The Use of CA-125 KELIM to Identify Which Patients Can Achieve Complete Cytoreduction after Neoadjuvant Chemotherapy in High-Grade Serous Advanced Ovarian Cancer

(1) Background: Neoadjuvant chemotherapy followed by interval debulking surgery is used in the treatment of advanced ovarian cancer. However, no tool can safely predict if complete cytoreduction after 3-4 cycles can be achieved. This study aims to investigate if the KELIM score can be a triage tool in the identification of patients that will be ideal candidates for interval debulking surgery (IDS). (2) Methods: We retrospectively analyzed the records of patients with high-grade serous advanced ovarian cancer that were treated in the 1st Department of Obstetrics-Gynecology, 2012-2022, with neoadjuvant chemotherapy followed by IDS. Patient characteristics, oncological outcome and follow-up information were collected. The primary outcome was the association of the KELIM score with residual disease. (3) Results: 83 patients were categorized into two groups: Group A (51 patients) with favorable (≥1) and Group B (32 patients) with unfavorable (<1) KELIM scores. A statistically significant correlation between KELIM and residual disease (p < 0.05) exists, showing that patients with a favorable KELIM score can achieve a complete IDS. Furthermore, there was a statistically significant difference in overall survival (p = 0.017), but no difference was observed in progression-free survival (p = 0.13); (4) Conclusions: KELIM seems to safely triage patients after neoadjuvant chemotherapy and decide who will benefit from IDS.

Recent management of endometrial cancer: a narrative review of the literature

Endometrial cancer is a common female gynecological neoplasia and its incidence rate has increased in the past years. Due to its predominant symptoms, most women will present uterine bleeding. It is usually diagnosed at an early stage and surgery has an important role in the treatment plan. The prognosis and quality of life of these patients can be quite favorable, if proper treatment is offered by surgeons. Traditionally, more invasive approaches and procedures were offered to these patients, but recent data suggest that more conservative and minimal invasive choices can be adopted in the treatment algorithm. Minimal invasive surgery, such as laparoscopy and robotic surgery, should be considered as an acceptable alternative, compared to laparotomy with less comorbidities and similar oncological and survival outcomes. Furthermore, sentinel lymph node biopsy has emerged in the surgical staging of endometrial cancer, in order to replace comprehensive lymphadenectomy. It is associated with less intra- and postoperative complications, while preliminary data show no difference in survival rates. However, sentinel lymph node biopsy should be offered within a strict algorithm, to avoid residual metastatic disease. The aim of this review is to analyze all the available data for the application of minimal invasive surgery in early endometrial cancer and especially the role of sentinel lymph node biopsy.

Rate of Leiomyosarcomas during Surgery for Uterine Fibroids: 8-Year Experience of a Single Center

The aim of this study is to investigate the prevalence of occult malignant mesenchymal tumors in patients operated on for uterine fibroids in relation to the surgical approach and type of operation. A retrospective review of all patients that underwent surgery for uterine fibroids (January 2011-December 2018) at the 1st Department of Obstetrics & Gynecology at "Papageorgiou" Hospital. The surgical approach and clinicopathological characteristics were analyzed. A total of 803 patients were operated on: 603 (75.1%) with laparotomy, 187 (23.3%) laparoscopically, and 13 (1.6%) vaginally. Furthermore, 423 (52.7%) patients underwent hysterectomy and 380 (47.3%) myomectomies. Laparoscopy and myomectomy were offered to younger patients with fewer smaller uterine fibroids and were associated with statistically significant shorter hospitalization. The pathological reports revealed: 690 (86%) benign leiomyomas, 32 (4%) cellular leiomyomas, 29 (3.6%) degenerated leiomyomas, 22 (2.7%) adenomyomas, 18 (2.2%) atypical-bizarre leiomyomas, 1 (0.1%) STUMP, 5 (0.65%) endometrial stromal sarcomas, and 6 (0.75%) cases of leiomyosarcomas (LMS). All LMS were preoperatively characterized as suspicious and underwent abdominal hysterectomy. Morcellation was offered in two cases of atypical leiomyomas, with no morcellation-associated complication. Laparoscopy as a valuable surgical approach for young patients with fewer in number and smaller in size fibroids is associated with shorter hospitalization. The risk of unintended morcellation of LMS seems to be very low and can be reduced with careful preoperative work-up but not eliminated.

