.0001) as significant factors for severe postoperative morbidity. CONCLUSION: In EOC patients age, smoking and the duration of surgery have significant impact on the postoperative course. Only the duration of surgery can be positively influenced by a well-trained EOC team.

Dynamic changes of angiopoietins and endothelial nitric oxide supply during fluid resuscitation for major gyn-oncological surgery: a prospective observation.

BACKGROUND: Despite goal-directed hemodynamic therapy, vascular function may deteriorate during surgery for advanced abdominal tumor masses. Fluid administration has been shown to be associated with distinct changes in serum levels of functional proteins. We sought to determine how serum total protein and angiopoietin (ANG) levels change during major abdominal tumor surgery. In addition, ex vivo endothelial nitric oxide synthase (eNOS) activation as well as NO bioavailability in vivo were assessed. METHODS: 30 patients scheduled for laparotomy for late-stage ovarian or uterine cancer were prospectively included. Advanced hemodynamic monitoring as well as protocol-driven goal-directed fluid optimization were performed. Total serum protein, ANG-1, -2, and soluble TIE2 were determined pre-, intra-, and postoperatively. Phosphorylation of eNOS was assessed in microvascular endothelial cells after incubation with patient serum, and microvascular reactivity was determined in vivo by near-infrared spectroscopy and arterial vascular occlusion. RESULTS: Cardiac output as well as preload gradually decreased during surgery and were associated with a median total fluid intake of 12.8 (9.7-15.4) mL/kg*h and a postoperative fluid balance of 6710 (4113-9271) mL. Total serum protein decreased significantly from baseline (66.5 (56.4-73.3) mg/mL) by almost half intraoperatively (42.7 (36.8-51.5) mg/mL, p < 0.0001) and remained at low level. While ANG-1 showed no significant dilutional change (baseline: 12.7 (11.9-13.9) ng/mL, postop.: 11.6 (10.8 -13.5) ng/mL, p = 0.06), serum levels of ANG-2 were even increased postoperatively (baseline: 2.2 (1.6-2.6) ng/mL vs. postop.: 3.4 (2.3-3.8) ng/mL, p < 0.0001), resulting in a significant shift in ANG-2 to ANG-1 ratio. Ex vivo phosphorylation of eNOS was decreased depending on increased ANG-2 levels and ANG-2/1 ratio (Spearman r = - 0.37, p = 0.007). In vivo, increased ANG-2 levels were associated with impaired capillary recruitment and NO bioavailability (Spearman r = - 0.83, p = 0.01). CONCLUSIONS: Fluid resuscitation-associated changes in serum vascular mediator profile during abdominal tumor surgery were accompanied by impaired eNOS activity ex vivo as well as reduced NO bioavailability in vivo. Our results may explain disturbed microvascular function in major surgery despite goal-directed hemodynamic optimization.

A matched-pair analysis on survival and response rates between German and non-German cancer patients treated at a Comprehensive Cancer Center.

BACKGROUND: Research shows disparities in cancer outcomes by ethnicity or socio-economic status. Therefore, it is the aim of our study to perform a matched-pair analysis which compares the outcome of German and non-German (in the following described as 'foreign') cancer patients being treated at the Center for Integrated Oncology (CIO) Köln Bonn at the University Hospital of Bonn between January 2010 and June 2016. METHODS: During this time, 6314 well-documented patients received a diagnosis of cancer. Out of these patients, 219 patients with foreign nationality could be matched to German patients based on diagnostic and demographic criteria and were included in the study. All of these 438 patients were well characterized concerning survival data (Overall survival, Progression-free survival and Time to progression) and response to treatment. RESULTS: No significant differences regarding the patients' survival and response rates were seen when all German and foreign patients were compared. A subgroup analysis of German and foreign patients with head and neck cancer revealed a significantly longer progression-free survival for the German patients. Differences in response to treatment could not be found in this subgroup analysis. CONCLUSIONS: In summary, no major differences in survival and response rates of German and foreign cancer patients were revealed in this study. Nevertheless, the differences in progression-free survival, which could be found in the subgroup analysis of patients with head and neck cancer, should lead to further research, especially evaluating the role of infectious diseases like human papillomavirus (HPV) and Epstein-Barr virus (EBV) on carcinogenesis and disease progression.

