Factor affecting lymph node metastasis in uterine papillary serous carcinomas: a retrospective analysis.

The aim of this study was to investigate the risk factors for lymph node metastasis (LNM) in patients with uterine serous cancer (USC) who underwent systematic staging surgery. Eighty patients who were operated on for pure uterine serous papillary carcinoma between 2008 and 2020 in our clinic were retrospectively analysed. The effects of demographic information and clinicohistopathological characteristics of the included patients on LNM were examined. The median age of the patients included in the study was 64.3 and the tumour diameter was 3.8 cm. At the time of diagnosis, 65.8% of the cases were in the advanced stage, while 34.2% were in the early stage. There was no LNM in 42 (52.5%) of the cases, only pelvic in six (7.5%), only paraaortic LNM in four (5%) patients, and both pelvic and paraaortic LNM in 24 (30%) patients. When factors that may affect LNM were evaluated with multivariate analysis, lymphovascular space invasion (LVSI) and cytology positivity were found to be independent risk factors (p < 0.05). In addition, the rate of isolated paraaortic lymph node involvement in LNM positive patients is 5%, which is 100% associated with LVSI.Impact StatementWhat is already known on this subject? Uterine papillary serous carcinomas (UPSC) are an uncommon and aggressive histological subtype of endometrial cancer. The high risk of recurrence and tendency to migrate into the abdomen of these tumours is not always connected with lymph node and distant organ metastasis, tumour size, LVSI positive and depth of myometrial invasion.What do the results of this study add? Most patients with UPSC are diagnosed at an advanced stage. In this study, in which 80 patients with pure serous histology were evaluated retrospectively, and LVSI and peritoneal cytology positivity were found to be two important prognostic factors for lymph node metastasis.What are the implications of these findings for clinical practice and/or further research? In this study, cytology and LVSI positivity were identified as two predictive markers for LNM, and it is seen that cytology positivity still maintains its importance in these tumours with peritoneal spread. Furthermore, patients with isolated paraaortic lymph node involvement were shown to be LVSI positive, and isolated paraaortic LNM should be investigated in patients with LVSI positivity.

Uterine adenosarcomas: A dual-institution experience.

There has been limited literature about treatment and follow-up strategies of uterine adenosarcomas because of their rare nature. For this study we retrospectively investigated the medical database of the two major womens' health hospitals in Turkey. A total of 15 patients were identified from the hospital's database. Median follow-up was 86.43 months for all patients. Seven out of 15 patients had recurrences during their follow-up. Among these 7 patients, 4 of them had stage IA disease. Median Disease Free Survival (DFS) and Overall Survival (OS) were calculated as 41.47 and 57.21 months, respectively. According to our study, polypoid tumours confined to the uterus with superficial myometrial invasion can be treated without comprehensive surgical staging. We believe that, publishing all the data in an organised manner even though they are small in size, gives us an opportunity to design meta-analysis for the development of more appropriate treatment strategies.

Retrospective evaluation of borderline ovarian tumors: single center experience of 183 cases.

PURPOSE: Borderline ovarian tumors (BOTs) constitute about a quarter of epithelial ovarian malignancies and require different treatment approaches. The present study aims to document the experience of a single center on the treatment outcome of women who had conservative or comprehensive surgery for BOTs. METHODS: One hundred eighty-three patients with BOTs, diagnosed and/or treated in our center between January of 2000 and March of 2013, were reviewed retrospectively. RESULTS: The mean age at diagnosis was 40.6 years old (range 17-78). Ninety-five patients (51 %) were ≤40 years. Comprehensive surgical staging and fertility sparing surgery were performed in 49 % (n = 91) and 48 % of patients (n = 89) respectively. A hundred and forty-seven patients had stage IA disease (80 %). The most common type of BOT was serous in histology with 18 % bilateralism. CA-125 and CA-199 levels were increased in 29 (19 %) and 15 (10 %) patients with stage IA disease. Non-invasive tumor implants were diagnosed in 9 patients (4 %) and uterine involvement was 2 % among BOT patients that underwent hysterectomies. The mean post-operative follow-up period was 20.4 months (range 6-78 months). Disease recurrence was seen in 5 patients indicating overall recurrence rate of 2.7 %. CONCLUSIONS: In our study, we evaluated a large data pool of 183 patients diagnosed with borderline epithelial ovarian tumors. BOTs have a relatively better prognosis than invasive epithelial ovarian cancer. Surgery with proper staging is the cornerstone of treatment. Patients with BOTs at the early stage can undergo fertility sparing surgery with close follow-up.