Objective and Subjective Appetite Assessment in Patients with Gynecological Cancer: A Pre- and Post-Operative Pilot Study

Although appetite and its disorders have been implicated in disease progression and outcomes, ghrelin concentrations, an objective appetite measure, are rarely assessed in patients with gynecological malignancies. The present study aimed to assess changes in post-operative versus pre-operative appetite levels in patients with gynecological cancers scheduled for tumor removal surgery (N = 53). Acylated ghrelin concentrations were assessed as an objective appetite proxy, whereas the Council of Nutrition appetite questionnaire (CNAQ) was employed as a subjective appetite measure. Ghrelin concentrations were increased post-operatively (median: 12.1 pg/mL, IQR: 0.67 to 23.5, p-value = 0.001) but the perceived appetite of patients (CNAQ) remained unchanged (median: -1, IQR: -3 to 1). Tumor removal surgery decreased all anthropometric indices (body weight, body mass index, waist and hips circumferences, triceps skinfolds, body fat, fat mass and fat mass index, p-value ≤ 0.001 for all) and doubled the risk of malnutrition among patients. No difference was recorded in the change in participants' objective and subjective appetite when they were classified according to the tumor type. No correlation was observed between ghrelin concentrations and CNAQ score pre-operatively (Spearman's rho correlation coefficient = -0.181, p-value = 0.298) or post-operatively (Spearman's rho correlation coefficient = 0.071, p-value = 0.684). The observed post-operative rise in ghrelin concentrations is associated with body weight loss and consists of a possible defense mechanism of the human body, aiming to prolong survival.

SUCCOR cone study: conization before radical hysterectomy

OBJECTIVE

To evaluate disease-free survival of cervical conization prior to radical hysterectomy in patients with stage IB1 cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2009).

METHODS

A multicenter retrospective observational cohort study was conducted including patients from the Surgery in Cervical Cancer Comparing Different Surgical Aproaches in Stage IB1 Cervical Cancer (SUCCOR) database with FIGO 2009 IB1 cervical carcinoma treated with radical hysterectomy between January 1, 2013, and December 31, 2014. We used propensity score matching to minimize the potential allocation biases arising from the retrospective design. Patients who underwent conization but were similar for other measured characteristics were matched 1:1 to patients from the non-cone group using a caliper width ≤0.2 standard deviations of the logit odds of the estimated propensity score.

RESULTS

We obtained a weighted cohort of 374 patients (187 patients with prior conization and 187 non-conization patients). We found a 65% reduction in the risk of relapse for patients who had cervical conization prior to radical hysterectomy (hazard ratio (HR) 0.35, 95% confidence interval (CI) 0.16 to 0.75, p=0.007) and a 75% reduction in the risk of death for the same sample (HR 0.25, 95% CI 0.07 to 0.90, p=0.033). In addition, patients who underwent minimally invasive surgery without prior conization had a 5.63 times higher chance of relapse compared with those who had an open approach and previous conization (HR 5.63, 95% CI 1.64 to 19.3, p=0.006). Patients who underwent minimally invasive surgery with prior conization and those who underwent open surgery without prior conization showed no differences in relapse rates compared with those who underwent open surgery with prior cone biopsy (reference) (HR 1.94, 95% CI 0.49 to 7.76, p=0.349 and HR 2.94, 95% CI 0.80 to 10.86, p=0.106 respectively).

CONCLUSIONS

In this retrospective study, patients undergoing cervical conization before radical hysterectomy had a significantly lower risk of relapse and death.

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy in the treatment of rare tumors with peritoneal metastases

PURPOSE

Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal intraoperative chemotherapy (HIPEC) is the standard treatment for tumors presented with peritoneal metastases (PM). Data in the literature about the treatment of rare tumors with PM are limited and of low-quality. The aim of the study was to assess the outcome and safety of CRS and HIPEC for these tumors.

METHODS

Patients with rare tumors with PM that underwent CRS and HIPEC between 2005-2018, were retrospectively analyzed. Clinical and histopathological variables were correlated to survival.

RESULTS

43 patients, mean age 55.7 ± 12.9 years, underwent 48 cytoreductions. The most frequent histopathologic type was sarcomatosis (31.3%). The majority of the patients (70.8%) had limited extent of peritoneal disease. Complete or near-complete cytoreduction was achieved in 83.3% of the cases. Severe morbidity was recorded in 12.6%. The median disease-free survival and overall survival were 11 and 63 months, respectively. Although the completeness of cytoreduction was found to be significantly related to survival, the extent of peritoneal carcinomatosis was the single prognostic factor.