Prevention of Anastomotic Leakage in Ovarian Cancer Debulking Surgery and Its Impact on Overall Survival.

AIM: The aim of this retrospective study was to investigate the impact of anastomotic leakage on survival rate and to define potential factors of risk and protection from bowel anastomotic leakage in patients with bowel segment resection treated for epithelial ovarian cancer in an accredited high-volume center. PATIENTS AND METHODS: Data of 136 patients treated with bowel resection between 2010 and 2017 were collected. All operations were performed by three accredited gynecological oncologists and by two specialized colorectal surgeons. Survival and anastomotic leakage rates were analyzed as per preoperative treatment, number and localization of anastomoses, grading of ovarian cancer, and protective loop ileostomy. RESULTS: In total, anastomotic leakage was observed in 23 out of 165 anastomoses (13.9%), representing 23 anastomotic leakages in 136 patients (16.9%). The 30-day mortality rate was 0.73%. There was no statistically significant difference in anastomotic leakage rate depending on localization and number of anastomoses (p=0.634). Patients with a protective loop ileostomy (n=22/136 patients) had no anastomotic leakage (0.0%, p=0.021). The anastomotic leakage rate was significantly different in patients without protective loop ileostomy depending on bevacizumab administration [no bevacizumab: 15/111 (13.5%) vs. bevacizumab administration: 4/8 (50.0%), p=0.007]. Tumor-positive resection margins in bowel segments were an independent prognostic factor (relative risk=6.3; 95% confidence intervaI=3.1-12.9). CONCLUSION: In this data set, protective loop ileostomy likely reduced the anastomotic leakage rate after bowel resection in selected cases of ovarian cancer treated with debulking surgery. Especially in patients treated with bevacizumab, protective loop ileostomy should be considered. There was no significant impact of leakage rate on overall survival.

Network of Mediators for Vascular Inflammation and Leakage Is Dysbalanced during Cytoreductive Surgery for Late-Stage Ovarian Cancer.

BACKGROUND: Cytoreductive surgery (CS) in late-stage ovarian cancer patients is often challenging due to extensive volume shifts, and high fluid intake may provoke postoperative complications. Expression of vasoactive mediators is altered in cancer patients, which may affect systemic vascular function. We sought to assess how serum levels of vasoactive markers and mediators change during CS in ovarian cancer. METHODS: Following IRB approval and informed consent, pre- and postoperative serum samples were analyzed in 26 late-stage ovarian cancer patients using multiplex protein arrays and ELISA. RESULTS: The proinflammatory cytokines and chemokines IL-6, IL-8, and CCL2 were significantly elevated after 24 hrs compared to the baseline values, with IL-6 and IL-8 being most prominently increased. While ANGPT1 remained unchanged after surgery, its competitive antagonist ANGPT2 was significantly increased. In contrast, serum levels of the ANGPT receptor TIE2 were decreased to 0.6 of the baseline values. While VEGF-D, E-selectin, P-selectin, ICAM-1, and PECAM-1 remained unchanged, serum activity of both thrombomodulin and syndecan-1 was significantly increased following surgery. CONCLUSION: We identified a regulatory network of acute-phase reaction during CS in late-stage ovarian cancer. This suggests that IL-6 exerts positive regulation of other proinflammatory mediators and, by upregulating ANGPT2 and suppressing ANGPT1, induces a serum profile that promotes vascular leakage. This may contribute to the observed hemodynamic alterations during CS procedures.

Self-reported physical, mental, and reproductive sequelae after treatment of abnormally invasive placenta: a single-center observational study.

