Endometrial cancer: the role of MRI quantitative assessment in preoperative staging and risk stratification.

BACKGROUND: New methods to reduce subjectivity in preoperative magnetic resonance imaging (MRI) staging of endometrial cancer are needed. PURPOSE: To investigate the role of MRI quantitative assessment in staging and risk stratification of endometrial cancer. MATERIAL AND METHODS: Preoperative T2-weighted (T2W) images and diffusion-weighted imaging of 42 patients were analyzed retrospectively by two radiologists. Tumor area ratio (TAR) and tumor volume ratio (TVRseg) were calculated by semi-automatic segmentation of the tumor and uterus on T2W imaging and apparent diffusion coefficient (ADC). TVR was also calculated by the 3D metric method (TVRmetric). Mean ADCtumor was calculated. The patients were allocated to risk groups regarding the stage, grade, and lymphovascular invasion (LVI) status. RESULTS: TAR, TVRmetric, T2W TVRseg, and ADC TVRseg showed a significant difference between the superficial and deep myometrial invasion groups (P < 0.001). All of these parameters showed a good diagnostic performance for detecting deep myometrial invasion (AUC>0.82), the highest accuracy rate (85%) was found with T2W TVRseg. LVI was significantly associated with TAR (P = 0.002) and T2W TVRseg (P = 0.014), while the cervical invasion was associated with TAR (P = 0.03). ADCtumor was significantly lower in high-grade tumors (P = 0.002). There was a significant difference in ADCtumor (P = 0.002), TAR (P = 0.004), and T2W TVRseg (P = 0.038) between the low- and high-risk groups. AUC of TAR and T2W TVRseg for detecting high-risk groups were 0.80 and 0.77, respectively, while AUC of ADCtumor for the low-risk group was 0.75. CONCLUSION: MRI quantitative assessments such as TAR, TVR, and ADCtumor may improve the accuracy of preoperative staging and can help in risk stratification of endometrial cancer.

Vaginally Assisted Laparoscopic Urethrolysis and Mesh Excision after Tension-free Vaginal Tape.

STUDY OBJECTIVE: To present technique of vaginally assisted laparoscopic urethrolysis and mesh excision after tension-free vaginal tape. DESIGN: Demonstration video. SETTING: Despite the Food and Drug Administration's warning to limit the use of mesh, midurethral sling surgery (MUS) has not significantly decreased, but operations for complications have increased 3 times [1]. Urethral obstruction after MUS has an incidence of 2.7% to 11% [2] that requires resurgery, which ranges from pull-down, mesh excision to urethrolysis and is chosen by the surgeon's experience. Retropubic urethrolysis and mesh excision are reported to be more successful [3]. Urethrolysis can be performed by a retropubic, transvaginal, or suprameatal approach. Transvaginal mesh excision and urethrolysis are not satisfactory in all cases, and it might be difficult to identify the mesh if it is dislocated proximally or buried in dense fibrosis, which may increase urethral/bladder injuries. Although vaginal urethrolysis and mesh removal are usually preferred as the primary approach, there is no randomized controlled trial comparing retropubic and vaginal urethrolysis with/without mesh removal. Gynecologists should master each technique to provide individualized treatment. Laparoscopic urethrolysis has the advantage of the identification of neighboring structures and provides a safer operation (Fig. 1). Combined vaginal and laparoscopic approaches can be used to totally remove the mesh and for difficult surgeries at the junction of the retropubic urethra and the midurethra (Fig. 2). INTERVENTIONS: (1) Timing of urethrolysis is controversial. Although urethral loosening or pulling down in the first few days and mesh excision in the first 15 days can be useful, urethrolysis can be chosen for delayed cases with marked fibrosis. Preoperative diagnostic cystoscopy to exclude urethral mesh erosion is essential. Intermittent catheterization until surgery should be done. (2) The technique is described in 5 steps. The arcus tendineus is an important landmark [4] (Fig. 3). CONCLUSION: Laparoscopic urethrolysis for urinary obstruction after MUS can be a safe and successful procedure after failed vaginal approach or can be considered as a primary approach in select cases.

What should be the goal for future development of colposcopy? Cons and pros of sensitivity and specificity.

