The safety of major gynaecologic cancer surgery without routine preoperative COVID-19 testing in the COVID-19 era: a multicentre, retrospective, case-control study.

Our goal was to address the safety of major gynaecologic cancer surgery without routine preoperative COVID-19 testing in the COVID-19 era. The databases of seven gynaecologic cancer centres were searched in order to identify all consecutive gynaecologic cancer patients undergoing major surgery between March 11, 2020 and May 15, 2020 for this retrospective, case-control study. The case group consisted of patients with histopathologically confirmed gynaecologic cancers, and each case was matched with two counterparts who had undergone primary surgery before the COVID-19 pandemic. The case and the control groups were compared in terms of length of hospital stay, admission to the intensive care unit (ICU), intraoperative and postoperative complications.During the study period, 154 women with gynaecologic cancer undergoing major surgery were identified. Although the case group had more co-morbidities compared to the control group (103/154 vs. 178/308, respectively; p = .04), the median length of hospital stays, the rate of ICU admission, intraoperative complication rates and postoperative complication rates were similar in the two groups. Gynaecologic cancer surgery may be performed safely in the COVID-19 era with similar rates of ICU admission, intraoperative and postoperative complications compared to the patients operated before the COVID-19 pandemic.IMPACT STATEMENTWhat is already known on this subject? Many societies have announced their guidelines about the surgical management of gynaecologic cancer patients during the COVID-19 pandemic. However, most of them are not evidence-based and mostly on expert opinions.What do the results of this study add? The main findings of this retrospective, case-control study indicate that the short-term (30 day) outcomes of gynaecologic cancer patients undergoing major surgery in the COVID-19 era are similar to those who had been operated before the COVID-19 pandemic. The length of hospital stays, the rates of admission to the ICU, intraoperative and postoperative complications were comparable between women undergoing major gynaecologic cancer surgery in the COVID-19 era and the women who had been operated before the pandemic.What are the implications of these findings for clinical practice and/or further research? We can suggest that definitive surgery may be performed for gynaecologic cancer patients in the COVID-19 era if the resources permit and appropriate precautions such as social distancing, isolation and the use of personal protective equipment are taken.

Is the extent of lymphadenectomy a prognostic factor in International Federation of Gynecology and Obstetrics stage II endometrioid endometrial cancer?

AIM: This study aimed to evaluate the prognostic significance of adequate lymph node dissection (LND) (≥10 pelvic lymph nodes (LNs) and ≥ 5 paraaortic LNs removed) in patients with International Federation of Gynecology and Obstetrics (FIGO) stage II endometrioid endometrial cancer (EEC). METHODS: A multicenter department database review was performed to identify patients who had been operated and diagnosed with stage II EEC at seven centers in Turkey retrospectively. Demographic, clinicopathological, and survival data were collected and analyzed. RESULTS: We identified 284 women with stage II EEC. There were 170 (59.9%) patients in the adequate lymph node dissection (LND) group and 114 (40.1%) in the inadequate LND group. The 5-year overall survival (OS) rate of the inadequate LND group was significantly lower than that of the adequate LND group (84.1% vs. 89.1%, respectively; p = 0.028). In multivariate analysis, presence of lymphovascular space invasion (LVSI) (hazard ratio [HR]: 2.39, 95% confidence interval [CI]: 1.23-4.63; p = 0.009), age ≥ 60 (HR: 3.30, 95% CI: 1.65-6.57; p = 0.001], and absence of adjuvant therapy (HR: 2.74, 95% CI: 1.40-5.35; p = 0.003) remained as independent risk factors for decreased 5-year disease-free survival (DFS). Inadequate LND (HR: 2.34, 95% CI: 1.18-4.63; p < 0.001), age ≥ 60 (HR: 2.67, 95% CI: 1.25-5.72; p = 0.011), and absence of adjuvant therapy (HR: 4.95, 95% CI: 2.28-10.73; p < 0.001) were independent prognostic factors for decreased 5-year OS in multivariate analysis. CONCLUSION: Adequate LND and adjuvant therapy were significant for the improvement of outcomes in FIGO stage II EEC patients. Furthermore, LVSI was associated with worse 5-year DFS rate in stage II EEC.

Retrospective Analysis of Pure Ovarian Immature Teratoma in Patients Aged 15-39 Years: A Turkish Multicenter Study.

