En Bloc Resection of Sentinel Lymph Nodes with the Hysterectomy Specimen in Endometrial Cancer.

OBJECTIVE: We demonstrate the surgical technique of removing the sentinel lymph nodes with its afferent lymphatic vessels attached to the hysterectomy specimen. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Sentinel lymph node sampling has been established as an acceptable staging method in endometrial cancer cases.1 Lymphatic anatomy has been described according to three consistent channels for endometrial cancer dissemination: (1) an upper paracervical pathway draining external or obturator lymph nodes; (2) a lower pathway draining internal iliac lymph nodes; and (3) the infundibulo-pelvic pathway with a course along the broad ligament.2 A study in patients with cervical cancer identified tumor cells in the afferent lymphatic vessels of the upper pathway, even when the corresponding sentinel node was negative (3/20 patients).3 This could be an important prognostic factor in patients with cervical cancer. Since the typical position of sentinel nodes is the same in both endometrial and cervical cancers, we aimed to assess the feasibility of removing 'en bloc' the sentinel node with its afferent lymphatic vessels, and the uterus.4 INTERVENTIONS: The Da Vinci Xi surgical system was used. Indocyanine green was injected cervically, the pelvic surgical spaces were developed, and the sentinel lymph nodes, along with the afferent lymphatic vessels, were identified using the Firefly infrared camera. The lymphovascular tissue was mobilized and separated from the uterine artery, which was skeletonized and ligated. Colpotomy was performed and the specimen was retrieved vaginally. DISCUSSION: Emerging evidence regarding diagnosis, characterization, and treatment of endometrial cancer has introduced a new era, based on minimally invasive techniques for staging through sentinel lymph node biopsy, molecular classification, and personalized treatment algorithms that include immune checkpoint inhibitors and targeted therapies.5 Lymph node staging is one of the most significant prognostic factors in endometrial cancer patients and is a guide for adjuvant treatment. Sentinel lymph node biopsy is not inferior to conventional lymphadenectomy and is in fact a better way of identifying low-volume cancer through the use of ultrastaging, as part of the sentinel node algorithm.6 The dissection technique described in this video could offer an improvement in the staging of endometrial cancer, ensuring that the true sentinel lymph node is identified and that potential cancer cells inside the afferent lymphatic vessels are also excised. Therefore, it could be utilized as a more accurate way of planning adjuvant treatment and consequently improving recurrence and survival; however more studies are needed to further evaluate the feasibility and sensitivity of identifying disease in the afferent lymphatic vessels. CONCLUSION: This novel surgical technique emphasizes the importance of anatomical knowledge and offers inspiration for studies with potential clinical benefit that should follow.

Conservative surgical approaches for small volume FIGO stage IB1 cervical cancer. Updated survival and obstetric outcomes of an expanded cohort.

OBJECTIVE: Standard surgical treatment of FIGO stage 1B1 cervical cancer is open radical surgery. However, there is increasing evidence that for small tumours a more conservative approach can minimise fertility consequences without impacting on long term oncologic outcomes. The objective of our study is to present survival and obstetric outcomes following extended follow-up for patients who underwent conservative management of small-volume stage 1B1 disease. METHODS: All patients with FIGO stage 1B1 cancer and estimated tumour volume of <500 mm3 in a loop biopsy specimen treated in Northern Gynaecological Oncology Centre between December 2000 and December 2021, were included in the study. Clinico-pathological and demographic data were collated alongside detailed follow-up and obstetric outcomes in conjunction with primary care and death register. RESULTS: 117 patients underwent conservative surgery for small volume stage 1B1 disease. 58 (49.5%) underwent fertility sparing conservative management with LLETZ while 59 (50.5%) underwent simple hysterectomy. Overall, 95% (111/117) of the patients underwent bilateral pelvic lymphadenectomy and 1 positive node was identified. There was no death related to cervical cancer and 1 recurrence identified during a median follow up of 8.5 years (1-20). 17 pregnancies have been recorded in patients underwent LLETZ and 17 live babies were born. No second trimester miscarriages were noted and there was one preterm delivery (36 weeks). CONCLUSION: Non-radical surgery with negative pelvic lymphadenectomy for smallvolume stage 1B1 cervical cancer ensures excellent survival without compromising obstetric outcomes. Should these results be verified by the ongoing prospective studies, radical surgery for these patients may be avoided.