PURPOSE: To discuss what features of colposcopy should be developed for the future in different settings. RESULT: There are cons and pros of aiming sensitivity, negative predictive value and specificity and positive predictive value. In case of diagnosis and intervention, methods increasing the specificity and positive predictive value will help to decrease unnecessary interventions. Besides, HPV test is highly sensitive and has a good negative predictive value. It is usually available before colposcopy. CONCLUSION: Colposcopy can be used in a screening or diagnostic/interventional scenario. Aims to improve sensitivity or specificity may change according to the aim of colposcopy. However, in the presence of highly sensitive tests which are performed before colposcopy, first goal to improve for colposcopy can be specificity and positive predictive value.

Clinical relevance of objectifying colposcopy.

PURPOSE: To evaluate the clinical value of four objective colposcopic criteria inner border, ridge sign, cuffed crypt openings and rag sign to diagnose cervical intraepithelial neoplasia grade 2 or worse (CIN 2+), using video exoscopy and to compare it to subjective graduating signs. METHODS: Retrospective evaluation of video recordings of 444 patients, referred for diagnostic colposcopy, who underwent cervical biopsies, and if indicated loop excisions. Most severe histological diagnosis was recorded. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios (LR) with 95% confidence interval, for CIN 2+ were calculated. RESULTS: Single biopsy, two biopsies and magnification-guided loop excision were performed in 60.8, 39.2 and 70.5% of patients, respectively. Sensitivity, specificity, PPV and NPV to detect CIN 2+ were 19.3, 99.2, 98.3 and 35.8%, for inner border sign; 53.1, 93.5, 94.7 and 47.6%, for ridge sign; 51.5, 84.9, 88.2, and 44.3%, for cuffed crypt openings, and 40.7, 96.4, 96.1 and 42.5%, for rag sign, respectively. The positive likelihood ratio (LR+) was 26.7 and the negative likelihood ratio (LR-) was 0.81, for inner border sign; 8.2 and 0.5, for ridge sign; 3.41 and 0.57 for cuffed crypt openings; and 11.3 and 0.62 for rag sign, respectively. 90% of CIN 2+ had at least one objective sign. Combination of any two objective signs significantly increased the LR of the presence of CIN 2+, and was clinically superior to any combination of graduating signs. CONCLUSION: Objective colposcopic criteria are clinically useful and significantly associated with CIN 2+.

Physical and mental workload in single-incision laparoscopic surgery and conventional laparoscopy.

OBJECTIVES: The aim of the present study is to evaluate mental workload and fatigue in fingers, hand, arm, shoulder in single-incision laparoscopic surgery (SILS) and multiport laparoscopy. METHODS: Volunteers performed chosen tasks by standard laparoscopy and SILS. Time to complete tasks and finger and hand strength were evaluated. Lateral, tripod, and pulp pinch strengths were measured. Hand dexterity was determined by pegboard. Electromyography recordings were taken from biceps and deltoid muscles of both extremities. The main outcome measurement was median frequency (MF) slope. NASA-TLX was used for mental workload. RESULTS: Time to complete laparoscopic tasks were longer in the SILS group (P < .05). Decrease of strength in fingers and hand were similar in SILS and standard laparoscopy. Pegboard time was increased in both hands after SILS (P < .05). MF slope of biceps muscle and deltoid muscle in SILS was far away from the reference slope. MF slope of biceps muscle and deltoid muscle in standard laparoscopy was close to reference slope, indicating there was more fatigue in biceps and deltoid muscles of both upper extremities in SILS group. NASA-TLX score was 73 ± 13.3 and 42 ± 19.5 in SILS and multiport laparoscopy, respectively (P < .01). Mental demand, physical demand, temporal demand, performance, effort, and frustration were, respectively, scored 10.7 ± 3.8, 11.7 ± 3.5, 12.2 ± 2.7, 11 ± 3, 13.6 ± 2.7, and 13.5 ± 2.8 in SILS and 6.3 ± 3.1, 6.6 ± 3.3, 7.3 ± 3.3, 7.1 ± 4.1, 7.9 ± 3.9, and 6.6 ± 3.8 in standard laparoscopy (P < .01). CONCLUSIONS: SILS is mentally and physically demanding, particularly on arms and shoulders. Fatigue of big muscles, effort, and frustration were major challenges of SILS. Ergonomic intervention of instruments are needed to decrease mental and physical workload.

