Immediate risk of HSIL presence in women who have both ASC-US cytology and negative high-risk HPV test.

PURPOSE: The authors aimed to detect immediate risk of having high grade squamous lesions (HSIL) in atypical squamous cells of uncertain significance(AS-CUS) and concomitant high-risk human papillomavirus (HrHPV) testing as negative [HrHPV(negative)AS-CUS]. MATERIALS AND METHODS: The authors performed immediate/baseline colposcopy on concomitant HrHPV (negative)AS-CUS cases. Pap tests were evaluated with liquid-based cytology (LBC) and HrHPV detection was performed in LBC material with PCR. Colposcopic diagnoses and biopsy results were compared with Pap test and HrHPV test results. RESULTS: There were 104 patients over a one-year period. In all, 84 cases were included. Colposcopic biopsies revealed low grade squamous intraepithelial lesion (LSIL) in 19 cases (23%) and HSIL in three cases (4%). Intrauterine device use and smoking were significantly correlated with presence of HSIL (p = 0.005 and p = 0.007 respectively). CONCLUSION: Similar data in literature, 4% of ASC-US-HrHPV (negative) cases are expected to have HSIL in follow-up periods less than six months. The present authors believe clinicians should be more open with their patients about limitations of Pap-HPV testing.

Changes in the ovarian stromal blood flow in patients treated with laparoscopic salpingostomy for ectopic pregnancy.

This study is aimed to evaluate the impact of laparoscopic salpingostomy on ovarian stromal blood flow indices in patients with ectopic pregnancy, and to compare the ovarian stromal blood flow indices with matched paired healthy women. We included 37 patients who underwent laparoscopic salpingostomy and 37 age- and parity-matched women as controls. The main outcome was the differences in ovarian volume, antral follicle count (AFC), and ovarian stromal blood flow indices between the study group participants after the surgery and the healthy controls. Comparison of the ovarian parameters between the study group after the surgery and the control group revealed no significant differences in terms of ovarian volume (p = 0.783), AFC (p = 0.253), ovarian stromal S/D ratios (p = 0.054), pulsatility index (PI; p = 0.938) and resistance index (RI; p = 0.041). In addition, comparison of the ovarian parameters before and after the surgical treatment revealed no significant differences in the ovarian volume (p = 0.141), AFC (p = 0.084), ovarian stromal S/D ratios (p = 0.187), PI (p = 0.102) and RI (p = 0.108). In conclusion, laparoscopic salpingostomy does not affect ovarian function in terms of ovarian stromal blood flow indices, ovarian volume, and AFC.

Comparison of risk of malignancy indices; RMI 1-4 in borderline ovarian tumor.

PURPOSE: The aim of this study was to evaluate prognostic values of the risk of malignancy index (RMI)/1-4 in patients with borderline ovarian tumors (BOTs). METHODS: The study consisted of 50 patients with BOT diagnosed and treated between 2005-2010 and 50 patients with benign adnexal massses between 2009-2010 as a control comparison group in the retropsective study. Preoperative serum CA125, U score, tumor size (S), and menopausal status were recorded. The RMI 1-3 was calculated according to the formula; UxMxCA125 and RMI4 formulation was; UxMxCA125xS. S equaled 1 for tumor size <7 cm and was 2 when size a 7 cm. The RMI 1-4 indices were calculated for all patients together with the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy (DA). The performances of RMI indices were evaluated by McNemar's test and determined the best score cutoff value by the receiver operating characteristic (ROC) curve. RESULTS: The mean age, median value of CA125, ultrasound score, menopausal status, median values of RMI 1-4 of BOTs were statistically higher than benign adnexal masses. The sensitivity of RMI 1-4 was 26, 36, 62, and 60% at cutoff 200 level, respectively. The areas under curve of RMI 1-4 were found to be 0.676, 0.665, 0.668 and 0.734, respectively. DA of RMI 1-4 was found to be 56, 59, 50, and 71, respectively. When RMI 1-4 indices were compared with each other RMI 4 was the best RMI for BOTs. CONCLUSION: RMI 4 was the best predictive RMI for preoperative discrimination of BOT at a cutoff level of 200.

Comparison of tumor markers and clinicopathological features in serous and mucinous borderline ovarian tumors.

