Nuri Peker

Chylous ascites following retroperitoneal lymphadenectomy in gynecologic malignancies: Incidence, risk factors and management

INTRODUCTION Chylous ascites is a rare form of ascites that results from accumulated lymph fluid in the peritoneal cavity caused by blocked or disrupted lymph flow through the major lymphatic channels. In the present study, our aim was to analyze the incidence, risk factors, diagnostic evaluation and management of chylous ascites after lymphadenectomy in gynecologic malignancies. METHODS A total of 458 patients who had undergone staging surgery for gynecologic malignancies at our institution between January 2010 and December 2013 were retrospectively reviewed. After the exclusion criteria were applied, 399 patients were divided into 2 groups based on the presence (n = 36) or absence (n = 363) of chylous ascites. RESULTS Among the 399 patients, 36 (9%) developed chylous ascites. The median time to onset was 4 days (range, 2-7 days). The analysis of the various features of lymphadenectomy showed that the number of para-aortic lymph nodes (PALNs) removed was significantly greater in the patients with chylous ascites (p < 0.001). A cut-off value of >14 PALNs was a good predictor of chylous ascites. In all patients, chylous ascites resolved with conservative management. CONCLUSIONS Postoperative chylous ascites was strongly associated with the number of harvested PALNs. According to our findings, we suggest that conservative treatment should be the first step in managing patients with chylous ascites. Using an abdominal drain after surgery seems to be an effective diagnostic tool and treatment method for chylous ascites.

Analysis of clinical and pathological characteristics, treatment methods, survival, and prognosis of uterine papillary serous carcinoma.

Purpose Uterine papillary serous carcinoma (UPSC) is an atypical variant of endometrial carcinoma with a poor prognosis. It is commonly associated with an increased risk of extrauterine disease. The aim of this study was to investigate clinical and pathological characteristics, therapeutic methods, and prognostic factors in women with UPSC. Methods All patients who underwent surgery for UPSC at a single high-volume cancer center between January 1995 and December 2010 were retrospectively reviewed. Patients who did not undergo surgical staging and those with mixed tumor histology were excluded. Univariate and multivariate regression models were used to identify the risk factors for overall survival (OS) and progression-free survival (PFS). Results A total of 46 patients were included, the majority of whom having stage I disease (IA, 13 [28.2%] and IB, 12 [26.7%]). Stages II, III, and IV were identified in 5 (10.9%), 8 (17.4%), and 8 (17.4%) women, respectively. Optimal cytoreduction was obtained in 67.3% of patients. Recurrences developed in 8 (17.4%) patients. Multivariate analysis confirmed that lymphovascular space invasion (LVSI) (odds ratio [OR] 26.83, p = 0.003) was the only independent prognostic factor for OS, whereas LVSI and optimal cytoreduction were found to be independent prognostic factors for PFS (OR 6.91, p = 0.013 and OR 2.69, p = 0.037, respectively). The 5-year overall survival rate was 63%. Conclusions Our study demonstrated that LVSI is the only independent prognostic factor for OS, whereas LVSI and optimal cytoreduction are independent prognostic factors for PFS in patients with UPSC

Evaluation of Factors Affecting Lymph Node Metastasis in Clinical Stage I-II Epithelial Ovarian Cancer

