Does the addition of salpingectomy or fimbriectomy to hysterectomy in premenopausal patients compromise ovarian reserve? A prospective study.

OBJECTIVE: To evaluate changes in ovarian reserve in patients following hysterectomy, with or without bilateral salpingectomy or fimbriectomy. STUDY DESIGN: Open-label, prospective cohort trial of patients undergoing hysterectomy for benign uterine indications. Levels of follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH), and ultrasonic measures of peak systolic flow velocity/diastolic velocity (S/D) ratio and resistance index (RI) in the ovarian artery were taken from patients before and 6 weeks after hysterectomy, hysterectomy+salpingectomy or hysterectomy+fimbriectomy. RESULTS: The study period was from November 2011 to May 2014. Sixty patients were included in the final analysis, after two patients were lost to follow-up and one patient underwent bilateral oophorectomy. Of these 60 patients, 16 underwent hysterectomy alone (control group), and 44 were included in the study group (22 patients underwent hysterectomy+fimbriectomy and 22 patients underwent hysterectomy+salpingectomy). The mean age of patients was 46 years (standard deviation 4.07 years). Between-group dfferences in FSH, AMH, ovarian volume, ovarian artery S/D ratio and ovarian artery RI were not significant. CONCLUSION: The addition of salpingectomy or fimbriectomy to routine hysterectomy in premenopausal patients does not diminish ovarian reserve.

The Added Value of SPECT/CT in Sentinel Lymph Nodes Mapping for Endometrial Carcinoma.

OBJECTIVES: This study was designed to evaluate the detection rate (DR) and sensitivity of sentinel lymph node (SLN) mapping in patients with endometrial cancer using TC99m colloid and blue dye and to evaluate the contribution of preoperative planar lymphoscintigraphy (PLSG) and SPECT/CT. METHODS: A retrospective analysis of patients who underwent SLN mapping as part of their primary surgery for endometrial cancer. Patients underwent preoperative PLSG and later with additional SPECT/CT. Intraoperative detection was performed using TC99m colloid and blue dye by cervical injections. SLNs were sent separately for pathologic evaluation with ultrastaging. RESULTS: Fifty-three patients were included in this study. Successful preoperative mapping was achieved in 31 of 37 patients (84 %) who underwent SPECT/CT compared with only 30 of 45 patients (67 %) who underwent PLSG. SPECT/CT localizations of SLNs were anatomically accurate in 91 % of cases. Intraoperative DR of at least one SLN was 77 %, whilst the bilateral DR was 49 %. DR was significantly better using combined blue dye and TC99m colloid injections compared with blue dye alone: 81 versus 57 % for unilateral and 54 versus 28 % for bilateral mapping (P = 0.01, 0.009, respectively). Six cases of nodal metastasis were diagnosed: four by positive SLNs, and two cases were diagnosed using side-specific full dissection according to the SLN algorithm when SLN detection failed. There were no cases of false-negative results. CONCLUSIONS: SLN detection using cervical injections of TC99m colloid and blue dye is feasible and sensitive for patients with endometrial cancer. SPECT/CT aids to accurate locating of the SLN.

Can parametrectomy be avoided in early cervical cancer? An algorithm for the identification of patients at low risk for parametrial involvement.

AIMS: To assess the rate of parametrial involvement in a large cohort of patients who underwent radical hysterectomy for cervical cancer and to suggest an algorithm for the triage of patients to simple hysterectomy or simple trachelectomy. METHODS: Multicenter retrospective study of patients with cervical cancer stage I through IIA who underwent radical hysterectomy and pelvic lymphadenectomy. The patients were divided into 2 groups according to whether or not the parametrium was involved. The two groups were compared with regard to the clinical and histopathological variables. Logistic regression of the variables potentially assessable prior to definitive hysterectomy such as age, tumor size, lymph-vascular space invasion (LVSI) and nodal involvement was performed. RESULTS: Five hundred and thirty patients had specific histological data on parametrial involvement and in 58 (10.9%) patients, parametria was involved. Parametrial involvement was significantly associated with older age, tumors larger than 2 cm, deeper invasion, LVSI, involved surgical margins, and the presence of nodal metastasis. By triaging patients with a tumor ≤ 2 cm and no LVSI, the parametrial involvement rate was 1.8% (2/112 patients). With further triage of patients with negative nodes, the rate of parametrial involvement was 0% (0/107 patients). CONCLUSION: Using a pre-operative triage algorithm, patients with early small lesions, no LVSI and no nodal involvement may be spared radical surgical procedures and parametrectomy. Further prospective data are urgently needed.

Can angle of progression in pregnant women before onset of labor predict mode of delivery?