Purpose: To evaluate the clinicopathological characteristics and surgical outcomes in patients with pure ovarian immature teratomas (POITs). Materials and Methods: In this multicenter study, a retrospective review was made of the databases of six Gynecology Oncology Departments in Turkey to identify patients with POITs who had undergone surgery between 1993 and 2019. Results: Evaluation was made of 48 patients with a median age at diagnosis of 22.5 years (range, 15-37 years). In 40 (83%) patients, stage I was determined and in eight patients, an advanced stage (IIIB, IIIC, and IVB) was determined. Tumors were found to be grade I in 17 (35.4%) cases, grade II in 12 (25%), and grade III in 19 (39.6%). Fertility-sparing surgery was applied to 42 (87.5%) patients and radical surgery to 6 (12.5%). The median follow-up was 60 months (range, 3-246 months). Recurrence was seen in seven patients, all with grade III tumors. In the final pathological examination of recurrent tumors, mature teratoma was reported in five patients, and immature teratoma in one patient. Salvage surgery was not performed in one patient as the tumor was unresectable and so a regimen of bleomycin, etoposide, and cisplatin (BEP) was administered. Conclusion: POITs are rare tumors seen at a young age, and benign or malignant relapse can be seen in these tumors. In this cohort, the malignant recurrence rate was 4.1%, and the benign recurrence rate was 10.4%. All the recurrences were in grade III tumors. Benign recurrences can be treated with surgery alone and the malignant group should be treated with surgery followed by chemotherapy.

Relationship of lymph node status with survival and recurrence among women with endometrial cancer.

OBJECTIVE: To explore the relationship of lymph node ratio (LNR) and other lymph node parameters with disease-free (DFS) and overall (OS) survival among women with endometrial cancer. METHODS: Retrospective analysis of data of women diagnosed with endometrial cancer at Hacettepe University Hospitals, Ankara, Turkey, between 2003 and 2013. Women who had their surgical procedure, pathology review, and follow-up at Hacettepe University Hospitals were included in the study. Receiver operator characteristic (ROC) curve analysis was used to determine the threshold LNR associated with survival. RESULTS: Overall, 376 women were included in the study. A higher number of excised metastatic lymph nodes was associated with decreased survival. ROC curve analysis determined a threshold LNR of 0.03. Women with LNR higher than 0.03 had decreased DFS (P<0.001) and OS (P<0.001) relative to those with LNR of 0.03 or lower. LNR of 0.1 was found to be a significant cutoff value for DFS (P=0.023) and OS (P=0.036) among women with at least one metastatic lymph node. CONCLUSION: LNR may be used as a prognostic tool in endometrial cancer. Future studies will help to define a precise threshold of LNR in order to implement this prognostic factor in daily practice.

Using a pessary during radiotherapy in reducible pelvic organ prolapse and vaginal cancer: a case report and review of the literature.

PURPOSE: Primary vaginal cancer and pelvic organ prolapse (POP) combination is extremely rare. Although definitive chemoradiotherapy (CRT) and brachytherapy (BT) is the standard treatment for advanced stage primary vaginal cancer, there is a limited data about the treatment of primary vaginal cancer combined with POP due to its rarity. In addition, radiotherapy (RT) process may be difficult in these cases and often result in more toxicity. CASE PRESENTATION: In this case report, we present a 77-year-old woman with a diagnosis of primary vaginal cancer associated with POP, who was treated with definitive CRT using a pessary to restore vaginal anatomy for optimal radiation. Following CRT, complete response was observed and vaginal cuff BT was performed. The patient tolerated the treatment very well and is still alive without disease at 10-months follow-up. CONCLUSIONS: Combined primary vaginal cancer and POP is an extremely rare clinical entity, with only a few cases reported in the literature. When applying CRT in these cases, critical organ doses may be higher than expected due to the downward descent of the pelvic organs. Especially in elderly patients, a pessary can be used as a non-surgical procedure to restore the anatomy for symptom relief during definitive CRT. Additionally, it allows tumors to be targeted more precisely.

Does tumor size have prognostic value in patients undergoing lymphadenectomy in endometrioid-type endometrial cancer confined to the uterine corpus?