OBJECTIVE: The aim of this study was to assess tumor markers and clinicopathological findings of patients with serous and mucinous borderline ovarian tumor (BOT) features. METHODS: The study consisted of 50 patients that were diagnosed with and treated for BOT between 2005-2010 in three centers. CA125, CA19-9, and CA125+CA19-9 levels and clinicopathological features were compared in serous and mucinous histotypes. In serous and mucinous BOTs, correlations between tumor markers and demographics such as age, menopausal status, parity, clinical findings (stage, relapse, adjuvant chemotherapy, cytology, lymph node involvement and tumoral morphology (cystic-solid content, papilla, septation) were evaluated. RESULTS: There were no significant differences between serous and mucinous tumors in the clinicopathological features such as stage, tumor markers, age, menopausal status, or cytology. In serous BOTs we found a significant relation between elevated CA125+ CA19-9, CA19-9 and recurrence (p < 0.05). Also there was a significant relation between elevated CA125+ CA19-9, CA19-9 and cytology positivity (p < 0.05). We found a significant relation in serous BOTs between elevated CA125+CA19-9, adjuvant chemotherapy and lymph node metastases (p < 0.05). Also In mucinous BOTs with papilla formation we found a significant relation between elevated CA125 and CA125+ CA19-9 (p < 0.05). There was significant relation between cytology positivity and elevated CA19-9 in mucinous BOTs (p < 0.05). CONCLUSION: Serum tumor markers of serous and mucinous BOTs were different in relation to their clinicopathological features. This may reflect differences of serous and mucinous BOTs.

Does the localisation of tumour at stage I endometrial endometrioid adenocarcinoma have an impact on invasion of the tumour and individualisation of the surgical procedure?

OBJECTIVE: To detect whether the localisation of the tumour has an impact on the dissemination of the tumour and whether or not surgical procedures should be individualized according to the localisation of the tumour. MATERIAL METHOD: 106 clinically surgically stage I endometrial endometrioid carcinoma cases treated multi-institutionally at Gulhane Military Medical Academy (GATA) and Dr. Zekai Tahir Burak (ZTB) Women's Health Education and Research Hospital Gynecologic Oncology Units in the last five years were evaluated retrospectively. The tumours localised near the internal cervical os and not invading the cervical canal were accepted as lower uterine segment (LUS) localisation and the corporal location as upper uterine segment (UUS) localisation. RESULTS: Tumour localisation was more frequent in the upper segment than LUS (85.9% vs 14.1%). There was no statistically significant difference between only endometrial and only serous invasion rates. Myometrial invasion less than one-half was significantly higher in the UUS group than the LUS group (p < 0.05). Lymph vascular space involvement rate was significantly higher in the LUS group (60%, 9/15) than the UUS group (23 %, 21/91), (p < 0.01). Positive peritoneal cytology rate was 20% (3/15) in the LUS group and 6.6% (6/91) in the UUS group (p > 0.05). CONCLUSION: Patients with LUS involvement should be considered as high-risk patients. Thus more expanded surgery must be taken into consideration. In this study a limitation was the low number of patients with LUS involvement. Larger prospective studies are necessary to confirm our results.

Treatment of incidental adnexal masses at cesarean section: a retrospective study.

In this study, we evaluated the management of incidental adnexal masses observed at the time of cesarean section in our clinic during January 1992 to January 2005. The number of total live births was 35,153 and 8330 of them were by cesarean section (23.69%). There were 68 cases of incidental adnexal masses greater than 5 cm (68/8330, 0.8%). All of the masses were removed at cesarean section. The pathologic diagnosis of the masses were as follows: benign-benign cystic teratoma 20 (29.4%), simple serous cyst 8 (11.8%), simple mucinous 9 (13.2%), endometrioma 3 (4.4%), cystadenoma 14 (20.6%), and paraovarian-paratubal cyst 13 (19.1%) and malignant-struma ovarii 1 (1.5%). Cystectomy procedure during cesarean section did not alter the morbidity of the operation. So, we recommend resection of such incidental adnexal masses at cesarean section to avoid possible surgical procedures in future for the patient, although there is controversial data in literature.

The role of omentectomy and appendectomy during the surgical staging of clinical stage I endometrial cancer.