OBJECTIVES: The angle of progression (AOP), measured by transperineal ultrasound, has been used to assess fetal head descent during labor. Our aim was to assess whether, before onset of labor, parous women have a narrower AOP than do nulliparous women and if a narrow AOP is associated with a higher rate of Cesarean delivery. METHODS: In this prospective, observational study, we performed transperineal ultrasound in pregnant women not yet in labor at ≥ 39 weeks' gestation who delivered within 1 week of sonography. The AOP was compared as follows: in nulliparous women, between those who had a Cesarean section and those who delivered vaginally; and among women who delivered vaginally, between those who were nulliparous and those who were parous. RESULTS: Included in the study were 100 nulliparous and 71 parous women. Among those who delivered vaginally (n = 161), the median AOP before onset of labor was narrower in parous than in nulliparous women (98° (interquartile range (IQR)), 90-107° vs 104° (IQR, 97-113°), P < 0.001). Among the 100 nulliparous women, (1) the median AOP before onset of labor was narrower in those who went on to deliver by Cesarean section (n = 9) than in those delivered vaginally (n = 91) (90° (IQR, 85.5-93.5°) vs 104° (IQR, 97-113°), P < 0.001); (2) an AOP ≥ 95° (derived from the receiver-operating characteristics curve) was associated with vaginal delivery in 99% of women; and (3) 89% (8/9) of women who delivered by Cesarean section had an AOP < 95°. Among the 71 parous women, only one delivered by Cesarean section and all of those with an AOP < 95° delivered vaginally. CONCLUSION: A narrow AOP (< 95°) in non-laboring nulliparous women at term is associated with a high rate of Cesarean delivery. Parous women have a narrower AOP than do nulliparous women before the onset of labor; however, unlike in nulliparous women, a narrow AOP in parous women does not appear to be associated with Cesarean delivery and most parous women with such an angle go on to deliver vaginally.

Temporal pattern of recurrence of stage I endometrial cancer in relation to histological risk factors.

OBJECTIVE: To study the temporal pattern of endometrial cancer recurrence in relation to histological risk factors in a large multicenter setting. METHODS: 843 patients with apparent stage I endometrial cancer were followed for a median time of 38 months, documenting all recurrences. Patients were stratified as high risk based on the presence of at least one of the established histological risk factors: high tumor grade, penetration to the outer half of the myometrium, lymphvascular space involvement, lower uterine segment involvement and non endometroid histology. Survival analysis, including Kaplan-Meier curves, log-rank tests and multi-variate Cox proportional hazard regression were used to evaluate the equality of recurrence-free distributions for different levels of risk. RESULTS: Recurrence was documented in 66 cases. The presence of one or more of the histological risk factors was associated with significantly shorter recurrence free survival, not attenuating over time (p < 0.001). Age-adjusted Cox regression model demonstrated a significantly decreased recurrence-free survival (HR = 2.8 95% CI 1.5, 5.1) in the presence of risk factors. CONCLUSIONS: In patients with stage I endometrial cancer, the presence of histological risk factors is associated with a significantly higher recurrence rate, which does not attenuate over follow up time. This may allow for a selective approach in the follow- up of endometrial cancer patients.

Lower uterine segment involvement is associated with adverse outcome in patients with stage I endometroid endometrial cancer: results of a multicenter study.

OBJECTIVE: To quantify the relative risk associated with lower uterine segment involvement (LUSI) on outcome measures in patients with apparent stage I endometroid endometrial cancer. METHODS: A cohort of 769 consecutive patients with endometroid endometrial carcinoma apparent stage I, who underwent surgery in five gynecological oncology centers in Israel; 138 patients with and 631 without LUSI were followed for a median time of 51 months. Local recurrence, recurrence-free and overall survival were compared between the two groups. RESULTS: LUSI was associated with grade 3 tumor (p=0.002), deep myometrial invasion (p<0.001), and the presence of lymphvascular space involvement (p=0.01). There were 22 cases of local recurrences, 40 cases of distal recurrences and 80 patients died. Univariate survival analysis showed that patients with LUSI had trend toward lower regional recurrence-free survival (p=0.09), and significant lower distant recurrence-free survival (p=0.04) and lower overall survival (p=0.002). The Cox proportional hazards model demonstrated a significantly decreased overall survival (HR=2.3; 95% CI 1.3, 3.9; p=0.003) in cases with LUSI. CONCLUSIONS: In patients with apparent stage I endometroid endometrial cancer, the presence of LUSI is a poor prognostic factor, associated with a significantly higher risk of distal recurrence and death. The presence of LUSI warrants consideration when deciding upon surgical staging or postoperative management.

Does hysteroscopy affect prognosis in apparent early-stage endometrial cancer?