Subserosal uterine injection of blue dye for the identification of the sentinel node in patients with endometrial cancer: a feasibility study.

OBJECTIVE: To define the detection rate, sensitivity, and negative predictive value (NPV) of the sentinel node technique in patients with endometrial cancer. METHODS: Patients with endometrial cancer after informed consent underwent subserosal injection of blue dye during hysterectomy in a tertiary gynae/oncology department between 2010 and 2014. The procedure was performed in all cases by the same team including two gynae/oncologist consultants and one trainee. All relevant perioperative clinicopathological characteristics of the population were recorded prospectively. The identified sentinel nodes were removed separately and a completion bilateral pelvic lymphadenectomy followed in all cases. Simple statistics were used to calculate the sensitivity and NPV of the method on per patient basis. RESULTS: Fifty-four patients were included in this study. At least one sentinel node was mapped in 46 patients yielding a detection rate of 85.2%. Bilateral detection of sentinel nodes was accomplished in only 31 patients (57.4%). The mean number of sentinel nodes was 2.6 per patient and the commonest site of identification was the external iliac artery and vein area (66%). Six patients (11%) had a positive lymph node, and in five of them, this was the sentinel one yielding a sensitivity of 83.3% and an NPV of 97.5%. The overall detection rate improved significantly after the first 15 cases; however, this was not the case for the bilateral detection rate. CONCLUSION: Our study is in accordance with previous studies of sentinel node in endometrial cancer and further demonstrates and enhances the confidence in the technique. In the current era of an ongoing debate on whether a systematic lymphadenectomy in patients with endometrial cancer is still necessary, we believe that the sentinel node is an acceptable alternative and should be applied routinely in tertiary centres following a strict algorithm.

Prognostic factors for recurrence in early stage adult granulosa cell tumor of the ovary.

OBJECTIVE: Adult granulosa cell tumors (AGCTs) account for less than 5 % of all ovarian malignancies, whereas the majority (95 %) occurs after the age of 30 (adult-type) and present at an early stage. Aim of this study is to identify clinical and pathological risk factors for recurrence in early stage AGCTs. METHODS: Retrospective review of patients with AGCT of the ovary, treated surgically at our institution from 1996 to 2011. Clinical, pathological and follow-up data were collected. Systematic analysis was performed to determine variables for predicting recurrence. RESULTS: In total, 43 patients were identified. The mean age at diagnosis was 54.3 years and 65.1 % of them were postmenopausal. All patients underwent surgical staging and intraoperative rupture of the tumor occurred in four of them (9.3 %). The majority of the cases were staged as IA (72.1 %) while 10 (23.3 %) were staged as IC and only two patients as IIB. Mitotic index was 4 or more in 34.9 % of the patients and nuclear atypia was moderate to high in 60.5 %. During follow-up period (mean 9.2 years), recurrence occurred in three patients (7 %) with no deaths recorded so far. The cumulative recurrence free rate for the first 2 years was 97.6 % (SE = 2.4 %), for 5 years 94.9 % (SE = 3.5 %) and for 10 years 91.0 % (SE = 5.1 %).Tumor size, stage and mitotic index proved to be independent predictors for recurrence at the multivariate analysis. CONCLUSIONS: Recurrence in early stage AGCT seems to be associated with stage, tumor size and mitotic index. All the above should be taken into consideration when tailored postoperative management is planned.

European Society of Gynecological Oncology Task Force for Fertility Preservation: Clinical Recommendations for Fertility-Sparing Management in Young Endometrial Cancer Patients.

Endometrial cancer (EC) in young women of reproductive age is a relatively rare diagnosis. However, since in the modern era women delay their childbearing for a variety of social reasons, more and more women in the near future will be nulliparous and have a diagnosis of EC at the same time. Hence, a more conservative approach of EC is desirable to preserve fertility of these women, without compromising their survival. Recently, the number of studies reporting encouraging results on fertility-sparing management of EC with high dose of progestins is increasing. It seems that preserving the uterus and the ovaries in a carefully selected patient with EC confers only a very small risk combined with an enormous benefit. Selection of women suitable for such a conservative approach, as well as method of treatment, follow-up, recurrence, obstetric outcomes, and survival rates are very important parameters when consulting women with EC wishing to preserve their fertility. In this article, we try to elucidate all the previously mentioned aspects and formulate clinical recommendations, based on published data, about the most proper approach and consultation of these patients.

