Hasan Turan

Synchronous Primary Cancers of the Endometrium and Ovary With the Same Histopathologic Type Versus Endometrial Cancer With Ovarian Metastasis: A Single Institution Review of 72 Cases.

Objective The purpose of this study was to evaluate the clinicopathological characteristics and survival outcomes of women with simultaneous endometrial and ovarian carcinomas having the same histopathologic type. Materials and Methods A review of medical records from 1997 to 2015 identified 72 patients with simultaneous carcinomas of the endometrium and ovary with the same histopathologic type. Patients with synchronous primary cancers of endometrium and ovary (SCEOs) were compared with patients with primary endometrial cancer with ovarian metastasis (ECOM). Clinical and pathological data were obtained from the patients’ medical records. Clinicopathological variables including categorical data were analyzed by &khgr;2 or Fisher exact test and continuous data by a Student t test. A Kaplan-Meier survival analysis was performed and compared by using the log-rank test. Results A univariate and multivariate analysis of 72 patients with SCEO with the same histopathologic type revealed that SCEO is an independent prognostic factor of 10-year overall survival. There were 31 patients in the SCEO group and 41 patients in the ECOM group. With a mean follow-up time of 68.2 months, the 10-year overall survival rates were 61.3% and 36.6% in SCEO and ECOM groups, respectively (P = 0.029). Age, menopausal status, stage of ovarian cancer, performing lymphadenectomy, grade of endometrial tumor, omental metastasis, and residual tumor were found to be significant risk factors for recurrence in the synchronous group. Conclusions The differentiation between SCEO and ECOM is of great clinical importance while our results showed a better prognosis for patients with SCEO compared with patients with ECOM. More aggressive therapeutic approaches may be considered for patients with SCEO who are older, postmenopausal, and/or have advanced grade of endometrial tumor, omental metastasis, and residual tumor. Lymphadenectomy should be performed in every patient with SCEO.

Rare cutaneous metastasis in vulvar squamous cell carcinoma without any distant organ spread.

Vulvar cancer is the fourth most common gynaecologic cancer, representing 5% of malignancies of the female genital tract. It occurs most commonly in post-menopausal women with a mean age of 65. In recent years, an increase in incidence rates in young women has been observed. In the United States, about 4900 cases of vulvar cancer are diagnosed and 1000 patients die of vulvar cancer per year (Siegel et al. 2014). Two different pathways for vulvar carcinogenesis have been identified: HPV-dependent and induced by chronic inflammation. HPV is responsible for 60% for all cases. Of the vulvar cancers related to HPV about 55.5% are caused by two strains, HPV-16 or HPV-33 (Insinga et al. 2008). There are three ways that vulvar cancer spreads. First, direct extension to adjacent structures, such as vagina, urethra, clitoris, anüs. A second way of spread is by the lymphatic route. The third way of tumour spread is the haematogenous route associated with advanced disease. Cutaneous metastasis of vulvar cancer is very rare and only nine cases had been reported till 2010 (Wang et al. 2010).

Surgical Treatment of Metastatic Ovarian Tumors From Extragenital Primary Sites.

Objective The purpose of this study was to investigate the outcomes and prognostic factors of metastasectomy in patients with metastatic ovarian tumors from extragenital primary sites. Materials and Methods All patients with pathologically confirmed metastatic ovarian tumors between January 1997 and June 2015 were included in this study. A total of 131 patients were identified. The data were obtained from the patients’ medical records. Clinicopathological features were evaluated by both univariate and multivariate analyses. Results The primary sites were colorectal region (53.4%), stomach (26%), and breast (13%). Preoperative serum CA 125 and CA 19-9 levels were elevated in 29.4% and 39.8% of the patients, respectively. Cytoreductive surgery was performed in 41.2% of the patients. Seventy-three (55.7%) patients had no residual disease after surgery. Sixty-six (49.6%) patients had combined metastases at the time of the surgery to sites including the liver, pancreas, lung, bone, lymph nodes, bladder, or the intestine. With a median follow-up of 33 months, the median survival time was 22 months. The estimated 5-year survival probability is 0.26. On univariate analysis, primary cancer site, combined metastasis outside the ovaries, residual disease, preoperative serum CA 125 and CA 19-9 levels, and histologic type were significant parameters for overall survival. Furthermore, residual disease, preoperative serum CA 19-9 level, and primary cancer site were found to be independent prognostic factors on multivariate analysis. Conclusions The most common primary sites for ovarian metastasis are gastrointestinal tract. Metastasectomy may have beneficial effects on survival, especially if the residual disease is less than 5 mm. Prospective studies warranted to evaluate the value of metastasectomy in patients with ovarian metastasis.

The Combination of Preoperative Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography and Sentinel Lymph Node Mapping in the Surgical Management of Endometrioid Endometrial Cancer.