Assessment of extrauterine spread is the most important objective of surgical staging in the endometrioid adenocarcinoma of uterine corpus. The role of omentectomy and appendectomy in the staging procedure is unclear. In this study, our objective was to determine whether omentectomy and appendectomy should be a part of the surgical staging in endometrioid adenocarcinoma of uterine corpus. Fifty-one patients who were diagnosed as clinical stage I endometrioid adenocarcinoma of corpus uteri were reviewed. Demographic, clinicopathologic, and surveillance data were collected from hospital charts. Grade, myometrial invasion, cervical and adnexal involvement and positive peritoneal cytology, lymph node and omentum and appendix involvement were recorded. The median age of 51 women was 60.45 years. Median follow-up period was 46.19 months. Microscopic omental involvement was detected in three cases (6%). Two cases (3.9%) of metastasis to appendix were seen. Omentum metastasis was more common in the patient with adnexal involvement, lymph node metastasis, and deep myometrial invasion (P= 0. 014, P= 0. 046, and P= 0. 033, respectively). Median survival was 53 months. We conclude that omentectomy gives additional information about extrauterine spread of tumor without increased operational morbidity and should be performed as a component of surgical staging in the presence of normal appeared omentum.

CA19-9 may have clinical significance in mature cystic teratomas of the ovary.

The objective of this study was to evaluate size, bilaterality, histopathologic origin, and the serum levels of some tumor markers in patients with mature cystic teratomas (MCTs) of the ovary. Retrospective study of 80 patients operated at Department of Obstetrics and Gynecology, Gulhane Military Medical Academy, Turkey, between the years 1998 and 2003 was performed. The mean age was 33.1 +/- 11.3 years (median 34; range 15-69). The mean tumor diameter was 7.2 +/- 4.5 cm (median 5; range 3-20). The mean serum CA19-9 level was 101.2 +/- 179.7 IU/mL (range 1-841, normal value < 37), the mean serum CA125 level was 32.0 +/- 37.8 U/mL (range 2.2-205, normal value < 35), the mean carcino-embryogenic antigen (CEA) level was 1.46 +/- 1.20 ng/mL (range 0.2-4.8, normal value 3.4), and the mean serum alpha-fetoprotein (AFP) level was 2.7 +/- 3.0 ng/mL (range 0.1-10.5, normal value <8.1). The elevated rate of CA19-9, CA125, CEA, and AFP was 38.8% (31/80), 25% (18/72), 9.1% (4/44), and 8.7% (4/46), respectively. The bilaterality rate was 27.5% (22/80). Patients with an elevated serum CA19-9 level showed significantly higher bilaterality rate (51.6% versus 12.2%, P < 0.05) than the patients with low levels. Likelihood ratio for bilaterality was 2.8 for CA19-9 and 4.6 for CA125. Bilateral teratomas showed a significantly higher rate of ectodermal component than the unilateral ones (100% versus 74.3%, P < 0.05). Ovarian MCTs were diagnosed especially during the reproductive period. CA19-9 may be the only important marker in the diagnosis of MCTs. Elevated levels of CA19-9 and CA125 may be an indicator of bilaterality. Since levels of CA19-9 and CA125 may be elevated in both benign and malignant conditions, interpretation of these findings must be made in light of the clinical condition of the patient.

Solitary splenic metastasis of squamous cell carcinoma of the uterine cervix: a case report and review of the literature.

A 45-year-old patient presented with complaints of vaginal bleeding and pelvic pain. Fractioned probe curettage was performed and reported as Stage IIa, grade 3, squamous cell carcinoma of the uterine cervix. The patient underwent radical hysterectomy type III, bilateral salpingo-oophorectomy, omentectomy, appendectomy, and pelvic para-aortic lymph node dissection according to our clinical protocol. Adjuvant radiation therapy was planned. A splenic mass of 8 cm in diameter was revealed on computed tomography at the end of the third year of the disease-free follow-up period. Fine needle aspiration biopsy was performed and reported as metastatic carcinoma correlated to the previous cervical cancer. Debulking surgery was performed. The patient died one year after the second surgical operation. Spleen metastasis in patients with squamous cell carcinoma of the uterine cervix is exceedingly rare. Nonetheless we recommend screening of all intra-abdominal organs including the spleen as a rare metastastic site in follow-up examination protocols.

Is adjuvant therapy necessary for peritoneal cytology-positive surgical-pathologic Stage I endometrial cancer? Preliminary results.

