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Gracia M, Yildirim Y, Macuks R, Mancari R, Achimas-Cadariu P, Cusine-Lopez L, Novak Z, Dallaku K, Zapardiel I. Impact of perioperative characteristics on the recurrence risk and survival of patients with uterine leiomyosarcoma. Int J Gynaecol Obstet 2023; 163:868-874. [PMID: 37485666 DOI: 10.1002/ijgo.14998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/20/2023] [Accepted: 07/01/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVES To analyze the impact of perioperative characteristics on the risk of recurrence in patients with uterine leiomyosarcomas. METHODS A sub-analysis of the SARComa of the UTerus (SARCUT) study, which is a multicentric cross-sectional pan-European study that included 390 patients diagnosed with leiomyosarcoma, between 2001 and 2007. Perioperative factors related to risk of recurrence and survival were analyzed. RESULTS The 5-year and 10-year disease-free survivals (DFS) were 46% and 55%, respectively. Overall survival at 5 and 10 years was 34% and 47%, respectively. The most important factors related to global recurrence were the incomplete cytoreduction (hazard ratio [HR] 2.87; 95% confidence interval [CI] 1.91-4.31); performing bilateral adnexectomy (HR 2.71; 95% CI 1.23-5.93); tumor persistence after any treatment (HR 2.38; 95% CI 1.39-4.06); and adjuvant chemotherapy administration (HR 2.55; 95% CI 1.82-3.58) or adjuvant radiotherapy (HR 2.26; 95% CI 1.53-3.32). The major factors significantly associated with pelvic relapse were tumor persistence after any treatment (HR 3.63; 95% CI 1.83-7.20) and adjuvant radiotherapy (HR 2.74; 95% CI 1.44-5.20). Incomplete cytoreduction was the most important factor associated with distant relapse (HR 1.91; 95% CI 1.22-2.97). The most important factors related to overall survival were tumor persistence after any treatment (HR 4.59; 95% CI 2.51-8.40), incomplete cytoreduction (HR 3.68; 95% CI 2.44-5.56), tumor margin involvement (HR 2.41; 95% CI 1.64-3.55) and adjuvant chemotherapy (HR 1.91; 95% CI 1.31-2.78). CONCLUSIONS Complete cytoreduction is the main prognosis factor impacting the DFS and overall survival of patients with uterine leiomyosarcoma. Adjuvant chemotherapy administration was associated with decreased rates of DFS and overall survival. The adjuvant radiotherapy was associated with a higher risk of global recurrence.
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Affiliation(s)
- Myriam Gracia
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
| | | | - Ronalds Macuks
- Latvian Oncology Center of Riga Eastern Clinical University Hospital, Riga, Latvia
| | - Rosanna Mancari
- Division of Gynecologic Oncology, European Institute of Oncology, IRCCS, Milan, Italy
- Gynecologic Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | | | - Zoltan Novak
- Department of Gynecologic Oncology, National Institute of Oncology, Budapest, Hungary
| | - Kastriot Dallaku
- Obstetric Gynecology University Hospital Koco Gliozheni, Tirana, Albania
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
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Gorostidi M, Yildirim Y, Macuks R, Mancari R, Achimas-Cadariu P, Ibañez E, Corrado G, Bartusevicius A, Sukhina O, Zapardiel I. Impact of Hospital Case Volume on Uterine Sarcoma Prognosis: SARCUT Study Subanalysis. Ann Surg Oncol 2023; 30:7645-7652. [PMID: 37460742 DOI: 10.1245/s10434-023-13826-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/12/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND High-complexity and low-prevalence procedures benefit from treatment by referral centers. The volume of cases necessary to maintain high training in the treatment of gynecologic sarcoma is currently unknown. This study aimed to determine differences in survival and recurrence as a function of the volume of patients treated per center. METHODS The multicentric cross-sectional SARComa of the Uterus (SARCUT) study retrospectively collected cases of uterine sarcomas from 44 centers in Europe from January 2001 to December 2007. The survival of patients treated in high case-volume (HighCV) centers was compared with the survival of patients treated in low case-volume (LowCV) centers. RESULTS The study enrolled 966 patients: 753 in the LowCV group and 213 in the HighCV. Overall survival (OS) was 117 months, and cancer-specific survival (CSS) was 126 months. The difference was significant (respectively p = 0.0003 and 0.0004, log rank). After adjustment for other confounding factors, the remaining significant factors were age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.03-1.05), histology (HR, 1.19; 95% CI, 1.06-1.34), extrauterine involvement (HR, 1.61; 95% CI, 1.24-2.10) and persistent disease after treatment (HR, 3.22; 95% CI, 2.49-4.18). The cytoreduction performed was significantly associated with the CSS and OS in both groups. The log rank for surgical cytoreduction was a p value lower than 0.0001 for OS, lower than 0.0001 for the LowCV centers, and 0.0032 for the HighCV centers. CONCLUSIONS The prognosis for patients with uterine sarcoma is directly related to complete tumor cytoreduction, histologic type, and FIGO stage, with significant differences between low and high case-volume centers. Patients with uterine sarcomas should be centralized in HighCV centers to improve their oncologic outcomes.
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Affiliation(s)
- Mikel Gorostidi
- Obstetrics and Gynecology Department, Hospital Universitario Donostia, San Sebastián, Spain.
