Ovarian cancer management in an ESGO ovarian cancer center of excellence: a systematic case study of the interprofessional and interdisciplinary interaction

PURPOSE

With growing knowledge about ovarian cancer over the last decades, diagnosis, evaluation and treatment of ovarian cancer patients have become highly specialized, and an individually adapted approach should be made in each woman by interdisciplinary cooperation. The present study aims to show the variety and extent of medical specialties involved at our institution according to the European Society of Gynecologic Oncology (ESGO) Quality indicators (QI).

METHODS

A woman, diagnosed with high-grade ovarian cancer, International Federation of Gynecology and Obstetrics (FIGO) class IVb was selected for a single case observational study. The observation period (total = 22d) comprised preoperative diagnostic procedures, including imaging, the in-patient stay for cytoreductive surgery, and the postoperative course and case discussion at our interdisciplinary tumor board. Data were obtained by self-reporting and by patient file review.

RESULTS

Patient tracking demonstrated an interdisciplinary cooperation of 12 medical specialties [62 physicians (63% male, 37% female)], 8 different types of nursing staff [n = 59 (22% male, 78% female)], and 9 different types of perioperative/administrative staff (n = 23; male 17,4%, female n = 19, 82,6%). Contact with the patient was direct (n = 199; 76%) or without face-to-face interaction (n = 63; 24%).

CONCLUSION

The present study demonstrates the high diversity of physicians and the affiliated medical staff, as well as interdisciplinary intersections within teams of a specialized hospital. Matching the ESGO QIs, this report underlines the requirement of an adequate infrastructure for the complex management of advanced ovarian cancer patients. Future prospective studies are warranted to evaluate the specific procedures and actions to optimize the interprofessional and interdisciplinary workflows.

Health-related quality of life metrics as endpoints in surgical trials: hype or hope?

The management of gynecological cancer has evolved considerably over the past decades in almost every field of treatment. Surgery plays a major role in the treatment algorithm. However, these invasive interventions can have profound implications for the quality of life (QoL) of affected individuals. The routine implementation of QoL measurements in clinical trials has become common, reflecting a new research 'standard', despite the fact that all available QoL instruments were not designed nor validated prospectively for surgical trials. This review seeks to address whether patient reported outcomes and QoL measurements rightfully take center stage in current surgical trials, leading to direct implementation for the benefit of patient care, or are they simply more of a researcher's hope. We will also provide an 'action plan' to better implement QoL measurements in future surgical trials.

Prognostic value of CA125 kinetics, half-life, and nadir in the treatment of epithelial ovarian cancer: a systematic review and meta-analysis

OBJECTIVE

To investigate the prognostic value of cancer antigen 125 (CA125) related variables on progression free survival and overall survival in primary and recurrent ovarian cancers.

METHOD

A comprehensive review of the Medline, Embase, and Cochrane Library databases was conducted to identify relevant literature on survival outcomes according to the ELIMination Rate Constant K (KELIM), Gynecologic Cancer InterGroup (GCIG) CA125 response criteria, CA125 half-life, and CA125 nadir levels during first line or later line chemotherapy. The search included articles published before February 2023. Cut-off values determining the favorable/unfavorable score of each study were extracted, and pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were analyzed using a random effects model to identify the relationship between survival outcomes of the favorable/unfavorable groups, which was determined by an individual model using CA125 kinetics.

RESULTS

A total of 27 studies with 14 444 patients with epithelial ovarian cancer were included in this meta-analysis. In primary ovarian cancer, a favorable KELIM score, determined by individual modeled cut-off values, was associated with a significant progression free survival (HR 0.53, 95% CI 0.45 to 0.62) and overall survival (HR 0.51, 95% CI 0.43 to 0.62) benefit in the primary setting. The favorable KELIM scored group also correlated with a better progression free survival (HR 0.54, 95% CI 0.47 to 0.62) in relapsed disease. We failed to demonstrate a better prognostic value of the GCIG response criteria and the CA125 half-life for progression free survival and overall survival.

CONCLUSION

Novel chemotherapy response scores, such as KELIM, may be more clinically relevant than other prognostic models using CA125 kinetics, being directly associated with a more favorable survival in both the primary and relapsed setting in patients with epithelial ovarian cancer.

STUDY REGISTRATION

The systemic review and meta-analysis were registered in PROSPERO (CRD42023385512).

