Tayup Simsek

Heterotopic triplet pregnancy (twin tubal) in a natural cycle with tubal rupture: Case report and review of the literature

The incidence of heterotopic/ectopic pregnancy has risen in recent years, largely due to more frequent use of ovulatory medicine and increased incidence of pelvic inflammatory disease. In a natural cycle, it is a very rare event. Most heterotopic/ectopic pregnancies are localized in the uterine tube and, usually, it is diagnosed when symptoms develop. We report the case of a 37 year‐old, gravida 2, para 0, abortion 1 woman with no known risk factors for heterotopic pregnancy. The patient attended the emergency department because of acute abdominal pain. She was evaluated in our department and a heterotopic twin pregnancy in the tube was diagnosed by transvaginal sonography. Intrauterine pregnancy with positive fetal cardiac activity at 9 weeks of gestation according to crown‐rump length measurement was detected. Laparotomy was carried out because of acute abdominal syndrome. Right ruptured tubal ectopic/heterotopic pregnancy and hemoperitoneum were diagnosed. Right salpingectomy was carried out. Pathology revealed monochorionic twin tubal pregnancy. In a review of the literature, this is first case of twin tubal pregnancy in one uterine tube. In conclusion, heterotopic pregnancy in twin form in the uterine tube is possible in natural cycles. Intrauterine pregnancy does not exclude extrauterine pregnancy in natural cycles.

Total Laparoscopic Versus Open Radical Hysterectomy in Stage IA2–IB1 Cervical Cancer: Disease Recurrence and Survival Comparison

BACKGROUND Few reports have examined the impact of laparoscopic approach on survival outcomes in patients with early-stage (IA2-IB1) cervical cancer (CC). In this study we aimed to compare disease recurrence and survival outcomes of total laparoscopic radical hysterectomy (TLRH) with those for open radical hysterectomy (ORH) and pelvic lymphadenectomy in patients with early-stage CC. PATIENTS AND METHODS A single-center, retrospective analysis was conducted in a total of 68 patients who treated with TLRH (n=22) or ORH (n=46) between 2007 and 2010. The primary endpoint of the study was progression-free survival (PFS). RESULTS Median follow-up time was 42.50 months (range, 38.40-55.42 months) for the TLRH group and 43.50 months (range, 37.66-52.65) for the ORH group. The study groups were comparable in terms of baseline characteristics except the ORH group had more patients with tumor size greater than 2 cm (P=.026), depth of stromal invasion greater than 33% (P<.0001), and International Federation of Gynecology and Obstetrics stage IB1 disease (P=.019). However, these factors had no impact on overall and PFS in Cox regression analyses. In total, three recurrences were observed in the TLRH group. Two of the 3 patients were alive with no evidence of disease, and the remaining individual was alive with disease (AWD). In the ORH group, 5 patients had recurrences. Two of the 5 patients died of disease, and three were AWD. The estimated 3-year PFS (86.1% versus 90.6%, respectively; P=.32) and overall survival (100% vs. 95.4%, respectively; P=.82) were comparable in the TLRH and ORH groups. CONCLUSIONS TLRH and ORH have similar survival outcomes in patients with early-stage CC.

Analysis of Metastatic Regional Lymph Node Locations and Predictors of Para-aortic Lymph Node Involvement in Endometrial Cancer Patients at Risk for Lymphatic Dissemination.

Objective The aim of this study was to provide detailed knowledge of the metastatic lymph node (LN) locations and to determine factors predicting para-aortic LN metastasis in endometrial cancer patients at risk (intermediate/high) for LN involvement. Methods A prospective case series with planned data collection was conducted in a total of 173 patients who treated with systematic pelvic para-aortic lymphadenectomy up to the renal vessels. All the LNs removed from pelvic and para-aortic basins—low or high according to the level of the inferior mesenteric artery—were evaluated separately. Logistic regression analyses were performed to determine the impact of variables on para-aortic metastasis. Results Lymph node metastasis was observed in 21.9% of the patients, pelvic LN involvement in 17.9%, para-aortic LN involvement in 15.0%, both pelvic and para-aortic LN involvement in 10.9%, and isolated para-aortic LN involvement in 4.0%. The most common metastatic LN locations were the external iliac (50.0%), obturator (50.0%), and low precaval regions (36.8%). The least common location of metastasis was the high precaval region (5.3%). Among patients with para-aortic LN metastasis, 42.3% had metastasis above the inferior mesenteric artery. The number of metastatic pelvic LNs greater than or equal to 2 was the only independent predictor of para-aortic metastasis in multivariate analysis (odds ratio, 23.38; 95% confidence interval, 1.35-403.99; P = 0.030), with 96.94% sensitivity, 95.87% specificity, 98.6% positive predictive value, and 97.0% negative predictive value. Conclusions The current study supports the idea that in patients at risk of LN involvement, the systematic lymphadenectomy should be performed up to the renal vessels due to the high rate of upper level involvement.