- Biodonostia Health Research Institute, San Sebastián, Spain.
- Basque Country University (UPV/EHU), San Sebastián, Spain.
| | | | - Ronalds Macuks
- Department of Gynecology and Obstetrics, Riga Stradin's University, Riga, Latvia
| | - Rosanna Mancari
- Division of Gynecologic Oncology, European Institute of Oncology, IRCCS, Milan, Italy
- Gynecologic Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | | | - Giacomo Corrado
- Dipartimento Scienze della Salute della Donna, del Bambino, e di Sanità Pubblica, Ginecologia Oncologica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Woman, Child Health and Public Health, Gynecologic Oncology Unit, A. Gemelli University Hospital Foundation, IRCSC, Rome, Italy
| | | | - Olena Sukhina
- Clinical Oncology Department and Radiation Oncology Department, Grigoriev Institute for Medical Radiology and Oncology, Kharkov, Ukraine
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
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Gorostidi M, Yildirim Y, Macuks R, Mancari R, Achimas-Cadariu P, Ibañez E, Corrado G, Bartusevicius A, Sukhina O, Zapardiel I. ASO Visual Abstract: Impact of Hospital Case Volume on Uterine Sarcoma Prognosis: SARCUT Study Subanalysis. Ann Surg Oncol 2023; 30:7667-7668. [PMID: 37648890 DOI: 10.1245/s10434-023-14209-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Mikel Gorostidi
- Gynecology Department, Hospital Universitario de Donostia, San Sebastián, Spain.
- Biodonostia Health Research Institute, San Sebastián, Spain.
- Basque Country University, San Sebastián, Spain.
| | | | - Ronalds Macuks
- Latvian Oncology Center of Riga Eastern Clinical University Hospital, Riga, Latvia
| | - Rosanna Mancari
- Division of Gynecologic Oncology, European Institute of Oncology, IRCCS, Milan, Italy
- Gynecologic Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | | | - Giacomo Corrado
- Department of Experimental Clinical Oncology, Gynecologic Oncology Unit, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
- Department of Woman, Child Health, and Public Health, Gynecologic Oncology Unit, A. Gemelli University Hospital Foundation, IRCSC, Rome, Italy
| | | | - Olena Sukhina
- Clinical Oncology Department and Radiation Oncology Department, Grigoriev Institute for Medical Radiology and Oncology, Kharkov, Ukraine
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
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Macuks R, Yildirim Y, Mancari R, Achimas-Cadariu P, Madhuri TK, Ortega E, Mallmann M, Zivanovic O, Zapardiel I. Prognostic factors in undifferentiated uterine sarcoma: a subanalysis of the SARCUT study. Arch Gynecol Obstet 2023; 308:981-988. [PMID: 37193821 DOI: 10.1007/s00404-023-07057-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 04/26/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE The aim of this study was to analyze the prognostic factors related to the recurrence rate and overall survival of patients with undifferentiated uterine sarcoma. METHODS An international multicenter study involving 43 international centers, the SARCUT study, collected 966 uterine sarcoma cases; among them 39 cases corresponded to undifferentiated uterine sarcoma and where included in the present subanalysis. The risk factors related to the oncological outcomes where analyzed. RESULTS The median age of the patients was 63 (range 14-85) years. Seventeen (43.5%) patients presented FIGO stage I. The 5-year overall survival (OS) was 15.3% and 12-months disease-free survival (DFS) 41%. FIGO stage I was significantly associated with a better prognosis. In addition, patients who received adjuvant radiotherapy showed significant longer disease-free survival compared to those without adjuvant radiotherapy (20.5 vs. 4.0 months, respectively; p = 0.04) and longer overall survival (34.7 vs. 18.2 months, respectively; p = 0.05). Chemotherapy administration was associated with shorter DFS (HR 4.41, 95% CI 1.35-14.43, p = 0.014). Persistent disease after primary treatment (HR = 6.86, 95% CI 1.51-31.09, p = 0.012) and FIGO stage IV (HR 4.12, 95%CI 1.37-12.44, p = 0.011) showed significant worse prognosis for OS. CONCLUSION FIGO stage seems to be the most important prognostic factor in patients with undifferentiated uterine sarcoma. Adjuvant radiotherapy seems to be significantly associated also to a better disease-free and overall survival. On the contrary, the role of chemotherapy administration remains unclear since was associated to a shorted DFS.
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Affiliation(s)
- Ronalds Macuks
- Department of Gynecology and Obstetrics, Riga Stradins University, Dzirciema Street 16, RigaRiga, 1007, Latvia.