CONCLUSIONS

CRS followed by HIPEC is an effective and safe method in the treatment of rare tumors with PM. Further large, well-designed prospective studies are needed to validate these results.

Radical hysterectomy in early cervical cancer in Europe: characteristics, outcomes and evaluation of ESGO quality indicators

INTRODUCTION

Comprehensive updated information on cervical cancer surgical treatment in Europe is scarce.

OBJECTIVE

To evaluate baseline characteristics of women with early cervical cancer and to analyze the outcomes of the ESGO quality indicators after radical hysterectomy in the SUCCOR database.

METHODS

The SUCCOR database consisted of 1272 patients who underwent radical hysterectomy for stage IB1 cervical cancer (FIGO 2009) between January 2013 and December 2014. After exclusion criteria, the final sample included 1156 patients. This study first described the clinical, surgical, pathological, and follow-up variables of this population and then analyzed the outcomes (disease-free survival and overall survival) after radical hysterectomy. Surgical-related ESGO quality indicators were assessed and the accomplishment of the stated recommendations was verified.

RESULTS

The mean age of the patients was 47.1 years (SD 10.8), with a mean body mass index of 25.4 kg/m² (SD 4.9). A total of 423 (36.6%) patients had a previous cone biopsy. Tumor size (clinical examination) <2 cm was observed in 667 (57.7%) patients. The most frequent histology type was squamous carcinoma (794 (68.7%) patients), and positive lymph nodes were found in 143 (12.4%) patients. A total of 633 (54.8%) patients were operated by open abdominal surgery. Intra-operative complications occurred in 108 (9.3%) patients, and post-operative complications during the first month occurred in 249 (21.5%) patients, with bladder dysfunction as the most frequent event (119 (10.3%) patients). Clavien-Dindo grade III or higher complication occurred in 56 (4.8%) patients. A total of 510 (44.1%) patients received adjuvant therapy. After a median follow-up of 58 months (range 0-84), the 5-year disease-free survival was 88.3%, and the overall survival was 94.9%. In our population, 10 of the 11 surgical-related quality indicators currently recommended by ESGO were fully fulfilled 5 years before its implementation.

CONCLUSIONS

In this European cohort, the rate of adjuvant therapy after radical hysterectomy is higher than for most similar patients reported in the literature. The majority of centers were already following the European recommendations even 5 years prior to the ESGO quality indicator implementations.

Cervical Pathology Following HPV Vaccination in Greece: A 10-year HeCPA Observational Cohort Study

BACKGROUND

In Greece the population-level impact of HPV vaccination is unknown due to lack of official registries. This study presents in a pragmatic frame the comparison of cervical pathology data between HPV-vaccinated and unvaccinated women referred for colposcopy.

PATIENTS AND METHODS

This is an observational prospective cohort study performed in 7 academic Obstetrics and Gynaecology Departments across Greece between 2009-2019. Cases were women that had completed HPV vaccination before coitarche and were referred for colposcopy due to abnormal cytology. For each vaccinated woman an unvaccinated matched control was selected.

RESULTS

A total of 849 women who had been vaccinated before coitarche and 849 unvaccinated controls were recruited. The combination of cytological, colposcopic and molecular findings necessitated treatment in only a single case among vaccinated (0.1%) and in 8.4% among unvaccinated.

CONCLUSION

HPV vaccination at a proper age can markedly reduce development of severe cervical precancers and consequently the need for treatment, as well as their long-term related obstetrical morbidity.

A risk factor analysis of complications after surgery for vulvar cancer

Introduction

Despite the less frequent use of surgery in patients with vulvar cancer, the high rates of postoperative complications are still a matter of concern. The aim of the present study was to identify risk factors that influence postoperative complications rates in vulvar cancer and identify specific clinical parameters that may influence their incidence.

Materials

Patients who underwent curative-intent surgery for squamous cell carcinoma of the vulva from 2003 to 2018 were selected. All patient characteristics were analyzed as risk factors for the development of postoperative lymphocele, lymphedema, and wound dehiscence. The patients were followed up for 2 years postoperatively.

Results

The investigation comprised 121 patients, of whom 18.1% developed wound dehiscence, 17.7% a lymphocele, and 20.4% lymphedema. We found no significant evidence of an association between patient’s characteristics and postoperative complications. The depth of tumor invasion and the appearance of lymph-node metastasis were significantly associated with postoperative complications. Free resection margins of 5 mm or more were associated with a reduced risk of postoperative complications compared to resection margins less than 5 mm. No complications were encountered after sentinel node biopsy (SNB). Complication rates were associated with inguinofemoral lymphadenectomy, but not with the extent of lymphadenectomy. The development of a lymphocele or wound dehiscence may be correlated with the development of long-term lymphedema.