Sonographic Monitoring of Growth of Uterine Myomas in Untreated Women and Respective Influence Factors

Research Question What are the growth patterns of uterine myomas in untreated premenopausal women? Which factors influence the growth rate of uterine myomas in premenopausal women? Method All premenopausal women who presented to the outpatient myoma consultation clinic between January 2005 and March 2022 at least twice were screened. Exclusion criteria were hormonal therapy, pregnancy, and postmenopausal status. Results A total of 189 patients were included in our study which focused on the respective largest uterine myoma of each woman. An ideal linear growth over time was assumed. Most myomas (82%) increased in size. The mean annual growth of these myomas was 68.42 cm ³ . The most important prognostic factor for growth was the initial size of the myoma. The absolute annual growth of myomas measuring > 50 cm ³ at first presentation was higher compared to smaller myomas (p < 0.001). The relative annual growth rate was highest for myomas measuring between 20 and 50 cm ³ at the initial presentation (p = 0.003). The relative annual growth rate in women older than 40 years was significantly lower than that in women below the age of 40 years (p = 0.003). Conclusion Overall, it is difficult to make an individual prognosis about the growth pattern of a uterine myoma in a specific patient. It should be noted especially in asymptomatic patients that spontaneous regression of myoma size can also occur in premenopausal women.

Primary Treatment Results in Patients with Ovarian, Fallopian or Peritoneal Cancer-Results of a Clinical Cancer Registry Database Analysis in Germany

Background: The current therapy of ovarian cancer is based on the so-called “Three-Pillar-Model”, consisting of surgery, chemotherapy and maintenance therapy. This study represents the first major analysis of a federal cancer database of OC patients from the states Berlin/Brandenburg in Germany. The primary objective was to evaluate the prevailing established quality indicators surgical outcome, adjuvant chemotherapy and integrity of surgical staging in early stages. Methods: Data from the Clinical Cancer Registry for Brandenburg and Berlin of the years 2009−2019 were analyzed. Objectives were defined by a working group of selected physicians. Descriptive statistics were performed, as well as survival analysis. Results: A total of 2771 primary OC cases were included. Results regarding histological subtype met the suspected allocation with predominantly high-grade serous OC in advanced stage. The rate of complete surgical staging in FIGO stages I−IIA was 57%, and the rate of macroscopic complete resection in >FIGO III was 53%. Five-year survival rate varied from 79% (FIGO I) to 40% (FIGO III). Rate of adjuvant chemotherapy was above 50%. Conclusion: The results elucidate quality measurements and treatment results and show good treatment outcomes in patients with primary diagnosis. However, they also indicate deficits and can help to establish new quality indicators to further improve the treatment.

Quality assurance and improvement in oncology using guideline-derived quality indicators - results of gynaecological cancer centres certified by the German cancer society (DKG)

PURPOSE

Based on the example of Gynaecological Cancer Centres (GCCs) certified by the German Cancer Society, this study evaluates the results of medical-guideline-derived quality indicators (QIs) for cervical cancer (CC) and ovarian cancer (OC), examines the development of indicator implementation over time as well as the status of guideline-compliant care and identifies improvement measures.

METHODS

QI results for patients with CC and OC treated in GCCs between 2015 and 2019 are analysed. The median, overall proportion and standard deviation of each QI were calculated. Two-sided Cochran-Armitage tests were applied.

RESULTS

QIs are divided into two categories: process-organization (PO-QIs) and treatment-procedures (TP-QIs), to allow a differentiated analysis for identifying improvement measures. PO-QIs that reflect the implementation of processes and structures show a high degree of application. PO-QIs have a tremendous influence on the quality of care and are easy to implement through SOPs. TP-QIs report on treatments that are performed in the GCC. TP-QIs that report on systemic therapies reach a plateau where the guideline is known, but patient-related-factors meaningfully prevent further increase. TP-QIs that report on surgical interventions fluctuate. The most relevant factors are practitioners' personal skills. Besides the discussion of results amongst peers during the audit, improvement measures could include surgical courses or coaching.

CONCLUSION

The analysis shows that a combination of different measures is necessary to anchor quality sustainably in health care and thus improve it.

