Askin Dogan

Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: A randomized controlled trial

OBJECTIVE To investigate whether gum chewing affects the return of bowel function after complete staging surgery for gynecologic malignancies. METHODS A total of 149 patients undergoing abdominal complete surgical staging for various gynecological cancers were randomized into a gum-chewing group (n=74) or a control group (n=75). The patients chewed sugarless gum three times from the first postoperative morning until the first passage of flatus. Each chewing session lasted 30 min. Total abdominal hysterectomy with systematic pelvic and para-aortic lymphadenectomy was performed on all patients as part of complete staging surgery. Groups were compared in terms of time to first bowel movement time, first flatus and feces pass time, postoperative analgesic and antiemetic drug requirement, postoperative oral intake tolerance, mild ileus symptoms and hospital stay. RESULTS The mean time to flatus (34.0 ± 11.5 vs. 43.6 ± 14.0 h; p<0.001), mean time to defecation (49.6 ± 18.7 vs. 62.5 ± 21.5h; p<0.001), mean time to bowel movement (41.5 ± 15.7 vs. 50.1 ± 5.9h; p=0.001), mean time to tolerate diet (4.0 ± 0.8 vs. 5.0 ± 0.9 days; p<0.001), mean length of hospital stay (5.9 ± 1 vs. 7.0 ± 1.4 days; p<0.001) were significantly reduced in patients that chewed gum compared with controls. Mild ileus symptoms were observed in 27 (36%) patients in the control group compared to 11(14.9%) patients in the gum-chewing group [relative risk, 2.4; 95% confidence interval, 1.2-4.5; p=0.004]. Severe symptoms were observed in two patients (2.7%) in the control group. CONCLUSIONS Gum chewing early in the postoperative period following elective total abdominal hysterectomy and systematic retroperitoneal lymphadenectomy hastens time to bowel motility and ability to tolerate feedings. This inexpensive and well-tolerated treatment should be added as an adjunct in postoperative care of gynecologic oncology.

Lymphovascular space invasion and cervical stromal invasion are independent risk factors for nodal metastasis in endometrioid endometrial cancer

The purpose of this study was to investigate the potential roles of pathological variables in the prediction of nodal metastasis in women with endometrioid endometrial cancer (EC).

Chylous ascites following retroperitoneal lymphadenectomy in gynecologic malignancies: Incidence, risk factors and management

INTRODUCTION Chylous ascites is a rare form of ascites that results from accumulated lymph fluid in the peritoneal cavity caused by blocked or disrupted lymph flow through the major lymphatic channels. In the present study, our aim was to analyze the incidence, risk factors, diagnostic evaluation and management of chylous ascites after lymphadenectomy in gynecologic malignancies. METHODS A total of 458 patients who had undergone staging surgery for gynecologic malignancies at our institution between January 2010 and December 2013 were retrospectively reviewed. After the exclusion criteria were applied, 399 patients were divided into 2 groups based on the presence (n = 36) or absence (n = 363) of chylous ascites. RESULTS Among the 399 patients, 36 (9%) developed chylous ascites. The median time to onset was 4 days (range, 2-7 days). The analysis of the various features of lymphadenectomy showed that the number of para-aortic lymph nodes (PALNs) removed was significantly greater in the patients with chylous ascites (p < 0.001). A cut-off value of >14 PALNs was a good predictor of chylous ascites. In all patients, chylous ascites resolved with conservative management. CONCLUSIONS Postoperative chylous ascites was strongly associated with the number of harvested PALNs. According to our findings, we suggest that conservative treatment should be the first step in managing patients with chylous ascites. Using an abdominal drain after surgery seems to be an effective diagnostic tool and treatment method for chylous ascites.