Conclusion

FIGO stage at diagnosis influences the risk of postoperative complications. The use of SNB minimized postoperative complications. Correlations between the free microscopic resection margin distance and the risk of postoperative wound dehiscence must be investigated further.

SUCCOR study: an international European cohort observational study comparing minimally invasive surgery versus open abdominal radical hysterectomy in patients with stage IB1 cervical cancer

BACKGROUND

Minimally invasive surgery in cervical cancer has demonstrated in recent publications worse outcomes than open surgery. The primary objective of the SUCCOR study, a European, multicenter, retrospective, observational cohort study was to evaluate disease-free survival in patients with stage IB1 (FIGO 2009) cervical cancer undergoing open vs minimally invasive radical hysterectomy. As a secondary objective, we aimed to investigate the association between protective surgical maneuvers and the risk of relapse.

METHODS

We obtained data from 1272 patients that underwent a radical hysterectomy by open or minimally invasive surgery for stage IB1 cervical cancer (FIGO 2009) from January 2013 to December 2014. After applying all the inclusion-exclusion criteria, we used an inverse probability weighting to construct a weighted cohort of 693 patients to compare outcomes (minimally invasive surgery vs open). The first endpoint compared disease-free survival at 4.5 years in both groups. Secondary endpoints compared overall survival among groups and the impact of the use of a uterine manipulator and protective closure of the colpotomy over the tumor in the minimally invasive surgery group.

RESULTS

Mean age was 48.3 years (range; 23-83) while the mean BMI was 25.7 kg/m² (range; 15-49). The risk of recurrence for patients who underwent minimally invasive surgery was twice as high as that in the open surgery group (HR, 2.07; 95% CI, 1.35 to 3.15; P=0.001). Similarly, the risk of death was 2.42-times higher than in the open surgery group (HR, 2.45; 95% CI, 1.30 to 4.60, P=0.005). Patients that underwent minimally invasive surgery using a uterine manipulator had a 2.76-times higher hazard of relapse (HR, 2.76; 95% CI, 1.75 to 4.33; P<0.001) and those without the use of a uterine manipulator had similar disease-free-survival to the open surgery group (HR, 1.58; 95% CI, 0.79 to 3.15; P=0.20). Moreover, patients that underwent minimally invasive surgery with protective vaginal closure had similar rates of relapse to those who underwent open surgery (HR, 0.63; 95% CI, 0.15 to 2.59; P<0.52).

CONCLUSIONS

Minimally invasive surgery in cervical cancer increased the risk of relapse and death compared with open surgery. In this study, avoiding the uterine manipulator and using maneuvers to avoid tumor spread at the time of colpotomy in minimally invasive surgery was associated with similar outcomes to open surgery. Further prospective studies are warranted.

Breast cancer in women younger than 35 years old

PURPOSE

Women ≤ 35 years old with breast cancer constitute a special group. Considering the impact of the disease and its prognosis, these patients face some specific problems that are not present in older women. What are the prognostic features of the survival rate in very young women with breast cancer?

METHODS

Retrospective analysis of very young women with breast cancer from the Surgical-Oncologic Breast Cancer Department at "Theagenio" Anticancer Hospital, 2003-2016. Patient and tumor characteristics, treatment options and follow-up information were collected. Univariate-multivariate analyses were conducted and survival rates were calculated.

RESULTS

The median age was 34 years old. 53 patients (41%) had T1, 36 (28%) had T2, 7 (5.4%) had T3 and 33 (25.6%) had T4 stage tumors. Most women, 114 (88.4%), had ductal carcinoma in their histology. Furthermore, positive axillary lymph nodes were present in 62 women (48%). In the immunochemistry report, 91 patients (70.5%) were hormone receptor positive, HER2 was overexpressed in 32 patients (24.8%) and 27 patients presented with triple-negative subtype. Out of 65 patients tested for Ki-67, 51 (78.5%), had a high expression (cut-off value of 20%). After adjusting for all possible factors, the risk of recurrence and death was six times higher in the positive lymph node group, (p < 0.001). The median disease-free and overall survival was 133 and > 173 months, respectively.