The experiance of tertiary center for adult granulosa cell tumor: which factors predict survival?

BACKGROUND: This retrospective study aims to evaluate the clinical course and long-term outcomes of patients diagnosed with adult granulosa cell tumors (AGCT). METHODS: The study analyzed a cohort of 112 AGCT patients with a median follow-up of 87 months. Data regarding disease-free survival (DFS), overall survival (OS), recurrence rates, and prognostic factors were collected and analyzed. Surgical interventions, including lymphadenectomy and cytoreductive surgery, were assessed for their impact on outcomes. RESULTS: The study revealed favorable long-term outcomes, with a 5-year DFS of 85% and a 10-year DFS of 83%. Additionally, a 5-year OS of 100% and a 10-year OS of 96% were observed. Recurrence occurred in 13.4% of cases, with advanced stage and positive peritoneal cytology identified as independent poor prognostic factors for DFS. Lymph node involvement was rare, and routine lymphadenectomy did not improve outcomes. Conservative surgery showed comparable DFS rates to definitive surgery in early-stage disease. However, cytoreductive surgery was crucial for advanced and recurrent tumors, with complete tumor resection enhancing survival outcomes. CONCLUSION: The study underscores the importance of vigilant follow-up and individualized treatment strategies for AGCT patients. Despite the retrospective nature of the analysis, the substantial patient cohort and meticulous surgical interventions contribute valuable insights into AGCT management. Prospective multicenter studies are warranted to further elucidate prognostic factors and optimize treatment approaches for this rare malignancy.

Revisiting Querleu-Morrow Radical Hysterectomy: How to Apply the Anatomy of Parametrium and Pelvic Autonomic Nerves to Cervical Cancer Surgery?

In 2008, Querleu and Morrow proposed a novel classification of radical hysterectomy, which was quickly accepted by the professional oncogynecological community. The Querleu and Morrow (Q-M) classification of radical hysterectomy has provided a unique opportunity for uniform surgical and anatomical terminology. The classification offers detailed explanations of anatomical landmarks and resection margins for the three parametria of the uterus. However, there are still some disagreements and misconceptions regarding the terminology and anatomical landmarks of the Q-M classification. This article aims to highlight the surgical anatomy of all radical hysterectomy types within the Q-M classification. It discusses and illustrates the importance of anatomical landmarks for defining resection margins of the Q-M classification and reviews the differences between Q-M and other radical hysterectomy classifications. Additionally, we propose an update of the Q-M classification, which includes the implementation of parauterine lymphovascular tissue, paracervical lymph node dissection, and Selective-Systematic Nerve-Sparing type C2 radical hysterectomy. Type D was modified according to current guidelines for the management of patients with cervical cancer. The detailed explanation of the surgical anatomy of radical hysterectomy and the proposed update may help achieve surgical harmonization and precise standardization among oncogynecologists, which can further facilitate accurate and comparable results of multi-institutional surgical clinical trials.

Do HPV 16 positive/ASC-H cervical cancer screening results predict CIN 2+ better than other high-risk HPV subtypes?

Objective: To determine whether patients with atypical squamous cells, cannot exclude high grade squamous intraepithelial neoplasia (ASC-H) cytology have a correlation between high-risk human papillomavirus (HPV) type and CIN 2+1 lesion in final pathology. Material and Methods: The study was conducted retrospectively, using data from three tertiary gynecologic oncology centers located in various regions of Turkey. Data from 5,271 patients who had colposcopy between January 2003 and January 2021 were analyzed. Results: A total of 163 patients who had ASC-H cervical cytology test results, based on the Bethesda 2014 classification were eligible, and of these 83 (50.9%) who tested positive for HPV were included in the study. There was no correlation between the occurrence of CIN 2+ lesions and age (p=0.053). If there was any HPV 16 positivity (only HPV 16, HPV 16 and 18, HPV 16 and others) the presence of CIN 2+ lesions in the final pathology increased significantly. In HPV 16 positive ASC-H patients, the probability of CIN 2+ lesions in the final pathology were 72.5% while this rate was 48.1% in HPV 16 negative group (p=0.033). Conclusion: The guidelines do not provide a comprehensive definition of the role of the HPV test in managing ASC-H. Positive high-risk HPV types, especially HPV 16, together with an ASC-H smear result should bring to mind the possibility of high-grade dysplasia.