Placental-site trophoblastic tumor and fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography.

OBJECTIVE: Pre-operative imaging characteristics of placental site trophoblastic tumor (PSTT) are variable and non-specific. Although magnetic resonance imaging (MRI), ultrasonography, chest CT and X-rays findings have been studied the fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (¹8F-FDG PET/CT) findings of PSTT have not been previously documented. We present the findings of a first case of PSTT evaluated by pre-operative ¹8F-FDG PET/CT. A suspicious mass was biopsied and revealed PSTT in post-operative pathological examination. She was referred to the gynecology-oncology department. The ¹8F-FDG PET/CT scan revealed a 27 x 20 mm laterally expanded lesion that showed increased ¹8F-FDG uptake (SUVmax: 5.20) on the right isthmus of the uterus. The ¹8F-FDG PET/CT findings were in accordance with those from chest X-ray/s, CT and pelvic ultrasonography. A systematic, nerve sparing, paraaortic and pelvic lymph node dissection along with total hysterectomy and salpingoopherectomy was performed. The patient was discharged uneventfully. CONCLUSION: ¹8F-FDG PET/CT scan was able to identify the mass in the uterus which was shown by pathology to be PSTT. This finding of PET/CT was in accordance with other imaging techniques. Lymphatic mapping of ¹8F-FDG PET/CT in this case was also in accordance with surgery and pathology findings.

Hypoxia-inducible factor-1α, adrenomedullin and Bcl-2 although expected are not related to increased uptake of fluorine-18-fluorodeoxyglucose in endometrial cancer.

OBJECTIVE: To study the relation between SUVmax, hypoxia inducible factor 1α (HIF-1α), angiogenetic factor adrenomedullin (AM) and antiapoptotic factor Bcl-2 in endometrial cancer. SUBJECTS AND METHODS: Thirthy eight patients who were diagnosed after a preoperative endometrial biopsy with endometrium cancer underwent pre-operative positron emission tomography/computed tomography (PET/CT) utilizing fluorine-18-fluorodeoxy glucose (¹8F-FDG). Maximum standardized uptake values (SUVmax) of the primary tumor were measured. After hysterectomy and bilateral salpingo-oophorectomy, microscopic slides of the 38 endometrial adenocarcinoma patients were evaluated by a surgical pathologist to confirm the diagnosis. Immunohistochemical staining for AM, Bcl-2 and HIF-1α was studied. RESULTS: In all patients, ¹8F-FDG uptake was detected. The mean SUVmax of the tumors was 11.8 ± 5.9. Although SUVmax was higher in HIF-1α positive tumors, this finding was not statistically important. No correlation was found between SUVmax and HIF-1α positivity. Mean SUVmax was 6.4 ± 3 and 12.3 ± 1.4 in AM negative and AM positive patients, respectively. Mean SUVmax was 10.6 ± 4.9 and 12.3 ± 1.4 in Bcl-2 negative and Bcl-2 positive patients, respectively. We found no correlation between SUVmax, AM or Bcl-2 expression. Allred scores were not related with SUVmax in regression analysis. CONCLUSION: Our study in a small number of patients is the first to show that SUVmax, although expected is not associated with HIF-1α, AM or with Bcl-2 in endometrial cancer. Increased uptake of ¹8F-FDG in endometrial cancer seems to be independent of HIF-1α and its downstream factors.

Laparoscopic pelvic lymphadenectomy in 32 pregnant patients with cervical cancer: rationale, description of the technique, and outcome.

