Thomas Papathemelis

Visualization of polypropylene and polyvinylidene fluoride slings in perineal ultrasound and correlation with clinical outcome.

Introduction and Hypothesis. Complications and malfunctioning after TOT can occur due to several factors, such as the material of the sling. The aim of the present study is to evaluate morphology and functionality of two types of slings (PVDF; polypropylene) in vivo using perineal ultrasound (PUS). Materials. In n = 47 women with TOT four criteria for PUS were taken and checked for possible differences: vertical stability of the sling position during Valsalva manoeuvre and contraction; distance “sling to urethra”; width of the sling and condition of the selvedges. Results. We observed an increased vertical displacement of the PP-slings, a significantly smaller variance to the extent of the displacement in PVDF-slings (P < 0.01), a significantly larger distance between sling and urethra (P < 0.001) in PVDF-slings, and a significantly smaller width of the PP-slings (P < 0.0001). Conclusion. Significant differences were found between the slings according to the four criteria. There was no difference established between the slings in the improvement of continence and no significant influence of the parameters was found for the resulting state of continence. In future studies, PUS may help to link differences in the morphology and functionality of in vivo slings to their material properties.

Laparoskopie in der gynäkologischen Onkologie

ZusammenfassungHintergrundGynäkologische Malignome werden zunehmend laparoskopisch operiert.Ziel der ArbeitDer vorliegende Beitrag gibt Antworten zu folgenden Fragen: Bei welcher Indikation in der gynäkologischen Onkologie kann laparoskopisch operiert werden? Ist eine der offenen Chirurgie vergleichbare Sicherheit gegeben?Material und MethodeEs erfolgte eine Auswertung der Literatur unter besonderer Berücksichtigung prospektiver randomisierter Studien. Der vorliegende Beitrag fasst die wesentlichen Publikationen endoskopischer Operationsverfahren beim Endometrium-, Zervix- und Ovarialkarzinom sowie der Borderline-Tumoren des Ovars zusammen.ErgebnisseDie operative Therapie von Frühstadien des Endometrium- und Zervixkarzinoms, einschließlich der pelvinen und paraaortalen Lymphonodektomie, kann laparoskopisch durchgeführt werden. Die bisherige Datenlage lässt auf eine der Laparotomie vergleichbare onkologische Sicherheit schließen. Für das Zervixkarzinom wird beim lokal fortgeschrittenen Tumor ein endoskopisches operatives Staging zur Bestimmung einer intraperitonealen Ausbreitung und des paraaortalen Lymphknotenstatus zunehmend häufiger durchgeführt. Für Frühstadien des Ovarialkarzinoms wird aufgrund einer umfassenderen Evaluationsmöglichkeit die offene Operation empfohlen, zumal keine randomisierte Studie zum Vergleich von Laparoskopie und Laparotomie existiert. Einen wichtigen Stellenwert hat die Laparoskopie zur Diagnostik bei unklaren ovariellen Befunden sowie bei der Fokussuche im Fall eines „Cancer-of-unknown-primary“(CUP)-Syndroms und zur Gewebeentnahme vor einer neoadjuvanten Therapie. Einen festen Platz besitzt die Laparoskopie bei der Operation ovarieller Borderline-Tumoren.SchlussfolgerungenFrühstadien des Endometrium- und des Zervixkarzinoms sowie Borderline-Tumoren des Ovars können laparoskopisch sicher operiert werden. Alle invasiven Ovarialkarzinome sollen offen operiert werden. Bei fortgeschrittenen Stadien gynäkologischer Malignome wird die Laparoskopie zur Diagnostik eingesetzt, insbesondere beim Zervixkarzinom zur Evaluation des paraortalen Lymphknotenstatus und beim Ovarialkarzinom zur Gewebeentnahme vor einer geplanten neoadjuvanten Therapie.AbstractBackgroundLaparoscopy is increasingly being used for operative treatment of gynecological malignancies.AimThis article supplies answers to the following questions: what are the indications in gynecological oncology for laparoscopic operations? Does one of the open surgical procedures offer comparable oncological safety?Material and methodsAn analysis of the literature was carried out with respect to prospective randomized trials. This article summarizes the important publications on endoscopic operative procedures for endometrial, cervical and ovarian cancer as well as borderline ovarian tumors.ResultsOperative treatment of early stage endometrial and cervical cancer can be carried out using laparoscopy, including pelvic and para-aortic lymphadenectomy. The current data suggest that there is comparable oncological safety between laparoscopy and laparotomy. Surgical staging can be used to assess the retroperitoneal para-aortic lymph node status before chemoradiation of locally advanced cervical cancer. Operative treatment of early stage ovarian cancer should be carried out via midline incision laparotomy because of a superior evaluation of the bowels, retroperitoneum and upper abdomen. Laparoscopy plays an important role in the diagnostics of cancer of unknown primary (CUP) syndrome and to acquire tissue biopsies before neoadjuvant chemotherapy. Borderline ovarian tumors can be treated laparoscopically without impairing patient prognosis.ConclusionsLaparoscopy of early stage endometrial and cervical cancer and borderline ovarian tumors can be performed with oncological safety and comparable prognosis to open surgery. Invasive ovarian cancer should be treated via open surgery. In cases of advanced stage gynecological malignancies laparoscopy provides a diagnostic tool facilitating the assessment of the para-aortic lymph node status before chemoradiation of cervical cancer and allows acquisition of tissue biopsies of ovarian cancer before neoadjuvant chemotherapy.

