Dimitrios Zacharakis

Safety of hormone replacement therapy in gynaecological cancer survivors

Therapy for endometrial, ovarian and cervical cancer in young women can cause sudden onset of intense menopausal symptoms, such as hot flushes, emotional disorders and sexual dysfunction. In order to overcome these unpleasant and sometimes severe symptoms, hormone replacement therapy (HRT) has proven to be very effective. However, its safety remains controversial. We reviewed English literature and examined whether administration of HRT in this specific population is related with more recurrences and worse prognosis. Current scientific data, comprising mainly retrospective studies, suggest that recurrence rates and survival are comparable between HRT users and non-users. However, large randomised trials are missing and definitive conclusions cannot be drawn. Gynaecological cancer survivors using HRT, although they seem to have little if any risk for recurrence, should be correctly informed about the lack of strong evidence.

Ultrasonographic markers and preoperative CA‐125 to distinguish between borderline ovarian tumors and stage I ovarian cancer

Preoperative evaluation of ovarian masses has become increasingly important for optimal planning of treatment. The aim of this study was to assess the role of preoperative serum cancer antigen 125 (CA‐125) levels in correlation with ultrasonographic features in order to distinguish between borderline ovarian tumors (BOTs) and stage I epithelial ovarian carcinoma (EOC).

Safety and efficacy of the cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth

Abstract Introduction: The aim of this study was to evaluate the safety and efficacy of the combined treatment of cervical pessary and endovaginal progesterone for the prevention of spontaneous preterm birth (SPB) in women with a short cervical length (CL) between 20 and 24 weeks of gestation. Materials and methods: This is a prospective study of women with a singleton pregnancy and a sonographically detected mid-trimester CL ≤25 mm. The primary outcome measure was spontaneous delivery before 34 weeks (238 days) of gestation. Results: The study sample consisted of 90 women with a mean CL of 14.2 mm (SD=6.5 mm). Of the women, 34.4% had at least one risk factor for SPB; 7.8% delivered preterm before 34 weeks of gestation, and 25.6%, before 37 weeks. Neonatal death occurred in two (2.2%) cases due to respiratory distress syndrome. Lower body mass index values, history of preterm delivery and number of second trimester miscarriages were independently associated with delivery before 34 weeks. Conclusion: The combination of vaginal progesterone and cervical pessary for the prevention of SPB in women with a short cervix is safe and well tolerated. This therapy was associated with pregnancy prolongation, reduced prematurity rate and a low rate of perinatal complications.

Occult Stress Urinary Incontinence in Women With Pelvic Organ Prolapse: Is the One Step Surgical Approach a Risky Choice?

Objectives Occult stress urinary incontinence (SUI, OSUI) is defined as the demonstration of SUI after pelvic organ prolapse (POP) reduction. The aim of this study was to evaluate the effectiveness and complication rates of the 1-step surgical approach for treating women with POP and OSUI. Methods Retrospective study of women with POP and OSUI who underwent a concomitant prolapse and midurethral sling procedure was conducted. Main outcome measures were absence of postoperative urodynamic stress incontinence (USI) and absence of postoperative SUI at 12 months. Secondary outcome measures included evaluation of objective and subjective parameters related to the lower urinary tract function and assessment of the quality of life. Results Of the 244 women, 205 women (84%) attended the 12-month postoperative follow-up visit and were included in the study. Overall, 87.8% (180/205) of the patients had absence of postoperative urodynamic stress incontinence, whereas 95.1% (195/205) did not report postoperative SUI. Evaluation of parameters related to the postoperative lower urinary tract dysfunction showed that (a) 43% of women with preexisting urgency symptoms continued to have urgency, (b) 16.7% of patients presented de novo urgency, (c) de novo detrusor overactivity occurred in 9.3% of patients, and (d) 4.9% of women with preoperative obstructive voiding symptoms continued to have obstructive voiding symptoms after combined surgery. Kings Health Questionnaire data analysis showed a statistically significant improvement in all domains. Conclusions This 1-step approach is both safe and effective and could be offered as a valid operative choice for those women who wish or should avoid a repeat surgical procedure for postoperative SUI.

Merkel cell carcinoma in pelvic lymph nodes after surgical staging for endometrial cancer: A case report and review of the literature.

INTRODUCTION Merkel cell carcinoma (MCC) is a rare malignant neuroendocrine tumor of the skin. PRESENTATION OF CASE We present a case of MCC in pelvic lymph nodes, revealed after surgical staging for endometrial cancer. A 54-year-old Caucasian woman presented to our department with a three-month history of postmenopausal bleeding. After proper preoperative evaluation, the patient underwent total abdominal hysterectomy, bilateral salpingo-ophorectomy and pelvic lymph node dissection. The pathology report confirmed the presence of a small, grade I, endometrioid adenocarcinoma and MCC in the pelvic lymph nodes. Primary site of the disease could not been retrieved. The tumor board decided adjuvant chemotherapy (carboplatin and etoposide) and close follow-up every 2months. Our patient is alive with no evidence of disease 12months after surgery. DISCUSSION It is noteworthy that 19% of the patients with MCC had lymph node metastasis with no apparent primary lesion. The mechanism of this regression remains unclear, although a higher apoptotic activity has been observed in MCC than other skin tumors. In addition, other co-malignancies have also been linked to MCC patients. The explanation for the frequent occurrence of other primary neoplasms in patients with MCC is still unclear. However, a reasonable cause could be an altered genetic profile or an immuno-compromised situation in these patients. CONCLUSION Further analytic investigations are needed to clarify the role of various factors in the spontaneous regression or not of this neuroendocrine tumor as well as in the simultaneous genesis of other primary carcinomas.