Clinical value of pre-operative scoring systems to predict leiomyosarcoma: results of a validation study in 177 patients from the NOGGO-REGSA Registry

Objectives

Benign leiomyomas are the most common uterine tumors. In contrast, uterine leiomyosarcomas are malignancies with a poor prognosis due to difficulties in early diagnosis and inappropriate surgical treatment. Most often they are diagnosed incidentally after surgery performed for treatment of leiomyoma. As the appropriate surgical treatment is crucial for survival of the patient, there is a high demand to predict leiomyosarcoma pre-operatively. Available scoring systems to discriminate leiomyoma from leiomyosarcoma are based on retrospective studies with limited numbers of patients and are not implemented in routine clinical practice.

Methods

The aim of our study was to evaluate a recently published score—the pre-operative leiomyosarcoma (pLMS) score—to determine whether it would have been predictive of leiomyosarcoma in 177 patients from the NOGGO-REGSA study, a German register of histologically proven gynecological sarcoma detected during routine clinical investigation.

Results

The threshold of the pLMS score for ‘leiomyosarcoma not probable’ (< −3) failed for 7.5% of the patients and the threshold ‘indicator for leiomyosarcoma’ (>+1) was true for 39.1% of the patients. 53.4% of the patients were attributed to the group ‘additional investigations are recommended’ (−3 to +1). The most relevant parameters in our analysis were suspicious sonography and rapid growth, but neither have been quantitatively defined.

Conclusion

In our validation cohort, the pLMS score seems not to be a reliable tool to predict leiomyosarcoma and therefore we do not recommend its clinical implementation to identify leiomyosarcoma.

Surgery due to mechanical bowel obstruction in relapsed ovarian cancer: clinical and surgical results of a bicentric analysis of 87 patients

Introduction

Mechanical bowel obstruction is a frequent acute and life-threatening event in relapsed ovarian cancer. Salvage surgery after failure of all conservative approaches, resulting in short bowel syndrome (SBS) constitutes a therapeutic dilemma. Our aim was to evaluate patients’ surgical and clinical outcome in these highly palliative situations. Previous, limited, data reported a high morbidity and mortality. However, recent surgical and therapeutical improvements in relapsed ovarian cancer (ROC) offer better identification of patients who might benefit from surgery in an effort to extend the window of opportunity to subsequently offer these patients novel systemic therapeutic approaches.

Material and methods

All subsequent ROC patients between 2012 and 2017 with acute mechanical bowel obstruction who underwent salvage extraperitoneal en bloc intestinal resection were retrospectively identified. Data were collected from two ESGO certified Ovarian Cancer Centers of Excellence (Charité Berlin and Imperial College London) and systematically evaluated regarding surgical and clinical outcomes.

Results

Overall, 87 ROC patients were included in the analysis (median age 56 years, range 24–88), 47% were platinum resistant. High grade serous was the most common histology (76%) while most of the patients (67%) had at least two previous lines of treatment. Mean observed OS was 7.8 months. After salvage surgery, 46% of the patients had a residual small bowel length < 180 cm and 18% > 180 cm resulting in 41% in need of total parental nutrition. In 80% of the patients a permanent stoma was necessary. 30d morbidity and mortality was 74% and 10%, respectively. More than half of the patients were able to receive further courses of chemotherapy after surgery.

Discussion

Salvage surgery for bowel obstruction in ROC patients needs careful consideration and identification of optimal surgical candidates to have the maximal therapeutic benefit. Despite the challenging morbidity profile, most patients managed to proceed to subsequent novel and conventional systemic treatment and so have their window of therapeutic opportunity extended.

Improving the prediction of surgical outcome at secondary cytoreduction in patients with ovarian cancer: Results from retrospective part of HELP-ER study NOGGO TR2/ENGOT OV47-TR