| | | | - Rosanna Mancari
- Division of Gynecologic Oncology, European Institute of Oncology, IRCCS, Milan, Italy
- Gynecologic Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | | | | | - Michael Mallmann
- Department of Obstetrics and Gynecology, University Hospital Bonn, Bonn, Germany
| | - Oliver Zivanovic
- Department of Obstetrics and Gynecology, University Hospital Bonn, Bonn, Germany
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
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Coronado PJ, Alonso-Espias M, Yildirim Y, Macuks R, Mancari R, Achimas-Cadariu P, Aniorte SM, Mitidieri M, Lambaudie E, Dubois N, Zapardiel I. Lymph node dissection in uterine leiomyosarcomas: A matched-pair study. Gynecol Oncol 2023; 174:28-33. [PMID: 37146437 DOI: 10.1016/j.ygyno.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/01/2023] [Accepted: 04/12/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVE To assess the impact of the lymph node dissection (LND) in the disease-free (DFS) and overall survival (OS) of the women treated surgically of uterine leiomyosarcoma (ULMS). MATERIAL AND METHODS A multicentric retrospective study was conducted among European countries collecting patients diagnosed of uterine sarcoma (SARcoma of the UTerus - SARCUT study). A total of 390 ULMS were selected for the present study to compare patients who underwent LND and those who did not. A further matched-pair subanalysis identified 116 women, 58 pairs (58 with LND and 58 without it) comparable in age, tumor size, surgical procedures, extrauterine disease and adjuvant treatment. Demographic data, pathology results and follow-up were abstracted from medical records and analyzed. Disease-free (DFS) and overall survival (OS) were studied using Kaplan-Meier curves and Cox regression analysis. RESULTS Among the 390 patients, the 5-year DFS was significantly higher in no-LDN group comparing to the LDN group (57.7% vs. 33.0%; HR 1.75, 95% CI 1.19-2.56; p = 0.007), but not the 5-year OS (64.6% vs. 64.3%; HR 1,10 95% CI 0,77-1,79; p = 0.704). In the matched-pair subanalysis, there were no statistical differences between the study groups. The 5- year DFS was 50.5% in the no-LND and 33.0% in the LND group (HR 1.38; 95% CI 0,83-2.31; p = 0,218) and the 5-year OS was 59.7% and 64.3% respectively (HR 0.81; 95% CI 0,45-1,49; p = 0,509). CONCLUSIONS LND performed in women diagnosed of ULMS have no impact neither in the disease-free nor in the overall survival compared to patients without LDN in a complete homogeneous group.
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Affiliation(s)
- Pluvio J Coronado
- Women's Health Institute, Hospital Clínico San Carlos, IdISSC, School of Medicine, Complutense University, Madrid, Spain
| | | | | | - Ronalds Macuks
- Latvian Oncology Center of Riga Eastern Clinical University Hospital, Riga, Latvia
| | - Rosanna Mancari
- Division of Gynecologic Oncology, European Institute of Oncology, IRCCS, Milan; Gynecologic Oncology Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | | | | | | | | | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
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Zapardiel I, Gracia Segovia M, Macuks R, Mancari R, Achimas-Cadariu P, Corrado G, Bartusevicius A, Sukhin V, Muruzabal JC, Coronado Martín PJ, Gardella B, Piek JM, Concin N, Arab C, Papatheodorou D, Polterauer S, Iacoponi S, Nieto T, Lopez-Sanclemente MC, Trukhan H, Gil MM, Bakinovskaya I, Dalamanava A, Cucurull M, Rovski D, Baquedano L, Chiva L, Mardas M, Mavrichev SA, Klat J, Lopez de la Manzanara CA, Yildirim Y. Prognostic factors in patients with uterine sarcoma: the SARCUT study. Int J Gynecol Cancer 2023:ijgc-2022-004204. [PMID: 37192761 DOI: 10.1136/ijgc-2022-004204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
OBJECTIVE Uterine sarcomas are a rare and heterogeneous group of malignancies that include different histological sub-types. The aim of this study was to identify and evaluate the impact of the different prognostic factors on overall survival and disease-free survival of patients with uterine sarcoma. METHODS This international multicenter retrospective study included 683 patients diagnosed with uterine sarcoma at 46 different institutions between January 2001 and December 2007. RESULTS The 5-year overall survival for leiomyosarcoma, endometrial stromal sarcoma, undifferentiated sarcoma, and adenosarcoma was 65.3%, 78.3%, 52.4%, and 89.5%, respectively, and the 5-year disease-free survival was 54.3%, 68.1%, 40.3%, and 85.3%, respectively. The 10-year overall survival for leiomyosarcoma, endometrial stromal sarcoma, undifferentiated sarcoma and adenosarcoma was 52.6%, 64.8%, 52.4%, and 79.5%, respectively, and the 10-year disease-free survival was 44.7%, 53.3%, 40.3%, and 77.5%, respectively. The most significant factor associated with overall survival in all types of sarcoma except for adenosarcoma was the presence of residual disease after primary treatment. In adenosarcoma, disease stage at diagnosis was the most important factor (hazard ratio 17.7; 95% CI 2.86 to 109.93). CONCLUSION Incomplete cytoreduction, tumor persistence, advanced stage, extra-uterine and tumor margin involvement, and the presence of necrosis were relevant prognostic factors significantly affecting overall survival in uterine sarcoma. The presence of lymph vascular space involvement and administration of adjuvant chemotherapy were significantly associated with a higher risk of relapse.