The effect of platinum-based combination chemotherapy on the lymph nodes in advanced-stage epithelial ovarian cancer: does it decrease the incidence of lymph node involvement?

This paper aims to determine the impact of platinum-based combination chemotherapy on the lymph nodes in advanced-stage epithelial ovarian carcinoma. From 1997 to 2000, the patients in whom we performed lymphadenectomy before (group A) or after chemotherapy (group B) in the Department of Obstetrics and Gynecology, Akdeniz University School of Medicine were enrolled in this study. A total of 47 cases were included in the study. Twenty five cases had lymphadenectomy during the initial laparatomy and 22 cases during second-look procedures. Lymph node metastasis was detected in 14 (56%) patients in group A and in 10 (45·4%) cases in group B ( P > 0·05). Platinum-based combination chemotherapy does not decrease significantly the incidence of involved lymph nodes in advanced-stage epithelial ovarian carcinoma.

The relationship between hypertension and plasma allantoin, uric acid, xanthine oxidase activity and nitrite, and their predictive capacity in severe preeclampsia

It is controversial that uric acid (UA) levels are related to the severity of hypertension in preeclampsia (PE). Our aim in this study was to determine whether UA, xanthine oxidase activity (XOA), allantoin and nitrite levels are related to arterial blood pressure (BP) in PE. We formed a control group (n = 20) and a PE group (n = 20) for the study. Their BPs and plasma UA, XOA, allantoin and nitrite levels were measured. The values from the control and PE pregnant women were assessed via a Wilcoxon matched-pairs test. A Pearson correlation test was also performed. In addition, the diagnostic value of these tests was evaluated via receiver operating characteristic (ROC) analysis. The BP, UA, XOA and allantoin levels in the PE patients were found to be higher when compared with those of the pregnant controls. The UA, XOA and allantoin levels showed high correlations with BP in cases of PE. However, there was no superiority among the correlations. No differences were observed between the groups in terms of nitrite levels and the relationship between nitrite and BP. UA, XOA and allantoin levels may be high due to placental cell death because of abnormal trophoblastic activity observed in PE. Moreover, the reactive oxygen products that are created during the genetic material degradation may explain how UA, XOA and allantoin levels are related to BP. According to ROC analysis, UA, XOA and allantoin assays are reliable predictors for the determination of PE.

Possible relationship between endocrine disrupting chemicals and hormone dependent gynecologic cancers.

The effects of the natural and synthetic estrogens have been studied for a long time but the data regarding estrogen related chemicals (endocrine disrupting chemicals, EDCs) and their effects on reproductive system are scarce. EDCs are hormone like agents that are readily present in the environment, which may alter the endocrine system of humans and animals. Approximately 800 chemicals are known or suspected to have the potential to function as EDC. Potential role of EDCs on reproductive disease has gained attention in medical literature in recent years. We hypothesize that exposure to low doses of EDCs in a chronic manner could cause hormone dependent genital cancers including ovarian and endometrial cancer. Long term exposure to low concentrations of EDCs may exert potentiation effect with each other and even with endogenous estrogens and could inhibit enzymes responsible for estrogen metabolism. Exposure time to these EDCs is essential as we have seen from Diethylstilbestrol experience. Dose-response curves of EDCs are also unpredictable. Hence mode of action of EDCs are more complex than previously thought. In the light of these controversies lower doses of EDCs in long term exposure is not harmless. Possibility of this relationship and this hypothesis merit further investigation especially through in vivo studies that could better show the realistic environmental exposure. With the confirmation of our hypothesis, possible EDCs could be identified and eliminated from general use as a public health measure.

Survival analysis of pelvic lymphadenectomy alone versus combined pelvic and para-aortic lymphadenectomy in patients exhibiting endometrioid type endometrial cancer