Laparoscopic radical trachelectomy is an alternative to laparotomy with improved perioperative outcomes in patients with early-stage cervical cancer.

OBJECTIVE: Radical trachelectomy is an established surgical approach for managing young women with cervical cancer wishing to preserve fertility. The aim of this study was to compare perioperative outcomes between laparoscopic (LRT) and abdominal radical trachelectomy (ART). METHODS: We reviewed the records of all women undergoing either LRT or ART in our institution since 2004. Demographic data, clinicopathologic data, and perioperative outcomes were collected and compared between the 2 procedures. RESULTS: Overall, 27 women were identified. All of them had stage IB1 disease. Eleven (40.8%) women underwent LRT, whereas 16 (59.2%) women underwent ART. Age, parity, and body mass index, as well as histologic type, grade, and presence of lymphovascular space invasion were comparable between groups. The median length of the parametrial tissue removed was shorter in LRT versus ART (P = 0.022). The median blood loss and length of stay were significantly reduced in the LRT group (85 vs 800 mL, P < 0.001; and 4 versus 7 days, P = 0.003). The median operative time was longer with the laparoscopic approach (320 versus 192.5 minutes, P < 0.001). Early grade 1 to 2 postoperative morbidity (mainly high urinary residuals) was comparable between groups; however, more grade 3 and late morbidity events were recorded in the ART group. CONCLUSIONS: This first comparison study between LRT and ART for fertility preservation in women with cervical cancer shows that laparoscopy performed better in terms of blood loss and length of stay. Laparoscopic radical trachelectomy could be the preferred option for these patients; however, further studies are needed to confirm comparable survival outcomes.

The role of intraoperative fluid optimization using the esophageal Doppler in advanced gynecological cancer: early postoperative recovery and fitness for discharge.

OBJECTIVE: To determine the effect of fluid optimization using esophageal Doppler monitoring (EDM) when compared to standard fluid management in women who undergo major gynecological cancer surgery and whether its use is associated with reduced postoperative morbidity. METHODS: From January 2009 to December 2010, women undergoing laparotomy for pelvic masses or uterine cancer had either fluid optimization using intraoperative EDM or standard fluid replacement without using EDM. Cases were selected from 2 surgeons to control for variability in surgical practice. Demographic and surgical details were collected prospectively. Univariate and multivariate analyses were performed to quantify the association between the use of EDM with "early postoperative recovery" and "early fitness for discharge." RESULTS: A total of 198 women were operated by the 2 prespecified surgeons; 79 women had fluid optimization with EDM, whereas 119 women had standard anesthetic care. The use of ODM was associated with earlier postoperative recovery (adjusted odds ratio, 2.83; 95% confidence interval, 1.20-6.68; P = 0.02) and earlier fitness for discharge (adjusted odds ratio, 2.81; 95% confidence interval, 1.01-7.78; P = 0.05). Women with advanced-stage disease in the "EDM" group resumed oral diet earlier than women in the "no EDM" group (median, 1 day vs 2 days; P = 0.02). These benefits with EDM did not extend to women with early-stage disease/benign/borderline tumors. No significant difference in postoperative complications was noted. CONCLUSIONS: Intraoperative fluid optimization with EDM in women with advanced gynecological cancer may be associated with improved postoperative recovery and early fitness for discharge. Studies with adequate power are needed to investigate its role in reducing postoperative complications.

Laparoscopically assisted radical vaginal hysterectomy versus radical abdominal hysterectomy for the treatment of early cervical cancer.