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Affiliation(s)
- Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
| | | | - Ronalds Macuks
- Riga East Clinical University Hospital Latvian Oncology Center, Riga, Latvia
| | - Rosanna Mancari
- Gynecologic Oncology Department, IRCCS, Milan, Italy
- Gynecologic Oncology Department, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Patriciu Achimas-Cadariu
- Gynecologic Oncology Department, The Oncology Institute 'Prof Dr Ion Chiricuta' Cluj-Napoca, Cluj-Napoca, Romania
| | - Giacomo Corrado
- Policlinico Universitario Agostino Gemelli Dipartimento Scienze della Salute della Donna e del Bambino, Roma, Italy
| | - Arnoldas Bartusevicius
- Department of Obstetrics and Gynaecology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vladyslav Sukhin
- Oncology, Radiology and Radiation Medicine, V N Karazin Kharkiv National University, Harkiv, Ukraine
- Oncogynecology, Grigoriev Institute for Medical Radiology NAMS of Ukraine, Harkiv, Ukraine
| | - Juan C Muruzabal
- Gynecologic Oncology Unit, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
| | | | - Barbara Gardella
- Gynecologic Oncology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jurgen M Piek
- Gynecologic Oncology Department, Catharina Hospital and Catharina Cancer Institute, Eindhoven, Netherlands
| | - Nicole Concin
- Department of Gynecology and Obstetrics, Innsbruck Medical Univeristy, Innsbruck, Austria
- Division of General Gynecology and Gynecologic Oncology, Department of Obstetrics and Gynecology, Gynecologic Cancer Unit, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Clemente Arab
- Gynecologic Oncology Department, Hospital Luis Tisné. Universidad de Chile, Santiago, Chile
| | | | - Stephan Polterauer
- Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Vienna, Austria
| | - Sara Iacoponi
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
| | - Teresa Nieto
- Gynecologic Oncology Department, Hospital Universitario Santa Cristina, Madrid, Spain
| | - Martha C Lopez-Sanclemente
- Gynecologic Oncology Department, Torrecárdenas Hospital Complex, Almeria, Andalucía, Spain
- Gynecologic Oncology Department, Clinica Diatros, Barcelona, Spain
| | - Hanna Trukhan
- Gynecologic Oncology Department, N N Alexandrov National Cancer Center, Minsk, Belarus
| | - Maria M Gil
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
| | - Irina Bakinovskaya
- Gynecologic Oncology Department, N N Alexandrov National Cancer Center, Minsk, Belarus
| | - Alena Dalamanava
- Gynecologic Oncology Department, N N Alexandrov National Cancer Center, Minsk, Belarus
| | - Marc Cucurull
- Catalan Institute of Oncology, L'Hospitalet de Llobregat, Catalunya, Spain
| | - Dzmitry Rovski
- Gynecologic Oncology Department, N N Alexandrov National Cancer Center, Minsk, Belarus
| | - Laura Baquedano
- Gynecologic Oncology Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Luis Chiva
- Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain
| | - Marcin Mardas
- Department of Gynecological Oncology, Poznan University of Medical Sciences, Poznan, Wielkopolskie, Poland
| | | | - Jaroslav Klat
- Obstetrics and Gynecology Department, University Hospital Ostrava, Ostrava, Moravskoslezský, Czech Republic
| | | | - Yusuf Yildirim
- Gynecologic Oncology Department, Tepecik Training and Research Hospital Clinics, Konak, Izmir, Turkey
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Lanner M, Nikolova T, Gutic B, Nikolova N, Pletnev A, Selcuk I, Vlachos DE, Razumova Z, Bizzarri N, Theofanakis C, Lepka P, Kahramanoglu I, Han S, Nasser S, Molnar S, Hudry D, Montero-Macías R, de Lange N, Macuks R, Hasanov MF, Karimbayli R, Gagua I, Andrade C, Pardal C, Dotlic J, Alvarez RM, Hruda M, Fruhauf F, Ekdahl L, Antonsen SL, Sukhin V, Eriksson AGZ, Gliozheni E, Delic R, Satanova A, Kovacevic N, Gristsenko L, Babloyan S, Zalewski K, Bharathan R. Subspecialty training in Europe: a report by the European Network of Young Gynaecological Oncologists. Int J Gynecol Cancer 2020; 31:575-584. [PMID: 33361458 DOI: 10.1136/ijgc-2020-002176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND ESGO (European Society of Gynaecological Oncology) and partners are continually improving the developmental opportunities for gynaecological oncology fellows. The objectives of this survey were to evaluate the progress in the infrastructure of the training systems in Europe over the past decade. We also evaluated training and assessment techniques, the perceived relevance of ENYGO (European Network of Young Gynaecological Oncologists) initiatives, and unmet needs of trainees. METHODOLOGY National representatives of ENYGO from 39 countries were contacted with an electronic survey. A graduation in well/moderately/loosely-structured training systems was performed. Descriptive statistical analysis and frequency tables, as well as two-sided Fisher's exact test, were used. RESULTS National representatives from 33 countries answered our survey questionnaire, yielding a response rate of 85%. A national fellowship is offered in 22 countries (66.7%). A logbook to document progress during training is mandatory in 24 (72.7%) countries. A logbook of experience is only utilized in a minority of nations (18%) for assessment purposes. In 42.4% of countries, objective assessments are recognized. Trainees in most countries (22 (66.7%)) requested additional training in advanced laparoscopic surgery. 13 (39.4%) countries have a loosely-structured training system, 11 (33.3%) a moderately-structured training system, and 9 (27.3%) a well-structured training system. CONCLUSION Since the last publication in 2011, ENYGO was able to implement new activities, workshops, and online education to support training of gynaecological oncology fellows, which were all rated by the respondents as highly useful. This survey also reveals the limitations in establishing more accredited centers, centralized cancer care, and the lack of laparoscopic training.