OBJECTIVE: To analyze the types of treatment of abnormally invasive placenta (AIP) and to investigate the self-reported physical and mental short- and long-term sequelae. METHODS: This single-center observational study was performed between 2003 and 2017. Women with prenatal or intrapartum diagnosis of AIP were identified through the departmental database. Classification was performed according to the time of diagnosis establishment and the type of treatment. Medical complications overall and according to the type of treatment were analyzed. Data about women's perception of diagnosis, treatment, and short- and long-term sequelae were gathered by questionnaire. RESULTS: Cases were classified into four groups: prenatal diagnosis, cesarean hysterectomy (A, n = 10); prenatal diagnosis, expectant management (B, n = 19); intrapartum diagnosis, cesarean hysterectomy (C, n = 6); intrapartum diagnosis, conservative therapy (D, n = 20). Depth of invasion, total units of transfused red blood cells, and the need for reoperation differed between the treatment groups. Expectant management was successful in 94.7% of cases. Irrespective of the treatment group, 73.3% of women perceived the condition as serious or life-threatening; 30.0% utilized psychological support; and 36.7% reported persistent pain or problems. 37.5% of women after uterine preservation had another live birth, AIP recurred in 44.4% of cases. CONCLUSION: Conservative management of AIP is feasible in selected cases. The condition is perceived as life-threatening and has a lasting impact on the physical, mental, and reproductive health of those affected. This finding merits further investigation. AIP continues to be a condition with high morbidity.

Ribavirin in Acute Hepatitis E Infection in Patients with Gynecological Cancer: A Case Series.

Hepatitis E virus infection is usually a self-limited disease. However, during the last years there has been growing evidence for prolonged and chronic infection occurring in patients with immunosuppression. Also patients with malignant and rheumatic diseases have been identified to be at risk for chronic hepatitis E. However, their course and prognosis are not well characterized and there have been no reports of hepatitis E virus infection in patients with gynecological cancer. Here, we report three Caucasian females with breast and ovarian cancers presenting with elevation of aminotransferase levels during anticancer treatment. Although only few or no clinical hints suggested hepatitis E virus infection, the diagnosis of hepatitis E virus infection was confirmed by seroconversion, which might occur with some delay, and/or by polymerase chain reaction. While two patients had a self-limited course, the third patient with a high-risk oncological constellation required ribavirin in order to resume chemotherapy. These cases highlight the need for hepatitis E virus testing in patients with gynecological cancer and elevated aminotransferase levels. Further, these cases show that in selected high-risk patients, ribavirin treatment may be necessary based on the decision of a multidisciplinary team.

Prostate-specific membrane antigen in breast cancer: a comprehensive evaluation of expression and a case report of radionuclide therapy.

PURPOSE: Prostate-specific membrane antigen (PSMA), a protein product of the folate hydrolase 1 (FOLH1) gene, is gaining increasing acceptance as a target for positron emission tomography/computer tomography (PET/CT) imaging in patients with several cancer types, including breast cancer. So far, PSMA expression in breast cancer endothelia has not been sufficiently characterized. METHODS: This study comprised 315 cases of invasive carcinoma of no special type (NST) and lobular breast cancer (median follow-up time 9.0 years). PSMA expression on tumor endothelia was detected by immunohistochemistry. Further, vascular mRNA expression of the FOLH1 gene (PSMA) was investigated in a cohort of patients with invasive breast cancer provided by The Cancer Genome Atlas (TCGA). RESULTS: Sixty percent of breast cancer cases exhibited PSMA-positive endothelia with higher expression rates in tumors of higher grade, NST subtype with Her2-positivity, and lack of hormone receptors. These findings were confirmed on mRNA expression levels. The highest PSMA rates were observed in triple-negative carcinomas (4.5 × higher than in other tumors). Further, a case of a patient with metastatic breast cancer showing PSMA expression in PET/CT imaging and undergoing PSMA radionuclide therapy is discussed in detail. CONCLUSIONS: This study provides a rationale for the further development of PSMA-targeted imaging in breast cancer, especially in triple-negative tumors.