CONCLUSION

Breast cancer in very young women appears with large size and high-grade tumors, high incidence of infiltrated axillary lymph nodes, high Ki-67 expression and intrinsic subtypes with poor prognosis. As a result, these women need to be treated by a multidisciplinary team.

Papillary squamotransitional cell carcinoma of the uterine cervix: a case report and review of the literature

Background

Papillary squamotransitional cell carcinoma of the uterine cervix is a rare neoplasm, a subtype of transitional cervical carcinoma that appears to be a variation of squamous cervical carcinoma. It has a disposition toward metastasis at an advanced stage and local recurrence. Owing to the difficulty of illustrating the invasion histologically, misdiagnosis is likely to affect the patient’s prognosis.

Case presentation

We present a case report of an 81-year-old Caucasian patient with squamotransitional cell carcinoma with unusual clinical behavior that was primarily thought to be ovarian cancer. According to the clinical examination and radiologic imaging, the patient had no vaginal bleeding and a normal cervix. Nevertheless, the tumor was already metastasized at the retroperitoneal tissue and at the right ovary. Computed tomography-guided biopsy of the right adnexa gave no further clarification. Although the tumor resembled urothelial cancer, this diagnosis was dismissed because of the results of immunohistochemistry analysis with CK7⁺, CK5⁺, and CK20⁻. Because of the differential diagnosis of ovarian cancer, we decided in favor of an exploratory surgical approach. Hysterectomy with bilateral adnexectomy, extensive retroperitoneal tumor debulking, and infragastric omentectomy was performed by laparotomy. Histopathology revealed a squamotransitional cervical cancer as the primary tumor with a tumor stage of pT3b, pN1 (1/2), V0, RX, G2, corresponding to International Federation of Gynecology and Obstetrics stage IIIB.

Conclusions

As far as we are aware, this is the first report of papillary squamotransitional cell carcinoma of the uterine cervix metastatic to the ovary without vaginal bleeding and with a clinically and radiologically unsuspicious cervix. Physicians should always contemplate papillary squamotransitional cell carcinoma of the uterine cervix in unclear cases with ovarian metastasis, especially if the histology indicates a transitional cancer (CK7⁺ and CK20⁻), before proceeding with treatment. More cases are needed to illuminate the clinical characteristics and categorization of papillary squamotransitional cell carcinoma of the uterine cervix.

Mismatch repair deficiency and aberrations in the Notch and Hedgehog pathways are of prognostic value in patients with endometrial cancer

The aim of this study was to investigate the prognostic value of the Hedgehog (Gli, Patched-1, Shh, Smo) and Notch (Jag1, Notch2, Notch3) pathway members, in comparison to a panel of proteins (ER, PgR, HER2/neu, Ki67, p53, p16, PTEN and MMR) previously suggested to be involved in the pathogenesis of endometrial cancer, in association with clinical outcome and standard clinicopathological characteristics. A total of 204 patients with histological diagnosis of endometrial cancer treated from 2004 to 2013 were included. The evaluation of protein expression was assessed by immunohistochemistry. Univariate analysis showed that higher Ki67 labeling, expression of PTEN, p16, Notch2 and Notch3 proteins, as well as MMR proficiency were associated with increased relapse and mortality rate. Additionally, Patched-1 protein expression was associated with worse DFS, while p53 overexpression was associated with worse OS. In multivariate analyses, patients with MMR proficient tumors had more than double risk for death than patients with MMR deficient (MMRd) tumors (adjusted HR = 2.19, 95% CI 1.05–4.58, p = 0.036). Jag1 positivity conferred reduced mortality risk (HR = 0.48, 95% CI 0.23–0.97, p = 0.042). However, as shown by hierarchical clustering, patients fared better when their tumors expressed high Jag1 protein in the absence of Notch2 and Notch3, while they fared worse when all three proteins were highly expressed. Patched-1 positivity conferred higher risk for relapse (HR = 2.04, 95% CI 1.05–3.96, p = 0.036).

Aberrant expression of key components of the Notch and Hedgehog signaling pathways, as well as MMRd may serve as independent prognostic factors for recurrence and survival in patients with endometrial cancer.

Correlation between Adenomyosis and Endometrial cancer: 6-year experience of a single center

INTRODUCTION

Adenomyosis often co-exists in the pathological specimens after surgery for endometrial cancer. The aim of this study is to describe the clinicopathological and oncological characteristics of these patients and further investigate the possibility of malignant transformation in the adenomyotic tissue.