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Affiliation(s)
- Maximilian Lanner
- Department of Obstetrics and Gynaecology, Kardinal Schwarzenberg Klinikum, Schwarzach im Pongau, Austria
| | - Tanja Nikolova
- Klinikum Mittelbaden, Academic Teaching Hospital of Heidelberg University, Baden-Baden, Germany
| | - Bojana Gutic
- Gynaecology Department, Vojvodina Institute of Oncology, Sremska Kamenica, Serbia
| | - Natasha Nikolova
- Department of Obstetrics and Gynaecology and Centre for Perinatal and Reproductive Medicine, University of Perugia, Perugia, Italy
| | - Andrei Pletnev
- Department of Gynaecological Oncology, N.N. Alexandrov National Cancer Centre of Belarus, Minsk, Belarus
| | - Ilker Selcuk
- Gynaecological Oncology, Maternity Hospital, Ankara City Hospital, Ankara, Turkey
| | - Dimitrios-Efthymios Vlachos
- First Department of Obstetrics and Gynaecology, National and Kapodistrian University of Athens, Athens, Greece
| | - Zoia Razumova
- Department of Women's and Children's Health, Division of Neonatology, Obstetrics and Gynaecology, Karolinska Institute, Stockholm, Sweden
| | - Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A Gemelli, IRCCS, Rome, Italy
| | - Charlampos Theofanakis
- Department of Gynaecological Oncology, General Hospital of Athens Alexandra, Athens, Attica, Greece
| | - Piotr Lepka
- Department of Oncology, Gynaecological Oncology Clinic, Wroclaw Medical University and 2nd Lower Silesian Oncology Centre, Wroclaw, Poland
| | - Ilker Kahramanoglu
- Department of Obstetrics and Gynaecology, Division of Gynaecological Oncology, Istanbul University Cerrrahpasa Medical Faculty, Istanbul, Turkey
| | - Sileny Han
- Gynaecological Oncology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Sara Nasser
- Department of Gynaecological Oncology, Gynaecology Clinic with Oncologic Surgery Centre, Charité Comprehensive Cancer Centre, Campus Virchow Klinikum, Berlin, Germany
| | - Szabolcs Molnar
- Department of Obstetrics and Gynaecology, University of Debrecen Faculty of Medicine, Debrecen, Hungary
| | - Delphine Hudry
- Department of Gynaecological Oncology, Centre Oscar Lambret, Lille, France
| | - Rosa Montero-Macías
- Gynaecologic and Breast Oncologic Surgery Department, European Hospital Group Georges-Pompidou, Paris, France
| | - Natascha de Lange
- Department of Gynaecological Oncology, Universitair Medisch Centrum Groningen, Groningen, Netherlands
| | - Ronalds Macuks
- Department of Obstetrics and Gynaecology, Riga Stradins University, Riga, Latvia
| | - Mir Fuad Hasanov
- Department of Obstetrics and Gynaecology, Medical Center-University of Freiburg, Freiburg, Baden-Württemberg, Germany
| | - Ramina Karimbayli
- Department of Oncogynaecology, The National Centre of Oncology, Baku, Azerbaijan
| | - Irina Gagua
- Department of Gynaecology, Research Institute of Clinical Medicine, Todua Clinic, Tbilisi, Georgia
| | - Claudia Andrade
- Department of Gynaecology, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Catarina Pardal
- Department of Obstetrics and Gynaecology, Hospital de Braga, Braga, Portugal
| | - Jelena Dotlic
- Clinic of Obstetrics and Gynaecology, Clinical Centre of Serbia, University of Belgrade, Beograd, Serbia
| | - Rosa Maria Alvarez
- Department of Gynaecological Oncology and Breast Cancer, Santa Cristina University Hospital, Madrid, Spain
| | - Martin Hruda
- Department of Obstetrics and Gynaecology, 3rd Medical Faculty, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Filip Fruhauf
- Department of Obstetrics and Gynaecology, General University Hospital, Charles University, Prague, Czech Republic
| | - Linnea Ekdahl
- Department of Obstetrics and Gynaecology, Division of Gynaecologic Oncology, Skåne University Hospital Lund, Lund, Sweden
| | - Sofie Leisby Antonsen
- Gynaecological Department, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Vladyslav Sukhin
- Department for Gynaecological Oncology, Grigoriev Institute for medical Radiology and Oncology NAMS, Kharkov, Ukraine
| | - Ane Gerda Zahl Eriksson
- Department of Gynaecological Oncology, Division of Cancer Medicine, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Elko Gliozheni
- Department of Obstetrics and Gynaecology, Maternity Koco Gliozheni Hospital, Tirana, Albania
| | - Ratko Delic
- Department of Obstetrics and Gynaecology, General Hospital Celje, Celje, Slovenia
| | - Alima Satanova
- Department of Gynaecological Oncology, Kazakh Institute of Oncology and Radiology, Almaty, Kazakhstan
| | - Nina Kovacevic
- Department of Gynaecological Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Liidia Gristsenko
- Department of Obstetrics and Gynaecology, The North Estonian Medical Centre, Tallinn, Estonia
| | - Suzanna Babloyan
- Department of Obstetrics and Gynaecology, Yerevan State Medical University, Yerevan, Armenia
| | - Kamil Zalewski
- Gynaecological Oncology, Świętokrzyskie Cancer Centre, Kielce, Poland
| | - Rasiah Bharathan
- Department of Gynaecological Oncology, Maidstone Hospital, Maidstone, Kent, UK