The therapeutic benefit of lymphadenectomy in patients exhibiting endometrial cancer (EC) remains controversial. The aim of the present study was to determine whether the addition of para-aortic lymphadenectomy to pelvic lymphadenectomy (PLND) improves survival in patients with endometrioid type EC. A single tertiary-center, retrospective analysis was conducted in a total of 186 patients who were surgically treated with either PLND alone (n=97) or combined pelvic and para-aortic lymphadenectomy (PPaLND; n=89). Adjuvant treatments were assigned according to the Gynecologic Oncology Group (GOG) risk of recurrence analysis. The primary endpoint of the present study was progression-free survival (PFS). The median follow-up time was 38 months (95% confidence interval, 36.47–42.90) for all patients. No statistically significant differences were identified between the two groups in terms of overall survival (OS), PFS or time to progression (TTP). Kaplan-Meier estimates of three-year OS, PFS and TTP for patients with low or low-intermediate risk were as follows: PLND, 100, 98.7 and 98.7%, respectively; and PPaLND, all 100%. The estimated three-year OS, PFS and TTP for patients with high or high-intermediate risk were as follows: PLND, 92.3, 81.3 and 81.3%; and PPaLND, 90.7, 77.1 and 80.9%, respectively. No statistically significant differences were detected in the three-year OS, PFS and TTP between the lymphadenectomy groups, regardless of the GOG risk of recurrence (PLND, 98.4, 95.3 and 95.3%; and PPaLND, 94.9, 87.1 and 89.4%). Therefore, the combination treatment, PPaLND did not provide any survival advantage over pelvic lymphadenectomy alone.

Detection of precancerous cervical conditions using elastic light single-scattering spectroscopy

We have investigated the potential application of elastic light single-scattering spectroscopy (ELSSS) as an adjunctive tool for screening of cervical precancerous lesions non-invasively and in real time. Ex-vivo measurements were performed on 95 cervix biopsy tissue of 60 patients. Normal cervix tissue from 10 patients after hysterectomy was used as a control group. Correlation between ELSSS spectra and histopathology results were investigated. It was found that the spectral slope was positive for all the spectra taken on normal cervix tissue samples from the control group. We assumed that if there is only one spectrum with a negative spectral slope among the all spectra taken on a biopsy specimen, the biopsy specimen is pathologically abnormal. This shows that pap smear and ELSSS results are in good agreement. Most biopsy tissue samples had both positive and negative spectral slopes. Therefore, we calculated the percentage of negative spectral slopes and hypothesized that this was correlated to dysplastic percentage of the epithelial tissue of the biopsy material. The ROC curve was calculated using the dysplastic percentage and high squamous intraepithelial lesion (HSIL) and low squamous intraepitherlial lesions (LSIL) biopsy specimens were differentiated from non HSIL and LSIL with a sensitivity and specificity of 70.4% and 66.7% respectively, with p < 0.05.

Diagnosis abnormal cervical tissue by elastic light scattering spectroscopy and correlation with the results of Pap-smear examination

We have investigated the potential application of elastic light single-scattering spectroscopy in detection of cervical precancerous lesions non-invasively and in real time. Ex-vivo spectroscopic measurements were performed on 95 cervix biopsy tissue of 60 patients. Normal cervix tissue from 10 patients after hysterectomy was used as a control group. It was found that the spectral slope was positive and negative for the spectra taken on normal cervix and precancerous cervix tissue respectively. Sign of the spectral slopes were used as a parameter to differentiate normal cervix tissue from dysplastic cervix tissue. Elastic light single-scattering spectroscopy measurements in defining cervical tissue were 100% consistent with Pap-smear results.

A study detection of the ROS1 gene fusion by FISH and ROS1 protein expression by IHC methods in patients with ovarian malignant or borderline serous tumors

OBJECTIVE ROS1 is an orphan receptor protein tyrosine kinase which is supposed to undergo genetic rearrangement in carcinogenesis. In the current study, we aimed to investigate the frequency and clinicopathologic features associated with ROS1 gene fusion and ROS1 protein expression in patients with ovarian serous carcinoma or serous borderline tumors. MATERIALS AND METHODS Tissue samples of 102 patients with high or low grade serous carcinoma and borderline serous tumors were selected randomly from the archives of Department of Gyneco-pathology, and analyzed for ROS1 gene expression. (Fluorescence in situ hybridization (FISH) method was used to assess ROS1 gene rearrangement, while ROS1 protein expression was analyzed using immunohistochemistry. RESULTS The study consisted of 94 cases of high-grade serous carcinoma (92.1%), 2 cases of low-grade serous carcinoma (%2) and 6 cases of serous borderline tumor (5.9%). ROS1 gene rearrangement analysis revealed that 4 patients (3.9%) were FISH-positive; whereas the immunohistochemical analysis yielded only 1 patient (0.9%) exhibiting faint positive expression of ROS1 protein. Given the low incidences of ROS1 gene rearrangement and protein expression, their relationships with clinicopathologic parameters could not be statistically analyzed. CONCLUSION Although rare, patients with ovarian serous carcinoma or serous borderline tumor may exhibit ROS1 gene rearrangement and ROS1 protein expression. Further large-scale studies are necessary to explore the clinicopathologic significance of ROS1 gene expression in ovarian serous carcinoma.