Prognostic Significance of Retroperitoneal Lymphadenectomy, Preoperative Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio in Primary Fallopian Tube Carcinoma: A Multicenter Study

Purpose The purpose of this study is to evaluate the prognostic role of preoperative neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) and the need for para-aortic lymphadectomy in patients with primary fallopian tube carcinoma (PFTC). Materials and Methods Ninety-one patients with a diagnosis of PFTC were identified through the gynecologic oncology service database of six academic centers. Clinicopathological, surgical, and complete blood count data were collected. Results In univariate analysis, advanced stage, suboptimal surgery, and NLR > 2.7 were significant prognostic factors for progression-free survival, whereas in multivariate analysis, only advanced stage and suboptimal surgery were significant. In addition, in univariate analysis, cancer antigen 125 ≥ 35 U/mL, ascites, advanced stage, suboptimal surgery, NLR > 2.7, PLR > 233.3, platelet count ≥ 400,000 cells/mm3, staging type, and histological subtype were significant prognostic factors for overall survival (OS); however, in multivariate analysis, only advanced stage, suboptimal surgery, NLR > 2.7, and staging type were significant. Inclusion of pelvic and para-aortic lymphadenectomy in surgery showed significant association with longer OS, with a mean and median OS of 42.0 months and 35.5 months (range, 22 to 78 months), respectively, vs. 33.5 months and 27.5 months (range, 14 to 76 months), respectively, for patients who underwent surgery without para-aortic lymphadenectomy (hazard ratio, 3.1; 95% confidence interval, 1.4 to 5.7; p=0.002). Conclusion NLR (in both univariate and multivariate analysis) and PLR (only in univariate analysis) were prognostic factors in PFTC. NLR and PLR are inexpensive and easy tests to perform. In addition, patients with PFTC who underwent bilateral pelvic and para-aortic lymphadenectomy had longer OS.

Nutritional status, cachexia, and anorexia in women with peritoneal metastasis and intraperitoneal chemotherapy: a longitudinal analysis

Objective To describe the nutritional status of women with peritoneal metastasis (PM) from recurrent ovarian, fallopian, or peritoneal cancer and to assess longitudinal variations of the cachexia-anorexia syndrome (CAS) during palliative pressurized intraperitoneal aerosol chemotherapy (PIPAC). Methods Nutritional assessment included body mass index (BMI), bioelectrical impedance analysis (BIA), and blood chemistry. CAS presence/absence was recorded before and during repeated cycles (1–11) of PIPAC. Results Eighty-four patients with peritoneal cancer (n=5) or PM from recurrent ovarian (n=77) or fallopian tube (n=2) cancer were included. At baseline, resting metabolism (RM) (1,432±172 kcal/day), visceral fat level (7.5±3.2), skeletal muscle mass (27.2%±4.6%), upper arm circumference (27.9±4.6 cm), lower leg circumference (35.1±3.9 cm), serum parameters (albumin [3.5±0.7 g/dL], total protein [6.3±0.9 g/dL], and transferrin [202±60 mg/dL]) were below normal limits. C-reactive protein (CRP) (4.3±6.8 mg/dL), caliper body fat (35.7%±6.3%), and total body fat mass (35.6%±8.5%) were above normal limits. Nineteen/84 (23%) patients had CAS at baseline. Deterioration or stabilization/improvement of CAS was observed in 9/55 (16.4%) and 46/55 (83.6%) patients with follow-up data, respectively. Baseline body fat mass, visceral fat level, skeletal muscle mass, caliper body fat, BMI, ascites, Karnofsky index, RM, and CRP, as well as tumor response were not predictive of CAS deterioration. Conclusion Nutritional decline and onset or deterioration of CAS are difficult to predict. Careful measuring and monitoring of nutritional parameters and CAS in all patients seems to be necessary in order to identify those patients in need of enteral/parenteral nutrition support.

A phase I, single-arm, open-label, dose escalation study of intraperitoneal cisplatin and doxorubicin in patients with recurrent ovarian cancer and peritoneal carcinomatosis