Background/aim: We aimed to define the effect of tumor size on recurrence and survival rates in patients with stage I­II endometrioid-type endometrial cancer. Materials and methods: A total of 550 patients who had total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic-paraaortic lymphadenectomy were included. Patients with extrauterine spread, sarcomatous components, or synchronized tumor and those who did not undergo lymphadenectomy or did not have data on tumor size were excluded. Results: The median tumor size was 35 mm (range: 3­335 mm). According to the 2009 International Federation of Obstetrics and Gynecology (FIGO) criteria, 245 cases were defined as stage IA, 271 as stage IB, and 34 as stage II. The 5-year disease-free survival (DFS) rate was 92% and the 5-year disease-specific survival (DSS) rate was 99%. The effects of prognostic factors on DFS were evaluated. Older age, stage II disease, deep myometrial invasion, and receiving adjuvant radiotherapy were associated with decreased DFS. There was no statistically significant association between tumor size and DFS. The 5-year DFS for patients with a tumor diameter of <35 mm, which was the median tumor size of the entire group, was 94%, while it was 89% for patients having a tumor diameter of >35 mm (P = 0.128). Conclusion: Tumor size was not a risk factor predicting recurrence in patients with stage I or II endometrioid-type endometrial cancer who had lymphadenectomy.

Prognostic factors and oncological outcomes of ovarian yolk sac tumors: a retrospective multicentric analysis of 99 cases.

PURPOSE: To investigate the clinico-pathological prognostic factors and treatment outcomes in patients with ovarian yolk sac tumors (YST). METHODS: A multicenter, retrospective department database review was performed to identify patients with ovarian YST who underwent surgery between 2000 and 2017 at seven Gynecologic Oncology Centers in Turkey. RESULTS: The study group consisted of 99 consecutive patients with a mean age of 23.9 years. While 52 patients had early stage (stage I-II) disease, the remaining 47 patients had advanced stage (stage III-IV) disease. The uterus was preserved in 74 (74.8%) of the cases. The absence of gross residual disease following surgery was achieved in 76.8% of the cases. Of the 54 patients with lymph node dissection (LND), lymph node metastasis was detected in 10 (18.5%) patients. Of the 99 patients, only 3 patients did not receive adjuvant therapy, and most of the patients (91.9%) received BEP (bleomycin, etoposide, cisplatin) chemotherapy. Disease recurred in 21 (21.2%) patients. The 5-year disease-free survival (DFS) and overall survival (OS) in the entire cohort were 79.2% and 81.3%, respectively. In multivariate analysis, only residual disease following initial surgery was found to be significantly associated with DFS and OS in patients with ovarian YST (p = 0.026 and p = 0.001, respectively). CONCLUSIONS: Our results demonstrate the significance of achieving no visible residual disease in patients with ovarian YST. Fertility-sparing approach for patients with no visible residual disease affected neither DFS nor OS. Although high lymphatic involvement rate was detected, the benefit of LND could not be demonstrated.

Effect of Adjuvant Therapy on Oncologic Outcomes of Surgically Confirmed Stage I Uterine Carcinosarcoma: a Turkish Gynecologic Oncology Study

Background: Uterine carcinosarcoma is rare neoplasm that mostly presents as metastatic disease. Stage is one of the most important prognostic factor, however, the management of the early stage uterine carcinosarcoma is still controversial. Aims: To evaluate prognostic factors, treatment options, and survival outcomes in patients with surgically approved stage I uterine carcinosarcoma. Study Design: Cross-sectional study. Methods: Data of 278 patients with uterine carcinosarcoma obtained from four gynecologic oncology centers were reviewed, and 70 patients with approved stage I uterine carcinosarcoma after comprehensive staging surgery were studied. Results: The median age of the entire cohort was 65 years (range; 39-82). All patients underwent both pelvic and paraaortic lymphadenectomy. Forty-one patients received adjuvant therapy. The median follow-up time was 24 months (range; 1-129). Nineteen (27.1%) patients had disease failure. The 3-year disease-free survival and cancer-specific survival of the entire cohort was 67% and 86%, respectively. In the univariate analysis, only age was significantly associated with disease-free survival (p=0.022). There was no statistical significance for disease-free survival between observation and receiving any type of adjuvant therapy following staging surgery. Advanced age (<75 vs ≥75 years) was the only independent prognostic factor for recurrence (hazard ratio: 3.8, 95% CI=1.10-13.14, p=0.035) in multivariate analysis. None of the factors were significantly associated with cancer-specific survival. Conclusion: Advanced age was the only independent factor for disease-free survival in stage I uterine carcinosarcoma. Performing any adjuvant therapy following comprehensive lymphadenectomy was not related to the improved survival of the stage I disease.

