Deep obturator lymph node dissection in gynaecological cancer patients: Is it feasible and useful?

Our aim was to investigate the feasibility and outcomes of deep obturator lymph node (DOLN) dissection in gynaecological cancer patients. A prospective study included 62 patients with a diagnosis of ovarian, endometrial or cervical cancer who underwent surgery. In the study group, 36 patients underwent obturator lymph node dissection above and under the obturator nerve, while 26 control group patients underwent routine obturator lymph node dissection above the obturator nerve. Groups were compared with respect to dissected lymph node count, intraoperative characteristics and early postoperative complications. Total lymph node count in the DOLN dissected group was greater than that in the control group, and the difference was statistically significant. No statistically significant difference was found between the groups, regarding postoperative complications and intraoperative characteristics. The total number of lymph nodes dissected by using DOLN dissection increased without an increase in intra- and postoperative complications in gynaecological cancer patients.

The Value of Preoperative CA 125 Levels in Prediction of Myometrial Invasion in Patients with Early-stage Endometrioid- type Endometrial Cancer.

AIM: To evaluate the relationship between pre-operative CA-125 levels and myometrial invasion in patients with early-stage endometrioid-type endometrial cancer. MATERIALS AND METHODS: Two-hundred and sixty patients were diagnosed with endometrial cancer between January 2007 and December 2012. Of these, 136 patients with stage 1 endometrioid histologic-type and documented pre-operative serum CA-125 levels were included in the study. Age, preoperative CA-125 level, histologic grade, surgical grade, and presence of deep myometrial invasion were recorded. Additionally, 16, 20, and 35 IU/ml cutoff values were used and compared to evaluate the relationship between pre-operative CA-125 levels and myometrial invasion. RESULTS: The average serum CA-125 level was 35.4±36.7 in patients with deep myometrial invasion, and 21.5±35.8 in cases without deep myometrial invasion. The relationship between the presence of deep myometrial invasion and CA-125 cut-off values (16, 20, 35 IU/ml) was statistically significant, although the correlation was weak (p<0.05). When the relationship between 16, 20 and 35 IU/ml CA-125 cut-off values and the presence of deep myometrial invasion was studied, specifity and sensitivity values were identified as: 0.60-0.68 for 16 IU/ml; 0.73-0.48 for 20 IU/ml; and 0.89-0.33 for 35 IU/ml. The sensitivity of 16 IU/ml cut-off value was higher when compared to other values. CONCLUSIONS: This study demonstrates that preoperative serum CA-125 values maybe used as a predictive test in patients with early stage endometrioid-type endometrium cancer, and as a prognostic factor alone. Further studies should be conducted to identify different CA-125 cut-off values in patients with low risk endometrial cancer.

Comparison of myometrial invasion and tumor free distance from uterine serosa in endometrial cancer.

BACKGROUND: We aimed to investigate whether the tumor free distance (the distance between the uterine serosa and the tumor at its deepest point) is useful in surgical staging and in predicting prognosis. MATERIALS AND METHODS: Data from patients who underwent complete surgical staging for endometrial cancer between January 2006 and June 2011 were reviewed retrospectively. All demographic findings, surgical stages, histological type and grade, myometrial invasion, lymphovascular space invasion as well as abdominal cytology, cervical, adnexal, and omental involvement, and lymph node metastasis were recorded. The relations between myometrial invasion and tumor free distance from uterine serosa with prognostic factors were investigated. RESULTS: Seventy patients were included in the study. Sixty-four (91.5%) had endometrioid type cancers and forty-four (62.9%) were grade 1. The deepest myometrial invasion was less than 1/2 in 42 patients (60%). In 18 patients (25.8%) lymphovascular invasion was noted. Eight (11.4%) were found to have cervical involvement, five (7.1%) had adnexal involvement and in 4 cases (5.7%) the peritoneal washings included malignant cells. Four patients had pelvic and one para-aortic node metastasis. We recognized that an invasion of more than 1/2 was correlated significantly with lymphovascular space involvement, histological grade, positive abdominal washing cytology, nodal and cervical involvement, but not with adnexal involvement. Tumor-free myometrial thickness was negative and statistically significant correlated with surgical stage, histological grade, lymphovascular space involvement, positive abdominal washing cytology, cervical and adnexal involvement. The importance of tumor- free myometrial thickness in determinating the lymphovascular space invasion was found to be highest in terms of sensitivity and specificity when crossing the ROC curve at 11 millimeters. CONCLUSIONS: Depth of myometrial invasion is more valuable for predicting lymph node metastasis than tumor-free myometrial thickness. The tumor-free myometrial thickness provides a better prediction for adnexal involvement.