Objective The goal of this study was to evaluate the combination of sentinel lymph node (SLN) mapping and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) scan in detection of lymph node involvement in patients with endometrioid endometrial cancer (EEC). Methods/Materials Ninety-five patients with EEC who had preoperative PET/CT imaging and underwent SLN mapping were retrospectively analyzed. Methylene blue dye was used and injected to the cervix at 3- and 9-o’clock positions (a total of 4 mL). Pelvic lymphadenectomy was performed on all of the patients after SLN mapping. If the SLN was negative in the initial hematoxylin and eosin staining, an ultrastaging study was performed for the SLNs. Results Sentinel lymph nodes were detected in 77 (81.1%) of 95 patients, with a mean of 2.951–9 SLNs. There was only 1 case (1.4%) with a positive SLN in the intraoperative frozen section examination in those patients with negative PET/CT findings and in whom SLNs were detected (n = 70). Among the remaining 69 patients with negative preoperative PET/CT findings and negative frozen section results for the SLNs, there were 2 patients with SLN involvement in the final ultrastaging pathology. In the patient-based analyses, the sensitivity, specificity, and positive and negative predictive values of the PET/CT and SLN frozen section were 33%, 100%, 100%, and 97.1%, respectively. Conclusions As no metastases in the nonsentinel pelvic lymph nodes were found in patients with EEC who had both negative PET/CT findings and frozen section results of the SLNs in both hemipelvises, we suggest using both methods to reduce the incidence of unnecessary systematic lymphadenectomy.

Expression of PTEN and β-Catenin and Their Relationship With Clinicopathological and Prognostic Factors in Endometrioid Type Endometrial Cancer.

Objective The aim of this study was to investigate rates of expression of PTEN (phosphatase and tensin homolog deleted on chromosome 10) and &bgr;-catenin and their relationship with clinicopathological and prognostic factors in endometrioid type endometrial cancer (EC). Methods and Materials PTEN and &bgr;-catenin expressions of 59 operated patients with EC between January 2000 and December 2008 and followed-up until December 2014 in Cerrahpasa School of Medicine, Gynecologic Oncology Division, were evaluated retrospectively. Clinical data were obtained from patient files, and pathological data were obtained from pathology records. Each patient had 4 paraffin sections of tumoral tissue. These sections were stained by immunohistochemical methods. Clinical features and postoperative histopathologic findings were analyzed using Fisher exact test or the &khgr;2 test as appropriate. The Kaplan-Meier method was used to generate the survival curves. Results During median follow-up of 102 months, tumor recurrence and disease-related mortality were observed in 10 (16.9%) and 7 (11.9%) cases, respectively. Immunohistochemical staining of PTEN and &bgr;-catenin were positive in 61% and 69.5% of all cases, respectively. Positive staining of PTEN was positively correlated with myometrial invasion (P= 0.02). There was no correlation between &bgr;-catenin and clinicopathological factors. PTEN or &bgr;-catenin positivity were not significant prognostic factors for 5-year overall survival (P = 0.37, P = 0.62, respectively) and 5-year disease-free survival (P = 0.28, P = 0.58, respectively). Conclusions PTEN and &bgr;-catenin expressions cannot be used to determine prognosis in patients with EC as PTEN and &bgr;-catenin staining status were found to have no significant effect on 5-year overall survival and disease-free survival. Positive staining of PTEN may be associated with increased myometrial invasion. Meta-analyses and broader studies are needed to evaluate the prognostic value of PTEN and &bgr;-catenin in EC.

Primary signet ring cell carcinoma of the cervix: A case report and review of the literature.

Highlights • To date, only 18 cases with primary signet cell carcinoma of the cervix has been reported.• Differentiation of primary tumour from metastatic signet cell carcinoma carries significant important while treatment and prognosis differ significantly.

See and treat strategy by LEEP conization in patients with abnormal cervical cytology

OBJECTIVES To determine the overtreatment and re-LEEP rates of see and treat strategy (S & T) in women who underwent S & T by LEEP and to identify the risk factors for overtreatment and surgical margin and/or endocervical curettage positivity. MATERIAL AND METHODS A total of 800 patients who underwent S & T in Istanbul University Cerrahpasa Medical Faculty between June 2010 and June 2016 were retrospectively analyzed. RESULTS Overtreatment rate was found to be 46.6%, decreasing with higher grade of cervical smear abnormalities. Age more than 45, low grade of cervical cytologic abnormality and absence of glandular involvement were associated with higher overtreatment rates. The more advanced the histopathology, the more increased risk of surgical margin on LEEP and ECC positivity (p < 0.0001, for both). Glandular involvement was associated with both surgical margin and ECC positivity. CONCLUSIONS S & T can be used in patients with high grade cytologic anomaly with an acceptable overtreatment rate. In addition, bigger pieces of specimens may need to be removed during LEEP in patients who have suspicious images of higher grade of abnormalities on colposcopy to reduce surgical margin or ECC positivity. When high rate of ECC positivity in patients with HSIL cytology is considered, we suggest performing ECC to every patients with HSIL.