Tumoral PD-L1 expression defines a subgroup of poor-prognosis vulvar carcinomas with non-viral etiology.

Vulvar cancer is rare but incidence rates are increasing due to an aging population and higher frequencies of young women being affected. In locally advanced, metastatic or recurrent disease prognosis is poor and new treatment modalities are needed. Immune checkpoint blockade of the PD-1/PD-L1 pathway is one of the most important advancements in cancer therapy in the last years. The clinical relevance of PD-L1 expression in vulvar cancer, however, has not been studied so far. We determined PD-L1 expression, numbers of CD3+ T cells, CD20+ B cells, CD68+ monocytes/macrophages, Foxp3+ regulatory T cells and CD163+ tumor-associated macrophages by immunohistochemistry in 103 patients. Correlation analysis with clinicopathological parameters was undertaken; the cause-specific outcome was modeled with competing risk analysis; multivariate Cox regression was used to determine independent predictors of survival. Membranous PD-L1 was expressed in a minority of tumors, defined by HPV-negativity. Its presence geographically correlated with immunocyte-rich regions of cancer islets and was an independent prognostic factor for poor outcome. Our data support the notion that vulvar cancer is an immunomodulatory tumor that harnesses the PD-1/PD-L1 pathway to induce tolerance. Accordingly, immunotherapeutic approaches might have the potential to improve outcome in patients with vulvar cancer and could complement conventional cancer treatment.

Preoperative breast MRI-examination for all patients with histologically proven breast cancer? A concept for a prospective multicenter trial.

Background A published retrospective data of our study group demonstrated that premenopausal women, patients with lobular invasive breast cancer or patients with high breast density [American College of Radiology (ACR) classification 3+4] significantly benefit from magnetic resonance imaging (MRI) leading to additional detection of malignant foci of 20.2% in the index and 2.5% in the contralateral breast, which would otherwise not be detected by routine imaging. Critics of preoperative MRI focus on higher false-positive rates leading to unnecessary surgical procedures and mastectomies. Therefore, MRI in preoperative imaging remains controversial. Methods To validate our retrospective data we initiate a prospective one-armed multicenter trial for patients with histologically confirmed breast cancer performing routine imaging by ultrasound and mammography followed by MRI imaging based on menopause status, histologic subtype, ACR and Breast Imaging Reporting and Data System (BIRADS)-classification. Primary endpoint is the rate of additional findings and change of treatment strategy, secondary endpoints are local recurrence-free, distant recurrence-free and overall survival. Additional MRI findings are calculated to be above 10% with a number of 100 patients recruited and a power of 80%. Conclusion MRI is detecting more tumor foci than conventional imaging but remains controversial in primary breast cancer for preoperative imaging because of the fear of over-diagnosis and the increased morbidity of additional potentially unnecessary surgical procedures. This planned one-armed prospective multicenter trial is designed to confirm our retrospectively revealed data defining subgroups with significant benefit of preoperative MRI to come to a consensus avoiding over-diagnosis and false-positive results leading to clinically beneficial and cost-effective use of preoperative MRI.

Lipofilling effects after breast cancer surgery in post-radiation patients: an analysis of results and algorithm proposal.

BACKGROUND: Lipofilling or autologous fat transfer is an established technique in plastic surgery. Herein, we describe the lipofilling effects after implant-based breast reconstruction in post-radiation patients and propose an algorithm for indication of lipofilling. METHODS: Forty patients with a history of breast cancer were included in this retrospective analysis. Patients had undergone either breast conserving therapy or mastectomy. Twenty-six patients underwent additional radiation therapy. Patients were assessed using a post-radiation skin scoring classification. RESULTS: In total, 68 lipofilling procedures were analyzed. Scar release, skin softening, improved quality of life, and improvement of post-radiation findings are results of lipofilling with a closed filtration system. In all patients with post-surgical radiation, an improvement of tissue quality was observed. Staging revealed that lipofilling improved mean post-radiation skin scores of 2.40 ± 0.89 to 1.21 ± 0.76 (p ≤ 0.000). There was no recurrence of breast cancer in our study patients. CONCLUSIONS: This study introduces an algorithm using lipofilling in reconstructive breast surgery and especially in post-radiation patients with low risks as well as very high acceptance in patients with various indications for this procedure. A regenerative aspect was also detectable in patients following radiation therapy and reconstruction. Lipofilling is a safe and effective procedure with a low incidence of minor complications. It is therefore a feasible method to resolve volume deficiencies and asymmetric results after oncologic breast surgery. Nevertheless, a prospective study has now been initiated focusing on the oncologic safety of lipofilling including ultrasound and radiological examinations to validate the findings of this initial study. Level of Evidence: Level IV, therapeutic study.