The objective of the study was to compare the outcome measures of patients with endometrial adenocarcinoma diagnosed by endometrial biopsy, uterine curettage, or hysteroscopy. Medical records of 392 women diagnosed with apparent early-stage endometrial adenocarcinoma were reviewed. Data concerning the mode of diagnosis, histologic type and grade, surgical stage, peritoneal washings and lymph nodes status, and patient's outcome were retrieved. During the study period, 99 (25.3%) cases were diagnosed by endometrial biopsy, 193 (49.2%) by uterine curettage, and 100 (25.5%) by hysteroscopy. There were 347 (88.5%) cases of endometrioid adenocarcinoma and 45 (11.5%) of poor histologic types, including serous papillary, clear cell, and small cell cancer. Three hundred and sixteen (80.6%) patients had stage I disease, 8 (2.0%) stage II, and 68 (17.4%) stage III. Peritoneal cytology was positive in only one case. Recurrent disease occurred in 6.9% patients, of which 50% had local recurrence and 50% had distant. Recurrent disease was found in 15.2% patients diagnosed by endometrial biopsy, in 4.7% where uterine curettage was used, and in 5% when hysteroscopy was applied. No statistically significant difference in the survival rate between the different diagnostic methods applied was found, although a higher recurrence rate was noted following endometrial biopsy. After a median follow-up time of 25 months for patients undergoing hysteroscopy, there was no difference in recurrence rates and/or overall survival compared to other diagnostic procedures implying that hysteroscopy can be safely used in the diagnosis of endometrial cancer.

The role of L1-CAM immunohistochemial staining in the diagnosis of abdominal-pelvic cancer of uncertain primary site in women.

OBJECTIVE: The L1 adhesion molecule (L1-CAM,CD171) is over expressed in ovarian and endometrial carcinomas and other tumors derived from the Mullerian tract. Here we evaluated whether L1-CAM could serve as a novel tumor marker for the diagnosis of metastatic abdominal-pelvic cancers of uncertain origin in women. PATIENTS AND METHODS: During a 6-year period we investigated 28 patients with metastatic abdominal or pelvic cancer with uncertain primary-origin. In all these cases a thorough clinical, surgical, pathologic and immunohistochemistry evaluation was performed and correlated to the L1-CAM expression as determined by immunohistochemical staining. RESULTS: In 20 patients where the differential diagnosis was primary ovarian or endometrial cancer and primary or recurrent colon cancer, L1 immunohistochemistry staining allowed or supported the correct diagnosis. In four cases L1 staining allowed the correct diagnosis between breast and ovarian cancer. In two cases vaginal metastases of unknown origin were positive to L1 immunohistochemistry staining implying their mullerian origin and one case each of inguinal lymph node metastases and abdominal wall cancer that were positive for L1-CAM, allowed the correct diagnosis of primary ovarian cancer. In a whole, L1-CAM was of crucial role of delinating the final diagnosis in 17 of the 28 cases described. CONCLUSIONS: L1-CAM, a new tumor marker, was found to be specific for metastatic cancer originating from mullerian origin. Its incorporation into the conventional immunohistochemistry analysis in cases of cancer of unknown primary in women, allows a correct diagnosis and subsequent treatment in the majority of cases with abdominal-pelvic carcinomatosis.

The management of an early-missed abortion after radical trachelectomy--a case report and a review of the literature.

UNLABELLED: Radical trachelectomy (RT) has been reported for almost 20 years. This case report describes and addresses the issue of the clinical management of early-missed abortion in a patient after RT with a cerclage. CASE: A 35-year-old woman who had a RT 2 years ago due to cervical carcinoma stage IB1 presented with a missed abortion of an 8-week gestational age. At the end of the RT, a cerclage suture was inserted in the remaining internal oss of the cervix. The patient went through a cervical dilatation followed by suction curettage guided by ultrasonography without compromising the cerclage. This case report suggests that dilatation and suction curettage without compromising the cervical cerclage is a feasible option in the clinical management of early abortion in a patient after RT.

Dermatomyositis following the diagnosis of ovarian cancer.

We present a case history of a woman who developed dermatomyositis following the diagnosis of stage IV ovarian cancer. Dermatomyositis is a rare paraneoplastic syndrome that usually precedes the diagnosis of ovarian cancer by several months or years. Ours is the fifth reported case of dermatomyositis after an established diagnosis of ovarian cancer in the literature.

Non-Hodgkin's lymphoma presenting as advanced ovarian cancer--a case report and review of literature.