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Zapardiel I, Iacoponi S, Coronado PJ, Zalewski K, Chen F, Fotopoulou C, Dursun P, Kotsopoulos IC, Jach R, Buda A, Martinez-Serrano MJ, Grimm C, Fruscio R, Garcia E, Sznurkowski JJ, Ruiz C, Noya MC, Barazi D, Diez J, Diaz De la Noval B, Bartusevicius A, De Iaco P, Otero M, Diaz M, Haidopoulos D, Franco S, Blecharz P, Zuñiga MA, Rubio P, Gardella B, Papatheodorou DC, Yildirim Y, Fargas F, Macuks R. Prognostic factors in patients with vulvar cancer: the VULCAN study. Int J Gynecol Cancer 2020; 30:1285-1291. [PMID: 32571891 DOI: 10.1136/ijgc-2019-000526] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/29/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE This study aimed to analyze the prognostic factors for overall and progression-free survival in patients with vulvar cancer. METHODS This international, multicenter, retrospective study included 2453 patients diagnosed with vulvar cancer at 100 different institutions. Inclusion criteria were institutional review board approval from each collaborating center, pathologic diagnosis of invasive carcinoma of the vulva, and primary treatment performed at the participating center. Patients with intraepithelial neoplasia or primary treatment at non-participating centers were excluded. Global survival analysis and squamous cell histology subanalysis was performed. RESULTS After excluding patients due to incomplete data entry, 1727 patients treated for vulvar cancer between January 2001 and December 2005 were registered for analysis (1535 squamous, 42 melanomas, 38 Paget's disease and 112 other histologic types). Melanomas had the worse prognosis (p=0.02). In squamous vulvar tumors, independent factors for increase in local recurrence of vulvar cancer were: no prior radiotherapy (p<0.001) or chemotherapy (p=0.006), and for distant recurrence were the number of positive inguinal nodes (p=0.025), and not having undergone lymphadenectomy (p=0.03) or radiotherapy (p<0.001), with a HR of 1.1 (95% CI 1.2 to 1.21), 2.9 (95% CI 1.4 to 6.1), and 3.1 (95% CI 1.7 to 5.7), respectively. Number of positive nodes (p=0.008), FIGO stage (p<0.001), adjuvant chemotherapy (p=0.001), tumor resection margins (p=0.045), and stromal invasion >5 mm (p=0.001) were correlated with poor overall survival, and large case volume (≥9 vs <9 cases per year) correlated with more favorable overall survival (p=0.05). CONCLUSIONS Advanced patient age, number of positive inguinal lymph nodes, and lack of adjuvant treatment are significantly associated with a higher risk of relapse in patients with squamous cell vulvar cancer. Case volume per treating institution, FIGO stage, and stromal invasion appear to impact overall survival significantly. Future prospective trials are warranted to establish these prognostic factors for vulvar cancer.
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Affiliation(s)
- Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
| | - Sara Iacoponi
- Gynecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
| | - Pluvio J Coronado
- Gynecology Department, Hospital Clinico Universitario San Carlos - IdISSC, Madrid, Spain
| | - Kamil Zalewski
- Gynecologic Oncology Department, Maria Sklodowska-Curie Memorial Cancer Center - Institute of Oncology, Warsaw, Poland
| | - Frank Chen
- Department of Gynecology, Campus Virchow-Klinikum, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Christina Fotopoulou
- Department of Gynecology, Campus Virchow-Klinikum, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Polat Dursun
- Department of Obstetrics and Gynecology Division of Gynecologic Oncology, Baskent University School of Medicine, Ankara, Turkey
| | | | - Robert Jach
- Gynecology Department, University Hospital, Jagiellonian University, Krakow, Poland
| | - Alessandro Buda
- Gynecologic Oncology Department, Hospital San Gerardo, Monza, Lombardia, Italy
| | | | - Christoph Grimm
- Division of General Gynaecology and Gynaecological Oncology, Medical University of Vienna - Vienna General Hospital, Vienna, Austria
| | - Robert Fruscio
- Gynecologic Oncology Department, Hospital San Gerardo, Monza, Lombardia, Italy
| | - Enrique Garcia
- Gynecologic Oncology Department, Fundacion Instituto Valenciano de Oncologia, Valencia, Spain
| | | | - Cristina Ruiz
- Gynecologic Oncology Department, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Maria C Noya
- Gynecology Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Galicia, Spain
| | - Dib Barazi
- Gynecologic Oncology Department, Ciudad Sanitaria de Bellvitge, Barcelona, Spain
| | - Javier Diez
- Gynecologic Oncology Department, Hospital de Cruces, Vizcaya, Spain
| | | | - Arnoldas Bartusevicius
- Gynecologic Oncology Department, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Kaunas, Lithuania
| | | | - Maria Otero
- Gynecology Department, Complejo Hospitalario de Leon, Leon, Spain
| | - Maria Diaz
- Gynecology Department, Complejo Hospitalario Universitario Juan Canalejo, La Coruña, Spain
| | | | - Silvia Franco
- Gynecology Department, Hospital Vall D'Hebron, Barcelona, Spain
| | - Pawel Blecharz
- Gynecologic Oncology Department, Maria Sklodowska-Curie Memorial Cancer Center, Krakow, Poland
| | - Miguel A Zuñiga
- Gynecology Department, Complejo Hospitalario Torrecardenas, Almeria, Spain
| | - Patricia Rubio
- Gynecology Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Barbara Gardella
- Gynecologic Oncology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Yusuf Yildirim
- Gynecologic Oncology Department, Ege Gynaecology Training and Research Hospital, Izmir, Turkey
| | - Francesc Fargas
