Alpaslan Kaban

Surgical management of squamous cell vulvar cancer without clitoris, urethra or anus involvement

Vulvar cancers, which constitute 5% of all gynecologic cancers, are the fourth most common female genital cancers, preceded by uterine, ovarian and cervical cancers. The treatment methods employed for vulvar cancers have changed over the years, with previously applied radical surgical approaches, such as en bloc resection, being gradually suspended in favor of treatment approaches that require dissection of less tissue. While the removal of less tissue, which todays approaches have focused on, prevents morbidity, this method seems to result in higher risks of recurrence. It is therefore important that the balance between preventing the recurrence of the disease and forefending against postoperative complications and vulvar deformity be properly understood. As a working assumption, if patients with vulvar cancer are diagnosed at an early stage, properly evaluated and administered appropriate treatment, the most positive results can be obtained. This paper aims to highlight this assumption and demonstrate, through the provision of actual data, how to plan the treatment approach for patients who are diagnosed early. Statements extracted from the National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2016 Sub-Committees on vulvar squamous cell carcinoma and articles by the European Society of Gynaecological Oncology (ESGO) regarding Vulvar Cancer Recommendations were used to obtain updated information.

Does the Increased Rate of Serous Component (≤25% vs. >25%) Increase Recurrence in Endometrial Cancer With Serous Plus Endometrioid Histology?

OBJECTIVE The aim of the study is to investigate the effect of increasing serous component ratio on survival in endometrium cancer patients with serous plus endometrioid histology. METHODS The study cases included 33 patients who underwent surgery for endometrial cancer and had serous plus endometrioid carcinoma based on the pathology report between 2005 and 2014. Univariate Cox regression analysis was used for evaluation of the effects of age, stage, lymphadenectomy, serous component ratio, lymphovascular space invasion, depth of myometrial invasion, and tumour size criteria on disease-free survival (DFS) and overall survival (OS). RESULTS Median age was 63.0 years (range 45-81), and median follow-up duration was 54 months (range 13-144). Serous component ratio was less than 25% in 18 patients (55%) and more than 25% in 15 patients (45%). The rate of recurrence, DFS and OS were similar in the two groups (P = 0.695, P = 0.238, P = 0.134, respectively). Twenty-five patients (76%) were stage 1-2; 8 patients were (24%) stage 3-4. We evaluated the relationships of age, stage, lymphadenectomy, serous component ratio, lymphovascular invasion, myometrial invasion depth, and tumour size criteria with DFS and OS by univariate Cox regression analysis. Among these criteria, only the stage was detected to be in a significant relationship with DFS and OS (log rank test P < 0.001 and P = 0.01). CONCLUSION This study supported that the most important prognostic factor in patient with serous plus endometrioid histology is the stage of the cancer. Patients with a serous component ratio of less than 25% had similar recurrence and mortality rates to those with more than 25%.

Prognostic Factors in Patients Undergoing Primary Cytoreductive Surgery for FIGO Stage IIIC Ovarian, Tubal or Peritoneal Cancer

OBJECTIVE The aim of the study is to investigate factors related to overall survival in advanced stage ovarian, tubal, or peritoneal cancer and to identify strong and weak prognostic factors. METHODS We retrospectively reviewed 190 patients who underwent primary cytoreductive surgery between 2003 and 2013. RESULTS Median overall survival duration was founded 58 months (95% CI 49-67). Five-year overall survival ratio was 48.5%. Presence of tumour at upper abdomen, suboptimal cytoreduction (residual >1 cm), surgery without lymphadenectomy, and presence of peritoneal ascites more than 1 L had a significantly negative effect on overall survival, but not histological grade and CA-125 level, by univariate Cox analysis. Age and presence of tumour in the upper abdomen were independent poor prognostic factors according to multivariate Cox model (HR 1.025; 95% CI 1.009-1.040 and HR 1.533; 95% CI 1.039-2.263, respectively). CONCLUSION This study supports that the presence of tumour in the upper abdomen is the most important independent poor prognostic factor in patients with performed primary surgery for advanced stage ovarian, tubal, and peritoneal cancer. Upper abdominal metastasis is the most important predictive factor for optimal cytoreduction (P <0.001, HR 6.567; 95% CI 3.059-14.096).