Pre‐ and postoperative magnetic resonance imaging (MRI) findings in patients treated with laparoscopic sacrocolpopexy. Is it a safe procedure for all patients?

Laparoscopic sacrocolpopexy (LSCP) is a reference operation for apical compartment prolapse repair. Aim of this study is to describe the early and midterm postoperative MRI findings of the lumbosacral region (LSR) in patients undergoing LSCP and to detect any imaging changes that the presence of the mesh may cause on patients with preexisting degenerative disease of the LSR.

Reply to: Cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth: is evidence sufficient?

We would like to thank Madar et al. [1] for their comments referring our article “Safety and efficacy of the cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth” [2]. We agree with them that no definitive conclusions can be drawn out of randomized trials. Although the lack of a control group in our study is a major limitation, all women that took part in the study underwent frequent sonographic cervical screening and were treated following the same protocol, thus making the study more homogenous. Moreover, all doctors involved in this study were certified for both ultrasonograhic cervical assessment and pessary placement. As the authors of the letter have already mentioned, the daily clinical practice sometimes differs substantially from the results of randomized trials. In addition, randomized trials on the pessary use in women with short cervix had conflicting results, whereas the influence of the ethnicity on the results may be significant [3–6]. Therefore, we believe that the single center international experience in the management of rare events in pregnancy, such as a short cervix in the second trimester, should be appropriately reported. This management should be based on not only the good knowledge of the literature but also the logic and the operators experience, which represents what is called “reality-based medicine”. The current study reported our experience on the combined treatment of pessary and simultaneous vaginal progesterone administration, which had not been tested in any randomized trial to date. More importantly, we neither overinterpreted nor overemphasized our results. In fact, we concluded by saying, “.... the present study has shown that combined treatment with cervical pessary and vaginal progesterone is a safe and feasible option, which may be beneficial for the prolongation of the pregnancy and therefore could be an effective method for preventing SPB. This can only be confirmed in a large multicenter randomized study”.

EP25.17: Images produced by 3D ultrasound scan could warn investigator regarding the nature of the ovarian lesion

Objectives: To investigate if the calculation of the digital signal of the images that are produced via 3D software application could help in the identification of ovarian borderline lesions via ultrasonography. Methods: Ultrasonographic volumes of 22 borderline ovarian tumours and 18 serous cysts (as controls) were analysed via 3D Render Mode application. Main image was isolated from the surrounded noise and inverted. The signals produced by these images may be transformed into numerical data via ImageJ system; the last is a free web application. Results: Signals produced by images originated from inverted borderline volumes were calculated at the level of 68.566, ranging from 1.677-128.776. On the other hand, images produced by images that belong to the inverted serous cysts volumes gave significantly increased signals when compared to borderline tumours (135.264; range: 96.308-165.978; p<0.01). Conclusions: Despite the limited number of cases, it is indicated that calculation of the signals produced by specific images of borderline tumours could imply the malignant nature of the mass. Pattern recognition of the cyst could support the diagnosis.

Non-blood medical care in gynecologic oncology: a review and update of blood conservation management schemes.

This review attempts to outline the alternative measures and interventions used in bloodless surgery in the field of gynecologic oncology and demonstrate their effectiveness. Nowadays, as increasingly more patients are expressing their fears concerning the potential risks accompanying allogenic transfusion of blood products, putting the theory of bloodless surgery into practice seems to gaining greater acceptance. An increasing number of institutions appear to be successfully adopting approaches that minimize blood usage for all patients treated for gynecologic malignancies. Preoperative, intraoperative and postoperative measures are required, such as optimization of red blood cell mass, adequate preoperative plan and invasive hemostatic procedures, assisting anesthetic techniques, individualization of anemia tolerance, autologous blood donation, normovolemic hemodilution, intraoperative cell salvage and pharmacologic agents for controlling blood loss. An individualised management plan of experienced personnel adopting a multidisciplinary team approach should be available to establish non-blood management strategies, and not only on demand of the patient, in the field of gynecologic oncology with the use of drugs, devices and surgical-medical techniques.

P30.10: Translabial ultrasound: an alternative ultrasonographic approach in the assessment of placenta preavia and cervix incompetence

performed at 36+3 weeks gestation under general anesthesia with central venous and arterial access in full anticipation of an intraoperative haemorrhage possibly necessitating peripartum hysterectomy. Following delivery of a healthy baby girl, the placenta was allowed to separate spontaneously and minimal blood loss occured. A tubal ligation was performed. She had an uneventful postoperative course and was discharged on day 4 following surgery. A morbidly adherent placenta occurs with an estimated incidence of one in 2500 pregnancies and is traditionally managed by elective caesarean hysterectomy, which carries significant risk for maternal morbidity and mortality, coupled with a loss of reproductive capacity. While many case reports are published on conservative management of this condition, a patient’s reproductive capacity following such management is uncertain and subsequent pregnancy outcomes are rarely reported. This case describes the excellent and encouraging outcome following conservative management of placenta praevia increta and highlights that this method, in selected cases, is a viable option for morbidity reduction and fertility preservation.