Murat Gultekin

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.

Ascites and epithelial ovarian cancers: a reappraisal with respect to different aspects

Ascites is a common finding in patients with epithelial ovarian cancer (EOC). Clinico-pathologic correlations with respect to the presence of ascites, positive cytology and prognostic role of ascites, and the impact of ascitic volumes were not previously studied extensively. A total of 372 patients with EOC were retrospectively evaluated with respect to presence and amount of ascites, cytologic findings, and survival. Two groups were compared by using Chi-square, Students t and Mann-Whitney U, binary logistic regression, Kaplan Meier and Cox-regression analysis tests, where appropriate. Omental metastasis (P < 0.001; OR: 3.21, 95% CI = 1.945–5.297) and mean number of metastatic lymph nodes (P= 0.008; OR: 1.063, 95% CI = 1.016–1.112) were significantly related with presence of ascites. Evaluation of ascitic volume at different thresholds revealed lymphatic-omental metastasis, and also the disease stage to be significantly different among patient groups at lower threshold values and the positive cytology and high-grade diseases at higher threshold values. In conclusion, presence of ascites correlates with both the intraperitoneal and also the retroperitoneal tumor spread. Amount of ascites has different correlations with the clinico-pathologic factors depending on the thresholds chosen. At lower volumes, lymphatic and omental metastasis seems to correlate with the development of ascites. Once ascites develops, tumor grade seems to be important for larger ascites volumes. Neither the presence of ascites or its volume nor the cytologic positivity was an independent predictor of survival.

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

Posthysterectomy intestinal prolapse after coitus and vaginal repair

IntroductionTransvaginal bowel evisceration following either vaginal or abdominal gynecologic operations is a very rare complication. Furthermore, vaginal cuff rupture with the prolapse of the small bowel through the vagina during sexual intercourse after abdominal hysterectomy in a premenopausal woman is even more rare. However, regardless of the etiology, transvaginal evisceration requires prompt recognition and surgical intervention.Case report Here, we report a premenopausal woman who developed transvaginal bowel evisceration during the first postoperative intercourse.

Endometrial osseous metaplasia: an evolving cause of secondary infertility

OBJECTIVE To present an endometrial osseous metaplasia case and reemphasize that the condition is a cause of secondary infertility. DESIGN Case report. SETTING Department of Obstetrics and Gynecology in a university hospital in Turkey. PATIENT(S) A 33-year-old multiparous woman was admitted to our institution with secondary infertility that had lasted for 2 years. She had experienced one first-trimester and one second-trimester abortion, 3 years and 2 years ago, respectively. On transvaginal sonography, a linear curvy echogenity was observed. INTERVENTION(S) Hysteroscopic examination revealed multiple bony spicules, extending perpendicularly from the posterior uterine wall in to the uterine cavity and occupying almost two thirds of the cavity. Thereafter, a resectoscopic excision of the bony spicules was performed. MAIN OUTCOME MEASURE(S) A normal endometrium and uterine cavity. RESULT(S) Two weeks after the operation, ultrasonographic evaluation was in the normal range, and the patient currently is trying to conceive spontaneously. CONCLUSION(S) Although the role of office hysteroscopy in the evaluation of infertile couple is still under debate, clinicians should keep this rare disorder in mind, especially in patients with a history of late abortion, and should evaluate such cases by hysteroscopy when sonographic features are encountered.

Sentinel lymph node detection in early stage cervical cancer: a prospective study comparing preoperative lymphoscintigraphy, intraoperative gamma probe, and blue dye

ObjectiveThe objective of this prospective study was to determine the feasibility of sentinel lymph node (SLN) detection in patients with cervical cancer using lymphoscintigraphy (LS), gamma probe, and blue dye.MethodsA total of 32 patients with early stage cervical cancer (FIGO IA2-IIA) who were treated with total abdominal hysterectomy and bilateral pelvic and paraortic lymphadenectomy underwent SLN biopsy. LS was performed on all the patients following the injection of 74 MBq technetium-99m-nanocolloid pericervically. The first appearing persistent focal accumulation on either dynamic or static images of LS was considered to be an SLN. Blue dye was injected just prior to surgical incision in 16 patients (50%) at the same locations as the radioactive isotope injection. During the operation, blue-stained node(s) were excised as SLNs. For gamma probe, a lymph node was accepted as an SLN, if its ex vivo radioactive counts were at least 10-fold above background radioactivity. SLNs, which were negative by routine hematoxylin and eosin (H&E) examination, were histopathologically reevaluated for the presence of micrometastases by step sectioning and immunohistochemical staining with pancytokeratin.ResultsAt least one SLN was identified for each patient by gamma probe. Intraoperative gamma probe was the most sensitive method with a technical success rate of SLN detection of 100% (32/32), followed by LS 87.5% (28/32) and blue dye 68.8% (11/16), respectively. The average number of SLNs per patient detected by gamma probe was 2.09 (range 1–5). The localizations of the SLNs were external iliac 47.8%, obturatory 32.8%, common iliac 9%, paraaortic 4.4%, and paracervical 6%. Micrometastases, not detected by routine H&E were found by immunohistochemistry in one patient. On the basis of the histopathological analysis, the negative predictive value for predicting metastases was 100%, and there were no false-negative results.ConclusionsPreoperative LS with radiocolloids, intraoperative lymphatic mapping with blue dye and gamma probe are all feasible methods comparable with each other for SLN detection in early stage cervical cancer patients, but gamma probe is the most useful method in terms of technical success.