Non-Hodgkin's lymphoma involving the ovaries is unusual and may cause confusion for the clinician since its presentation might resemble other, much more frequent tumors. Malignant lymphoid cells may occur in the ovary either as a primary neoplasm or as a secondary manifestation of a disseminated occult or known disease. The most common presenting signs or symptoms of malignant lymphomas involving the ovaries are abdominal or pelvic pain or mass. We present here a unique case of non-Hodgkin's lymphoma involving the ovaries presenting as advanced ovarian cancer with a pelvic mass, pleural effusion, and marked elevation of CA-125.

High-risk endometrial cancer in young indigent women.

OBJECTIVE: The aim of this study was to evaluate a different prevalence and clinical pattern of high-risk endometrial cancer in an indigent population of young women. METHODS: Charts of 71 consecutive patients, treated for endometrial adenocarcinoma during a 6-year period, were reviewed. The patients were divided into two groups contingent upon age--(i) those who were below 40 years and (ii) those who were over 40. Based on histological type, grade, and stage, both groups were subdivided into a low, intermediate, or high-risk cancer category. RESULTS: Of the 13 (18.3%) patients in the younger age group, five patients (38.4%) had high-risk endometrial cancer, compared to only eight patients (13.8%) in the older age group. CONCLUSION: In contradiction to previous reports, our results show that a higher proportion of young indigent women diagnosed with endometrial cancer have a high-risk cancer. Delay in diagnosis can explain only some of the discrepancies in the special clinical pattern of endometrial cancer among this population. Other possible explanations include nutritional differences, genetic susceptibility, immunological status, and high-risk behavior. More epidemiological studies are needed for complete understanding of the unfavorable outcome of endometrial cancer in these young women.

Uterine evacuation with misoprostol during radiotherapy for cervical cancer in pregnancy.

Radiotherapy as definitive treatment for invasive cervical cancer during pregnancy causes spontaneous abortion in most cases. Surgical evacuation of the uterus is indicated when abortion does not occur, exposing patients to additional morbidity. Two Latin American women, diagnosed with FIGO stage IB2 cervical cancer at approximately 15 weeks gestation, underwent radiotherapy with radiosensitizing chemotherapy. After intrauterine fetal demise was detected, both women underwent induction with misoprostol. Results included one complete abortion and one incomplete abortion without complications or delays in treatment. These cases demonstrate that induction with misoprostol appears to be a safe and effective alternative to surgical evacuation of the uterus when spontaneous abortion fails to occur during radiotherapy for locally advanced cervical cancer.

Pregnancy outcome after laparoscopy or laparotomy in pregnancy.

STUDY OBJECTIVE: To assess obstetric performance and fetal outcomes after laparoscopy or laparotomy performed during pregnancy. DESIGN: Nationwide, multicenter, retrospective chart review (Canadian Task Force classification II-2). SETTING: Seventeen hospitals throughout Israel: 12 university or university-affiliated hospitals and 5 general hospitals. PATIENTS: Three hundred eighty-nine pregnant women. INTERVENTION: Laparoscopy or laparotomy for various indications. MEASUREMENTS AND MAIN RESULTS: Of 192 laparoscopies performed, 141 were during the first, 46 during the second, and 5 during the third trimester; respective figures for 197 laparotomies were 63, 110, and 24. No intraoperative complications were reported for either procedure. Six and 25 women had complications after laparoscopy and laparotomy, respectively. There was no significant difference in abortion rates between groups. Mean gestational age at delivery and mean birthweight were comparable between groups. No significant difference was found in frequency of fetal anomalies between groups or when compared with the Israel register of anomalies. CONCLUSION: Operative laparoscopy seems to be as safe as laparotomy in pregnancy.

Trophoblastic peritoneal implants after laparoscopic treatment of ectopic pregnancy.

Persistent trophoblastic activity after salpingostomy for ectopic pregnancy implies the presence of intra-abdominal trophoblastic tissue, usually within the fallopian tube. We report a case of disseminated trophoblastic peritoneal implants, presenting as hemoperitoneum three weeks after laparoscopic salpingectomy. Only 23 such cases have been reported. Surgical treatment of ectopic pregnancy, especially by the laparoscopic technique, may cause intraperitoneal spread and reimplantation of trophoblastic tissue. Precautions for minimizing this complication are discussed.

Reseal of ruptured membranes after genetic amniocentesis. A case report.

BACKGROUND: One of the most significant complications following genetic amniocentesis is rupture of membranes, reported to occur in 1.15-1.7% of cases. Management of such cases is controversial. CASE: Genetic amniocentesis complicated by ruptured membranes was diagnosed in a 36-year-old woman. The membranes resealed after 48 hours, and the patient had a favorable outcome. CONCLUSION: In the case of genetic amniocentesis complicated by ruptured membranes, if chorioamnionitis does not develop, reseal can be expected to occur within seven days in the majority of cases. Thus, conservative management should be the first option.