Mehmet Coskun Salman

Prognostic factors in adult granulosa cell tumors of the ovary: a retrospective analysis of 80 cases

OBJECTIVE Ovarian granulosa cell tumors are rare malignancies with a relatively favorable prognosis. However, patients still suffer from disease-related mortality. Therefore, the prognostic factors should be clarified. The purpose of this study was to investigate the clinical and pathologic characteristics related with disease recurrence and mortality in adult type ovarian granulosa cell tumors. METHODS Eighty surgically staged patients with granulosa cell ovarian tumor treated at the Hacettepe University Hospital between 1982 and 2006 were retrospectively reviewed. Clinical and pathological characteristics were analyzed. RESULTS Granulosa cell ovarian tumors accounted for 4.3% of malignant ovarian neoplasms. Mean age was 47.6 years. The most common presenting symptom was abnormal uterine bleeding (53.7%). Endometrial pathology was detected in 51.2% of patients preoperatively. Seventy percent of patients were diagnosed at stage I, and 53.8% of patients received adjuvant treatment. Mean follow-up was 67.5 months. Overall 5-year and 10-year survival was 91% and 86%, respectively. Mean survival was 147.1 months. Recurrence rate was 11.2%. In univariate analysis, advanced stage, advanced age, residual disease after surgery, and need for adjuvant treatment were associated with disease-related mortality and advanced stage disease and absence of initial staging surgery were associated with disease recurrence. However, in multivariate analysis, only initial stage was found to be a significant prognostic factor. CONCLUSION Initial stage seems to be the single most important prognostic factor in ovarian granulosa cell tumors. Therefore, a comprehensive staging surgery should be attempted to document the real extent of disease and to estimate the oncologic outcome more accurately.

Association between fertility drugs and gynecologic cancers, breast cancer, and childhood cancers

Ovulation‐inducing drugs have been widely used for various types of infertility since the beginning of 1960s and their use increases day by day parallel to the success achieved in fertility treatment. However, the researches performed in the last two decades have begun to discuss about the safety of these drugs and the risks associated with their use. Especially, the potential neoplastic effects of these drugs are increasingly questioned. The studies have discussed whether there is an association between the exposure to ovulation‐inducing drugs and the incidence of various cancers. Moreover, several studies have been performed to reveal whether there is an increased risk of childhood cancers in children conceived after fertility treatment. The point we reached through the available data is that the risk of breast, uterine and invasive ovarian cancers is not increased, but the risk of borderline ovarian tumors might increase after such a therapy. The risk of cancer has been found similar for children conceived after fertility treatment and those conceived naturally. It should also be kept in mind that cancers are overdiagnosed in infertile women population because of the close medical surveillance, which may also contribute to the early detection of cancers. Although it is still early to state the last words on this topic, the possible association should be addressed when obtaining an informed consent before starting treatment.

Comparison of WHO and endometrial intraepithelial neoplasia classifications in predicting the presence of coexistent malignancy in endometrial hyperplasia

OBJECTIVE The most commonly used classification system for endometrial hyperplasia is the World Health Organization system which is based on subjective criteria. Another classification system is endometrial intraepithelial neoplasia (EIN) system which uses diagnostic criteria including cytological demarcation, crowded gland architecture, minimum size of 1 mm, and careful exclusion of mimics, and aims to identify a precancer or cancer. The objective of this study was to compare the two classification systems in terms of predicting the presence of a coexistent cancer in surgically treated patients. METHODS Biopsy and hysterectomy specimens of 49 women who were subjected to surgery with a preoperative diagnosis of endometrial hyperplasia (EH) according to the WHO system were re-evaluated retrospectively by using EIN system. RESULTS Among the 49 patients, 69.4% had complex atypical EH and 75.5% had EIN at biopsy specimens. EIN was detected in 94.1% of complex atypical EH, and 41.7% of non-atypical EH. Nine women (18.4%) had endometrial cancer. Among women with cancer, all had complex atypical EH or EIN. The rate of coexistent endometrial cancer was 26.5% in women with complex atypical EH and 24.3% in women with EIN. CONCLUSION Diagnoses of atypical or complex atypical EH and EIN had similar sensitivities and negative predictive values in predicting the coexistent endometrial cancer. Either of these two classification systems may be used safely when an experienced pathologist is available. However, use of the objective EIN system may be preferred whenever possible to prevent diagnostic errors in centers where an experienced pathologist is not available.