METHODS

We retrospectively reviewed the medical records of all patients that underwent hysterectomy for endometrial cancer (January 2012 - December 2017). The pathological reports were studied and when adenomyosis was present, the pathological slides were reviewed in order to discover any malignant change in the adenomyotic tissue. The clinicopathological characteristics and oncological results were described.

RESULTS

Out of 229 cases of endometrial cancer, 64 (28%) patients had concurrently endometrial cancer and adenomyosis. Among these 64 patients, 7 (11%) had malignant transformation of adenomyosis. The mean age of patients suffering from both endometrial cancer and adenomyosis was 63.2 years old and 57 (89%) of these patients, had early endometrial cancer. Concerning the patients with malignant transformation of adenomyosis, their mean age was 65 years old with no premenopausal case.

DISCUSSION

Adenomyosis has been described in the last decades, but its malignant transformation into endometrial cancer is not fully undercovered. Further investigation is needed in order to clarify the pathologic progression of adenomyotic lesions to endometrial cancer.

Novasure impedance control system versus microwave endometrial ablation for the treatment of dysfunctional uterine bleeding: a double-blind, randomized controlled trial

PURPOSE OF INVESTIGATION

To compare the efficacy and safety of two different second-generation ablation devices, Novasure impedance control system and microwave endometrial ablation (MEA), in cases of abnormal uterine bleeding (AUB).

MATERIALS AND METHODS

This is a randomized controlled trial that took place in a single Gynecological Department of a University Hospital. Sixty-six women with dysfunctional uterine bleeding (DUB), unresponsive to medical treatment, were included in the trial. The ratio of women allocated to bipolar radio-frequency ablation or MEA was 1:1. Follow-up assessments were carried out at three and 12 months post-ablation. The present main outcome measure was amenorrhea rates 12-months post-treatment.

RESULTS

The rate of amenorrhea at 12-months post-ablation was significantly higher in women treated by Novasure (25/33; 75.8%) as compared to those treated by MEA (8/33; 24.2%) (rate difference: +51.5%, 95% CI: +27.8 to +67.7).

CONCLUSION

In women with DUB, endometrial ablation with Novasure bipolar radiofrequency impedance-controlled system is associated with increased rates of amenorrhea at 12-months post-treatment as compared to the MEA method.

Pregnancy management and outcome in women with chronic kidney disease

An increasing number of pregnancies occur in the presence of chronic kidney diseases (CKD), mainly including chronic glomerulonephritis (GN), diabetic nephropathy (DN), and lupus nephritis (LN). The most important factor affecting fetal and maternal prognosis is the degree of renal function at conception. In the majority of patients with mild renal function impairment, and well-controlled blood pressure, pregnancy is usually successful and does not alter the natural course of maternal renal disease. Conversely, fetal outcome and long-term maternal renal function might be seriously threatened by pregnancy in women with moderate or severe renal function impairment. The last few years, advances in our knowledge about the interaction of pregnancy and renal function resulted in the improvement of fetal outcome in patients with chronic renal failure and also in the management of pregnant women with end-stage renal disease (ESRD) maintained on dialysis. However, women with impaired renal function and those on dialysis should be carefully counseled about the risks of pregnancy.

Operative treatment of gynaecologic diseases in puberty: seven years of experience

PURPOSE OF INVESTIGATION

The aim of this study is to present the incidence and surgical management of gynaecologic pathology in adolescence in the 1st Obstetrics and Gynecology Department of Aristotle University of Thessaloniki.

METHODS

After a retrospective review of the medical records of over a seven year period (2004-2011), 32 adolescent patients with reported surgical gynaecologic procedures were identified and analysed.

RESULTS

Fourteen out of the 16 adolescents with ovarian masses (eight neoplastic and eight non-neoplastic) were treated by laparoscopy. Congenital anomalies were diagnosed in seven patients and only one of them was treated by laparotomy. The rest were surgically treated for uterine leiomyoma (1), ectopic pregnancy (2), pelvic abscess (1), mesosalpingeal cysts (2), mesenterian cyst (1) and investigation of chronic pelvic pain.

DISCUSSION

Although benign ovarian cysts and congenital anomalies represent the major indication for operative treatment of gynaecologic diseases in puberty, laparoscopy and/or hysteroscopy should be the gold standard procedure after careful preoperative investigation.

Obstetric outcome in adolescence: a single centre experience over seven years

PURPOSE OF INVESTIGATION

The aim of this study was to compare the obstetric outcome of adolescent pregnant women (aged < or = 18) with the outcome of adult pregnant women who delivered in a tertiary university hospital.