Radical Hysterectomy or Total Mesometrial Resection-Two Anatomical Concepts for Surgical Treatment of Cancer of the Uterine Cervix.

A radical hysterectomy is the standard method of surgical treatment for patients with early-stage cancer of the uterine cervix. It was first introduced more than 100 years ago. Since then, various and many different radical procedures, which diverge in terms of radicality, have been described. Inconsistencies are clearly seen in practical anatomy, which were defined as surgically created artifacts. Moreover, the disparity of the procedure is most notable regarding the terminology of pelvic connective tissues and spaces. Despite these controversies, the procedure is widely performed and implemented in the majority of guidelines for the surgical treatment of cancer of the uterine cervix. However, a different and unique concept of surgical treatment of cervical cancer has been reported. It is based on ontogenetic anatomy and maps any tissue in the mature organism according to its embryologic development. The clinical implementation of this theory in the context of early cervical cancer is total mesometrial resection. The present article aims to describe and compare the anatomical and surgical basics of a radical hysterectomy (type C1/C2) and total mesometrial resection. Discrepancies regarding the terminology, resection lines, and surgical planes of both procedures are highlighted in detail. The surgical anatomy of the pelvic autonomic nerves and its surgical dissection is also delineated. This is the first article that compares the discrepancy of classic anatomy and ontogenic anatomy regarding surgical treatment of cancer of the uterine cervix. Clinical data, oncological outcome, and neoadjuvant and adjuvant treatment regarding both procedures are not the topic of the present article.

Surgical Anatomy and Dissection of the Hypogastric Plexus in Nerve-Sparing Radical Hysterectomy.

Radical hysterectomy is a central surgical procedure in gynecological oncology. A nerve-sparing approach is essential to minimize complications from iatrogenic injury to the pelvic nerves, resulting in postoperative urinary, anorectal, and sexual dysfunction. The hypogastric plexus (HP), a complex network of sympathetic and parasympathetic nerves, plays a critical role in pelvic autonomic innervation. This article offers a comprehensive overview of the surgical anatomy of the HP and provides a step-by-step description of HP dissection, with a particular emphasis on preserving the bladder nerve branches of the inferior HP. A thorough understanding and mastery of the anatomical and surgical nuances of HP dissection are crucial for optimizing outcomes in nerve-sparing gynecologic-oncological procedures.

Pelvic Sidewall Anatomy in Gynecologic Oncology-New Insights into a Potential Avascular Space.

The surgical treatment of gynecological malignancies is, except for tumors diagnosed at the earliest stages and patients' desire for fertility preservation, not limited to only the affected organ. In cases of metastatic iliac lymph nodes, gynecological tumors or recurrences located near the pelvic sidewall, oncogynecologists should dissect tissues in that region. Moreover, surgery of deep infiltrating endometriosis, e.g., within the sacral plexus, or oncological procedures, such as a laterally extended endoplevic resection or a laterally extended parametrectomy, often require a dissection of the pelvic sidewall. Dissection should be meticulous, and detailed knowledge of anatomy is mandatory. There are many controversies among authors regarding the terminology in the pelvic sidewall. In particular, several imprecise or confusing definitions exist in regard to the region located medially to the psoas major muscle. Therefore, after discussing the anatomy of the pelvic sidewall and the commonly used terminology, we define a new term and boundaries of a potential avascular space, the medial psoas space. Contrary to the variety of earlier definitions, the proposed boundaries relate to a truly avascular space and could help surgeons to avoid complications resulting from misleading anatomical descriptions. Additionally, describing the clear boundaries of and possible anatomical variations in the medial psoas space may urge oncogynecologists to consider different approaches during surgery. The purpose of the present study is to describe the anatomy of the pelvic sidewall and the applications of the medial psoas space in gynecologic oncology.