Background: Systematic lymphadenectomy is useful for accurate staging of early-stage ovarian cancer and has obvious prognostic value. Accurate staging may prevent unnecessary postoperative chemotherapy. The aim of this study was to evaluate the rate of lymph node involvement and factors affecting it in clinically early-stage epithelial ovarian cancer (EOC; stages I, II). Patients and Methods: The study included 163 patients who underwent surgery at our hospital between January 2004 and April 2017 and who were diagnosed with early-stage EOC based on preoperative and intraoperative examination. Patient data were retrospectively analyzed. The rate of lymph node involvement and factors affecting it were analyzed. Results: Of 163 patients, 21 (12.9%) had lymph node metastasis, whereas 16 (16.3%) of 98 patients who underwent comprehensive lymphadenectomy had lymph node metastasis. According to the univariate results for patients undergoing any type of lymphadenectomy, the rate of positive lymph nodes was significantly higher (37.1%) in those with bilateral ovarian involvement (p < 0.001). The rate was significantly higher in patients with positive intraabdominal fluid cytology (25.9%; p < 0.001), serous histology (20.5%; p = 0.02), and grade 3 disease (33.3%; p < 0.001). In multivariate logistic regression analysis, the rate was significantly higher in patients with bilateral adnexal involvement (p = 0.012). The risk of positive lymph nodes was significantly higher in patients with grade 3 disease (p = 0.016). Conclusion: Comprehensive lymphadenectomy increases the detection rate for metastatic lymph nodes in patients with clinically early-stage EOC. The rate of lymph node involvement is significantly higher in grade 3 tumors, serous cytology, bilateral adnexal involvement, and positive intraabdominal fluid cytology.

Can concurrent high-risk endometrial carcinoma occur with atypical endometrial hyperplasia?

BACKGROUND This study investigated the frequency of high-risk cancer types in hysterectomy material obtained from patients who were diagnosed with atypical endometrial hyperplasia (AEH) by endometrial sampling. MATERIALS AND METHODS A total of 227 patients with AEH were retrospectively included in the study. Hysterectomy material was examined as both perioperative frozen section (FS) and paraffin-embedded permanent section (PS). Grade III tumors, grade II tumors larger than 2 cm, over 50% myometrial invasion, cervical involvement, and serous or clear cell histology were considered high-risk. RESULTS In final pathology, 57 (25.1%) patients had endometrial cancer and 7 (3%) patients had high-risk cancer. Overall analysis of FS/PS agreement yielded a Cohens Kappa (K) coefficient of 0.420 (moderate agreement). There was moderate (K = 0.526) agreement between FS and PS in detecting tumor grade, and good agreement (K = 0.653) in evaluation of myometrial invasion. CONCLUSION High-risk endometrial cancer can coexist with AEH. It should be remembered that despite preoperative and FS examinations, these high-risk tumors can be overlooked until final pathology.

Spontaneous rupture of a splenic artery aneurysm during the third trimester of pregnancy

Abstract Spontaneous rupture of a splenic artery aneurysm (SAA) during pregnancy is a rare but life-threatening situation typically presenting with sudden and unexpected fetal and maternal death. The etiology is unclear; however, there is a strong association between pregnancy and the rupture of a SAA. Maternal and fetal prognosis is poor and mortality rates remain at 70% and 90%, respectively. Here, we present a case report of the spontaneous rupture of a SAA at the 35th week of gestation, which presented as suddenly developed hypovolemic shock ending in fetal and maternal death.

Pelvic tuberculosis mimicking ovarian cancer: a series of 13 cases

Introduction: In this study, we aimed to investigate the incidence of pelvic tuberculosis mimicking ovarian cancer. Material and methods: The data of a total of 13 patients diagnosed with peritoneal or genital tuberculosis in the gynecologic oncology unit between January 1, 2004 and January 1, 2016 were retrospectively analyzed. Results: The mean age of the patients was 39.4 ±14.1 (range: 22–67) years. The mean parity number was 1.69 ±1.1 (range: 0–5) and mean body mass index was 23.3 ±4.1 (range: 18–43) kg/m2. The mean cancer antigen 125 (CA125) level was 473 ±394 (range: 22–1153) U/ml. The most common complaints were abdominal pain (n = 3) and bloating (n = 9). The most common ultrasonographic findings were diffuse ascites and adnexal mass. No signs of malignancy were found in 6 patients who underwent paracentesis and in 5 patients who underwent endoscopy preoperatively. Six patients underwent laparoscopic surgery, whereas 7 patients underwent laparotomy by subumbilical medial incision. Findings in abdominal examination included diffuse adhesions (13/13), diffuse ascites (11/13), pelvic mass (10/13), and diffuse nodular formations (11/13). Conclusions: In tuberculosis-endemic regions, peritoneal tuberculosis should be considered in the differential diagnosis of malignant adnexal masses. Although various tests are helpful, histopathological and bacterial examination of tissue samples is of utmost importance for establishing a definitive diagnosis.