Risk Factors for Recurrence in Low-Risk Endometrial Cancer: A Case-Control Study

Aim: The aim of this study was to investigate the risk factors for recurrence in patients with low-risk endometrial cancer (EC). Patients and Methods: This retrospective study was performed using 10 gynecological oncology department databases. Patients who met the following criteria were included in the study: (a) endometrioid-type histology, (b) histological grade 1 or 2, (c) no or < 50% myometrial invasion, (d) no intraoperative evidence of extrauterine spread, and (e) the patient underwent at least a pelvic lymphadenectomy. Recurrence was detected in 56 patients who were histologically diagnosed with low-risk EC, and these patients made up the case group. A total of 224 patients with low-risk EC without recurrence were selected (control group) using a dependent random sampling method. The case and control groups were match-paired in terms of grade, stage, and operative technique. Results: Lymphovascular space invasion (LVSI) (odds ratio (OR) 5.8, 95% confidence interval (CI) 2.0-16.9; p = 0.001) and primary tumor diameter (PTD) ≥ 20 mm (OR 6.6, 95% CI 2.7-15.8; p < 0.001) were found to be independent risk factors for recurrence in women with low-risk EC. Conclusion: The presence of LVSI and PTD ≥ 20 mm seem to be significant risk factors for recurrence in women with low-risk EC.

YKL-40 in the diagnosis, prediction of prognosis, and platinum sensitivity in serous epithelial ovarian cancer

Objective: To evaluate the use of YKL-40 in the discrimination between benign and malignant adnexal mass and to determine its prognostic value in assessing residual tumor after primary cytoreduction and platinum sensitivity in serous epithelial ovarian carcinoma (EOC). Materials and Methods: During the three years from January 2015 to December 2017, a nonconsecutive series of 100 patient (60 malignant, 40 benign) who underwent surgery for an adnexal mass were enrolled in the study. Preoperatively, serum samples were collected for YKL-40 level analysis. Results: YKL-40 [receiver operator characteristics (ROC)-area under curve (AUC)=0.83] was a significantly better predictor of EOC than cancer antigen-125 (ROC-AUC=0.75). Using a cut-off for YKL-40 of 47.7 ng/mL had a sensitivity of 80% and a specificity of 70%. Higher serum YKL-40 levels were associated with advanced stage, higher grade, residual tumor after primary cytoreduction and recurrence. Platinum-sensitive patients had significantly elevated levels of YKL-40 compared with platinum-resistant or refractory patients. Conclusion: The results obtained from our study support the use of serum YKL-40 for the discrimination between malignant and benign ovarian tumors. YKL-40 levels in patients with serous EOC may also predict disease residual disease after primary cytoreduction and recurrence. Further studies are needed to understand the relationship between YKL-40 and platinum sensitivity.

The use of colposcopic punch biopsy in the management of abnormal cervical cytology: a 5–year retrospective audit

Abstract The aim of this study was to determine the accuracy of colposcopic punch biopsy to detect cervical epithelial neoplasia (CIN) II + in patients with abnormal cervical cytology and the major colposcopic findings in patients who underwent a loop electrosurgical excision procedure (LEEP), subsequently. A total of 231 patients with abnormal cervical cytology who underwent a colposcopy guided cervical biopsy and subsequent LEEP were analysed. The mean age was 33.4 ± 8.7 years. CIN II + rate on LEEP pathology was significantly higher in patients with high-grade cytology, compared to those with a low-grade cytology (92 vs. 55%, p < .0001). CIN II + was found in 80, 98 and 100% of colpocopic biopsies of patients with LSIL, HSIL and AGC, respectively. The overall concordance rate between a colposcopic biopsy and LEEP was 41% with a kappa coefficient. The overall underestimation of CIN II + was 10.5%. On a patient-based analysis, the sensitivity, specificity, PPV and NPV of colposcopic biopsy were 89.4, 47.1, 79.5 and 66%, respectively. More than two cervical biopsies had 100% sensitivity for CIN II + on LEEP pathology. The specificity and PPV decreased with increasing number of cervical biopsies. A see-and-treat strategy may be considered for high-grade cytologies. Patients with a low-grade cytology should be managed with more than two colposcopic biopsies. Impact statement What is already known on this subject? The improper management of women with CIN can increase the risk for cervical cancer. The ability of the colposcopic punch biopsy to detect the severity of a cervical abnormality has been called into question as false negative rates of up to 50% being reported. What do the results of this study add? The overall underestimation of CIN II + was found to be 10.5%. More than two cervical biopsies had 100% sensitivity for CIN II + on LEEP pathology. What are the implications of these findings for clinical practice and/or further research? The see-and-treat strategy is an appropriate choice for patients with a high-grade cytology. Patients with a low-grade cytology should be managed with more than two colposcopic biopsies.