Imaging in secondary tumors of the ovary.

Metastatic involvement of the ovaries is not rare. The most common tumor types metastasizing to the ovaries, from non-gynecological organs, are breast, colorectal, gastric, and appendix tumors. Lymphogenous, hematogenous, and transcoelomic pathways have all been proposed among potential pathways. Early diagnosis and treatment have an important potential to improve the patient outcome. Krukenberg tumors typically appear as complex semisolid masses with varying amounts of solid and cystic components. Ovarian metastases from the colon primaries are predominantly cystic in nature. Secondary lymphomatous involvement of ovary is mostly bilateral and solid with heterogeneous signal intensity on MRI. Metastatic breast cancer to the ovaries is typically bilateral and tends to be of small size. Among all the other imaging characteristics, bilateral involvement of secondary tumors of the ovary appears to be most potentially helpful finding in differentiating from primary ones.

Comparison of Mayo and Milwaukee Risk Stratification Models for Predicting Lymph Node Metastasis in Endometrial Cancer.

OBJECTIVE: The aim of this study was to compare Mayo and Milwaukee risk stratification models for predicting lymphatic dissemination in patients with endometrial cancer (EC). METHODS: A total of 904 patients with EC underwent surgical treatment between 2004 and 2016 at Hacettepe University Hospital, and clinicopathological data of patients were retrieved from the computerized database of the Hacettepe University. Patients who did not undergo lymphadenectomy and who had nonendometrioid histology, stage-IV disease, and synchronous epithelial ovarian and EC were excluded. All slides of the cases were reviewed by the same gynecologic pathology subspecialist. RESULTS: The study group consisted of 307 consecutive patients with a mean age of 59.4 years (range, 26-86 years). Lymph node metastasis was detected in 28 subjects (9.1%). Primary tumor diameter, depth of myometrial invasion, lymphovascular space invasion, and cervical stromal and glandular involvement were associated with lymph node metastasis. Patients with low-risk histological features based on Mayo risk stratification system in our study group had a 0% rate of lymph node positivity. However, of the 28 patients with lymph node metastasis, 3 (10.7%) had low-risk features based on Milwaukee model. The sensitivity, specificity, false negative rate (FNR) and false positive rate of Mayo and Milwaukee risk stratification models for predicting lymphatic dissemination among women with endometrioid EC were 100%, 27.3%, 0%, and 72.7%; and 89.3%, 61.3%, 10.7%, and 38.7%, respectively. CONCLUSIONS: Although Milwaukee risk stratification model had a lower false positive rate and can decrease the number of lymphadenectomies, FNR of this new model was found as 10.7% in the present study. Furthermore, we found that Mayo model had a lower FNR and higher sensitivity. Therefore, Mayo model still looks more beneficial to predict lymph node metastasis in patients with endometrioid EC and Milwaukee risk stratification model still requires external validation.

The Clinicopathological Study of 21 Cases With Uterine Smooth Muscle Tumors of Uncertain Malignant Potential: Centralized Review Can Purify the Diagnosis.

OBJECTIVE: The objective of this study was to investigate the clinicopathological features and factors associated with recurrence in patients with uterine smooth muscle tumor of uncertain malignant potential (STUMP). METHODS: Forty-six cases diagnosed between 2000 and 2014 from 2 tertiary centers underwent blind slide review. Initial diagnosis included smooth muscle tumors with equivocal diagnosis, STUMPs, and cases that were named as leiomyosarcomas (LMS) or low-grade LMS despite not fulfilling the Stanford criteria. RESULTS: In total, 21 patients with a final diagnosis of STUMP were available. Fifteen (68.1%) of 22 patients with an initial diagnosis of STUMP, 4 (22.2%) of 18 cases with an equivocal smooth muscle tumor diagnosis, and 2 (33.3%) of 6 cases with an initial diagnosis of LMS were interpreted as STUMP after slide review. The mean age at diagnosis was 43 years (range, 20-64 years). The mean follow-up time was 65.9 months (range, 10-154 months). Four patients (19.0%) developed recurrent disease. Recurrent tumors were LMS in 3 patients (75%). One patient (4.8%) with recurrence succumbed to disease. There was no difference in patients' age (P = 1.0) or type of initial surgery (uterus conserving versus hysterectomy) (P = 0.57) between patients who recurred and did not recur. CONCLUSIONS: Uterine STUMPs can harbor significant uncertainty regarding the original diagnosis and clinical outcomes. Recurred cases may have an aggressive clinical course associated with multiple relapses and death. Uterine mesenchymal tumors other than ordinary myomas and overt sarcomas deserve a second opinion in centers with experience because the real diagnosis may vary significantly.