OBJECTIVE: Individualized treatment of pregnant patients with cervical cancer is mandatory; hence, information on nodal status is pivotal to allow a waiting strategy in early-stage disease.We aimed to verify the oncological safety and surgical reproducibility of a standardized laparoscopic pelvic lymphadenectomy in pregnant patients with cervical cancer. METHODS: We standardized laparoscopic pelvic lymphadenectomy during the first and second term of gestation in 32 patients with cervical cancer since 1999. According to gestational week (GW) of less than 16 GWs or more than 16 GWs, 2 different techniques were used. RESULTS: The International Federation of Gynecology and Obstetrics stages were IA in 10 patients, IB1 in 17 patients, IB2 in 4 patients, and IIA in 1 patient. Mean (SD) GW was 17.5 (5.1) weeks. Mean (SD) operative time was 105.4 (29) minutes. Mean (SD) blood loss was 5.3 (10.2) mL. There were no conversion to laparotomy and no intraoperative complications. A median number of 14 pelvic lymph nodes (range, 8-57) were harvested. Median hospital stay was 6 days. Median follow-up is 42.5 months (range, 17-164). Four patients had lymph node metastases. Five patients interrupted their pregnancy. Fourteen patients were given neoadjuvant platin-based systemic therapy. All patients are alive and disease free. All children born through cesarean delivery at a mean (SD) 34 (1.9) GWs are well and show normal clinical neurological development. CONCLUSIONS: To the best of our knowledge, this is the largest series so far reported on laparoscopic pelvic lymphadenectomy during pregnancy. This procedure is safe and associated with good oncological and obstetrical outcomes.

A multicentric randomized study comparing two techniques of magnification assisted loop excision of high-grade cervical intraepithelial neoplasia: video exoscopy and colposcopy.

PURPOSE: To compare loop excisions of cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) under video exoscopy, or colposcopic guidance, with respect to safety and effectiveness. METHODS: Prospective multicentric randomized trial of 300 patients, undergoing loop excision for CIN 2+ either under video exoscopy (group A) or colposcope (group B) guidance. Intra- and post-operative complications, resection margins, and removed cervical volume in both groups were evaluated. RESULTS: 19.3 % of patients in video exoscopy group and 15.5 % in colposcopy group (p = 0.67) had transformation zone (TZ) 3. 45/151 (29.8 %) of group A patients and 48/149 (32.2 %) of group B patients underwent top-hat procedure, i.e., one superficial excision followed by one deeper removal of the endocervical tissue (p = 0.74). There was no difference in intra- and post-operative complications in the two groups. Positive endocervical resection margins (R0) were 9.9 % in video exoscopy group and 8.7 % in colposcopy group, respectively. Unclear endocervical resection margins (Rx) were 2.0 % in both groups. Mean total excised cervical volume was 1.20 cubic centimeter (cc³) in group A, and 1.24 cc³ in group B, respectively. Recurrent disease occurred in 2.3 % of patients at 6 months follow-up. CONCLUSION: Magnification assisted loop excision of CIN 2+ is equally effective and safe under colposcopic and video exoscopy guidance. The latter technique could potentially offer an alternative treatment of CIN 2+ lesions for doctors unfamiliar with colposcope.

Granulosa cell tumor and concurrent endometrial cancer with (18)F-FDG uptake.

The findings and the role of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) for the diagnosis of ovarian granulosa cell tumor (OG) are described. We present the pre-operative findings of (18)F-FDG PET/CT scan of a case of OG concurrent with endometrium cancer and endometrial hyperplasia, which revealed a 48mm mass demonstrating mild increased metabolic activity on the right ovary. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. Frozen and paraffin-enbeded sections showed an encapsulated OG. There were few mitoses. There was concurrent atypical endometrial hyperplasia. In conclusion, we reported a case of an encapsulated OG, which showed mild uptake of the (18)F-FDG with concurrent endometrial cancer. There has been only one report of (18)F-FDG findings in primary ovarian granulosa cell tumor, similar to ours.

Comparison of the effects of laparoscopic bipolar electrocoagulation and intracorporeal suture application to ovarian reserve in benign ovarian cysts.