Uterine Rupture with Misoprostol at 19 Week of Gestation

İletişim Bilgisi / Correspondence Uzm.Dr. Nuri Peker , Acibadem Üniversitesi Tıp Fakültesi Atakent Hastanesi Kadın Hastalıkları ve Doğum Anabilim Dalı, İstanbul Türkiye E-mail: dr.ata1980@hotmail.com Geliş tarihi / Received: 01.02.2016 Kabul tarihi / Accepted: 07.06.2016 Çıkar Çatışması / Conflict of Interest: Yok / None 29 Uterine Rupture with Misoprostol at 19 Week of Gestation Ondokuz Hafta Gebelikte Misoprostol Kullanımına Bağlı Uterus Rüptürü Nuri Peker1, Ahmet Demir2

Prenatal radiation exposure

Pregnant women may be exposed to nonionizing, ionizing radiation and contrast media via diagnostic or therapeutic procedures and workplace exposure. When computed tomography or magnetic resonance imaging is performed on a pregnant woman, the effects of exposure to radiation, high magnetic fields and contrast media, which can be risky for a fetus, should be considered. Nonionizing radiation that is not significantly risky for a fetus includes microwave, ultrasound, radio frequency and electromagnetic waves, while ionizing radiation that can be teratogenic, carcinogenic or mutagenic includes particles and electromagnetic radiation. The effects of radiation are associated with the level of exposure and stage of fetal development. Organogenesis (two to seven weeks after conception) and the early fetal period (eight to fifteen weeks after conception) are the most sensitive stages for a fetus. Noncancerous health effects have not been determined at any stage of gestation with less than 50 mGy (5 rad) exposure dose of ionizing radiation. Higher exposure levels may lead to spontaneous abortion, growth restriction, and mental retardation. The risk of cancer is increased regardless of the dose. Although the use of iodinated contrast media is generally thought to be safe during pregnancy, the risk of fetal hypothyroidism should be considered and it should be used only when necessary. The use of gadolinium-based contrast media during pregnancy is controversial because of the lack of clinical data. The purpose of this article is to review the existing literature regarding the prenatal radiation exposure and to discuss fetal risk of radiation.

Endometrioma mimicking ovarian cancer with unusual high levels of serum CA 125 and Ca 19-9

Abstract A 35 year-old nulliparous woman was referred to our clinic with left ovarian mass (6x7 cm in size) accompanied by excessive free fluid at pouch of Douglas and elevated levels of serum CA 125 and CA 19-9 as 1061 IU/mL and 896 IU/mL, respectively. Laparotomy was performed with the suspect of ovarian cancer. Left ovarian endometrioma adherent to the sigmoid colon was observed and enuclated. Histopathological examination confirmed the diagnosis of endometrioma. Adnexal mass with free peritoneal fluid and high levels of tumor antigens; CA 125 and CA 19-9 mimicking ovarian cancer has been rarely diagnosed as endometrioma. Keywords: CA 125, CA 19-9, endometriosis Ozet Otuz bes yasinda, nullipar bir kadin adneksial kitle nedeni ile klinigimize sevk edildi. Douglas boslugunda belirgin sivi birikimi ve yuksek CA 125 (1061 IU/mL) ve CA 19-9 (896 IU/mL) seviyeleri ile birlikte 6x7 cm boyutlarinda sol over kitlesi vardi. Over kanseri on tanisi ile laparotomi yapildi. Sol yumurtalikta sigmoid kolona yapisik endometrioma bulundu ve cikartildi. Histopatolojik inceleme endometrioma tanisini dogruladi. Asit ve yuksek CA 125 ve CA 19-9 duzeyleri ile birlikte olan yumurtalik kanserini taklit eden endometrioma nadir saptanan bir durumdur. Anahtar sozcukler: CA 125, CA 19-9, endometrioma