MATERIALS AND METHODS

Delivery files from 2004 to 2011 were reviewed concerning age of the pregnant women, parity, gestational age, mode of delivery and birth weight of the neonates.

RESULTS

During the study period 119 (0.94%) out of 10,483 deliveries were performed in adolescent women. Caesarean section was the mode of delivery in 41 adolescent patients (34.45%), while the corresponding rate was 53.6% (5,556 cases) in adult pregnant women. The preterm labour rate in the adolescent group was 13.44% (16 cases) while in the adult group it was 21% (2,201 cases). The most frequent indication of caesarean section in the adults was previous caesarean section (21%).

DISCUSSION

In adolescent pregnancies the caesarean section rate was lower than in adult pregnancies. As far as the prevalent cause of caesarean section is concerned, it was repeat caesarean section for adults while in adolescents it was failure of labour to progress.

Laparoscopic management of unexpected borderline ovarian tumors in women of reproductive age

PURPOSE OF INVESTIGATION

The aim of this study was to review the clinical features of women with unexpected borderline ovarian tumours.

METHODS

Between October 1992 and December 2010, 1332 out of 4016 laparoscopies were performed for adnexal masses in women of reproductive age and 1838 cysts were removed. When ultrasonographic findings did not meet the criteria for low risk malignancy, tumour markers, colour Doppler and MRI/CT were applied. At laparoscopy any solid component or papilla was sent for rapid frozen section.

RESULTS

Borderline ovarian tumours were found in eight (0.6%) out of 1332 patients, two of which were bilateral. The mean age was 28.75 +/- 9.27 years and the mean diameter of the cysts was 5.1 +/- 1.7 cm. In two cases unexpected malignancy was discovered during the diagnostic and in six cases during the operative phase of the intervention.

CONCLUSION(S)

Risk of failure to diagnose cancer could be minimised with careful patient selection preoperatively. Adequate training on laparoscopic oncology is the necessary prerequisite for a safe laparoscopic approach.

Obstetric and neonatal outcome after assisted fertilization and spontaneous conception: a comparative study

PURPOSE

The widespread use of assisted reproduction technology (ART) is accompanied by concerns for potential adverse outcomes. The aim of the present study was to evaluate the impact of ART in obstetric and neonatal outcome.

METHODS

Data from labor ward records from 913 consecutive births were analyzed retrospectively, and the obstetric and neonatal outcomes of pregnancies after ART were compared with those after natural conception.

RESULTS

No major complications were noted after ART. A higher probability of cesarean section, lower gestational age at birth, lower birth weight and hospitalization in the Neontal Intensive Care Unit (NICU) was noted after ART, as compared with spontaneous conception. However, after exclusion of multifetal pregnancies, there was no significant difference in outcomes, except for cesarean section rates.

CONCLUSIONS

The higher proportion of multiple pregnancies after ART is associated with lower gestational age at birth, lower birth weights and higher NICU hospitalization rates.

Primary ovarian small cell carcinoma of pulmonary type with enlarged paraaortic lymph node masses: a case report and review of the literature

INTRODUCTION

Small cell carcinoma of the ovary of pulmonary type, is a rare, aggressive tumour with poor prognosis and its optimal management is unclear.

CASE PRESENTATION

A 55-year-old Caucasian woman presented with abdominal discomfort and left lumbar pain within a three-week period. At exploratory laparotomy, a 8 cm solid cystic mass of the left ovary was found infiltrating the sigmoid colon, and a bulky mass (11 x 7 x 4 cm) in the left paraaortic infrarenal region. Histopathological features resembling small cell carcinoma of the lungs and positive immunohistochemical stains provided a definite diagnosis of IIIC ovarian small cell carcinoma of pulmonary type. After six cycles chemotherapy with carboplatin and etoposide, the patient is still alive at 21 months from initial diagnosis.

DISCUSSION

In this case, the absence of peritoneal involvement and the extensive paraaortic adenopathy is suggestive of a different pattern of spread of this rare tumour. Optimal treatment seems to be radical primary debulking surgery resulting in no residual disease, maximizing the effect of adjuvant chemotherapy for this biological aggressive tumour.

Hormone therapy for postmenopausal endometrial cancer survivors: a survey among Greek obstetricians-gynaecologists

PURPOSE OF INVESTIGATION

In this study we evaluated the prescription attitude of Greek obstetricians-gynaecologists towards hormone replacement therapy (HRT) for endometrial cancer survivors.