BACKGROUND: Cervical cancer is the second most common cancer among women and is the most frequent cause of death from gynaecological cancers worldwide. Standard surgical management for selected early-stage cervical cancer is radical hysterectomy. Traditionally, radical hysterectomy has been carried out via the abdominal route and this remains the gold standard surgical management of early cervical cancer. In recent years, advances in minimal access surgery have made it possible to perform radical hysterectomy with the use of laparoscopy with the aim of reducing the surgical morbidity and promoting a faster recovery. OBJECTIVES: To compare the effectiveness and safety of laparoscopically assisted radical vaginal hysterectomy (LARVH) and radical abdominal hysterectomy (RAH) in women with early-stage (1 to 2A) cervical cancer. SEARCH METHODS: We searched the Cochrane Gynaecological Cancer Group Trials Register, and Cochrane Register of Controlled Trials (CENTRAL) Issue 7, 2013, MEDLINE, and EMBASE up to July 2013. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared laparoscopically assisted radical hysterectomy and radical abdominal hysterectomy, in adult women diagnosed with early (stage 1 to 2A) cervical cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently abstracted data and assessed risk of bias. MAIN RESULTS: We found one RCT, which included 13 women, that met our inclusion criteria and this trial reported data on LARVH versus RAH.Women who underwent LARVH for treatment of early-stage cervical cancer appeared to have less blood loss compared with those who underwent RAH. The trial reported a borderline significant difference between the two types of surgery (median blood loss 400 mL (interquartile range (IQR): 325 to 1050) and 1000 mL (IQR: 800 to 1025) for LARVH and RAH, respectively, P value = 0.05). RAH was associated with significantly shorter operation time compared with LARVH (median: 180 minutes with LARVH versus 138 minutes with RAH, P value = 0.05).There was no statistically significant difference in the risk of perioperative complications in women who underwent LARVH and RAH. The trial reported two (29%) and four (57%) cases of intraoperative and postoperative complications, respectively, in the LARVH group and no (0%) reported cases of intraoperative complications and five (83%) cases of postoperative complications in the RAH group. There were no reported cases of severe perioperative complications.Bladder and bowel dysfunction of either a transient or chronic nature remain major morbidities after radical hysterectomy, and the one included study showed that there may be significantly less after LARVH. AUTHORS' CONCLUSIONS: The included trial lacked statistical power due to the small number of women in each group and the low number of observed events. Therefore, the absence of reliable evidence, regarding the effectiveness and safety of the two surgical techniques for the management of early-stage cervical cancer, precludes any definitive guidance or recommendations for clinical practice. The trial did not report data on long-term outcomes, but was at moderate risk of bias due to very low numbers of included women.

Ultrasonographic markers and preoperative CA-125 to distinguish between borderline ovarian tumors and stage I ovarian cancer.

OBJECTIVE: Preoperative evaluation of ovarian masses has become increasingly important for optimal planning of treatment. The aim of this study was to assess the role of preoperative serum cancer antigen 125 (CA-125) levels in correlation with ultrasonographic features in order to distinguish between borderline ovarian tumors (BOTs) and stage I epithelial ovarian carcinoma (EOC). DESIGN: Retrospective study. SETTING: Tertiary University Hospital. POPULATION: We reviewed all women with BOTs and stage I EOC from January 2000 to December 2010. Data from 165 women (66 BOTs and 99 stage I EOC) were analyzed. METHODS: Multivariable logistic regression with stepwise selection of variables was used to determine which clinical variables, ultrasound features and CA-125 level were independently associated with invasiveness. MAIN OUTCOME MEASURES: Utility of ultrasonographic markers and CA-125 in the preoperative differential diagnosis between BOTs and stage I EOC. RESULTS: Women with CA-125 > 100 IU mL(-1) had almost three times greater likelihood of belonging in the EOC group [odds ratio (OR) 3.02; confidence interval (CI) 95%: 1.13-8.12]. Furthermore, the presence of large solid component (≥20% of the tumor comprised of solid components) was associated with 4.25 times greater odds of it to representing ovarian cancer rather than a BOT (OR 4.25; 95% CI: 2.05-8.82). In contrast, the presence of papillary projections was associated with a 73% lower likelihood of EOC (OR 0.27; 95% CI: 0.13-0.58). CONCLUSIONS: Preoperative CA-125 > 100 IU mL(-1) combined with the presence of a large solid component and the absence of papillary projections seems to improve the discriminative ability in favor of stage I EOC.

En-block cytoreduction for advanced ovarian cancer.