Perineal Ultrasound as a Complement to POP-Q in the Assessment of Cystoceles

Purpose. In the present study we want to propose a classification system to quantify cystoceles by perineal ultrasound (PUS). Materials and Methods. 120 PUS data were analyzed measuring the distance between the lowest point of the bladder and the midpubic line (MPL) during rest and Valsalva. Results were classified into groups and compared to POP-Q using the κ-coefficient. Results for exact bladder position were checked for interrater reliability using ICC and Pearsons coefficient and results for classification were checked using the κ-coefficient. Bladder positions at rest and Valsalva were correlated with the distance between these points. Results. Highly significant differences concerning the position at rest and the distance between rest and Valsalva were found between the groups. For the interrater agreement, the Pearson correlation coefficient was ρ = 0.98, the ICC (A-1) = 0.98, and κ = 1.00. Comparing the classification results for POP-Q and PUS, the kappa-coefficient was κ = 0.65. Conclusion. PUS using the MPL and the classification system is a highly reliable tool for the evaluation of cystoceles. PUS shows good correlation with POP-Q. Furthermore, PUS offers a doubtless identification of the descending organ. Further studies are needed to evaluate the clinical use of the classification system proposed here.

Entzündliche Erkrankungen der Adnexe

ZusammenfassungEntzündliche Unterbaucherkrankungen können Uterus, Tuben, Ovarien und das benachbarte Peritoneum betreffen. Meist kommt es durch sexuelle Übertragung von Keimen zur Infektion. Davon zu abzugrenzen sind Infektionen, die nach medizinischen Eingriffen, in der Schwangerschaft oder sekundär bei anderen abdominellen Entzündungen das kleine Becken betreffen. Die häufigsten Erreger sind Neisseria gonorrhoeae und Chlamydia trachomatis. Sie gelten als eine der Hauptursachen von tubarer Sterilität, chronischen Unterbauchschmerzen und ektopen Schwangerschaften Bei der Adnexitis handelt sich meist um eine klinische Diagnose anhand der typischen Symptome: beidseitige Unterbauchschmerzen mit Portioschiebeschmerz und häufig Symptombeginn nach der Menstruation. Die antibiotische Therapie sollte möglichst früh, im Zweifelsfall auch probatorisch, begonnen werden und ein breites Keimspektrum abdecken.AbstractPelvic inflammatory disease (PID) and upper genital tract infection describe inflammatory changes in the uterus, tubes, ovaries and/or the peritoneum of the small pelvis. It is usually initiated by a sexually transmitted agent which distinguishes PID from pelvic infections caused by medical procedures, pregnancy and other primary abdominal processes. The most common initiating pathogens are Neisseria gonorrhoeae and Chlamydia trachomatis which account for many cases of tubal infertility, chronic pelvic pain and ectopic pregnancies. The clinical diagnosis is imprecise and includes symptoms, such as lower abdominal pain with cervical motion tenderness and the onset of pain during or shortly after menstruation. Clinicians should maintain a low threshold of suspicion for the diagnosis of PID and start antibiotic treatment early, preferably with a combination of broad spectrum antibiotics.