Impact of prognostic factors on survival rates in patients with ovarian carcinoma.

PURPOSE: The aim of the present study was to invesitigate the impact of significant clinico-pathological prognostic factors on survival rates and to identify factors predictive of poor outcome in patients with ovarian carcinoma. MATERIALS AND METHODS: A retrospective chart review of 74 women with pathologically proven ovarian carcinoma who were treated between January 2006 and April 2011 was performed. Patients were investigated with respect to survival to find the possible effects of age, gravida, parity, menstruel condition, pre-operative Ca-125, treatment period, cytologic washings, presence of ascites, tumor histology, stage and grade, maximal tumor diameter, adjuvan chemotherapy and cytoreductive success. Also 55 ovarian carcinoma patients were investigated with respect to prognostic factors for early 2-year survival. RESULTS: The two-year survival rate was 69% and the 5-year survival rate was 25.5% for the whole study population. Significant factors for 2-year survival were preoperative CA-125 level, malignant cytology and FIGO clinical stage. Significant factors for 5-year survival were age, preoperative CA-125 level, residual tumor, lymph node metastases, histologic type of tumor, malignant cytology and FIGO clinical stage. Logistic regression revealed that independent prognostic factors of 5-year survival were patient age, lymph node metastasis and malignant cytology. CONCLUSIONS: We consider quality registries with prospectively collected data to be one important tool in monitoring treatment effects in population-based cancer research.

Multicenter analysis of gestational trophoblastic neoplasia in Turkey.

BACKGROUND: To evaluate the incidence, diagnosis and management of GTN among 28 centers in Turkey. MATERIALS AND METHODS: A retrospective study was designed to include GTN patients attending 28 centers in the 10-year period between January 2003 and May 2013. Demographical characteristics of the patients, histopathological diagnosis, the International Federation of Gynecology and Obstetrics (FIGO) anatomical and prognostic scores, use of single-agent and multi-agent chemotherapy, surgical interventions and prognosis were evaluated. RESULTS: From 2003-2013, there were 1,173,235 deliveries and 456 GTN cases at the 28 centers. The incidence was calculated to be 0.38 per 1,000 deliveries. According to the evaluated data of 364 patients, the median age at diagnosis was 31 years (range, 15-59 years). A histopathological diagnosis was present for 45.1% of the patients, and invasive mole, choriocarcinoma and PSTTs were diagnosed in 22.3% (n=81), 18.1% (n=66) and 4.7% (n=17) of the patients, respectively. Regarding final prognosis, 352 (96.7%) of the patients had remission, and 7 (1.9%) had persistence, whereas the disease was mortal for 5 (1.4%) of the patients. CONCLUSIONS: Because of the differences between countries, it is important to provide national registration systems and special clinics for the accurate diagnosis and treatment of GTN.

Tumor-like cystic endosalpingiosis in the myometrium: a case report and a review of the literature.

Endosalpingiosis is a disorder of the Mullerian system characterized by benign glands lined with tubal type epithelium and involves the peritoneum, subperitoneal tissues and retroperitoneal lymph nodes. Myometrial endosalpingiosis is very rare. A 44-year-old female presented to the hospital complaining of menorrhagia. Gynecological and radiologic examination revealed a pelvic mass 7.5 cm in diameter, suggestive of a leiomyoma with secondary cystic changes. The gross examination showed an intramural large cyst within the right fundic wall of the uterus. Microscopically, the cyst consisted of multiple micro-macro cysts lined with benign tubal epithelium. With these findings, the diagnosis was cystic endosalpingiosis. In this report, the clinicopathologic features of a cystic endosalpingiosis case located in the myometrium was presented with a review of the literature.

Effect of surgical staging on 539 patients with borderline ovarian tumors: a Turkish Gynecologic Oncology Group study.