Oncological Outcomes of Stage II Endometrial Cancer: A Retrospective Analysis of 250 Cases.

OBJECTIVE: The aim of this study was to investigate the effect of different surgical approaches, adjuvant therapy, and pathological characteristics on oncological outcomes in patients with 2009 International Federation of Gynecology and Obstetrics (FIGO) stage II endometrial cancer (EC). METHODS: A multicenter, retrospective department database review was performed to identify patients with FIGO 2009 stage II EC who underwent surgical staging between 2002 and 2015 at 5 gynecologic oncology centers in Turkey. RESULTS: Original pathology reports of 4867 patients who underwent surgical treatment for EC were analyzed. The study group consisted of 250 FIGO stage II patients. Of these patients, 203 (81.2%) had endometrioid and 47 (18.8%) had nonendometrioid histologic subtype of EC. Whereas 199 patients (79.6%) underwent type I hysterectomy, the remaining 51 patients (20.4%) underwent radical hysterectomy. Of the 250 patients, 208 patients (83.2%) had adjuvant therapy including radiotherapy (pelvic external beam radiotherapy and/or vaginal brachytherapy [VBT]) and/or platinum-based chemotherapy. Disease recurred in 29 patients (11.6%). The 5-year disease-free survival (DFS) and overall survival (OS) for the entire cohort were 82% and 85%, respectively. Multivariate analysis showed that only adjuvant treatment (P = 0.001; hazard ratio, 4.02; 95% confidence interval, 1.72-9.36) was significantly associated with DFS. According to multivariate analysis, only age older than 60 years (P = 0.01; hazard ratio, 3.03; 95% confidence interval, 1.3-7.04) was identified as an independent risk factor for OS. However, there were no differences in OS when evaluated by grade, histology, tumor size, type of hysterectomy, or adjuvant treatment. CONCLUSIONS: In stage II EC, adjuvant external beam radiotherapy ± VBT were associated with increased DFS but not OS. However, the benefit of VBT alone on DFS could not be demonstrated. Only age was an independent risk factor for OS. Type of hysterectomy and histologic subtype of the tumor for patients with uterus-confined disease improved neither DFS nor OS in our study group.

Histological Follow-Up in Patients with Atypical Glandular Cells on Pap Smears.

CONTEXT: Atypical glandular cells (AGCs) result in the Papanicolaou (Pap) smear may be associated with significant genital and nongenital neoplastic processes. AIMS: To evaluate the underlying histopathology in women who had AGCs on Pap smears. SETTINGS AND DESIGN: Retrospective cross-sectional study. PATIENTS AND METHODS: Clinicopathological data of patients who had AGC on Pap smears and underwent histological workup between January 2004 and December 2014 were retrieved from the computerized database of a tertiary care center. Patients with a prior history of cervical intraepithelial neoplasia or gynecological cancer were excluded. STATISTICAL ANALYSIS USED: Chi-square test or Fisher's exact tests were used as appropriate. RESULTS: Cytological examination of the uterine cervix was carried out in 117,560 patients. We identified 107 patients (0.09%) with AGC and 80 of those with histological follow-up were included in the study. The median age at diagnosis was 47 years (range, 18-79), and 32 women (40%) were postmenopausal, while 56 (70%) had gynecological symptoms. Significant preinvasive or invasive lesions on pathological examination were detected in 27 (33.8%) patients, including 12 endometrial adenocarcinomas (15%), 8 cervical carcinomas (10%), 3 cervical intraepithelial neoplasia II/III (3.75%), 2 ovarian adenocarcinomas (2.5%), and 2 metastatic tumors (2.5%). Univariate analysis showed that postmenopausal status (P < 0.001), age >50 years old (P < 0.001), having symptoms at the time of admission (P = 0.041), and AGC "favor neoplasia" smear results (P = 0.041) were the clinical factors associated with significant pathological outcome. CONCLUSIONS: Patients with AGC on Pap smears should be evaluated vigilantly with histological workup, especially if they are postmenopausal or symptomatic.