Impact of Open Laparoscopy in Patients Under Suspicion of Ovarian Cancer.

BACKGROUND/AIM: Feasibility and value of diagnostic open laparoscopy (DOL) was assessed in patients presenting under suspicion of advanced ovarian cancer (AOC) mostly with large-volume ascites. PATIENTS AND METHODS: This retrospective study analyzed 143 consecutive patients who underwent DOL for histopathological verification of AOC performed from 2002 to 2012. RESULTS: Out of the 143 patients presenting at our Center with an ovarian mass and mostly with ascites under suspicion of ovarian cancer, we diagnosed 125 AOCs, three AOCs with three concomitant tumors of other origin, and 15 other diseases causing an ovarian mass and ascites mimicking AOC (e.g. gastrointestinal malignancies, tuberculosis, mesothelioma, endometrial cancer and benign conditions). CONCLUSION: DOL can be considered a valid and safe diagnostic tool for histopathologically verifying epithetlial ovarian cancer and preventing patients with other diagnoses undergoing the wrong course of therapy.

Introducing Hyperthermic Intraperitoneal Chemotherapy into Gynecological Oncology Practice - Feasibility and Safety Considerations: Single-Center Experience.

BACKGROUND: Within the surgical oncology community interest is increasingly focusing on combining surgical cytoreduction and regional chemotherapeutic drug delivery to manage solid abdominal tumors. In particular, the role of hyperthermic intraperitoneal chemotherapy (HIPEC) is evolving for treating epithelial ovarian carcinomas (EOCs), as EOCs remain confined to the peritoneal cavity for most of their natural history. Currently there is no evidence from prospective trials to confirm an overall survival benefit associated with HIPEC. In addition, there are no generally accepted regimens, which results in heterogeneous clinical procedures. METHODS: We have initiated a HIPEC program at our institution and completed a phase I study of HIPEC with cisplatin in patients with platinum-sensitive recurrent EOC. The data have been published and prove the feasibility of this approach. In the process of introducing HIPEC, several safety measures had to be taken into consideration. RESULTS: We present the implications and requirements of introducing HIPEC in clinical practice and discuss our proposed procedure referring to the recent literature. CONCLUSION: HIPEC is feasible and can be performed safely in daily gynecological oncology routine provided that certain considerations and precautions are taken into account during its introduction to guarantee a proper and safe operating sequence.

Impact of Chemotherapy on Retroperitoneal Lymph Nodes in Ovarian Cancer.

BACKGROUND: Complete cytoreduction is the most important prognostic factor in ovarian cancer. However, there exist conflicting data on whether the removal of microscopic tumor metastasis in macroscopically unsuspicious retroperitoneal lymph nodes is beneficial. PATIENTS AND METHODS: Ovarian cancer tissues and tissues from lymph node metastasis of 30 patients with FIGO IIIC or IV disease undergoing neoadjuvant chemotherapy (NACT) were obtained and assessed using a validated regression score. Histopathological markers, size of largest tumor focus, and overall score were evaluated in lymph node and ovarian tissue. Regression and known prognostic factors were analyzed for influence on survival. RESULTS: No difference in the overall score between lymph nodes and ovarian tissue was shown, however, single parameters such as fibrosis and pattern of tumor infiltration, were significantly different. CONCLUSION: The pattern of tumor regression in lymph nodes and ovarian tissue are of prognostic value. Lymph node dissection even of unsuspicious nodes should, therefore, be performed.