PURPOSE: Aim of the present study is to determine the effects of bipolar electrocoagulation and intracorporeal suture on the ovarian reserve after ovarian cystectomy. METHODS: Sixty patients aged 18-42 years old and with a persistent adnexal mass were recruited to the study. Patients were randomized into suture hemostasis group or bipolar hemostasis group. Laparoscopic ovarian cystectomy was performed to all patients. Hemostasis was obtained by bipolar coagulation in 30 patients and by intracorporeal sutures in 30 patients. Serum levels of FSH, LH, estradiol, inhibin B and ultrasonographic measurements (antral follicle count and ovarian volume) were analyzed and recorded at day 3 of menstrual cycle, 1 and 3 months after the surgery. RESULTS: Basal FSH level measurement at the postoperative third month was significantly increased to 6.96 ± 1.86 mIU/ml (p < 0.05) in the bipolar electrocoagulation group. However, the decreased ovarian volume and antral follicle count was restored at the postoperative third month in the bipolar electrocoagulation group. Preoperative and postoperative FSH, LH, estradiol and inhibin B levels and ultrasonographic measurements were similar in the intracorporeal suture group. CONCLUSION: The unwanted effect of bipolar electrocoagulation on ovarian reserve is probably transient and causes minimal damage to ovary. FSH levels may be slightly elevated. Gentle use of bipolar electrocoagulation or intracorporeal are not found to effect ovarian reserve.

Determination of the Readability Level of Consent Forms Used in the Gynecology and Obstetrics Clinic at Suleyman Demirel University.

Background This study aimed to evaluate the readability level of consent forms used for interventional procedures in the obstetrics and gynecology clinic and to determine the readability of the texts according to the education level of the patient. Methodology This study determined the readability of patient consent forms used before interventional procedures in the gynecology and obstetrics clinic at the Suleyman Demirel University Hospital, Isparta. The consent forms were divided into two main groups according to their use in obstetrics and gynecology procedures. The readability level of consent forms was assessed using two readability formulas developed by Atesman and Bezirci-Yilmaz, which determine the readability level of Turkish texts in the literature. Results When the consent forms were analyzed according to Atesman's readability formula, they were found to be readable with more than 15 years of education at the undergraduate level, while according to Bezirci-Yilmaz's readability formula, they were found to be readable with 17 years of education at the postgraduate level. Conclusions Easy-to-read consent forms will ensure that patients are more informed about interventional procedures and participate more effectively in the treatment process. There is a need to develop readable consent forms suitable for the general education level.

The NEWS2 score predicts prolonged hospitalization in the intensive care unit in major surgery patients.

Objective: Gynecological malignancies are significant causes of mortality and morbidity in women worldwide. Although surgery is an important treatment method, both the extent of the surgery and the factors related to the patient affect postoperative processes. The National Early Warning Score 2 (NEWS2) is a simple, inexpensive, and safe early warning score developed in 2012 and updated in 2017. Although it is not commonly used in surgical patients, its use in patients who will undergo major surgery may provide insights about the postoperative process. This study investigates the importance of NEWS2 and its relationship in patients with for major gynecologic oncology surgery. Materials and Methods: Forty-four patients with gynecologic malignancies scheduled for major abdominal surgery were included in this study. Patients with a NEWS-2 score of <3 were included in group 1, and patients with a NEWS-2 score of more than 3 were included in groups 2. NEWS2 Score, Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation 2 scores (APACHE 2) were calculated. In addition, postoperative routine clinical and laboratory parameters were evaluated. Operation time, duration of intubation in the intensive care unit (ICU), the length of the intensive care stay, and length of hospitalization were recorded. Results: Duration of intubation in the ICU in group 1 with a NEWS2 <3 [8.2 (0-18) vs 16.2 (3-39), respectively; p<0.01], ICU length of stay [21.6 (4-27) vs 47.3 (4-113), respectively; p<0.01], length of hospitalization [11.6 (5-56) vs 18.6 (8-67), respectively; p<0.01]. NEWS2 >3 was significantly higher compared to group 2. The SOFA score was significantly higher in group 2 compared with group 1 [1.2±0.5 vs 4.1±1.9; respectively; p<0.01]. In the correlation analysis, the NEWS2 score level was positively correlated with the SOFA score (p<0.001, r=0.81) and hospitalization time (p<0.001, r=0.60) and neutrophil lymphocyte ratio (NLR) (p<0.001, r=0.47). Conclusion: These findings suggest that the NEWS2 score may be correlated with the length of intensive care intubation, length of intensive care stay, and length of hospitalization. NEWS2 is an effective and simple scoring system that provides information about postoperative outcomes in gynecologic oncology patients scheduled for major surgery.