What is the impact of stromal microinvasion on oncologic outcomes in borderline ovarian tumors? A multicenter case-control study.

PURPOSE: To investigate clinicopathological characteristics and oncological outcome of women with microinvasive BOTs. METHODS: A retrospective multicenter case-control study was conducted on 902 patients with BOT, who underwent surgery from January 2002 to December 2015 at six participating gynecologic oncology centers from Turkey. Among 902 patients, 69 had microinvasive BOT. For every patient with microinvasive BOT, two controls were randomly selected from another database based on decade of age and stage of disease at diagnosis. The clinical-pathological characteristics and oncological outcomes were compared between BOT patients with and without stromal microinvasion. Risk factors for poor oncological outcomes were investigated in a multivariate analysis model. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method. RESULTS: Patients with microinvasive BOT had a significantly higher rate of recurrence than patients without microinvasive BOT (17.4 vs 7.8%, OR 3.55, %95 CI 1.091-11.59, p = 0.03). Stage at diagnosis (stage I versus II/III) and type of surgery (cystectomy versus others) were found as other significant prognostic factors for recurrence in multivariate analysis (OR 8.63, %95 CI 2.48-29.9, p = 0.001 and OR 19.4, %95 CI 3.59-105.6, p = 0.001, respectively). Stromal microinvasion was found as a prognostic factor for significantly shorter DFS (26.7 vs 11.9 months, p = 0.031, log rank). However, there was no significant difference in OS between two groups (p = 0.99, log rank). CONCLUSION: Stromal microinvasion is significantly associated with decreased DFS. In addition, our study confirms that the risk of recurrence is higher in patients with microinvasive BOT.

Factors associated with survival after relapse in patients with low-risk endometrial cancer treated with surgery alone.

OBJECTIVE: To determine factors influencing overall survival following recurrence (OSFR) in women with low-risk endometrial cancer (EC) treated with surgery alone. METHODS: A multicenter, retrospective department database review was performed to identify patients with recurrent "low-risk EC" (patients having less than 50% myometrial invasion [MMI] with grade 1 or 2 endometrioid EC) at 10 gynecologic oncology centers in Turkey. Demographic, clinicopathological, and survival data were collected. RESULTS: We identified 67 patients who developed recurrence of their EC after initially being diagnosed and treated for low-risk EC. For the entire study cohort, the median time to recurrence (TTR) was 23 months (95% confidence interval [CI]=11.5-34.5; standard error [SE]=5.8) and the median OSFR was 59 months (95% CI=12.7-105.2; SE=23.5). We observed 32 (47.8%) isolated vaginal recurrences, 6 (9%) nodal failures, 19 (28.4%) peritoneal failures, and 10 (14.9%) hematogenous disseminations. Overall, 45 relapses (67.2%) were loco-regional whereas 22 (32.8%) were extrapelvic. According to the Gynecologic Oncology Group (GOG) Trial-99, 7 (10.4%) out of 67 women with recurrent low-risk EC were qualified as high-intermediate risk (HIR). The 5-year OSFR rate was significantly higher for patients with TTR ≥36 months compared to those with TTR <36 months (74.3% compared to 33%, p=0.001). On multivariate analysis for OSFR, TTR <36 months (hazard ratio [HR]=8.46; 95% CI=1.65-43.36; p=0.010) and presence of HIR criteria (HR=4.62; 95% CI=1.69-12.58; p=0.003) were significant predictors. CONCLUSION: Low-risk EC patients recurring earlier than 36 months and those carrying HIR criteria seem more likely to succumb to their tumors after recurrence.

Prognostic factors and treatment outcomes in surgically-staged non-invasive uterine clear cell carcinoma: a Turkish Gynecologic Oncology Group study.