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Background: Complete resection at secondary cytoreductive surgery is associated with prolonged progression free and overall survival for patients with relapsed ovarian cancer. Secondary cytoreductive surgery has no impact on survival rates, if macroscopically tumor clearance cannot be achieved. Therefore, in order to avoid unnecessary perioperative morbidity and mortality, selection of patients who will undergo secondary tumor debulking is crucial. This study aims to improve upon the contemporary Arbeitsgemeinschaft Gynäkologische Onkologie (AGO) score by including additional clinical variables like circulating HE4 and CA125 levels to predict surgical outcome at secondary cytoreduction. Methods: A total of 90 patients underwent secondary cytoreductive surgery and were retrospectively assigned a positive AGO score. Of those patients, 62 (68.9%) achieved optimal surgical outcome at secondary debulking with 28 (31.1%) patients retaining residual tumor mass ( > 0mm). Utilizing clinical variables including circulating HE4 and CA125 levels, we implemented a machine learning workflow to predict suboptimal surgical outcome in patients despite a positive AGO score. Results: We elucidated significantly lower levels of circulating HE4 (p = 0.0038) in patients with optimal surgical outcome compared to patients that retain macroscopic residual tumor at secondary cytoreductive surgery. Moreover, machine learning algorithms trained on clinical variables (e.g. serum HE4 level, serum CA125 level, age, Risk of Ovarian Malignancy Algorithmus (ROMA) score and occurrence of peritoneal carcinomatosis) achieved a mean area under the curve (AUC) of 78.4% based on 100 consecutive executions with randomized training and test sets. Conclusions: The application of machine learning allows to further improve the prediction of patients with high likelihood of achieving optimal surgical outcome at secondary cytoreduction. In turn, it might identify patients that would benefit from amplified treatment efforts. However, machine learning relies on large amounts of data to account for biological and clinical variation and produce predictions of sufficient/adequate quality. Given this limitation, we would validate this data within the prospective multicentric cohort of patients collected within NOGGO/ENGOT HELP_ER Trial.

Results of a German survey among patients with gynecological malignancies during the COVID-19 pandemic

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Background: The COVID-19 pandemic has had an immense impact on health care systems und social life. Due to limited resources, a rearrangement in medical care has been necessary in many countries. Strict rules of social distancing and postponing of medical appointments has brought major changes. At the beginning of the COVID-19 pandemic, in March 2020, several studies reflecting patient perception of cancer care modification were performed. Currently, there are still limited data on patient perception concerning changes in cancer treatment, their willingness to receive a COVID-19 vaccine, and their acceptance of social life restrictions. We initiated a multicentre prospective anonymous survey among patients with gynecological cancer to gather information about the current therapy situation and the impact of their treatment and social life. We will report the first preliminary results of 108 patients. Methods: We performed a survey among patients with gynecological cancer, who received treatment or were in follow-up at Charité Campus Virchow Klinikum between October and December 2020. The paper form questionnaire included three sections in which social background, current disease status, and patient perception of the COVID-19 implications on cancer care and social life were evaluated. Results: We included 108 patients. The median age of the participants was 59. The majority of the participants had ovarian cancer (69.4 %) and 70 % were under current cancer treatment. Almost 65 % were willing to receive a COVID-19 vaccine. More than 50 % reported anxiety and fear during the last 2 weeks. Only 16.2 % were more afraid of a COVID-19 infection than their cancer disease. Despite uncertainty of the COVID-19 pandemic, most patients fear tumour progression more than a COVID-19 infection. The cancer treatment appointments were altered in a small number of patients (9.4 %). Testing of COVID-19 was performed in 73 % of the participants. The acceptance of social measures was high; 87 % keeping social distance and over 90 % wearing a mask. Conclusions: Despite major challenges in cancer care due to the COVID-19 pandemic for the majority of the patients, the access to cancer treatment was less affected and the acceptance of prevention measures was high. Anxiety and fear was experienced by more than 50 %. The psychological effects of the COVID-19 pandemic should be further explored. The survey underscores the high need of information regarding COVID-19 and cancer.

Results of a German wide survey towards current surgical approach in early stage cervical cancer NOGGO MONITOR 11

Minimally invasive surgery (MIS) has become the standard approach in early stage cervical cancer (ECC). However, the recently published “LACC” trial and even others could show inferior PFS and OS of MIS compared to open radical hysterectomy. The results led to a widespread debate about the best surgical approach in ECC. The present survey aimed to get first insights after publication. NOGGO and AGE conducted a nationwide digital survey among 186 Gynecological Cancer Centers. Descriptive statistics and t-tests were performed using SPSS. A majority of the centers were of high expertise and/or experience in treatment of ECC and were highly aware of the LACC trial results. Trial quality and scientific value were rated as very good/good. However, still 40% would not change the standard of care to open surgery. Centers with higher volume and participating in clinical trials were more likely to change. This survey represents insights after the surprising results of recently published trials towards the surgical approach of ECC. There still seems to be a high need of future trials and possible explanations for the unexpected worse outcomes in the MIS group.