Impact of Extended Primary Surgery on Suboptimally Operable Patients With Advanced Ovarian Cancer.

OBJECTIVES: Extensive surgical efforts to achieve an optimal debulking (no residual tumor) in primary surgery of ovarian cancer are today's criterion standard in gyneco-oncologic surgery. However, it is controversial whether extensive surgery, including resections of metastases in the upper abdomen and bowel resections, is justifiable in patients with not completely operable lesions. METHODS: All patients who had undergone surgery for ovarian cancer in the years 2002 to 2013 at our institution were viewed (n = 472). We retrospectively identified 278 operations for primary ovarian cancer. Ninety-six (35%) of the 278 patients showed postoperative tumor residuals and were included in this study. RESULTS: Fifty-five (57%) of 96 patients underwent bowel resection, showing significantly higher complication rates (64% vs 39% minor complications, P = 0.017; 31% vs 9.8% severe complications, P = 0.013) compared with patients without bowel resections as well as no improvement in progression-free or overall survival (median overall survival, 19.5 vs 32.9; P = 0.382). Multiple anastomoses (≥2) were associated with higher rates for anastomotic leakage (16.7% vs 2.6%, P = 0.02) and a higher mortality (16.7% vs 0%, P = 0.04) compared with patients with only 1 anastomosis. Extensive surgery of the upper abdomen was not associated with a significant increase in complication rates. CONCLUSIONS: Because of the increased morbidity of bowel resections without any evidence for improvement of survival, we suggest to restrain from further resection of intestines if an optimal debulking seems not feasible after removal of the major tumor bulk.

Individual management of cervical cancer in pregnancy.

PURPOSE: The management of cervical cancer in pregnancy persists to be challenging. Therefore, identification of factors that influence the choice of therapeutic management is pivotal for an adequate patient counseling. METHODS: We present a literature review of 26 studies reporting 121 pregnancies affected by cervical cancer. Additionally, we add a retrospective case series of five patients with pregnancy-associated cervical cancer diagnosed and treated in our clinic between 2006 and 2013. RESULTS: The literature review revealed that the therapeutic management during pregnancy varies according to the gestational age at diagnosis, while in the postpartum period no influence on the treatment choice could be detected. Also in our case series the choice of oncologic therapy was influenced by the gestational age, the wish to continue the pregnancy and the risks of delaying definitive treatment. CONCLUSIONS: There are no standardized procedures concerning the treatment of cervical cancer in pregnancy. Therefore, in consultation with the patient and a multidisciplinary team, an adequate individualized treatment plan should be determined.

Development of obstetrical and gynecological journals, 2007 to 2013: a trend analysis.

PURPOSE: To analyze the trends and developments among journals in the specialty of obstetrics and gynecology. METHODS: Using the Journal Citation Reports from 2007 to 2013, we analyzed the impact factor (IF), Eigenfactor® Score (ES), and Article Influence® Score (AIS) of 43 journals in the field of obstetrics and gynecology published in this time period. RESULTS: From 78 journals of the Journal Citation Report 2013, 43 were selected for this study. The mean IF grew from 1.68 ± 0.97 in 2007 to 2.12 ± 1.05 in 2013, the ES from 0.0113 ± 0.0169 to 0.0114 ± 0.0140, and the AIS from 0.513 ± 0.302 to 0.663 ± 0.359. Differences in the IF, ES, and AIS between journals from the United States versus Europe could be observed. In most cases, the IF, ES, and AIS increased between 2007 and 2013. Strong correlations could be found between IF, AIS, and ES. CONCLUSIONS: The overall mean IF for obstetrical and gynecological journals increased over the analyzed time period. The IF remains the standard measure to compare scientific journals. It correlates well with two major alternative measures of scientific impact, the ES and especially the AIS. Other measures are evolving and might show superior usage in the future.