Routine appendectomy in epithelial ovarian carcinoma : Is it necessary?

OBJECTIVE: To detect risk factors for the appendiceal metastasis and to define the role of routine appendectomy in patients with epithelial ovarian carcinoma. METHODS: A total of 285 patients with epithelial ovarian carcinoma who had undergone primary cytoreductive surgery including appendectomy were retrospectively evaluated. Appendiceal involvement was divided into 2 groups: gross and microscopic. Clinicopathologic variables were evaluated for possible significance in terms of appendiceal metastasis. A second analysis was performed using the same variables to detect a possible relation with microscopic metastasis. In a subgroup analysis, we also analyzed the role of routine appendectomy in patients with clinically early stage disease. RESULTS: One-hundred six patients were found to have appendiceal metastasis (37%). Univariate and multivariate analysis revealed stage of disease as the unique factor determining the appendiceal metastasis (P < .001). Five patients with apparently stage I-II disease were upstaged due to isolated appendiceal metastasis (4.9%). In the second analysis excluding the patients with gross involvement, ascites was an independent predictor of microscopic involvement (P < .01). CONCLUSION: Routine appendectomy is indicated in all epithelial ovarian carcinoma patients as part of the initial surgical staging procedure because of a considerable rate of upstaging in early stage disease and optimal cytoreduction in advanced stages. LEVEL OF EVIDENCE: II-3

Surgical outcome of transobturator tape procedure in obese and non-obese women

The objective of this study was to assess the impact of body mass index (BMI) on transobturator tape (TOT) success rates, patient acceptability and complications 1 year following surgery. The medical records of stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) patients who underwent the TOT operation were retrospectively reviewed. The patients were divided into non-obese (BMI < 25) and obese (BMI ≥ 30) groups. Baseline and 1 year post-surgical outcomes were assessed by including multichannel urodynamics, Urogenital Distress Inventory (UDI-6) scores, Incontinence Impact Questionnaire (IIQ-7) scores and cure, failure and success rates. There were no significant differences between groups in terms of urodynamic parameters, objective cure rate and subjective success, quality of life scores, or postoperative complications. Both obese and non-obese patients had cure and/or improvement of their symptoms and had better quality-of-life in the postoperative period. As a conclusion, BMI does not affect the clinical effectiveness of TOT operation in the treatment of female SUI or MUI.

Multimodal interventions (chewing gum, early oral hydration and early mobilisation) on the intestinal motility following abdominal gynaecologic surgery

AIMS AND OBJECTIVES To determine the effects of chewing gum, early oral hydration and early mobilisation on the time of first bowel sounds, first passage of flatus and first defecation following abdominal gynaecologic surgery. BACKGROUND A major complication of abdominal surgical procedures is paralytic ileus which results in patient discomfort, prolonged length of hospital stay and increased cost of treatment. DESIGN Prospective randomised case-control study. METHODS Women who underwent abdominal gynaecological surgery for benign disorders under general anaesthesia were randomised into eight groups according to different combinations of interventions consisting of chewing gum, early oral hydration and early mobilisation. The effects of these interventions on the time of first bowel sounds, first passage of flatus and first defecation following abdominal gynaecologic surgery were investigated. The data were analysed using chi-square tests, t-test for independent samples, Tukeys HSD test, pairwise comparison test, one-way analysis of variance. RESULTS It was found that the time when bowel sounds were heard was shorter, the time first passage of flatus was shorter and first defecation occurred earlier in the 1st group of women who chew gum, were hydrated orally and were mobilised early after surgery than the other groups. It was also determined that these periods were longest in the women who did not receive any intervention and received the routine hospital care when compared with other groups. Duration of hospital stay was shorter in the women who chew gum, were hydrated orally and were mobilised early than the other groups. CONCLUSIONS Early oral feeding, early mobilisation and chewing gum are effective methods in terms of preventing paralytic ileus following abdominal gynaecological surgery, improving patient comfort and shortening the duration of hospitalisation. RELEVANCE TO CLINICAL PRACTICE Nurses may cause early recovery, improve the patient comfort, prevent paralytic ileus and shorten the duration of hospitalisation after gynaecologic abdominal surgery by recommending gum chewing, early mobilisation and early hydration.