OBJECTIVE: To compare the clinical and laboratory findings between adjuvant therapy performed and not performed on peritoneal cytology-positive patients with cytology-negative cases of surgical-pathologic Stage I endometrial cancer. METHODS: Twelve peritoneal cytology-positive and 12 negative surgical-pathologic Stage I endometrial cancer cases were used in the study. Adjuvant radiotherapy was performed for six cytology-positive patients (group I); no adjuvant therapy was performed for six cytology-positive (group II) and 12 cytology-negative patients (control group). Pelvic examination, vaginal cytology, serum CA125 levels and routine blood tests were checked at two-month intervals for two years and at six-month intervals for the third year. Abdominopelvic computerized tomography was planned annually. RESULTS: There was no statistically significant difference among the three groups and no recurrence in any group. CONCLUSION: We do not recommend adjuvant therapy for cytology-positive patients if the tumor is confined to the uterus.

Hormone replacement therapy in postmenopausal women with benign fibrocystic mastopathy.

OBJECTIVE: To compare the effects of five different hormone replacement regimens on fibrocystic mastopathy in postmenopausal women. DESIGN: This was a randomized, prospective, clinical, case-control study. METHODS: Two hundred and twelve women with benign cystic mastopathy were studied. The largest diameters of the breast cysts were measured using ultrasonography at study entry. Forty-eight women were randomized to the control group and did not take any medication. One hundred and sixty-four women were randomized to the following study groups. Group I (n = 46) were given conjugated estrogen (0.625 mg/day) and medroxyprogesterone acetate (5 mg/day) continuously. Group II (n = 22) were given only conjugated estrogens (0.625 mg/day) continuously; these were hysterectomized women. Group III (n = 32) were given transdermal estrogen (50 microg/day) and medroxyprogesterone acetate (5 mg/day) continuously. Group IV (n = 32) were given only transdermal estrogen (50 microg/day) continuously; these were also hysterectomized women. Group V (n = 32) were given tibolone (2.5 mg/day) continuously. Hormone therapy was continued for 12 months. Every 3 months the women were rescanned using ultrasonography to determine cyst diameters and examine characteristics such as internal echogenicity, and thickness and regularity of the cyst wall. Statistical assessment used Students' t test and Friedman analysis. RESULTS: In the control group, there was no statistically significant change in cyst dimensions. However, tibolone was associated with a decrease in cyst dimensions which was statistically significant, but none of the other four hormone replacement therapy regimens caused any significant negative effect on the benign cystic mastopathy.

Pelvic-paraaortic lymphadenectomy in clinical Stage I endometrial adenocarcinoma: a multicenter study.

PURPOSE: To show the importance of complete surgical pathologic staging of clinical Stage I endometrial adenocarcinoma. METHODS: A total of 106 consecutive cases of clinical Stage I endometrial adenocarcinomas in two different centers were studied. RESULTS: We found an isolated paraaortic invasion in one patient without pelvic node invasion (0.94%). There were only three cases of pelvic lymph-node invasion (2.83%) and three cases of pelvic-paraaortic lymph-node invasion. CONCLUSION: We recommend complete lymphadenectom; the real stages of the cases can be determined more correctly and excessive treatments can be avoided.

Yolk sac size and shape as predictors of poor pregnancy outcome.

Two hundred and fifty women, underwent endovaginal sonography in the first trimester to establish the normal size and shape of the secondary yolk sac and to assess the value of yolk sac evaluation in predicting poor pregnancy outcome. We calculated the correlation coefficients between yolk sac and menstrual age, yolk sac and crown-rump length and between yolk sac and mean gestational yolk sac diameter as r: 0.9581 (p < 0.001), r: 0.9427 (p < 0.0001) and r: 0.8855 (p < 0.0001), respectively. Of 250 cases, 219 had a normal pregnancy course through the end of the first trimester (Group I) while 31 had a poor prognosis such as abortion or embryonic demise (Group II). Eight of 219 in Group I and 20 of 31 in Group II had an abnormal yolk sac size. A yolk sac diameter out of two standard deviations of the mean for the menstrual age allowed prediction of an abnormal pregnancy outcome with a sensitivity of 65%, a specificity of 97%, a positive predictive value of 71%, and a negative predictive value of 95%. Ten of 219 and 9 of 31 had abnormal yolk sac shape. An abnormal yolk sac shape allowed prediction of an abnormal pregnancy outcome with a sensitivity of 29%, a specificity of 95%, a positive predictive value of 47% and a negative predictive value of 90.5%. We concluded that secondary yolk sac evaluation is a valuable tool to predict pregnancy outcome.