Clinicopathologic and survival results in serous endometrium carcinoma and subgroup analysis for mixed serous and pure serous histology

Objective: To review the clinicopathologic and survival outcomes of patients with serous endometrial cancer (EC) and to investigate subgroup analysis based on pure serous and mixed serous EC subtypes. Material and Methods: Patients who underwent EC surgery between 2002 and 2014 and who were reported as serous EC were enrolled in the study. All patients were diagnosed as having serous EC or mixed serous EC with serous component higher than 10% based on the postoperative pathology report. Results: A total of 93 patients were analyzed. The median disease-free and overall survival (OS) durations were 49.6 and 32.2 months, respectively. Forty-three patients (46.2%) relapsed and 35 patients (37.6%) died. The histologic type was pure serous EC in 52 (55.9%) and mixed EC in 41 (44.9%) patients. There was no statistical difference between the pure serous and mixed serous groups in terms of age, International Federation of Gynecology and Obstetrics stage, lymphadenectomy, lymph node metastasis or adjuvant therapy combinations. Twenty-nine (55.8%) patients in the pure serous group and 14 (34.1%) in the mixed serous group hade recurrence (p=0.038). Twenty-five (48.1%) patients in the pure serous group and 10 (24.4%) in the mixed serous group died (p=0.034). In the pure serous group, the mean disease-free and OS durations were shorter than in the mixed serous group (59 vs. 81 months and 73 vs. 95 months, log-rank p=0.055 and 0.041, respectively). Histologic type was a significant prognostic factor on recurrence and OS in the univariate analysis (Hazard ratio: 2.404, 95% Confidence interval: 1.01-5.71; 2.027, respectively), but not in the multivariate analysis, which included disease stage and age of the patients. Conclusion: Compared with pure serous and mixed serous endometrium cancer groups, primary surgical treatments, clinicopathologic features and adjuvant treatments were similar, but there was a survival difference. Patients with pure serous cancer had a worse prognosis. However histology was not an independent factor for survival.

Is Omentectomy Necessary for Non-Endometrioid Endometrial Cancer?

Background: In subtypes of non-endometrioid endometrium cancers (non-ECC), it is not clear whether the omentectomy is a part of debulking if visual assessment is normal. Recently, the ESMO-ESGO-ESTRO Endometrial Consensus Conference Working Group in their report titled “Endometrial Cancer: diagnosis, treatment and follow-up” recommended that omentectomy be performed in the serous subtype, but not in carcinosarcoma, undifferentiated endometrial carcinoma or clear cell. In this study, the question is whether omentectomy should be a part of a staging procedure in patients with non-ECC. Besides, the sensitivity and specificity of the visual assessment of omentum were analyzed. Methods: Patients diagnosed with non-ECC in 2 gynecological oncology clinics between 2005 and 2015 were retrospectively reviewed. Occult (absence of visible lesions) and gross (presence of visible lesions) omental metastasis rates of histological subtypes were analyzed. Results: We identified 218 patients with non-ECC. Thirty-four of them (15.1%) had omental metastases and 44.1% of these metastases (n = 15) were occult metastases. The sensitivity of the surgeons visual assessment of an omentum (positive or negative) was 0.55. The highest rate of omental metastasis was found in carcinosarcoma followed by serous, mixed subtypes, and clear-cell (20.4, 17.3, 16.6, 10.0%, respectively). Adnexal metastasis was the only factor associated with occult omental metastasis (p = 0.003). Conclusion: Omental metastases occur too often to omit omentectomy during surgical procedures for non-ECC regardless of histological subtypes, and visual assessment is insufficient in recognizing the often occult metastases. Omentectomy should be a part of the staging surgery in patients with non-ECC.