The standard treatment of advanced ovarian, fallopian tube and peritoneal cancer is cytoreductive surgery followed by platinum-based chemotherapy (du Bois et al., 2005). This type of cancer expands through the peritoneum, which is the thin and continuous epithelial layer covering the abdominopelvic cavity and abdominal organs. Several separate procedures in the lower and upper abdomen are necessary for complete cytoreduction (Phillips et al., 2018). Considering the continuity of the peritoneum, these procedures could potentially take the form of an en-block specimen (Kalra et al., 2021). This approach is technically quite challenging and needs excellent understanding of the anatomy. Our aim is to present the feasibility of removing one en-block specimen, composed of multiple excisions and to propose an intraoperative strategy on how to perform such a dissection. This video demonstrates an en-block primary cytoreduction in a 62-year-old patient with stage IIIC ovarian cancer (FIGO) who underwent laparotomy, right diaphragmatic stripping, Morrison's pouch and right abdominal peritonectomy, radical omentectomy, splenectomy and modified posterior exenteration with end-to-end rectosigmoid anastomosis. End result was complete cytoreduction and final histology showed high grade serous carcinoma. The postoperative period was uneventful, and the patient was discharged on day 6. She completed 6 cycles of carboplatin and paclitaxel chemotherapy and is free of disease 32 months later. In conclusion, this approach follows the dissemination pattern of ovarian cancer and allows for a better understanding of the anatomy of the peritoneum. We propose that en-block excisions might be particularly useful for the training of young Gynaecological Oncologists in order to enhance their knowledge of the anatomy and their surgical skills.

Small volume stage 1B1 cervical cancer: Is radical surgery still necessary?

OBJECTIVE: Current surgical treatment of FIGO stage 1B1 cervical cancer is radical surgery. However, several reports have shown that for small tumours a more conservative approach can be as effective in terms of survival, whilst at the same time reducing the morbidity associated with removing the parametrium. The objective of our study was to report survival and obstetric outcomes following conservative management of small-volume stage 1B1 disease. METHODS: All patients with FIGO stage 1B1 cancer and estimated tumour volume of less than 500 mm(3) in a loop biopsy specimen were included in the study, irrespective of other histological characteristics. A second loop biopsy was performed to rule out residual disease in 79% of patients. RESULTS: Sixty two women were identified with a median age of 35 years (range 27-67). Median tumour length was 9.75 mm (7.2-20) and median depth of invasion was 1.55 mm (0.3-5). Thirty five women (56.4%) were treated with loop biopsy, whilst 27 (45.6%) had simple hysterectomy. Fifty seven women (92%) had pelvic lymphadenectomy and one positive node was recorded. After a median follow up of 56 months (16-132) no recurrence was noted. Seven full term pregnancies have been achieved. There were no preterm deliveries or mid-term miscarriages. CONCLUSION: Cervical loop biopsy or simple hysterectomy combined with negative pelvic lymphadenectomy for small-volume stage 1B1 cervical cancer offers excellent prognosis in terms of survival. Postoperative morbidity is reduced and obstetric outcomes may be improved. Should these results be verified by further prospective studies, radical surgery for these women may be avoided.

Role of chromosome 3q26 gain in predicting progression of cervical dysplasia.

OBJECTIVE: This study aimed to determine whether 3q26 gain can predict which low-grade squamous intraepithelial lesions (LSILs) and atypical squamous cells of undetermined significance (ASCUSs) will progress to higher-grade squamous intraepithelial lesion (HSIL). METHODS: Liquid cytology specimens of LSIL and ASCUS from 73 women were examined using fluorescent in situ hybridization (FISH) for the detection of 3q26 gain. All women underwent colposcopy and biopsy at the initial visit and 40 of them with histology showing cervical intraepithelial neoplasia 1 (CIN 1) or human papillomavirus infection (koilocytosis) were included in the study. They were reevaluated with liquid cytology, colposcopy, and biopsy after a median follow-up of 17.5 months. RESULTS: A total of 40 cases were analyzed (31 LSILs and 9 ASCUSs). Of these cases, 8 (20%; 6 LSILs and 2 ASCUSs) were positive and 32 (80%) were negative for 3q26 gain according to FISH. Three of the 8 positive women (38%) progressed to HSIL/CIN 2 or worse, whereas none of the 32 negative women did so. 3q26 gain could predict progression with a negative predictive value of 100% (95% confidence interval, 89.1%-100%). In addition, women positive for 3q26 gain had a significantly lower regression rate compared with negative women (P = 0.009). CONCLUSIONS: In this first prospective study, 3q26 gain in LSIL/ASCUS cytology exhibited an impressive negative predictive value for progression to HSIL/CIN 2 or worse. Thus, 3q26 gain may be useful in stratifying patients' risk for progression and possibly alter management and reduce cost of follow-up.