OBJECTIVE: The objectives of this study were to examine demographic and clinicopathologic characteristics and to determine the effects of primary surgery, surgical staging and the extensiveness of staging. METHODS: In a retrospective Turkish multicenter study, 539 patients, from 14 institutions, with borderline ovarian tumors were investigated. Some of the demographic, clinical and surgical characteristics of the cases were evaluated. The effects of type of surgery, surgical staging; complete or incomplete staging on survival rates were calculated by using Kaplan-Meier method. RESULTS: The median age at diagnosis was 40 years (range 15-84) and 71.1% of patients were premenopausal. The most common histologic types were serous and mucinous. Majority of the staged cases were in Stage IA (73.5%). 242 patients underwent conservative surgery. Recurrence rates were significantly higher in conservative surgery group (8.3% vs. 3%). Of all patients in this study, 294 (54.5%) have undergone surgical staging procedures. Of the patients who underwent surgical staging, 228 (77.6%) had comprehensive staging including lymphadenectomy. Appendectomy was performed on 204 (37.8%) of the patients. The median follow-up time was 36 months (range 1-120 months). Five-year survival rate was 100% and median survival time was 120 months. Surgical staging, lymph node sampling or dissection and appendectomy didn't cause any difference on survival. CONCLUSION: Comprehensive surgical staging, lymph node sampling or dissection and appendectomy are not beneficial in borderline ovarian tumors surgical management.

HPV types in Turkey: multicenter hospital based evaluation of 6388 patients in Turkish gynecologic oncology group centers.

OBJECTIVE: To evaluate the prevalence of HPV DNA and cervical cytological abnormalities, to compare cervical cytology results and HPV DNA and to define HPV types distribution in a large series of Turkish women who have undergone HPV analysis in hospitals that are members of the Turkish Gynecological Oncology Group. MATERIAL AND METHOD: Between 2006 and 2010, a total of 6388 patients' data was retrospectively evaluated at 12 healthcare centers in Turkey. Demographic characteristics, cervical cytology results, HPV status and types were compared. RESULTS: The mean age of the patients was 38.9±10.2. Overall, 25% of the women were found to be HPV positive. Presence of HPV-DNA among patients with abnormal and normal cytology was 52% and 27%, respectively. There was significant difference with respect to decades of life and HPV positivity (p < 0.05). HPV was positive in (within the HPV (+) patients) 37%, 9%, 27%, 20%, 22%, and 41% of the ASCUS, ASC-H, LSIL HSIL, glandular cell abnormalities, and SCC cases respectively The most common HPV types in our study were as follows; HPV 16 (32%), HPV 6 (17%), HPV 11 (9%), HPV 18 (8%), HPV 31 (6%), HPV 51 (5%), HPV 33 (3%). CONCLUSION: In this hospital based retrospective analysis, HPV genotypes in Turkish women with normal and abnormal cytology are similar to those reported from western countries. Further population based prospective multicenter studies are necessary to determine non-hospital based HPV prevalence in Turkish women.

Hydatidiform mole in Turkey: results from six centers.

OBJECTIVE: To evaluate the clinical profile of gestational trophoblastic disease and to determine the incidence of hydatidiform mole (HM) from six centers in Turkey. STUDY DESIGN: A retrospective analysis of patients diagnosed with HM in six medical centers in Turkey from 2000 to 2010 was undertaken. Patients' age, gravidity, parity and abortion, presenting signs, histopathological results and their follow-up were recorded. RESULTS: From 2000 to 2010, 351,650 deliveries were recorded in six centers in Turkey, and 263 cases were diagnosed as HMs. Of the 263 patients the mean age was 28.2 years. The mean numbers of gravidity, parity and abortion were 2.6, 1.3 and 0.3, respectively. According to the medical histories, 3 (1.1%) patients had molar pregnancy previously and the presenting symptom was vaginal bleeding in symptomatic cases. After evacuation, histopathologic examination revealed complete mole in 175 (66.5%) patients and partial mole in 86 (32.6%) patients, and methotrexate was given as a prophylactic chemotherapy in 17 patients (6.4%) while 6 (2.2%) patients underwent hysterectomy procedure. CONCLUSION: According to the results the incidence of molar pregnancy is 0.7/1,000 deliveries. Because of its rarity, multicenter, community-based studies are needed to determine the real incidence.

Preoperative serum CA 125 level in the prediction of the stage of disease in endometrial carcinoma.