Impact of health-related quality of life (HRQoL) on short-term mortality in patients with recurrent ovarian, fallopian or peritoneal carcinoma (the NOGGO-AGO QoL Prognosis-Score-Study): results of a meta-analysis in 2209 patients

Objective

Recurrent ovarian cancer is an incurable disease with variable but poor prognosis. Health-related quality of life (HRQoL) is a patient-reported outcome measure generally applied to measure effects of therapies. Our aim was the development and validation of a risk score for the prediction of short-term mortality using the combination of sociodemographic and clinical factors and HRQoL.

Methods

For exploratory and validation analysis, the North-Eastern German Society of Gynecological Oncology (NOGGO) and Working Group Gynecological Oncology (AGO) study databases were screened for trials. Only trials which obtained defined HRQoL measurements were included in the final analysis. Multivariable logistic regression analyses were used to identify risk factors and their weighting for the risk score. Modulation with cubic regression analyses revealed median survival and short-term mortality defined as 1-year mortality for each value.

Results

For exploration, 974 patients from three clinical studies of the NOGGO and for validation, 1235 patients from several clinical studies of the AGO were eligible. The risk score included platinum-free interval, performance status, age, global QoL and nausea/vomiting. Receiver operating characteristic analysis showed a good predictive value with an area under the curve of 0.81 for model 1 in the exploration and 0.74 in the validation. Short-term mortality in model 1 was 8.2%, 23.5% and 58.4% in the exploration sample, and 19.7%, 38.1% and 63.4% in the validation sample for patients under low, medium and high risk, respectively.

Conclusions

This risk score discriminates well between recurrent ovarian cancer patients under low, medium and high risk of short-term mortality. It may help to identify a risk group under high risk for short-term mortality that can be used for randomization in clinical trials and may support decision making for palliative chemotherapy.

•

This newly developed NOGGO-AGO QoL prognosis score clearly discriminates recurrent ovarian cancer (rOC) patients under low, medium and high risk for short-term survival (<1 year).

•

The risk score included platinum-free interval, performance status, age, global QoL and nausea/vomiting.

•

NOGGO-AGO QoL score can be used for stratification or randomization in clinical trials and for identification of a group under high risk for short-term mortality.

•

It may also help the decision making for chemotherapy and provide more precise information of further life expectation for rOC patients.

Frailty Index for prediction of surgical outcome in ovarian cancer: Results of a prospective study

BACKGROUND

Complete macroscopic tumor resection is the strongest prognostic factor for patients with ovarian cancer, which requires complex surgery for achievement. Based on the mostly advanced tumor stage and high symptom burden many patients are classified as frail which may limit optimal surgical outcome. Aim of this study is to evaluate the predictive ability of Frailty Index for surgical outcomes in patients with ovarian cancer.

METHODS

This prospective study enrolled patients with ovarian cancer undergoing cytoreductive surgery. We classified frailty proposed by Mitnitski et al. regarding the cumulative deficit model of frailty. Utilizing Receiver Operator Characteristic (ROC) analysis and logistic regression, we determined predictive clinical factors for severe postoperative complications. The Kaplan-Meier method and log-rank test were used for overall survival analysis.

RESULTS

Out of f 144 enrolled patients, the overall prevalence of frailty based on a Frailty Index >0.26 and Frailty Index >0.15 was 33% and 74%, respectively. The logistic regression shows that frail patients with a Frailty Index >0.26 (Odds ratio (OR): 3.64, 95% CI: 1.34-9.85, p = 0.01), ECOG PS > 1 (OR 6.33, 95% CI:1.31-30.51, p = 0.02) and high surgical complexity score (OR 8.86, 95% CI:1.88-41.76, p = 0.006) had a significant higher risk for severe postoperative complications. According to multivariable cox regression Frailty Index >0.15 (hazard ratio (HR) (HR 1.87, 95% CI: 1.01-3.47, p = 0.048), residual tumor <1 cm (HR 2.75, 95%CI: 1.53-4.99, p = 0.001), residual tumor >1 cm (HR 5.00, 95% CI: 2.74-9.13, p < 0.001) and albumin<35.5 g/dl (HR 1.92, 95% CI: 1.08-3.43, p = 0.03) resulted as significant parameters for poor overall survival. Resulted as significant parameters for poor overall survival.