Endometrial stromal sarcoma arising from endometriosis of the terminal ileum: the role of immunohistochemistry in the differential diagnosis.

Low-grade endometrial stromal sarcoma (LESS) is an uncommon uterine malignancy. Occasionally, it may develop in extrauterine endometriotic lesions and present morphological characteristics mimicking various neoplasms, making its diagnosis very challenging. We report a rare case of a 56-year-old woman presenting with a pelvic mass, initially presumed to be of ovarian origin. After surgical excision the diagnosis of a LESS arising from foci of endometriosis of the terminal ileum was established. Pelvic lymph nodes and omentum were also infiltrated. The patient received adjuvant chemotherapy and medroxyprogesterone; she is alive with no evidence of disease after a follow-up of 38 months. Immunohistochemical characteristics of the tumor are very important for the differential diagnosis of this rare neoplasm and include diffuse strong positivity for CD 10, estrogen receptor expression and CD 34 negativity.

Abdominal radical trachelectomy for treatment of deep infiltrating endometriosis of the cervix.

Surgical management of deep infiltrating endometriosis can be very challenging even for experienced gynecologists. Radical procedures like bowel resection and nephrectomy have been reported for treatment of the disease. Our aim is to report abdominal radical trachelectomy for treatment of deep infiltrating endometriosis of the cervix causing obstructive uropathy and diminished kidney function. We present a 38-year-old woman who was treated in our department for cervical endometriosis involving the vagina and left parametrium. Abdominal radical trachelectomy, insertion of a pig-tail catheter in the left ureter and end-to-end anastomosis of the uterus with the vagina was performed to remove the endometriotic lesion. Cooperation between gynecologists, urologists and nephrologists enabled fertility preservation as well as improvement of renal function. Deep infiltrating endometriosis is a complex disease that requires a multidisciplinary approach. Abdominal radical trachelectomy for cervical lesions seems feasible in this setting and helps preserve fertility.

Differences in Patterns of Recurrence Between Primary and Interval Debulking Surgery for Advanced Ovarian Cancer.

BACKGROUND/AIM: This study aimed to identify differences in the pattern and timing of recurrence in patients with advanced ovarian cancer undergoing primary (PDS) or interval debulking surgery after neoadjuvant chemotherapy (NACT). PATIENTS AND METHODS: Data were prospectively collected on 105 patients from June 2016 to March 2020. RESULTS: There were 30 (50%) recurrences in the PDS group compared to 32 (72.7%) in the NACT group (p=0.020). An intra-abdominal relapse was more common in NACT compared to PDS patients (64.4% vs. 38.3%, p=0.008) and a recurrence in two or more sites (NACT: 44.4% vs. PDS: 23.3%, p=0.010). Among completely cytoreduced patients, a pelvic recurrence was more frequent in NACT patients (NACT: 50% vs. 22.4% in PDS, p=0.011). Progression-free survival (PFS) was longer in PDS compared to NACT (27 vs. 16 months, p=0.039). CONCLUSION: NACT patients experienced an unfavorable distribution and timing of recurrent disease compared to patient who underwent PDS.

Detection and credibility of sentinel node in vulvar cancer: a single institutional study and short review of literature.

PURPOSE: To evaluate the detectability and credibility of sentinel lymph node (SLN) in vulvar cancer. METHODS: With Tc99m-nanocolloid and methylene blue, we identified SLNs in 34 patients. In 27 cases both tracers were used, while in 7 only blue dye was used. Completion lymphadenectomy was performed in all patients. SLNs and non-SLNs were sent separately for pathologic evaluation. RESULTS: At least one SLN was identified in all patients. Detection rate per groin was not significantly higher in the combined versus blue dye only technique (42/50 vs. 10/14, p = 0.43). 99m-Tc was not superior to blue dye in detecting SLN (42/50 vs. 50/64, p = 0.65). Midline location of the tumor did not seem to negatively affect the procedure. Four false negatives were observed in three patients with tumors >4 cm. Negative predictive value of SLN was 100% for grade I tumors ≤ 4 cm in patients ≤ 71 years. CONCLUSION: Tc-99m does not seem to be superior to methylene blue in the detection of SLN in vulvar cancer. Patients of younger age with small, well-differentiated tumors appear to be the most suitable candidates for lymphatic mapping.