Topical testosterone versus clobetasol for vulvar lichen sclerosus.

Objective: To compare the effects of topical testosterone and clobetasol treatments on symptoms remission and recurrence rates in patients with vulvar lichen sclerosus (LS). Methods: A retrospective review of the records showed that, of 140 patients with biopsy‐proven vulvar LS, 80 were treated with applications of testosterone propionate 2% in petrolatum and 60 with clobetasol 17‐propionate 0.05%. Results: The response rates after 6 months were 77.5% for patients treated with testosterone and 91.7% for those treated with clobetasol (P = 0.02). The recurrence rates were 20% and 6.7% in the 2 groups, respectively (P = 0.02). Premenopausal patients had higher remission rates and lower recurrence rates than postmenopausal patients (P > 0.05). Considering whole patients, low remission rates and high recurrence rates were observed in patients who had had a hysterectomy (P > 0.05). Conclusion: Treatment of LS with a corticosteroid provided excellent remission rates. In this study, clobetasol 17‐propionate 0.05% was superior to testosterone for both remission induction and maintenance therapy.

A third evaluation of tertiary cytoreduction

To evaluate the impact of tertiary cytoreductive surgery (TCS) on patient survival and to determine predictors of optimal TCS.

Lymph node metastasis in grossly apparent clinical stage Ia epithelial ovarian cancer: Hacettepe experience and review of literature

BackgroundLymphadenectomy is an integral part of the staging system of epithelial ovarian cancer. However, the extent of lymphadenectomy in the early stages of ovarian cancer is controversial. The objective of this study was to identify the lymph node involvement in unilateral epithelial ovarian cancer apparently confined to the one ovary (clinical stage Ia).MethodsA prospective study of clinical stage I ovarian cancer patients is presented. Patients characteristics and tumor histopathology were the variables evaluated.ResultsThirty three ovarian cancer patients with intact ovarian capsule were evaluated. Intraoperatively, neither of the patients had surface involvement, adhesions, ascites or palpable lymph nodes (supposed to be clinical stage Ia). The mean age of the study group was 55.3 ± 11.8. All patients were surgically staged and have undergone a systematic pelvic and paraaortic lymphadenectomy. Final surgicopathologic reports revealed capsular involvement in seven patients (21.2%), contralateral ovarian involvement in two (6%) and omental metastasis in one (3%) patient. There were two patients (6%) with lymph node involvement. One of the two lymph node metastasis was solely in paraaortic node and the other metastasis was in ipsilateral pelvic lymph node. Ovarian capsule was intact in all of the patients with lymph node involvement and the tumor was grade 3.ConclusionIn clinical stage Ia ovarian cancer patients, there may be a risk of paraaortic and pelvic lymph node metastasis. Further studies with larger sample size are needed for an exact conclusion.

Port-site Metastasis after Laparoscopic Extraperitoneal Paraaortic Lymphadenectomy for Stage IIb Squamous Cell Carcinoma of the Cervix

We report a case of port-site metastasis near the optic trocar site after extraperitoneal laparoscopic lymphadenectomy for cervical carcinoma. A 42-year-old woman with International Federation of Gynecology and Obstetrics clinical stage IIb squamous cell carcinoma of the cervix was evaluated with laparoscopic extraperitoneal paraaortic lymphadenectomy for staging. The aortic nodes were positive. The patient was treated with chemotherapy and radiotherapy. Then brachytherapy was performed. The patient was treated with 6 cycles of weekly topotecan. At month 12, a 4-cm left retroperitoneal mass was detected and excised. Pathologic examination showed an invasive squamous cell carcinoma with tumor-positive margins. Laparoscopic surgery for cancer may result in iatrogenic metastases at the port sites. But all of the port-site recurrence can not be explained by current factors leading to tumor metastases.