Paraaortic Lymphadenectomy in Gynecologic Oncology-Significance of Vessels Variations.

Lymphadenectomy has been an essential part of the surgical treatment in surgical oncology, as the lymphatic channels and nodes are the main dissemination pathway for most of the gynecological cancers. Pelvic and paraaortic lymphadenectomy are frequent surgical procedures in gynecologic oncology. Paraaortic lymph node dissection facilitates staging, prognosis, surgical and postoperative management of patients. It is one of the most challenging retroperitoneal surgeries. A comprehensive knowledge of the paraaortic region is mandatory. Intraoperative bleeding is the most common complication during lymphadenectomy due to direct vascular injury, poor tissue handling, exuberant retraction and possible anatomical variations of the vessels in the paraaortic region. Approximately, one-third of women will have at least one anatomic variation in the paraaortic region. It must be stressed that anomalous vessels may be encountered in every woman who will undergo surgery. Consequently, detailed knowledge of anatomical vessels variations is required in order to prevent iatrogenic vessel injury. The importance of these variations is well described in urology, vascular and general surgery. Conversely, in oncogynecological surgery, there are few articles, which described some of the vessels variations in the paraaortic region. The present article aims to propose a surgical classification and to describe the majority of vessels variation, which could be encountered during paraaortic lymphadenectomy in gynecologic oncology. Moreover, surgical considerations in order to prevent anomalous vessels injury are well described.

Extrapelvic intravenous uterine leiomyomatosis mimicing cardiac myxoma and deep vein thrombosis.

Extrapelvic intravenous uterine leiomyomatosis is a rare smooth muscle neoplasm. Uterine leiomyomatosis is a histologically benign pathology. Rarely, it can be confused with a cardiac mass. A 44-year-old female patient was admitted with increasing severity of pain and swelling in both legs for the past week. The patient was initially diagnosed with bilateral deep vein thrombosis. After further evaluation, we decided that the patient had cardiac myxoma. However, we intraoperatively observed that the lesion in the right atrium was arising from the inferior vena cava. In the final postoperative histopathological evaluation, the definite diagnosis was extrapelvic intravenous leiomyomatosis. The patient was discharged uneventfully following her second operation.

Complete lymph node dissection: is it essential for the treatment of borderline epithelial ovarian tumors?

OBJECTIVE: The present study aims to compare the clinical and reproductive outcomes of women who have undergone lymph node dissection with those who have not and to discuss the indications for retroperitoneal evaluation in the treatment of borderline ovarian tumors. METHODS: The present study investigated 123 women who were finally diagnosed with borderline epithelial ovarian tumors at the study center between January 1999 and January 2009. A total of 68 patients (55.3%) were found to have a complete surgical staging procedure. RESULTS: The patients who underwent complete lymph node dissection were significantly younger than those who did not have lymphadenectomy. Thus, the ratio of postmenopausal women was significantly higher among those in whom retroperitoneal evaluation was performed. As expected, the intraoperative blood loss was significantly more and the hospital stay was significantly longer in patients who underwent complete lymph node dissection. Also, the non-serous borderline ovarian tumors were significantly more frequent in the latter patient group. However, overall and disease-free survival spans were found to be statistically similar for both study groups as well as the recurrence rate. CONCLUSIONS: Retroperitoneal evaluation can be spared in every woman with borderline ovarian tumor unless she is to undergo complete surgical staging procedure because of high recurrence risk, advanced stage disease or personal choice.

Coexistence of uterine adenomyosis is not associated with a better prognosis in endometrioid-type endometrial cancer.