CONCLUSION

Next to surgical complexity score, ECOG PS > 1 and recurrent surgery, Frailty Index >0.26 is associated with severe postoperative complications in patients with ovarian cancer. Besides tumor residuals and low albumin levels a Frailty Index >0.15 predicts poor survival.

Guidelines for vulvar and vaginal surgery: Enhanced Recovery After Surgery Society recommendations

This is the first collaborative Enhanced Recovery After Surgery Society guideline for optimal perioperative care for vulvar and vaginal surgeries. An Embase and PubMed database search of publications was performed. Studies on each topic within the Enhanced Recovery After Surgery vulvar and vaginal outline were selected, with emphasis on meta-analyses, randomized controlled trials, and prospective cohort studies. All studies were reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. All recommendations on the Enhanced Recovery After Surgery topics are based on the best available evidence. The level of evidence for each item is presented.

Results of the interprofessional and interdisciplinary Berlin round table on patient-reported outcomes, quality of life, and treatment expectations of patients with gynecological cancer under maintenance treatment

BACKGROUND

Patients' reported outcomes and their perspectives around their therapeutic management is a field of continuously increasing relevance in gynecological oncology. We report the results of the Berlin dialog on seven patient-reported parameters and outcomes concerning chemotherapy and maintenance treatment in patients with gynecological cancer.

METHODS

Key opinion leaders in gynecological oncology from different European counties and representatives of leading patients' advocate groups in Berlin held a consensus meeting in Berlin on April 6, 2019. Seven topics of interest were identified in advance around quality of life, iatrogenic toxicity, treatment decision-making processes, sexuality, participation in clinical trials, second opinion, and long-term survivors with the the following standard operating procedure for processing and discussion: (1) agreement on its relevance; (2) literature review, and (3) discussion and consensus statements.

RESULTS

All main topics reached a consensus approval. The defined statements emphasized the importance of patients' role in incorporating and establishing quality of life as an outcome parameter in clinical trials. Furthermore, discussants raised the importance of identifying new tools for reflecting patient-reported iatrogenic toxicity as well as emphasizing patients' rights in providing personal information, access to second opinion in the decision-making process, and their participation in clinical trials.

CONCLUSION

The results of this round table meeting could help redefine perspectives on the discussed topics and the importance for therapeutic management as well as for trial designs.

Nerve Sparing Radical Hysterectomy: Short-Term Oncologic, Surgical, and Functional Outcomes

There is an obvious prevalence of disparity in opinions concerning the technique of nerve-sparing radical hysterectomy and its application, despite agreement on the need to spare the pelvic autonomic nerve system during such a radical operation. Understanding the precise three-dimensional anatomy of paracolpium and its close anatomical relationship to the components of the pelvic autonomic nervous system is the key in performing the nerve-sparing radical hysterectomy. A total of 42 consecutive patients with primary cervical cancers, who were operated upon in our institution between January 2017 and June 2019, were analyzed, concerning surgical, urinary functional, and short-term oncologic outcomes. Two thirds of the patients had locally advanced tumors (T > 40 mm or pT ≥ IIA2) with a median tumor size of 44.1 mm. The nerve-sparing radical hysterectomy was combined with the complete recovery of bladder function in 90% of patients directly after surgery and in 97% of patients in the first 2 weeks. The recurrence rate in a median follow-up time of 18 months was 9.5%. The nerve-sparing radical hysterectomy approach, which depends on the comprehensive understanding of the precise entire anatomy of paracolpium, was found to be feasible and applicable, even in locally advanced tumors, with good functional results and convincing short-term oncologic outcomes.

Patients' perspectives towards malignant ascites: results of a prospective observational trial regarding expectations, characteristics and quality of life-a study of the North-Eastern-German Society of Gynecological Oncology

PURPOSE

Malignant ascites (MA) is a frequent and common symptom in (gyneco-) oncological patients. The present trial evaluated and assessed patients' characteristics, clinical features and the possible influence of MA on QoL measurements.

METHODS

A prospective observational trial was conducted from Oct 2013 until Nov 2016. Therefore an interdisciplinary questionnaire was developed. Overall 250 patients with histological confirmed MA were included with different cancer entities (gynecological, gastrointestinal). The correlation of MA caused symptoms and QoL measurements was assessed using Kendall's tau b. Multivariable logistic regression models were applied to analyze the risks of symptoms or severe limitation in daily activities.