OBJECTIVE: To assess the prognosis of surgically-staged non-invasive uterine clear cell carcinoma (UCCC), and to determine the role of adjuvant therapy. METHODS: A multicenter, retrospective department database review was performed to identify patients with UCCC who underwent surgical treatment between 1997 and 2016 at 8 Gynecologic Oncology Centers. Demographic, clinicopathological, and survival data were collected. RESULTS: A total of 232 women with UCCC were identified. Of these, 53 (22.8%) had surgically-staged non-invasive UCCC. Twelve patients (22.6%) were upstaged at surgical assessment, including a 5.6% rate of lymphatic dissemination (3/53). Of those, 1 had stage IIIA, 1 had stage IIIC1, 1 had stage IIIC2, and 9 had stage IVB disease. Of the 9 women with stage IVB disease, 5 had isolated omental involvement indicating omentum as the most common metastatic site. UCCC limited only to the endometrium with no extra-uterine disease was confirmed in 41 women (73.3%) after surgical staging. Of those, 13 women (32%) were observed without adjuvant treatment whereas 28 patients (68%) underwent adjuvant therapy. The 5-year disease-free survival rates for patients with and without adjuvant treatment were 100.0% vs. 74.1%, respectively (p=0.060). CONCLUSION: Extra-uterine disease may occur in the absence of myometrial invasion (MMI), therefore comprehensive surgical staging including omentectomy should be the standard of care for women with UCCC regardless of the depth of MMI. Larger cohorts are needed in order to clarify the necessity of adjuvant treatment for women with UCCC truly confined to the endometrium.

Stage IIIC transitional cell carcinoma and serous carcinoma of the ovary have similar outcomes when treated with platinum-based chemotherapy.

OBJECTIVE: Previous studies reported better outcomes for transitional cell carcinoma (TCC) of the ovary when compared with more common histologic types such as serous epithelial ovarian cancers (EOCs). The aim of this study was to compare the survival outcomes of platinum- based chemotherapy in patients with stage IIIC TCCs and serous EOCs. MATERIAL AND METHODS: Clinicopathologic features and survival data of patients with FIGO stage IIIC TCC and serous EOC who had undergone primary surgery followed by six cycles of intravenous platinum/taxane between 2007 and 2015 were retrieved from the database of Hacettepe University Hospital. RESULTS: We identified 14 (10.9%) TCCs and 114 (89.1%) serous EOCs. The median follow-up duration was 28 months (range, 3-101 months). Univariate analysis revealed that the TCCs and serous EOCs had similar progression-free survival (PFS) and overall survival (OS). Patients with residual disease less than 1 cm had longer OS than patients with residual disease greater than 1 cm (75.0 vs. 45.0 months, p=0.012). Cox regression analysis of all potential prognostic factors showed that the only independent prognostic factor significantly associated with OS was residual disease less than 1 cm [hazard ratio=0.38; 95% confidence interval: (0.19-0.77); p=0.007]. CONCLUSION: Surgically treated advanced stage TCCs did not have a significantly better prognosis after platinum/taxane-based chemotherapy when compared with serous EOCs. Residual tumor volume after primary surgery was the only independent predictor of OS in patients with EOC. Our results demonstrate the significance of achieving optimal cytoreduction in all histologic subtypes of EOC.

HPV types and E6/E7 mRNA expression in cervical samples from Turkish women with abnormal cytology in Ankara, Turkey.

BACKGROUND/AIM: Human papillomaviruses have been established as a risk factor for invasive carcinoma of the uterine cervix. HPV E6/E7 oncogene expression has recently emerged as a promising biomarker to determine the risk for progression to high-grade cervical lesions. The aim of this study was to evaluate HPV mRNA and DNA detection in samples with abnormal cytology. MATERIALS AND METHODS: Cervical specimens were obtained at the Department of Obstetrics and Gynecology via cervical brushes during January-October 2011. Liquid-based cytology slides were evaluated according to the 2001 Bethesda System. Cytology specimens from a total of 81 women with abnormal cytology were included. Real-time PCR and NASBA assays were performed to detect HPV DNA and E6/E7 mRNA, respectively. RESULTS: HPV DNA was identified in 73 samples (90.1%). HPV E6/E7 mRNA expression was observed in 45 samples (55.6%). A statistically significant difference was observed among cytological diagnosis groups. In 25 patients, a biopsy was performed during the follow-up. HPV DNA was detected in all of these patients. HPV E6/E7 expression was present only in CIN I-III diagnosed patients. CONCLUSION: The E6/E7 mRNA test is a robust indicator of cytological atypia and correlates better with progressive lesions than DNA assays.