BACKGROUND: Prognostic value of accompanying adenomyosis in endometrial cancer is the subject of interest due to their common etiology and co-occurrence frequency. However, it is still unclear whether adenomyosis has a role in the prognosis of endometrial cancer. AIMS: The aim of this study was to determine the effects of adenomyosis on the prognosis of patients with endometrial cancer. METHODS: In this study, medical records of 552 patients with endometrioid endometrial cancer who underwent surgery between 2007 and 2017 were retrospectively reviewed. The patients were divided into two groups based on the presence or absence of adenomyosis, and these two groups were compared in terms of the clinicopathological factors and survival outcomes of patients. RESULTS: Of these patients, 103 (18.7%) had adenomyosis, and the remaining 449 (81.3%) did not. The endometrial cancer patients with adenomyosis exhibited earlier stages (p < 0.001), lower tumor grades (p < 0.001), tumor sizes ≤ 2 cm (p = 0.002), myometrial invasion < 50% (p < 0.001), and negative lymphovascular space invasion (p < 0.001). The 5-year overall survival rate was comparable between the adenomyosis and non-adenomyosis groups (95 vs. 89.1%, respectively; p = 0.085). The presence of adenomyosis was significantly associated with a higher 5-year disease-free survival rate (95.1 vs. 87.9%; p = 0.047), but adenomyosis did not remain as a prognostic factor in multivariate analysis. CONCLUSION: The results of our study showed that the endometrioid endometrial cancer patients with adenomyosis are significantly associated with smaller tumor sizes, less myometrial invasion, lower tumor grades, less lymphovascular space invasion, and earlier FIGO stages. Nevertheless, adenomyosis was not found to be an independent prognostic factor for endometrioid endometrial cancer.

The impact of Loop Electrosurgical Excision Procedure and cold-knife conization training model on the surgical skills and confidence level.

OBJECTIVE: The purpose of this study is to evaluate the impact of loop electrosurgical excision procedure (LEEP) and cold-knife conization (CKC) active training model on the surgical education and confidence levels of gynecologists. MATERIALS AND METHODS: The LEEP and CKC hands-on training model consists of sausage, which is 2.5 cm in diameter, as cervix; plastic cup as vagina; foam rubber as posterior and anterior fornices; and cotton plate as the leukoplakia area. In total, 34 participants performed LEEP and CKC procedures on the training model under the guidance of mentors after theoretical lessons about the transformation zone, indications, and surgical techniques of LEEP and CKC. Afterward, a web-based survey was conducted to measure the effectiveness of this surgical model, and participants graded their learning and confidence levels on the same. RESULTS: We evaluated the educational levels of the course, which were based on the basic surgical steps of LEEP and CKC procedures, and the confidence levels of the participants with regard to the previous practice or expertise of LEEP and CKC. Importantly, participants in each group had similar learning gains irrespective of previous practice or expertise. Despite a significantly higher pre-course confidence level of participants who had previously performed LEEP (p<0.001) and CKC (p<0.001) against their non-practitioner counterparts, the post-course confidence levels were similar in each group (p=0.127 and p=0.845, respectively). In both groups, the participants had increased mean confidence scores, which were statistically significant for participants who had not previously performed the procedures (p=0.003, LEEP and p=0.002, CKC, respectively). CONCLUSION: This surgical training model on LEEP and CKC can impart a better level of education in participants, irrespective of their previous expertise/practice.

Clinicopathologic characteristics and treatment features of women with the incidental diagnosis of endometrial adenocarcinoma during infertility follow-up in Ankara, Turkey.

OBJECTIVE: The aim of this study was to investigate the clinical and laboratory features of patients with the incidental diagnosis of endometrial adenocarcinoma (EC) during infertility work-up, with special attention given to treatment approaches, recurrence rate, and fertility outcome. MATERIAL AND METHODS: The medical records of 577 patients who were diagnosed with EC and treated between 2007 and 2013 were included in the study. Out of 577 EC patients, 5.1% (n = 30) were ≤ 40 years of age. However, 10 patients had a history of infertility and had been diagnosed during evaluation for infertility. Patients' clinical and laboratory data were reviewed retrospectively. RESULTS: The mean age at diagnosis was 34.3 ± 4.5 years and the mean duration of infertility was 5.1 ± 4.7 years. Immediate staging surgery was performed on three patients. The others were treated with oral megestrol acetate and/or a levonorgestrel-containing intrauterine device (IUD) for 6 months. The mean duration of postoperative or postdiagnostic follow-up was 44.7 ± 25.9 months. The disease persistence and recurrence rates were 11.1% and 22.2%, respectively. Two patients achieved pregnancy naturally or by assisted reproductive technology (ART) trial. CONCLUSION: The investigation of patients during infertility work-up provides an opportunity to evaluate the endometrium and its malignancies in young women, when the disease is in its early stage and symptom free. The standard surgical treatment for early-stage EC is total hysterectomy with bilateral salpingo-oophorectomy. However, conservative management of early stage EC with progestational drugs, especially in young patients who wish to preserve their fertility, is acceptable with the possibility of future pregnancies.