RESULTS

125 questionnaires could be analyzed. The majority of patients with MA had diagnosis of ovarian cancer (68.8%) and were under current cancer treatment (57.6%), mostly chemotherapy. Over 50% reported abdominal tension as major symptom, around 56% of the patients had MA when cancer was firstly diagnosed. Regression analysis showed that patients with MA above 2l were significantly more likely to be harmed in everyday activities. However, the age, gender, type of malignancy and the current treatment (chemotherapy vs. no chemotherapy) had no significant influence.

CONCLUSION

MA has a significantly impact on QoL measurements in cancer patients and might influence everyday activities including basic needs like eating, walking and body care. There is a high need for more information and education of patients with MA.

A Retrospective Perinatal Data Analysis of Immigrant and German Women from Representative Birth Cohorts at the Virchow Hospital, Berlin

Introduction: The aim of this study was to define and characterise differences in the level of obstetric care provided to immigrant and German women. Materials and Methods: An analysis of the Virchow Hospital's birth registers was conducted for the years 1974, 1984 and 1994. The study population of 5445 patients was grouped according to ancestry/family origin on the basis of a name analysis, and subsequently also according to parity (primiparous or multiparous). On name analysis 2741 women were defined as German, 1598 were grouped as women of Turkish origin and 810 as immigrants of other origin. χ² tests and Fisher's exact test were used for significance testing (significance level p < 0.05), and a logistic regression analysis was performed. Results: Rates of caesarean section, episiotomy, higher grade perineal tears and severe postpartum haemorrhage did not differ between the groups. There were however significant differences in the use of uterine stimulants, analgesics in labour and both local and regional anaesthesia, with women of Turkish origin and other immigrants receiving anaesthesia less, but oxytocin more often. Rooming-in was more common among German primipara and multipara from 1984 onwards. Discussion: This retrospective analysis of three historical birth cohorts showed significant differences in perinatal care between German and immigrant women, presumably reflecting deficits in care. It seems remarkable that this trend has not changed over a time span of three decades despite a continuous increase in immigration and acculturation. A "research paradox", however, remains: Despite these increasing rates, there are no current or older, prospective or systematic studies of obstetric care in immigrants.

Correlation of intrapartum translabial ultrasound parameters with computed tomographic 3D reconstruction of the female pelvis

AIMS

Intrapartum translabial ultrasound [ITU] can be an objective, reproducible and more reliable method than digital vaginal examination when evaluating fetal head position and station in prolonged second stage of labor. However, two-dimensional (2D) ultrasound is not sufficient to demonstrate the ischial spines and other important "landmarks" of the female pelvis. Therefore, the purpose of this study was to evaluate the distance of the interspinous plane as a parallel line to the infrapubic line in 2D ITU with the help of 3D computed tomography and digital reconstruction.

RESULTS

Mean distance between the infrapubic plane and the tip of the ischiadic spine was 32.35 (±4.46) mm. The mean height was 166 (±7) cm; the mean weight was 67.5 (±18.4) kg. Body height and the measured distance were significantly correlated (P=0.025; correlation coefficient of 0.5), whereas body weight was not (P=0.37; correlation coefficient of -0.214).

CONCLUSIONS

With the present results, clinicians were enabled to transfer the reproducible measurements of the "head station" by ITU to the widespread but observer-depending vaginal examination. Furthermore, ITU can be verified as an objective method in comparison to subjective palpation with the ability to optimize the evaluation of the head station according to bony structures as landmarks in a standardized application.

Operative Therapy for Heterotopic Scar Pregnancy and Successful Birth of the Intrauterine Foetus - Case Report and Review of the Literature

A heterotopic pregnancy in the vicinity of a previous Caesarean section scar (HSP) occurs frequently after fertility treatment. In spite of the low incidence to date, the increasing numbers of Caesarean sections as well as IVF treatment will probably lead to a higher prevalence in the future. Up to now the literature contains only isolated case reports on therapeutic options. These range from conservative management through selective termination of the HSP by injections of methotrexate or potassium chloride into the amniotic sac to invasive methods such as resectoscopic removal or laparoscopy. In the case presented here we describe the successful excision of the HSP by laparotomy with a subsequent uncomplicated Caesarean section and delivery of a healthy baby at the 37 + 0 week of pregnancy.

