Nikolaos Akrivos

Risk factors in women 40 years of age and younger with endometrial carcinoma

Objective. To identify and compare risk factors among endometrial cancer patients ≤40 years of age, postmenopausal women with the same malignancy and women ≤40 years without malignancy. Design. Retrospective case–control study. Setting. Athens University, department of obstetrics and gynecology of a tertiary hospital serving a mainly urban population. Population. Endometrial cancer patients ≤40 years (study group, n = 40), postmenopausal women with the same malignancy (positive controls, n = 40) and women ≤40 (negative controls, n = 40) without endometrial cancer. Methods. Clinical history, treatment and follow‐up of patients were evaluated. Factors studied included age, histology, stage, grade, lymphovascular space involvement, body mass index (BMI), cytology, lymph node status, parity, smoking, family history, hypertension recurrence and survival. Main outcome measures. Differences in risk factors and characteristics. Results. Nulliparity, smoking and hypertension were significantly related with endometrial cancer in the study group compared to positive controls (p = 0.001, p < 0.01 and p < 0.001, respectively). BMI >30 significantly characterized patients in the study group compared to negative controls (p = 0.006). Finally, irregular menstruation and family history of cancer were observed more often in the study group compared to both control groups. Stage, grade, myometrial invasion, lymphovascular space involvement and lymph node status were comparable between the study and positive control groups. Conclusion. Nulliparity, obesity, unstable menstruation, smoking and cancer in the family are strongly correlated with endometrial cancer risk in women ≤40 years.

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.

Endometrial stromal sarcoma arising from endometriosis of the terminal ileum: The role of immunohistochemistry in the differential diagnosis

Low‐grade endometrial stromal sarcoma (LESS) is an uncommon uterine malignancy. Occasionally, it may develop in extrauterine endometriotic lesions and present morphological characteristics mimicking various neoplasms, making its diagnosis very challenging. We report a rare case of a 56‐year‐old woman presenting with a pelvic mass, initially presumed to be of ovarian origin. After surgical excision the diagnosis of a LESS arising from foci of endometriosis of the terminal ileum was established. Pelvic lymph nodes and omentum were also infiltrated. The patient received adjuvant chemotherapy and medroxyprogesterone; she is alive with no evidence of disease after a follow‐up of 38 months. Immunohistochemical characteristics of the tumor are very important for the differential diagnosis of this rare neoplasm and include diffuse strong positivity for CD 10, estrogen receptor expression and CD 34 negativity.

Survival after secondary cytoreduction for recurrent ovarian cancer: Which are the prognostic factors?

Significant controversy exists concerning the factors affecting survival after secondary cytoreduction (SCR) in recurrent ovarian cancer. This study aims to identify factors independently associated with survival after SCR.

Intraoperative Consultation in Ovarian Pathology

Ovarian specimens are very commonly submitted for intraoperative consultation (frozen section diagnosis) in order to confirm the presence of malignancy, to give the surgeon all the information for the histologic type of the tumor and finally determine the extent of surgery. In most cases, intraoperative consultation regarding ovarian masses accurately determines the type of malignancy. The pathologist and the gynecologist must be aware of the applications, indications and limitations of frozen section. Despite its limitations, frozen section diagnosis represents a sensitive and specific technique that can play a very important role in the management of ovarian disease.

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.

Subserosal uterine injection of blue dye for the identification of the sentinel node in patients with endometrial cancer: a feasibility study

ObjectiveTo define the detection rate, sensitivity, and negative predictive value (NPV) of the sentinel node technique in patients with endometrial cancer.MethodsPatients with endometrial cancer after informed consent underwent subserosal injection of blue dye during hysterectomy in a tertiary gynae/oncology department between 2010 and 2014. The procedure was performed in all cases by the same team including two gynae/oncologist consultants and one trainee. All relevant perioperative clinicopathological characteristics of the population were recorded prospectively. The identified sentinel nodes were removed separately and a completion bilateral pelvic lymphadenectomy followed in all cases. Simple statistics were used to calculate the sensitivity and NPV of the method on per patient basis.ResultsFifty-four patients were included in this study. At least one sentinel node was mapped in 46 patients yielding a detection rate of 85.2%. Bilateral detection of sentinel nodes was accomplished in only 31 patients (57.4%). The mean number of sentinel nodes was 2.6 per patient and the commonest site of identification was the external iliac artery and vein area (66%). Six patients (11%) had a positive lymph node, and in five of them, this was the sentinel one yielding a sensitivity of 83.3% and an NPV of 97.5%. The overall detection rate improved significantly after the first 15 cases; however, this was not the case for the bilateral detection rate.ConclusionOur study is in accordance with previous studies of sentinel node in endometrial cancer and further demonstrates and enhances the confidence in the technique. In the current era of an ongoing debate on whether a systematic lymphadenectomy in patients with endometrial cancer is still necessary, we believe that the sentinel node is an acceptable alternative and should be applied routinely in tertiary centres following a strict algorithm.

Abdominal radical trachelectomy for treatment of deep infiltrating endometriosis of the cervix

Surgical management of deep infiltrating endometriosis can be very challenging even for experienced gynecologists. Radical procedures like bowel resection and nephrectomy have been reported for treatment of the disease. Our aim is to report abdominal radical trachelectomy for treatment of deep infiltrating endometriosis of the cervix causing obstructive uropathy and diminished kidney function. We present a 38‐year‐old woman who was treated in our department for cervical endometriosis involving the vagina and left parametrium. Abdominal radical trachelectomy, insertion of a pig‐tail catheter in the left ureter and end‐to‐end anastomosis of the uterus with the vagina was performed to remove the endometriotic lesion. Cooperation between gynecologists, urologists and nephrologists enabled fertility preservation as well as improvement of renal function. Deep infiltrating endometriosis is a complex disease that requires a multidisciplinary approach. Abdominal radical trachelectomy for cervical lesions seems feasible in this setting and helps preserve fertility.

Amazing pelvic inflammatory disease

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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.