- Gynecology Department, Instituto Universitario Dexeus, Barcelona, Spain
| | - Ronalds Macuks
- Gynecologic Oncology Department, Riga East Clinical University Hospital Latvian Oncology Center, Riga, Latvia
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Polterauer S, Schwameis R, Grimm C, Macuks R, Iacoponi S, Zalewski K, Zapardiel I. Prognostic value of lymph node ratio and number of positive inguinal nodes in patients with vulvar cancer. Gynecol Oncol 2017; 147:92-97. [PMID: 28797698 DOI: 10.1016/j.ygyno.2017.07.142] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/24/2017] [Accepted: 07/30/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To estimate the prognostic significance of lymph node ratio and number of positive nodes in vulvar cancer patients. METHODS This international multicenter retrospective study included patients diagnosed with vulvar cancer treated with inguinal lymphadenectomy. Lymph node ratio (LNR) is the ratio of the number of positive lymph nodes (LN) to the number of removed LN. Patients were stratified into risk groups according to LNR. LNR was correlated with clinical-pathological parameters. Survival analyses were performed. RESULTS This analysis included 745 patients. In total, 292 (39.2%) patients had positive inguinal LN. The mean (SD) number of resected and positive LN was 14.1 (7.6) and 3.0 (2.9), respectively. High LNR was associated with larger tumor size and higher tumor grade. Patients with LNRs 0% (N0), >0<20%, and >20% had 5-year overall survival (OS) rates of 90.9%, 70.7%, and 61.8%, respectively (P<0.001). LNR was associated with both local and distant recurrence-free survival (P<0.001). Patients with 0, 1, 2, 3 or >3 positive lymph nodes had 5-year OS rates of 90.9%, 70.8%, 67.8%, 70.8% and 63.4% respectively (P<0.001). In multivariate analysis, LNR (P=0.01) and FIGO stage (P<0.001), were associated with OS, whereas the number of positive nodes (P=0.8), age (P=0.2), and tumor grade (P=0.7), were not. In high-risk patients, adjuvant radiotherapy was associated with improved survival. CONCLUSIONS LNR provides useful prognostic information in vulvar cancer patients with inguinal LN resection in vulvar cancer. LNR allows for more accurate prognostic stratification of patients than number of positive nodes. LNR seems useful to select appropriate candidates for adjuvant radiation.
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Affiliation(s)
- Stephan Polterauer
- Department of General Gynaecology and Gynaecological Oncology, Gynecologic Cancer Unit - Comprehensive Cancer Center, Medical University of Vienna, Vienna, 1090, Austria; Karl Landsteiner Institute for General Gynecology and Experimental Gynecologic Oncology, Vienna, 1090, Austria.
| | - Richard Schwameis
- Department of General Gynaecology and Gynaecological Oncology, Gynecologic Cancer Unit - Comprehensive Cancer Center, Medical University of Vienna, Vienna, 1090, Austria
| | - Christoph Grimm
- Department of General Gynaecology and Gynaecological Oncology, Gynecologic Cancer Unit - Comprehensive Cancer Center, Medical University of Vienna, Vienna, 1090, Austria
| | - Ronalds Macuks
- Latvian Oncology Center of Riga - Eastern Clinical University Hospital, Riga, Latvia
| | - Sara Iacoponi
- Gynecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
| | - Kamil Zalewski
- Department of Gynecologic Oncology, Holycross Cancer Center, Kielce, Poland; Department of Molecular and Translational Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Ignacio Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
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Ozola E, Macuks R, Vasiljeva J, Vasconcelos I, Nikolova T, Nikolov N. Questionnaire of Survey on Costs of Medical Manipulations and Funding of Medical Staff across the European Countries. Women Health 2015. [DOI: 10.19104/whi.2015.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Stankevica J, Macuks R, Baidekalna I, Donina S. Midline Involvement as a Risk Factor for Vulvar Cancer Recurrence. Asian Pac J Cancer Prev 2012; 13:5237-40. [DOI: 10.7314/apjcp.2012.13.10.5237] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Macuks R, Baidekalna I, Donina S. Urinary Concentrations of Human Epidydimis Secretory Protein 4 (He4) in The Diagnosis of Ovarian Cancer: A Case-Control Study. Asian Pac J Cancer Prev 2012; 13:4695-8. [DOI: 10.7314/apjcp.2012.13.9.4695] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Macuks R, Ozdemir H, Dursun P, Ozen OI, Haberal N, Ayhan A. Malignant intraperitoneal mesothelioma-Başkent University experience. J Turk Ger Gynecol Assoc 2011; 12:104-9. [PMID: 24591971 DOI: 10.5152/jtgga.2011.