OBJECTIVE We performed a phase I, single-arm, non-randomized, open-label, dose-escalation trial to determine the dose-limiting toxicity of intraperitoneal cisplatin and doxorubicin applied as pressurized intraperitoneal aerosol chemotherapy (PIPAC) in women with recurrent ovarian cancer. METHODS We used a standard 3 + 3 dose-escalation design with doxorubicin 1.5 mg/m2, cisplatin 7.5 mg/m2 q 4 to 6 weeks for 3 cycles and subsequent dose escalation steps (20% increment per step) in patients with recurrent ovarian cancer and peritoneal carcinomatosis. Toxicity and clinical efficacy were monitored. The primary endpoint was the maximum-tolerable dose. Secondary endpoints included histologic tumor regression and serum parameters. RESULTS 15 evaluable patients (3, 7, and 5 in cohorts 1, 2, and 3, respectively) on average received 2.3 PIPAC cycles. No dose limiting toxicities were found. Adverse side effects were 1 grade 3 event (colon perforation) and 85 grade 1/2 events including fatigue (n = 19), abdominal pain (n = 18), nausea/vomiting (n = 14), sleep disorder (n = 8), diarrhea (n = 5), and fever (n = 2). Liver and renal toxicity was not observed in any of the 3 cohorts (AST 19.1 ± 3.2, 25.8 ± 6.5, and 22.1 ± 4.5 IU/L, respectively; ALT 14.7 ± 3.5, 18.5 ± 5.6, and 23.3 ± 13.0 IU/L, respectively; GGT 45.7 ± 35.1, 25.2 ± 10.3, and 43.9 ± 26.4 IU/L, respectively; serum creatinine 1.06 ± 0.23, 0.80 ± 0.17, and 0.89 ± 0.35 mg/dL, respectively). No systemic hematologic toxicity, alopecia, or neurotoxicity was noted. The maximum tolerable dose was not reached. Histologic tumor regression was observed in 7/11 (64%) patients who underwent ≥2 PIPAC cycles. CONCLUSIONS PIPAC with cisplatin and doxorubicin may be safely used at an intraperitoneal dose of 10.5 mg/m2 and 2.1 mg/m2, respectively. Systemic toxicity of this therapy is low.

Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy for recurrent adult granulosa cell tumor: A case report

Background Adult granulosa cell tumor of the ovary (AGCT) is a rare functional sex-cord-stromal ovarian neoplasm characterized by low malignant potential and late relapse. Evidence-based management options for women with recurrent AGCT are limited. Case report We present the case of a 60-year-old woman with the fifth recurrence of AGCT initially diagnosed 19 years ago. After initial surgery in 1996, the patient underwent four additional surgical interventions for recurrent disease in 2005 (abdominal wall), 2009 (abdominal wall), 2010 (paravesical), and 2011 (paravesical). In 2011, she underwent pelvic irradiation with 50.5 Gray. In 2015, another recurrence was diagnosed based on an increase of serum inhibin and a tumor seen on CT scan in the right upper abdomen. The patient underwent cytoreductive surgery (CRS) with complete cytoreduction followed by hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin 50 mg/m2 and doxorubicin 15 mg/m2. No intra- or post-operative complications occurred. Final histology revealed recurrent AGCT with 6 cm in the largest diameter. Subsequently, antihormonal treatment with anastrozole 1.5 mg per day was prescribed. With a follow-up of six months, the patient is well and alive. Conclusion CRS and HIPEC are a reasonable treatment option for selected women with recurrent AGCT limited to the abdomen.

Pelvic tuberculosis, echinococcosis, and actinomycosis: Great imitators of ovarian cancer

To evaluate the demographic, laboratory, clinical and imaging findings, surgical procedures and complications in women with final pathology results of pelvic tuberculosis (PT), pelvic echinococcosis (PE) or pelvic actinomycosis (PA) following exploratory surgery for suspicion of ovarian cancer.

Loop Electrosurgical Excision Procedure (LEEP) with or without Intraoperative Colposcopy: A Randomized Trial