OBJECTIVE: To evaluate whether a preoperative serum CA-125 level in patients with endometrial carcinoma can provide additional information in determining the stage of disease, and which cutoff value is optimal in this respect. STUDY DESIGN: Retrospective chart review of 147 women with pathologically proven endometrial carcinoma who were treated between January 1999 and May 2009. The associations of preoperative CA-125 levels with the tumor stage, histologic type and grade, and the lymph node positivity were examined. To determine the values of cutoff point levels for serum tumor marker CA-125, the levels of 20 IU/ml and 35 IU/ml were compared. RESULTS: High CA-125 levels significantly correlated with advanced stage and lymph node metastases. The ROC curve determined that the best cutoff value was 20 U/ml. The sensitivity and specificity of a CA-125 cutoff level of 20 U/ml were 75% and 69.51%, respectively, with a positive predictive value of 80.6% and negative predictive value of 84.9%. CONCLUSION: The current study suggests that measurement of preoperative CA-125 is a clinically useful test in endometrial carcinoma patients. CA-125 appears to be a significant independent predictor of the advanced stage of the disease as well as lymph node metastases. The results complement a growing body of literature that supports the relationship between CA-125 level and stage of disease but more studies are needed to establish the appropriate cutoff level for serum CA-125 in this respect.

Efficacy of electrosurgical bipolar vessel sealing for abdominal hysterectomy with uterine myomas more than 14 weeks in size: a randomized controlled trial.

OBJECTIVE: To compare electrosurgical bipolar vessel sealing with conventional suturing during abdominal hysterectomy. METHODS: This was a randomized controlled prospective study. A total of 88 patients with myoma uteri larger than 14 weeks in size were divided into two groups: group A (44 patients who were administered the LigaSure vessel sealing system during surgery) and group B (44 patients who were administered conventional sutures during surgery). Total abdominal hysterectomy was performed in all patients. Hemoglobin reduction, operation time, hospital stay and visual analogue scale parameters of patients in both groups were compared. SPSS 16.0 was utilized in statistical analyses. The outcomes with a 95% confidence interval and a p value of less than 0.05 were regarded as significant. RESULTS: When the two groups were compared, it was observed that the LigaSure device significantly reduced the operation time (p < 0.05). Nevertheless, no statistically significant difference was determined in hemoglobin reduction, hospital stay and visual analogue scale parameters between the two groups. CONCLUSION: In myoma uteri cases larger than 14 weeks in size, LigaSure vessel sealing is a secure and comfortable method for surgeons to achieve shorter operation times in abdominal hysterectomy.

Cofactors in human papillomavirus infection and cervical carcinogenesis.

OBJECTIVE: This study aimed to identify the effect of various risk factors as the promoters of HPV infection, and to identify which HPV-positive women may have an increased risk of developing cervical cancer. METHODS: Smear preparations were examined and classified according to the Bethesda system. HPV-DNA detection and genotyping was carried out using polymerase chain reaction combined with reverse hybridization line-probe assays. Age, smoking habit, age at first sexual intercourse, number of sexual partners, number of term births, contraceptive method, progesterone therapy, history of sexually transmitted diseases, history or existence of warts and existence of cervical infection were recorded. RESULTS: 642 women (96 women with abnormal cervical cytology and 546 women with normal cytology) provided cervical samples. Smoking habit, number of sexual partners, number of term births, history of sexually transmitted diseases, history or existence of warts and existence of cervical infection were identified as the promoters of HPV infection. History of sexually transmitted diseases, history or existence of warts and existence of cervical infection were identified as cofactors affecting progression from HPV infection to cervical cancer. Neither of contraceptive methods studied was related to HPV infection or coexistence with malign transformation to cervical cancer. CONCLUSION: Information gathered from this study could be used to prioritize limited screening and treatment services to woman who have specific characteristics that may put them at an increased risk of HPV infection. Additionally, by identifying which women have a higher risk of cervical cancer; it may be possible to reduce the number of unnecessary colposcopies.

Comparision of Burch colposuspension and colporraphy anterior-Kelly plication operations for effectiveness and influence on life quality.