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 03/23/2011] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To evaluate diagnostic and treatment results of malignant intraperitoneal mesothelioma in one setting. MATERIALS AND METHOD 12 patients treated for malignant peritoneal mesothelioma from January 2007 to June 2009 in Başkent University Ankara Hospital, Department of Gynaecology and Obstetrics were evaluated. In a retrospective observational study design tumour stage, grade, differentiation, time from first symptoms, pleural involvement, peritoneal cancer index, surgical cytoreduction, chemotherapeutic regimen, number of cycles, disease free survival and overall survival were evaluated. Disease free survival, overall survival, time until first symptoms were researched. RESULTS The main presenting symptom was abdominal distension. Primary cytoreductive surgery followed by chemotherapy was performed in 9 patients. In 6 patients completeness of cytoreductive score below 2 was achieved. As a first line chemotherapy the most often used was cisplatin in combination with pemetrexed. Themean time from first symptoms until the diagnosis was 1.9 months. Disease free survival of 4.4±1.0 months after completing particular treatment and overall 1-year survival of 85.7 % was observed. No correlations between first symptoms (0.27, p=0.52), time until the diagnosis (-0.29, p=0.44) and overall survival were observed. Similarly, correlations between peritoneal cancer index (0.25, p=0.67), prior surgical score (-.45, p=0.37), completeness of cytoreduction score (0.61, p=0.27) and overall survival were not observed. CONCLUSIONS Because of the low number of patients and different treatment approaches data from a particular patient setting are inconclusive, but from the literature there is evidence that patients with malignant intraperitoneal mesothelioma should undergo optimal cytoreduction and receive a combination of cisplatin and pemetrexed as a first line chemotherapy for intravenous or cisplatin in different chemotherapy regimens using the intraperitoneal administration route, if accessible, with even higher overall survival rates.
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Affiliation(s)
- Ronalds Macuks
- Riga Stradins University, Riga, Latvia ; Department of Gynecological Oncology, Riga Eastern Clinical University Hospital, Riga, Latvia
| | - Halis Ozdemir
- Department of Gynecology and Obstetrics, Faculty of Medicine, Başkent University Ankara Hospital, Ankara, Turkey
| | - Polat Dursun
- Department of Gynecology and Obstetrics, Faculty of Medicine, Başkent University Ankara Hospital, Ankara, Turkey
| | - Ozlem Işıksaçan Ozen
- Department of Pathology, Faculty of Medicine, Başkent University Ankara Hospital, Ankara, Turkey
| | - Nihan Haberal
- Department of Pathology, Faculty of Medicine, Başkent University Ankara Hospital, Ankara, Turkey
| | - Ali Ayhan
- Department of Gynecology and Obstetrics, Faculty of Medicine, Başkent University Ankara Hospital, Ankara, Turkey
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Macuks R, Baidekalna I, Donina S. Diagnostic test for ovarian cancer composed of ovarian cancer symptom index, menopausal status and ovarian cancer antigen CA125. EUR J GYNAECOL ONCOL 2011; 32:286-288. [PMID: 21797118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
UNLABELLED The objective of the study was to evaluate accuracy of the diagnostic test composed of the ovarian cancer symptom index, ovarian cancer antigen CA125 and menopausal status. METHODS A case-control study consisting of 75 women--24 patients with ovarian cancer, 20 patients with benign ovarian diseases, and 31 age-matched healthy controls. RESULTS Sensitivity and specificity for the ovarian cancer symptom index alone was 83.3% and 48.3%, respectively. Specificity improved up to 70.9% when menopausal status was added. When CA125 (at cut-off level of 21 U/ml) was added to the ovarian cancer symptom index, the highest sensitivity and specificity was achieved resulting in 79.1% and 100.0%, respectively. CONCLUSIONS The ovarian cancer symptom index could be used as a first-step screening tool in combination with serum biomarkers followed by TVS examination with an acceptable sensitivity and specificity. However, further prospective studies with larger sample size are needed to reach clear conclusions.
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Affiliation(s)
- R Macuks
- Riga Stradins University, Latvia.
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Macuks R, Baidekalna I, Donina S. Comparison of different ovarian cancer detection algorithms. EUR J GYNAECOL ONCOL 2011; 32:408-410. [PMID: 21941963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
UNLABELLED The objective of the study was to evaluate the accuracy of a combined-two step ovarian cancer screening tool consisting of the ovarian cancer symptom index combined with either a risk of ovarian malignancy algorithm (ROMA) or a risk of malignancy index. MATERIAL AND METHODS The case-control study consisted of 31 patients with ovarian cancer, 30 patients with benign ovarian diseases and 27 age-matched healthy controls. RESULTS Sensitivity and specificity of the ovarian cancer symptom index among menopausal women were 84.6% and 52.9%, respectively. ROMA revealed the highest discriminative value when compared to others (AUC 98.4%). When the cutoff level of 28 was applied for menopausal women, ROMA revealed sensitivity and specificity of 95.8% and 93.1%, respectively. CONCLUSIONS The ovarian cancer symptom index could be used as the first step in ovarian cancer screening with subsequent application of ROMA as a second step screening tool. A larger sample size in both control and patient groups should be evaluated to reach clear conclusions.
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Affiliation(s)
- R Macuks
- Riga Stradins University, A. Kirhenstein's Institute of Microbiology and Virology, Riga, Latvia.
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