Incidence of Lymph Node Metastasis in Surgically Staged FIGO IA G1/G2 Endometrial Cancer With a Tumor Size of More Than 2 cm.

OBJECTIVE: The study aims to investigate effect of tumor size on lymphatic spread in patients with low-risk endometrial cancer (EC). METHODS: This study included patients with EC who underwent staging surgery with systematic lymphadenectomy between 2002 and 2015 at the Hacettepe University Hospital. Patients with grade 1 or 2 endometrioid type tumor who had 50% or lower myometrial invasion were included. Patients who had no myometrial invasion or had uterine high-risk features (nonendometrioid histology, grade 3, and deep myometrial invasion) were excluded. RESULTS: The study group consisted of 191 patients, and the mean age of the patients was 57.8 years. Of these patients, 124 (64.9%) had tumor size of more than 2 cm and 67 (35.1%) had tumor size of 2 cm or less. Lymph node metastasis was detected in 12 (9.7%) of the 124 patients with tumor size of more than 2 cm. On the other hand, none of the 67 patients (0%) with tumor size of 2 cm or less was found to have lymphatic involvement. Of the factors analyzed for correlation with lymph node metastasis in patients with low-risk EC, the presence of lymphovascular space invasion (LVSI) and primary tumor size were found to be significant predictors of lymphatic spread in univariate analysis (P < 0.001 and P = 0.009, respectively). In multivariate analysis, tumor size (odds ratio, 6.86; 95% confidence interval, 1.007-infinite; P < 0.05) and LVSI (odds ratio, 14.261; 95% confidence interval, 3.4-59.6; P < 0.001) were 2 independent predictors associated with lymphatic involvement. CONCLUSIONS: Our trial supports that tumor size of more than 2 cm and LVSI are 2 independent factors for lymph node metastasis in patients with low-risk EC. Both factors can be used together to select patients with traditional low-risk histologic features who would absolutely benefit from lymph node dissection.

Extrauterine Spread, Adjuvant Treatment, and Prognosis in Noninvasive Uterine Papillary Serous Carcinoma of the Endometrium: A Retrospective Multicenter Study.

OBJECTIVES: The aim of this retrospective multicenter study was to investigate the frequency of extrauterine metastasis and to evaluate the importance of surgical staging and adjuvant treatment among patients with noninvasive uterine papillary serous carcinoma (UPSC) of the endometrium. MATERIALS AND METHODS: A multicenter, retrospective department database review was performed to identify patients with UPSC of the endometrium who underwent surgical staging between 2000 and 2015 at 4 Gynecologic Oncology Centers in Turkey. Demographic, clinicopathological, and survival data were collected. RESULTS: A total of 182 patients with primary UPSC of the endometrium were identified. Of these, 33 (18.1%) had tumors limited to the endometrium with no myometrial invasion. Twenty (60.6%) of these 33 patients had no extrauterine involvement and International Federation of Gynecology and Obstetrics 2009 stage 1A disease was diagnosed after complete staging. The remaining 13 (39.4%) patients had disease beyond the uterine corpus including 5 with omental, 3 with adnexal, 1 with cervical stromal involvement, 1 with disease in the pelvic lymph nodes, and 1 with isolated para-aortic lymph node metastasis. Two patients had metastases in more than one location including omentum/adnexa/pelvic-para-aortic lymph nodes and omentum/pelvic-para-aortic lymph nodes, respectively. Of the 20 patients with disease confined to the endometrium, 6 (30%) patients received adjuvant treatment. CONCLUSIONS: Noninvasive UPSC has a high tendency for extrauterine spread and omentum is the most commonly involved location. Therefore, comprehensive surgical staging including omentectomy and pelvic-para-aortic lymph node dissection is mandatory in this group of patients. Risk of extrauterine spread is significantly associated with the presence of lymphovascular space invasion, elevated preoperative CA 125 levels, and positive peritoneal cytology. Adjuvant therapy for women with endometrium-confined disease improves neither progression-free survival nor overall survival.