Absence of phosphorylation-induced gelation of erythrocyte membrane skeletons: a diagnostic tool for hereditary spherocytosis

As yet there is no single test specific for the diagnosis of hereditary spherocytosis. In the search for a specific test, a method described by Pinder et al. [14] using a cAMP-independent protein kinase extracted from normal erythrocyte membranes was used. Membrane skeletons were prepared from erythrocyte ghosts by extraction with a non-ionic detergent, i.e., Triton X-100. Upon phosphorylation with c-AMP-independent protein kinase the suspension of normal membrane skeletons set to a gelatinous mass. Membrane skeletons from patients with spherocytosis failed to show this phenomenon. In order to clarify whether this phenomenological difference can be used as a diagnostic tool for hereditary spherocytosis, a semiquantitative method of observing the gelation process was used under definite shear stress conditions. We investigated 33 patients with different hemolytic anemias (spherocytosis, hereditary elliptocytosis, hereditary stomatocytosis, homozygous beta-thalassemia and enzymopenic hemolytic anemias). With the exception of spherocytosis, all preparations of membrane skeletons showed gelation after 30-50 min. Spherocytosis membrane skeletons did not show a significant gelation even after 12 h of incubation. Thus, the failing gelation is specific for the diagnosis of hereditary spherocytosis. The "gelation assay" might be a valuable method for defining patients with hemolytic anemias due to erythrocyte membrane defects. Its molecular basis and the possible importance for the pathogenesis of spherocytosis require further investigations.

Variable clinical severity of hereditary spherocytosis: relation to erythrocytic spectrin concentration, osmotic fragility, and autohemolysis

To determine whether stratifying hereditary spherocytosis by degree of severity could provide guidelines regarding which patients would benefit from splenectomy, we evaluated the clinical characteristics of 80 patients (63 children) and 27 healthy relatives. In addition to routine hematologic determinations, osmotic fragility, autohemolysis, erythrocyte spectrin content, and erythrocyte membrane lipid phosphorus were measured and correlated with the disease severity. Four categories were identified: (1) spherocytosis as a trait in symptom-free relatives of patients with recessively inherited disease; (2) mild and (3) moderate spherocytosis, largely observed in patients with dominantly inherited disease; and (4) severe spherocytosis, observed in only two patients, who were characterized by recessive inheritance and transfusion dependence. By the identification of carriers, a recessive mode of inheritance could be demonstrated in 20% of the families with spherocytosis. The erythrocyte spectrin concentration was normal in carriers and patients with mild spherocytosis, and was significantly reduced in the moderate and severe states of the disease. This difference was not accounted for by reduced membrane area of the cells, as measured by the phospholipid concentration per cell. We conclude that patients with mild spherocytosis usually do not require splenectomy during childhood and adolescence; patients with moderate or severe disease should have splenectomy. Patients with severe spherocytosis have a partial response to splenectomy but a considerable degree of increased hemolysis persists. Most patients with less than 80% of normal spectrin content require splenectomy.

Glucuronyl transferase deficiency and mild hereditary spherocytosis: effect of splenectomy

In a 6-year-old girl an association of hereditary spherocytosis and a defect in hepatic bilirubin metabolism has been found. The patient suffered from mild compensated haemolytic anaemia and excessive hyperbilirubinaemia (maximum concentration 581 mumol/l), the serum activity of liver enzymes was slightly increased. Examination of the erythrocyte membrane proteins revealed a deficiency of the major membrane skeletal protein, spectrin (about 75% of normal) which is probably the basic genetic defect of hereditary spherocytosis. Examination of the patient's family revealed a recessive mode of inheritance. The concentration of bilirubin conjugates in the patient's serum was decreased due to a reduced UDP-glucuronyl transferase activity found in homogenates of liver tissue. Histological liver examination showed an intrahepatic cholestasis, which is a secondary and reversible alteration resulting from severe hyperbilirubinaemia. After splenectomy, normalization of the increased haemolysis and hepatic dysfunction was observed. The excessive hyperbilirubinaemia can be explained by the association of an increased bilirubin load due to haemolytic anaemia and the diminished hepatic conjugation of bilirubin.