Aggressive angiomyxoma of vulva recurring 8 years after initial diagnosis

BackgroundAggressive angiomyxoma is an uncommon soft tissue tumor which preferentially involves pelvic and vulvoperineal regions of young adult females. The typical characteristics include gelatinous appearance and locally infiltrative nature without evidence of nuclear atypia or mitosis. Treatment involves surgery, but local recurrence is high in spite of apparently complete surgical resection.CaseA 28-year-old woman who had had a history of surgically excised aggressive angiomyxoma of vulva presented with a complaint of vulvar mass. The mass was removed and histopathologic examination revealed an aggressive angiomyxoma without necrosis, atypia, and mitosis.ConclusionAggressive angiomyxoma should be kept in mind when an asymptomatic and slow-growing vulvar mass is detected in young females. The surgery should aim wide local excision and long-term follow-up is necessary due to high rate of local recurrence.

Obesity does not affect the number of retrieved lymph nodes and the rate of intraoperative complications in gynecologic cancers.

OBJECTIVE Lymphadenectomy, in general, is a safe and well-tolerated procedure in gynecologic oncology. However, some technical difficulties may be experienced in obese women which may result in inadequate lymphadenectomy and increased complications. The purpose of this study is to retrospectively evaluate the effect of obesity on lymph node counts retrieved and complication rates observed during lymphadenectomy in gynecologic cancers. METHODS Patients with ovarian, endometrial or cervical cancers treated with initial surgery including bilateral pelvic and paraaortic lymph node dissection were grouped as non-obese and obese. These two groups were compared in terms of the number of retrieved lymph nodes and the rate of intraoperative complications directly related to lymph node dissection. RESULTS One hundred twenty-three patients were eligible with a mean age of 55.1 years and mean body mass index of 29.2 kg/m(2). Fifty-nine patients were obese while 64 were non-obese. Lymph node counts obtained in different stations and in total were similar among non-obese and obese patients. Rates of lymphadenectomy-related intraoperative complications including vascular, neural, intestinal, and bladder injury were also similar in non-obese and obese patients. CONCLUSION The obesity does not affect the lymph node counts and intraoperative complication rates adversely in women with gynecologic cancers. Therefore, adequate lymph node dissection should not be omitted based solely upon obesity in gynecologic oncology patients.

Role of postmenopausal bleeding pattern and women's age in the prediction of endometrial cancer

Women with postmenopausal bleeding should be evaluated efficiently to exclude endometrial carcinoma.

Bilateral actinomyces abscesses mimicking pelvic malignancy

Pelvic actinomycosis is a rare disease caused by Actinomyces israelii [1]. Patients typically present with weakness, weight loss, and pain associated with a unilateral mass [2]. Diagnosis is difficult without surgery and histopathologic examination [2,3]. A 44-year-old woman presented with a 3-month history of lower abdominal pain, nausea, vomiting, weakness, and a 16-kg weight loss. An intrauterine device (IUD) that she had kept for 8 years had been removed 3 months previously. An abdominopelvic examination revealed bilateral adnexal masses. Her hemoglobin level was 10.7 g/dL and white blood cell count 17,200/mm. Her body temperature, blood biochemistry, tumor markers,