BACKGROUND: Loop electrosurgical excision procedure is the standard surgical treatment for cervical dysplasia. Loop electrosurgical excision procedure is advised to be performed under colposcopic guidance to minimize adverse pregnancy outcomes. To date, there is no evidence from randomized trials for this recommendation. OBJECTIVE: We sought to assess the benefits of performing loop electrosurgical excision procedure under colposcopic guidance in women with cervical dysplasia. STUDY DESIGN: In a prospective, randomized trial, we compared loop electrosurgical excision procedure with loop electrosurgical excision procedure performed under direct colposcopic vision in a 1:1 ratio. The primary endpoint was resected cone mass; the secondary endpoints were margin status, fragmentation of the surgical specimen, procedure time, time to complete hemostasis, blood loss, and intraoperative and postoperative complications. A sample size of 87 per group (n = 174) was planned (with an assumed type I error of 0.05 and drop‐out rate of 5%) to achieve 90% power to detect a 25% reduction in cone mass (with an assumed cone mass of 2.5 ± 1.6 g in the control group) using a nonparametric test (Mann‐Whitney U). RESULTS: From October 2016 through December 2017, we randomized 182 women: 93 in the loop electrosurgical excision procedure group and 89 in the loop electrosurgical excision procedure–direct colposcopic vision group. Women undergoing loop electrosurgical excision procedure–direct colposcopic vision had significantly smaller cone specimens than those undergoing loop electrosurgical excision procedure (weight: median 1.86 [interquartile range 1.20–2.72] vs median 2.37 [interquartile range 1.63–3.31] g, respectively, P = .006). Secondary outcome measures did not differ significantly between groups: resection margin status involved vs free margin: 12 (13%) vs 75 (82%) and 11 (12.4%) vs 75 (84.3%); fragmentation no vs yes: 85 (92.4%) vs 7 (7.6%) and 84 (94.4%) vs 5 (5.6%); procedure time: 190 (interquartile range 138–294) and 171 (interquartile range 133–290) seconds; time to complete hemostasis: 61 (interquartile range 31–108) and 51 (interquartile range 30–81) seconds; intraoperative blood loss (&Dgr;hemoglobin): 0.4 (interquartile range 0.2–1.0) and 0.5 (interquartile range 0.1–0.9); complication rate: 6 (6.5%) and 2 (2.2%). In a multivariate analysis, study group allocation (P = .021) and parity (P = .028), but not age, body mass index, type of transformation zone, and dysplasia degree independently influenced the amount of resected cone mass. CONCLUSION: Loop electrosurgical excision procedure with intraoperative colposcopy leads to significantly smaller cone specimens without compromising margin status.

Thalidomide and lenalidomide for recurrent ovarian cancer: A systematic review of the literature

The present review aimed to assess the safety and efficacy of thalidomide and lenalidomide, two immunomodulatory drugs with anti-angiogenic properties, in women with recurrent ovarian, fallopian tube, and primary peritoneal cancer. A systematic review of the literature was conducted whereby Medline and the Cochrane Central Register of Controlled Trials were searched using terms associated with thalidomide, lenalidomide, and recurrent ovarian, fallopian tube and primary peritoneal cancer. Published English language case reports, trials and studies that described the safety and efficacy of thalidomide or lenalidomide alone, or in combination with other drugs were reviewed. A total of 16 clinical studies involving 394 patients treated with thalidomide (n=188), lenalidomide (n=77) and 129 controls were identified, including five case reports (n=6), three case series (n=45), two phase I trials (n=27), four phase II trials (n=109), and two randomized phase III trials (n=207). In a pooled analysis of thalidomide investigated as a single drug, the overall clinical benefit rate was 43% (43/99) with a mean time to progression of 5.6 months. The response rate (complete response + partial response) was 25%. In a phase III trial, the combination of thalidomide and topotecan significantly increased the overall response rate compared with topotecan alone [14/30 (47%) vs. 8/39 (21%)]. In another phase III trial involving women with asymptomatic biochemical recurrence, compared with tamoxifen, thalidomide was not more effective. Lenalidomide was investigated in three phase I trials and in one phase II trial with an overall clinical benefit rate of 52% (34/65), and a mean time to progression of 4.6 months. The response rate (complete response + partial response) was 6%. Systemic toxicity of both drugs was noted in >77% of patients with pneumonitis/pneumonia, fatigue, neuropathy and venous thromboembolism reported as the most common side effects. Thalidomide and lenalidomide are moderately active in recurrent ovarian cancer. Thalidomide possesses synergistic effects with topotecan. The toxicity of both drugs is considerable and there is a greater amount of data available for thalidomide compared to lenalidomide.