Depo-Provera: use of a long-acting progestin injectable contraceptive in Turkish women.

OBJECTIVE: To assess the demographic and clinical characteristics and experience of Turkish women treated with depot medroxyprogesterone acetate (DMPA). STUDY DESIGN: This prospective clinical study was carried on 9262 subjects, treated with DMPA at Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey, between 1996 and 2004. RESULTS: The mean age of study population was 28.4+/-4.6 years; 1759 (19%) subjects were breast-feeding at the time of the first injection. Eight (0.08%) pregnancies occurred, within 3 months of injection in 9262 women. Of 9262 cases, irregular bleeding occurred in 80% (7410) of the women. Discontinuation rate with this contraceptive method was recorded as 71% (6576) of the subjects. The rate of other predominant side effects was observed as follows: 8% for increase in weight, 8% for breast engorgement, 7% for mastalgia, 5% for headache. CONCLUSION: The results of this study suggest that DMPA may be an attractive contraceptive choice for both the patient and the physician in some clinical situations, especially in women at risk for complications with oral hormonal contraceptives and women who have had low compliance with other contraceptive methods. Moreover, DMPA contraception might be particularly appropriate in some cases such as in the postpartum period and in lactating women.

The effects of dynamization and destabilization of the external fixator on fracture healing: a comparative biomechanical study in dogs.

This study compared the effects of axial dynamization and staged destabilization on fracture healing. Bilateral midshafts of canine tibiae were osteotomized and fixed with an external fixator. The hind limbs were divided into two groups: the destabilized group in which the fixator's stiffness was progressively reduced over time and the axially dynamized group in which the fixator was axially dynamized. The healed tibiae were tested for 3-point bending in the anteroposterior plane. The biomechanical tests performed 2 months postoperatively revealed that the side with the destabilized fixator was more rigid than the side with the axially dynamized fixator, but the differences were insignificant (P=.20). This study showed staged destabilization of the fixator's stiffness was as effective on the enhancement of fracture healing as axial dynamization.

Clinical outcomes of cases with cervical dysplasia absent in cold knife conization specimens.

BACKGROUND: Cold knife conization is a surgical procedure that allows both diagnosis and treatment of cervical lesions at the same time. It is mainly performed for indications of high-grade cervical intraepithelial neoplasia (CIN). In this study, we aimed to investigate the clinical outcome of cases without CIN in cold knife conization specimen, following a high-grade lesion (CIN2/3) in cervical biopsy. MATERIALS AND METHODS: We performed a retrospective cohort study at a tertiary referral hospital between January 1st 2008 and August 1st 2012. Cases that underwent cold knife conization for CIN2/3 within the study period were included. Cone-negative (Group 1) and cone-positive (Group 2) cases were analyzed for various clinical parameters, and were compared in the 1-year post-conization period for histological recurrence and human papillomavirus (HPV) DNA status. RESULTS: A total of 173 women underwent cold knife conization for CIN2/3 within the study period. Twenty-two cases (12.7%) were included in Group 1 and 151 cases (87.3%) in Group 2. There were no significant differences between the two groups in terms of age, gravidity, parity, menopausal status and HPV-DNA status (pre-conization and 1 year post-conization) (p>0.05). Recurrence rates were also similar between the groups (9.1% vs 9.9%, p>0.05). CONCLUSIONS: Clinical outcomes were similar in terms of histological recurrence and HPV persistence after 1 year of follow-up between cone-negative and cone-positive cases. Clinical follow-up of cone-negative cases should therefore be performed similar to cone-positive cases.