Ofer Gemer

Preoperative CA‐125 level as a predictor of non optimal cytoreduction of advanced epithelial ovarian cancer

Background. Suboptimal cytoreduction of advanced ovarian cancer is related to initial tumor bulk which correlates with CA125 level.

BRCA germline mutations in women with uterine serous carcinoma--still a debate.

Objective: To determine the incidence of BRCA1 and BRCA2 mutations in an enlarged series of uterine serous carcinoma (USC) patients and to determine whether patients with USC are associated with a personal or familial history of breast or ovarian carcinoma. Methods: A cohort of all consecutive patients with diagnosed USC was identified for 9 years. Family pedigrees were drawn as far back and laterally as possible. In all patients, genomic DNA was extracted from peripheral blood samples and analyzed for the 3 mutations common in Ashkenazi Jewish patients. All patients went through total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy. Tubal, ovarian, and peritoneal carcinoma were ruled out clinically and pathologically in all patients. Results: Of 51 consecutive patients with USC in Ashkenazi Jews studied, we identified 13 patients (25.5%) who were previously found to have breast carcinoma, 17 patients (33.3%) who had a first-degree relative with breast or ovarian carcinoma, and 8 patients (15.7%) who were found to be carriers of 1 of the 3 BRCA germline mutations. Conclusions: This series of USC patients, the largest consecutive series to date, suggests a higher incidence of BRCA carriers among Ashkenazi Jews as compared with the general population. This high rate of BRCA germline mutations in USC patients coupled with a high rate of personal and familial cancer histories may suggest that USC is associated with the hereditary breast-ovarian syndrome. This potential association of USC to the BRCA-associated cancer spectrum may have implications for the clinical management and intervention of unaffected BRCA1-2 germline mutation carriers. However, at the current time, there are insufficient data to provide evidence-based guidelines regarding the optimal timing or specific intervention to prevent cancers in these high-risk women.

Prevalence of hydronephrosis in patients with genital prolapse

OBJECTIVE To determine the prevalence of hydronephrosis in patients with genital prolapse and evaluate contributing factors. METHODS Retrospective study of the records of 189 patients with pelvic organ prolapse who underwent preoperative renal imaging studies. RESULTS Of the 189 patients 31 (17.4%) had hydronephrosis; in 20 (10.6%) patients the hydronephrosis was mild, in 7 (3.7%) it was moderate and in 4 (2.7%) it was severe. The patients with hydronephrosis were older (mean age 68+/-9.5 SD vs. 60.5+/-10.8 SD, P<0.001) had a higher creatinine levels (0.84+/-0.4 SD vs. 0.78+/-0.3 SD P<0.005) and had a higher degree of uterine prolapse (mean 2.6+/-0.9 SD vs. 1.1+/-1.2 SD, P<0.005). After adjusting for age and type of prolapse, only patients with uterine prolapse remained significantly more likely to suffer from hydronephrosis (adjusted odds ratio 1.9, 95% CI 1.1, 3.2). CONCLUSION The prevalence of hydronephrosis in patients with genital prolapse is appreciable and is related primarily to degree of uterine prolapse.

Can parametrectomy be avoided in early cervical cancer? An algorithm for the identification of patients at low risk for parametrial involvement

AIMS To assess the rate of parametrial involvement in a large cohort of patients who underwent radical hysterectomy for cervical cancer and to suggest an algorithm for the triage of patients to simple hysterectomy or simple trachelectomy. METHODS Multicenter retrospective study of patients with cervical cancer stage I through IIA who underwent radical hysterectomy and pelvic lymphadenectomy. The patients were divided into 2 groups according to whether or not the parametrium was involved. The two groups were compared with regard to the clinical and histopathological variables. Logistic regression of the variables potentially assessable prior to definitive hysterectomy such as age, tumor size, lymph-vascular space invasion (LVSI) and nodal involvement was performed. RESULTS Five hundred and thirty patients had specific histological data on parametrial involvement and in 58 (10.9%) patients, parametria was involved. Parametrial involvement was significantly associated with older age, tumors larger than 2 cm, deeper invasion, LVSI, involved surgical margins, and the presence of nodal metastasis. By triaging patients with a tumor ≤ 2 cm and no LVSI, the parametrial involvement rate was 1.8% (2/112 patients). With further triage of patients with negative nodes, the rate of parametrial involvement was 0% (0/107 patients). CONCLUSION Using a pre-operative triage algorithm, patients with early small lesions, no LVSI and no nodal involvement may be spared radical surgical procedures and parametrectomy. Further prospective data are urgently needed.

Does salpingectomy affect the ipsilateral ovarian response to gonadotropin during in vitro fertilization-embryo transfer cycles?