OBJECTIVE: Our aim was to compare the effectivenesses and influences on life quality rates of patients who underwent Burch Colposuspension or Colporaphy Anterior-Kelly Plication for the surgical treatment of stress urinary incontinence (SUI). MATERIALS AND METHODS: 81 patients who applied to Izmir Ataturk Training and Research Hospital 3rd Obstetrics and Gynecology Department between the dates of January 2006 and June 2007 with complaints of urinary leakage and were diagnosed as SUI were included to our study. 41 patients (50.6%) underwent Burch colposuspension and ColporaphyAnterior-Kelly Plication were applied to 40 patients (49.4%). Patients were reexamined after 6 months following discharge in terms of complications, stress test, patient complaints and life quality scores. RESULTS: The mean age of patients as well as the number of postmenauposal ones who underwent Colporaphy Anterior-Kelly Plication was significantly higher (p < 0.05). The difference of hospitalization was statistically insignificant between two groups (p = 0.413, p > 0.05). Also the differences for the 6th month postoperative stres test results were statistically insignificant (p > 0.05). Life Quality Inqury results differences were statistically insignificant (p > 0.05). Preoperative and postoperative scores of the patients were compared and convalescence was detected. This convalescence was statistically significant for each three tests (p < 0.05). DISCUSSION: In this study the success rates were 87.8% for the Burch procedure and 75% for Colporaphy Anterior-Kelly Plication. all of the patients had benefited from both operations according to life quality inquries. Besides the fact that the Burch procedure is the gold standart for SUI Colporaphy Anterior-Kelly plication might be chosen for the older patients with pelvic organ prolapse (POP). There were no significant differences in terms of complications. The results of our study were consistent with those of other publications. Currently Burch operation is the gold standard treatment modality for SUI. Use of life quality inquries proved to be useful in patients' convalescence follow-up.

Urinary ascites following total abdominal hysterectomy.

Intraperitoneal urinary bladder perforation should be in differential diagnosis of acute renal failure soon after gynecological surgery. We present a case of massive urinary ascites and acute renal failure in a patient who presented 1 week after a total abdominal hysterectomy for simple endometrial hyperplasia. Biochemical features of uremia occur as a result of intraperitoneal extravasation of urine from urinary bladder and reabsorbtion through the peritoneum. Since those were the doctors who first diagnosed the patient, nephrologists performed dialysis therapy. After that long interval urinary catheterization of the patient had been applied. Without surgical repair and with long interval uretral catheterization primary dramatic resolution was seen as we expected. Nephrologists and gynecologists should be aware of this condition since pseudorenal failure which may resolve without dialysis might be seen due to intraperitoneal uinary bladder rupture following gynecological operations.

Prevalence and risk factors for human papillomavirus DNA in cervical cytology.

OBJECTIVES: This study aimed to detect the presence and prevalence of HPV-DNA in the cervical swab samples obtained from patients with cervical cancer, premalignant cervical lesions and benign cervical smear results, and to identify the potential risk factors influencing this prevalence. STUDY DESIGN: Smear preparations were examined and classified according to the Bethesda system. HPV-DNA detection and genotyping was carried out using polymerase chain reaction combined with reverse hybridization line-probe assays. Age, smoking habit, age at first sexual intercourse, number of sexual partners, number of term births, contraceptive method, progesterone therapy, history of sexually transmitted diseases, history or existence of warts, existence of cervical infection and the history of circumcision of male sexual partners were recorded. RESULTS: Six hundred and forty-two women (96 women with abnormal cervical cytology and 546 women with normal cytology) provided cervical samples. Multiplex PCR testing revealed that prevalence of HPV-DNA was 38.9% in our study population. HPV-DNA was detected in 78.3% of the women with cervical cancer and 76.9% of the women with HGSIL. Abnormal cervical cytology was observed in 30% of HPV-DNA positive cases and in 5.4% of HPV-DNA negative cases. Our findings also indicate that smoking habit, number of sexual partners, history of sexually transmitted diseases, and abnormal cervical cytology were associated with HPV infection. With respect to parity, there was a decreased risk of HPV infection with the increase in the number of births. CONCLUSIONS: Estimates of the prevalence of HPV infection vary greatly around the world, so the factors that contribute to the rare occurrence of cervical cancer after HPV infection might also differ from country to country. Information gathered from this study could be used to prioritize limited screening and treatment services given to woman who have specific characteristics that may put them at an increased risk of HPV disease.