The Prognostic Effect of HER2 Gene Amplification in High-Grade Endometrial Carcinomas and its Correlation with Protein Overexpression.

Introduction. New therapeutic agents and biomarkers are needed for the treatment of aggressive endometrial cancer subtypes. Recently, HER2 has been recommended to be tested routinely in serous endometrial cancers. The aim of this study is to investigate the correlation between HER2 (ERBB2) protein overexpression and HER2 gene amplification and the relationship of HER2 gene amplification with prognosis in cancers with serous morphology. In addition, the concordance of HER2 testing in paired curettage and hysterectomy specimens is also investigated. Methods. Twenty five serous carcinomas and 8 carcinosarcomas with a serous morphology were included in the study. HER2 staining was performed on whole tissue sections by immunohistochemistry (IHC) and fluorescent in situ hybridization (FISH). The system, which was proposed by Fader et al was used to evaluate the stainings. Results. Protein overexpression was detected in 27.3% (n = 9) of the cases, and gene amplification in 30.3% (n = 10). A significant positive correlation was found between the two methods (P < .0001). HER2 IHC revealed a heterogeneous staining pattern, such as intense complete membranous in solid areas, and basolateral in papillary and glandular areas. HER2 gene amplification was significantly associated with shorter overall (P = .005) and disease-free (P = .014) survival. The concordence of the results in curettage and hysterectomy specimens was also significantly high. Conclusion. HER2 is an important prognostic and predictive marker for endometrial cancers with serous morphology. HER2 IHC/ISH testing can be performed by using diagnostic curettage specimens which contain enough viable tumor cells. However, pathologists should be aware of the intratumoral heterogeneity for HER2 staining.

Artificial intelligence for prediction of endometrial intraepithelial neoplasia and endometrial cancer risks in pre- and postmenopausal women.

BACKGROUND: The current approach to endometrial cancer screening requires that all patients be able to recognize symptoms, report them, and carry out appropriate interventions. The current approach to endometrial cancer screening could become a problem in the future, especially for Black women and women from minority groups, and could lead to disparities in receiving proper care. Moreover, there is a lack of literature on artificial intelligence in the prediction and diagnosis of endometrial intraepithelial neoplasia and endometrial cancer. OBJECTIVE: This study analyzed different artificial intelligence methods to help in clinical decision-making and the prediction of endometrial intraepithelial neoplasia and endometrial cancer risks in pre- and postmenopausal women. This study aimed to investigate whether artificial intelligence may help to overcome the challenges that statistical and diagnostic tests could not. STUDY DESIGN: This study included 564 patients. The features that were collected included age, menopause status, premenopausal abnormal bleeding and postmenopausal bleeding, obesity, hypertension, diabetes mellitus, smoking, endometrial thickness, and history of breast cancer. Endometrial sampling was performed on all women with postmenopausal bleeding and asymptomatic postmenopausal women with an endometrial thickness of at least 3 mm. Endometrial biopsy was performed on premenopausal women with abnormal uterine bleeding and asymptomatic premenopausal women with suspected endometrial lesions. Python was used to model machine learning algorithms. Random forest, logistic regression, multilayer perceptron, Catboost, Xgboost, and Naive Bayes methods were used for classification. The synthetic minority oversampling technique was used to correct the class imbalance in the training sets. In addition, tuning and boosting were used to increase the performance of the models with a 5-fold cross-validation approach using a training set. Accuracy, sensitivity, specificity, positive predictive value, and F1 score were calculated. RESULTS: The prevalence of endometrial or preuterine cancer was 7.9%. Data from 451 patients were randomly assigned to the training group, and data from another 113 patients were used for internal validation. Of note, 3 of 9 features were selected by the Boruta algorithm for use in the final modeling. Age, body mass index, and endometrial thickness were all associated with a high risk of developing precancerous and cancerous diseases, after fine-tuning for the multilayer computer to have the highest area below the receiver operating characteristic curve (area under the curve, 0.938) to predict a precancerous disease. The accuracy was 0.94 for predicting a precancerous disease. Precision, recall, and F1 scores for the test group were 0.71, 0.50, and 0.59, respectively. CONCLUSION: Our study found that artificial intelligence can be used to identify women at risk of endometrial intraepithelial neoplasia and endometrial cancer. The model is not contingent on menopausal status or symptoms. This may be an advantage over the traditional methodology because many women, especially Black women and women from minority groups, could not recognize them. We have proposed to include patients to provide age and body mass index, and measurement of endometrial thickness by either sonography or artificial intelligence may help improve healthcare for women in rural or minority communities.