Survival after secondary cytoreduction for recurrent ovarian cancer: which are the prognostic factors?

OBJECTIVE: Significant controversy exists concerning the factors affecting survival after secondary cytoreduction (SCR) in recurrent ovarian cancer. This study aims to identify factors independently associated with survival after SCR. METHODS: We retrospectively retrieved 39 patients with recurrent ovarian cancer. All patients had been initially treated with primary cytoreduction in our institution and received platinum- and paclitaxel-based chemotherapy postoperatively. Disease-free interval (DFI) had to be longer than 6 months. A variety of clinicopathological factors were recorded. Multivariable Cox regression was performed to examine the associations of parameters with survival. RESULTS: Median survival was equal to 24 months, the median DFI was 22 months, and complete SCR had been achieved in 19/39 patients (48.7%, 95% CI: 32.4-65.2%). Higher number of recurrence sites, clear-cell histological type, and more advanced FIGO stage were independently associated with shorter survival; longer DFI was associated with longer survival. Noticeably, complete SCR lost its significance at the multivariable model, although it was associated with longer survival at the univariable analysis. CONCLUSIONS: Four factors seem capable of independently modifying survival after SCR: number of recurrence sites, DFI, FIGO stage, and clear cell histology. The two latter factors might reflect aggressive clinicopathological features of the tumor with long-term effect.

Risk factors in women 40 years of age and younger with endometrial carcinoma.

OBJECTIVE: To identify and compare risk factors among endometrial cancer patients ≤40 years of age, postmenopausal women with the same malignancy and women ≤40 years without malignancy. DESIGN: Retrospective case-control study. SETTING: Athens University, department of obstetrics and gynecology of a tertiary hospital serving a mainly urban population. POPULATION: Endometrial cancer patients ≤40 years (study group, n = 40), postmenopausal women with the same malignancy (positive controls, n = 40) and women ≤40 (negative controls, n = 40) without endometrial cancer. METHODS: Clinical history, treatment and follow-up of patients were evaluated. Factors studied included age, histology, stage, grade, lymphovascular space involvement, body mass index (BMI), cytology, lymph node status, parity, smoking, family history, hypertension recurrence and survival. MAIN OUTCOME MEASURES: Differences in risk factors and characteristics. RESULTS: Nulliparity, smoking and hypertension were significantly related with endometrial cancer in the study group compared to positive controls (p = 0.001, p < 0.01 and p < 0.001, respectively). BMI >30 significantly characterized patients in the study group compared to negative controls (p = 0.006). Finally, irregular menstruation and family history of cancer were observed more often in the study group compared to both control groups. Stage, grade, myometrial invasion, lymphovascular space involvement and lymph node status were comparable between the study and positive control groups. CONCLUSION: Nulliparity, obesity, unstable menstruation, smoking and cancer in the family are strongly correlated with endometrial cancer risk in women ≤40 years.

Erythrocyte membrane AChE, Na(+), K(+)-ATPase and Mg(2+) ATPase activities in mothers and their premature neonates in relation to the mode of delivery.

AIM: To investigate erythrocyte membrane AChE, Na(+), K(+)-ATPase and Mg(2+)-ATPase activities in mothers and their full-term or premature newborns in relation to the mode of delivery. METHODS: Blood was obtained from mothers pre- and post-delivery and the umbilical cord (CB) of their full-term newborns: Group A1 (n = 16) born with vaginal delivery (VD), Group B1 (n = 14) full-terms with scheduled cesarean section (CS), Group A2 (n = 12) prematures with VD, Group B2 (n = 14) prematures with CS. Total Antioxidant Status (TAS) and common laboratory tests were measured with routine methods, and the membrane enzyme activities spectrophotometrically. RESULTS: TAS was reduced in mothers post VD and in the CB whereas remained unaltered in CS mothers and their newborns. AChE and Na(+), K(+)-ATPase were increased in mothers post VD. AChE was lower in the CB of prematures than that of full-terms independently of the mode of delivery. Na(+), K(+)-ATPase activity was increased in the groups of mothers post VD and decreased in prematures. The enzyme was higher in prematures with CS than that with VD. Mg(2+)-ATPase activity was unchanged. CONCLUSION: The increased maternal AChE and Na(+), K(+)-ATPase activities may be due to the low TAS determined post VD, whereas their decreased activities in prematures to their immaturity.