METHODS

An anonymous questionnaire was sent to 900 members of the Hellenic Society of Obstetrics and Gynaecology, presenting a hypothetical case of an endometrial cancer survivor with indications for HRT, followed by a series of relevant questions.

RESULTS

Three hundred and three valid responses were received and analysed according to age, gender and practice setting. HRT would be prescribed by 30.4% of gynaecologists; as far as type of regimen is concerned, 67.4% would prescribe tibolone, 22.8% estrogen-only and 9.8% estrogen plus progestagen. In contrast, 69.6% would not prescribe HRT due to the fear of endometrial cancer recurrence (88.2%), development of breast cancer (2.8%) or both (4.7%); among them, 28.4% would prescribe central nervous system (CNS) medications, selective estrogen receptor modulators (SERMs), phyto-oestrogens or biphosphonates, as alternates.

CONCLUSIONS

One out of three Greek gynaecologists would prescribe HRT to endometrial cancer survivors. Alternative therapies, mainly CNS medications, would be suggested by the opposers.

Comparison of single versus multiple courses of antenatal betamethasone in patients with threatened preterm labor

PURPOSE OF INVESTIGATION

To compare single versus multiple courses of antenatal betamethasone administration with regards to the morbidity and mortality of preterm neonates.

METHODS

One-hundred and twenty-two women with threatened preterm labor were allocated to three different betamethasone schedules: 1) two doses of betamethasone 12 mg, intramuscularly, 24 hours apart (standard treatment) (n = 41); 2) standard treatment plus a third dose of 12 mg after seven days (n = 41); and, 3) standard treatment plus one dose of 12 mg every seven days until delivery (n = 40). Neonatal morbidity and mortality as well as maternal morbidity were evaluated.

RESULTS

Neonatal parameters, such as frequency of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis and neonatal mortality were not significantly different among the three groups for both singleton and multiple pregnancies. Similarly, maternal parameters were not significantly different among the three groups.

CONCLUSION

The administration of multiple betamethasone courses in threatened preterm labor is not superior to single courses with regards to neonatal morbidity and mortality, as well as to maternal morbidity.

Regulatory Τ-cell differentiation between maternal and cord blood samples in pregnancies with spontaneous vaginal delivery and with elective cesarian section

PROBLEM

The immunological mechanisms preventing fetal antigenic rejection during normal pregnancy and the extent to which the type of delivery influences lymphocyte reactions are elusive.

METHOD OF STUDY

Maternal peripheral blood and neonatal umbilical cord blood (CB) was collected upon labor after vaginal delivery or cesarian section. Leukocytes were analyzed with flow cytometry, focusing on regulatory and γ/δ T-cells.

RESULTS

In CB from neonates delivered by vaginal delivery, natural killer cells were increased. On the other hand, in maternal blood, γ/δ T-cells were increased, and activated T-cells (cluster of differentiation [CD]4+/25(dim) /122+ cells) were decreased. Moreover, maternal blood presented increased levels of T regulatory cell subsets like CD4+/25(high) /45RO+, CD4+/25(high) /DR+, CD4+/25(high) /CD38+ and CD4+/25(high) /71+. In CB, CD19+, CD4+/25(high) /45RA+ and CD4+/25(high) /122+ cells were increased.

CONCLUSION

The effect of delivery type on lymphocyte immunophenotype was minimal. Mothers' and neonates' lymphocyte subsets differed significantly. Mothers' phenotype comprised significantly of lymphocytes involved in tolerance (memory and activated regulatory T-cells, γ/δ T-cells).

Mucocele of the appendix mimicking an adnexal mass: a case report

Mucocele of the appendix is a rare entity usually mimicking an adnexal tumour. There is no specific imaging or screening method to determine the diagnosis with certainty preoperatively. Appendiceal malignancy can be the underlying cause, although it is not common. We present a case of an appendiceal mucocele mimicking an ovarian tumour by both clinical and imaging (TVS and MRI) methods. This pathological condition should be considered by all the gynaecologists in the differential diagnosis of a right-sided pelvic mass.

Complete uterine inversion during caesarean section: A case report

Inversion of the uterus through the uterine lower segment incision during a caesarean section is an extremely rare obstetric incident. It consists, though, an emergency complication that is potentially life-threatening, especially in cases of prolonged inversion, because haemodynamic instability and shock may occur. Prompt diagnosis and immediate uterine reversion are the key actions in the management of this serious complication.