The expression of stanniocalcin-1, estrogen receptor and progesterone receptor in endometrioid endometrial cancer.

Objective: To evaluate the expression of stanniocalcin-1 (STC-1) and to investigate the correlation of STC-1 with expression of estrogen receptor (ER), progesterone receptor (PR) and clinical parameters, histopathological findings and prognostic factors in endometrioid endometrial cancer (EEC). Materials and Methods: In this retrospective study, STC-1 (cytoplasmic), ER (nuclear), and PR (nuclear) stainings were applied to tissue microarray sections of 89 EEC, 27 endometrial intraepithelial neoplasia (EIN), and 21 normal endometrium (NE). Prognostic factors such as age, tumor size, depth of myometrial invasion, lymphovascular invasion, perineural invasion, and lymph node metastasis were compared with the expression of these markers. Results: ER showed significantly higher positivity in grade 1 EEC. PR expression was also higher in grade 1 EEC, but these findings were not statistically significant. Strong expression of STC-1 was observed in EIN and EECs compared with NE. STC-1 showed low staining in the NE, and high staining was also noted in the EIN foci adjacent to the NE. STC-1 expression was positively correlated with grade 1 EECs. Conclusion: STC-1 expression was positively correlated with low histologic grade in EECs. STC-1 can be used for distinguishing low-grade endometrioid tumors and high -grade endometrioid tumors in curretage specimens. Since STC-1 is related to well differentiated tumors, it can also be regarded as a good prognostic factor in EECs.

Clinical recommendation radical trachelectomy for fertility preservation in patients with early-stage cervical cancer.

Radical trachelectomy (RT) is a fertility-sparing procedure with the aim to provide adequate oncological safety to patients with cervical cancer while preserving their fertility. In the current review, indications, development of the procedure, technical aspects, preoperative and postoperative management, and oncological, fertility, and obstetric outcomes are discussed and studied with respect to whether the procedure is performed abdominally or vaginally. Complications of RT, staging, and more conservative alternatives to RT are discussed as well. A systematic MEDLINE search was performed, which yielded 218 articles, of which 75 were selected for further analysis based on the number of patients and the quality of the study. Strict morphologic criteria should be applied to the candidates to maintain oncological safety. When limited to a tumor less than 2 cm in diameter, the overall recurrence rate after vaginal RT is 3% to 6% and the death rate is 2% to 5%. Data on fertility and obstetric outcome are mostly based on the results of patients who underwent vaginal RT. More data are needed to be able to draw the same conclusions for abdominal RT. Fertility seems not to be decreased, but the risk for premature delivery is 2 to 3 times higher compared to women with an intact cervix. In locally advanced cervical tumors with a diameter larger than 2 cm, neoadjuvant chemotherapy followed by RT may be offered after explaining the experimental nature to the patient. In conclusion, RT is an oncologically safe technique in women with early invasive cancer. The rate of term pregnancies still needs improvement. Fertility-preserving treatment of women with tumors larger than 2 cm in diameter can be done by combining neoadjuvant chemotherapy and trachelectomy; however, experience is still limited.

Reduction of postoperative adhesions by trimetazidine: an experimental study in a rat model.