In a study on the influence of salpingectomy on the same patient ipsilateral ovarian response, 15 patients who were admitted to our department with the diagnosis of uni- or bilateral hydrosalpinges and who were successfully treated by laparoscopic salpingectomy were evaluated. The observed significant decrease in the ipsilateral ovarian response after salgingectomy, as reflected by the quantity of developing follicles during controlled ovarian hyperstimulation for IVF, should be presented to patients during the decision-making process, before offering salpingectomy for the treatment of hydrosalpinx.

The current clinical presentation of complete molar pregnancy

Abstract Objective: To study the current clinical presentation of complete molar pregnancy. Method: Retrospective study of the clinical and ultrasonographic records of 41 patients with complete hydatidiform mole. Results: 17 (41%) patients were asymptomatic. 24 patients (58%) presented with vaginal bleeding, 6 (15%) had excessive uterine size, 1 (2%) had anemia and 1 (2%) had hyperemesis. Non of the patients had any other systemic manifestation. Pre evacuation ultrasound was performed in all cases and molar pregnancy was diagnosed in 36 (88%). Conclusions: Currently with routine first trimester ultrasonography a significant proportion of patients with molar pregnancy are asymptomatic at the time of diagnosis.

Effect of closure versus nonclosure of peritoneum at cesarean section on adhesions: a prospective randomized study.

OBJECTIVE We sought to determine the effect of nonclosure of the visceral and parietal peritoneum during cesarean section on the formation of adhesions. STUDY DESIGN This was a prospective randomized trial of 533 women undergoing primary cesarean section; in 256 the peritoneum was left open and in 277 it was closed. Fifty women in the nonclosure group and 47 women in the closure group were subsequently evaluated intraoperatively at a repeat cesarean. The presence of adhesions and their severity were evaluated at several sites. RESULTS The nonclosure and closure groups were comparable with regard to the proportion of patients with adhesions at any site (60% vs 51%, respectively; P = .31). Time from incision to delivery was comparable in the nonclosure and closure groups (8.98 ± 4.7 vs 9.32 ± 5.2 minutes, respectively; P = .84). CONCLUSION Closure or nonclosure of the peritoneum at cesarean section did not lead to large differences in the adhesion rate.

Oral contraceptives and liver hemangioma: a case-control study

Objective.  To study whether there is an epidemiological association between liver hemangiomas and oral contraception use, as may be suggested by clinical observations of liver hemangioma growth during pregnancy and under estrogen administration.

A multicenter validation of computerized tomography models as predictors of non- optimal primary cytoreduction of advanced epithelial ovarian cancer.

AIMS To compare the validity of four predictive models of preoperative computerized tomography (CT) scans in predicting suboptimal primary cytoreduction in patients treated for advanced ovarian cancer. PATIENTS AND METHODS Preoperative CT scans of patients with stage III/IV epithelial ovarian cancer who underwent primary cytoreductive surgery at one of four medical centers were reviewed by radiologists blinded to surgical outcome. The validity of each set of CT criteria previously published by Nelson, Bristow, Dowdy, and Qayyum as predictors of suboptimal cytoreduction was assessed. RESULTS Data of 123 patients were evaluated. Optimal cytoreduction (largest diameter of residual tumor < or =1cm) was obtained in 90 (73.2%) patients. All CT models were able to significantly predict surgical outcome (p<0.02). The respective sensitivity, specificity, and accuracy of the CT models to predict sub-optimal cytoreduction was 64%, 64% and 64% for Nelsons criteria, 70%, 64% and 66% for Bristows criteria, 79%, 60%, and 65% for Dowdys criteria, and 67% 57% and 60% for Qayyums criteria. CONCLUSIONS Apart from Dowdys criteria, the accuracy rates of CT predictors of suboptimal cytoreduction in the original cohorts could not be confirmed in this cross validation. This study underscores the difficulty in devising universally applicable selection criteria or models that reliably predict surgical outcome across institutions and surgeons.

Budd-Chiari syndrome complicating severe preeclampsia in a parturient with primary antiphospholipid syndrome

A 27-year-old primipara with severe preeclampsia and primary antiphospholipid syndrome developed right upper quadrant pain, massive ascites, HELLP syndrome, and disseminated intravascular coagulation shortly following vaginal delivery. Computed tomography and color Doppler studies were compatible with complete thrombosis of the right hepatic veins, the Budd-Chiari syndrome. Anticoagulation was initiated, along with supportive measures, and the patient recovered completely. Imaging studies 6 months later were normal. This case demonstrates that nearly fatal forms of venous thrombosis may complicate preeclampsia in women with antiphospholipid syndrome; Doppler studies of the hepatic vein are of value in establishing the diagnosis.