OBJECTIVE: Trimetazidine (TMZ) reduces intracellular acidosis and inhibits oxygen-derived free radicals and neutrophile infiltration in ischemia and hypoxia, which are the primary steps of adhesion formation. Our aim is to study the anti-adhesion potential of trimetazidine in a rat uterine horn model. METHODS: Forty non-pregnant female Wistar-Albino rats were randomly assigned, with ten in each group, to receive 2 ml saline, or 5 mg/kg intraperitoneal trimetazidine postoperatively, and control and sham. TMZ was administered to TMZ postoperative group 5 mg/kg i.p. daily for 5 days after the operation. Both uterine horns were exposed, and then a 2 cm segment of the anti-mesenteric surface of both the uterine horns were traumatized in 10 spots with unipolar electrocautery for 2 s with a power of 50 Watts. All the animals were killed by lethal dose of ether on postoperative 14th day. Intraperitoneal adhesions were scored by clinical adhesion scoring system, and histological and morphometric analysis was performed. RESULTS: Total adhesion score (TAS) of control group was 10 while the sham group was found to be 0. TAS of the placebo group that was given saline (TAS 5), and postoperative TMZ applied group (TAS 3.5) were significantly lower than the control group (p < 0.05). The severity scores of postoperative TMZ and sham groups were significantly smaller than the other groups (p < 0.05). CONCLUSION: TMZ significantly reduced the extent and severity of horn adhesions. The promising efficacy demonstrated by the intraperitoneal TMZ in this model warrants further investigation in clinical trials focused on gynecological procedures.

Laparoscopic temporary clipping of uterine artery during laparoscopic myomectomy.

PURPOSE: Our aim is to study the feasibility and effect of bilateral laparoscopic temporary occlusion of uterine arteries by special vascular clamps on blood loss during laparoscopic myomectomy. METHODS: Of 166 women with symptomatic uterine myomas necessitating surgical intervention who wished to retain their uteri, 80 underwent laparoscopic uterine artery clipping and myomectomy (experimental group) and 86 received laparoscopic myomectomy only (control group). Main outcome measures were operating time, number and weight of leiomyomas, blood loss, Doppler examination of the uterine arteries and complications of procedure. RESULTS: In the experimental group the median hemoglobin drop measured on day 3 postoperatively was 1.2 g/dl. In the control group the mean hemoglobin drop measured on day 3 postoperatively was 1.45 g/dl. The time needed to put the clips in place (the time from the opening of the retroperitoneum and the positioning of the clips) varied between 6 and 40 min. No patient required blood transfusion. There were no conspicuous complications. CONCLUSION: The use of the clips has proved to be statistically effective in reducing hemoglobin loss during laparoscopic myomectomy.

The comparison of the prognostic value of scored patient generated subjective global assessment and Computed Tomography measured sarcopenia in patients with gynecological cancer.

BACKGROUND: Screening of the nutrition status is recommended for the early detection and treatment of cancer-associated malnutrition to improve the prognosis. We aimed to compare the prognostic value of Patient Generated-Subjective Global Assessment (PG-SGA) and CT measured sarcopenia in patients with gynecological cancer. METHODS: A total of 107 patients of which were 57 endometrial, 37 ovarian, and 13 cervical cancer who underwent surgery and evaluated by PG-SGA were enrolled. Skeletal muscle index (SMI) was calculated by automatic segmentation of the muscle area at the L3 level on abdominal CT scan and defined by the cut-off value of 38.9 cm2/m2. Karnofsky and Eastern Cooperative Oncology Group (ECOG) Performance Status scorings were performed. Hospitalization length (HL), overall- (OS), and progression-free- survival (PFS) were analyzed. Body muscle index (BMI) (kg/m2) was calculated. Serum CA-125 and albumin levels were obtained. RESULTS: The prevalence of malnutrition and sarcopenia were 67% and 26.2%, respectively. BMI was significantly associated with PG-SGA (p = 0.02) and SMI (p = 0.01). PG-SGA significantly correlated with CA-125 (r = 0.33, p = 0.002), ECOG (r = 0.29, p = 0.002), Karnofsky (r = -0.34, p < 0.001), and HL (r = 0.27, p = 0.004). PG-SGA showed a significant association with PFS (p = 0.007) and OS (p = 0.001). PG-SGA≥9 showed a significant relationship with prolonged HL, mortality, and progression (OR = 1.08; p = 0.03, OR = 23.09; p = 0.003, and OR = 5.39; p = 0.001, respectively). CONCLUSION: PG-SGA can identify patients at nutritional risk earlier than SMI. PG-SGA shows a higher correlation with HL and clinical performance scores than SMI. PG-SGA is a better prognostic factor for prolonged HL, OS, and PFS.