Is there a benefit of lymphadenectomy for overall and recurrence-free survival in type I FIGO IB G1-2 endometrial carcinoma? A retrospective population-based cohort analysis

PurposeThe recommended therapy for type I FIGO IB endometrial cancer (EC) is hysterectomy and adnexectomy, but the therapeutic benefits of additional pelvic and paraaortic lymph node dissection (LND) are still under discussion. In this study, we retrospectively evaluated overall survival (OAS) and recurrence-free survival (RFS) among patients with type I FIGO IB EC who did undergo systematic or elective lymphadenectomy or none at all.MethodsWe selected 299 individuals from the database of the German Tumor Centre Regensburg who were diagnosed between 1998 and 2015 with endometrial adenocarcinoma of the uterus type I FIGO IB. We applied multivariable Cox regression to the selected patient data and estimated hazard ratios for OAS and RFS against the performed intervention. Further, we carried out risk adjustments with respect to clinicopathological parameters, and performed model selection using conditional stepwise forward selection.ResultsWe observed significant benefits of LND in the unadjusted survival analysis; however, we did not confirm this effect in multivariable regression analysis upon risk adjustment. In this case, hazard ratio (HR) for OAS in patients without LND versus patients with LND is reduced to 1.214 (95% CI 0.771–1.911; p = 0.402), HR for RFS is 1.059 (95% CI 0.689–1.626; p = 0.795). Similarly, we were also able to eliminate the statistical benefit of systematic versus elective LND by risk adjustment.ConclusionsIn contrast to previous observations in high-grade EC, our study provides compelling evidence that LND, in particular systematic lymphadenectomy, is not beneficial for patients with type I FIGO IB EC in terms of long-term OAS and RFS.

Sentinel Lymph Node Biopsy in Breast Cancer Patients by Means of Indocyanine Green Using the Karl Storz VITOM® Fluorescence Camera

Currently, the use of radioisotope and blue dye for sentinel lymph node biopsy (SLNB) for axillary staging in breast cancer is common. Recently, indocyanine green (ICG) has been proposed as an alternative sentinel lymph node (SLN) tracking agent. We evaluated the clinical value of ICG as an additional tracer in combination with Technetium99m and as an alternative to Technetium99m for the identification of SLN in 104 breast cancer patients. 21 patients had at least 1 histologically tumor-positive SLN. All 21 patients were detected by ICG; in one of these 21 sentinel-positive patients, Technetium99m was unable to identify lymph node involvement. Our results show that ICG is as effective as the radioisotope for SLNB. In addition, as a near-infrared dye, it has the advantages of real-time visualization, lower cost, and wider availability, since no radioactive material needs to be handled. This trial is registered with German Clinical Trial Register Main ID: DRKS00013606.

Does post-operative radiochemotherapy improve survival in high-grade endometrial cancer patients? Results of a population-based cohort analysis of a cancer registry

PurposeAdjuvant treatment of high-grade endometrial cancer varies greatly due to the lack of definitive results from controlled randomized trials on the subject. In a retrospective study, we sought to investigate the influence of post-operative radio-, chemo, and radiochemotherapy on survival time and recurrence rates among high-grade endometrial cancer patients.Methods284 high-grade endometrial cancer patients (FIGOI–III, or unknown classification) diagnosed between 1998 and 2015 were retrospectively analyzed. All patients underwent surgery. Overall survival (OS), recurrence-free survival (RFS), and recurrence rates were compared for post-operative treatment modalities of radiotherapy alone (RT), chemotherapy alone (CTX), radiochemotherapy (RCT), and observation (OBS).ResultsPost-operative RCT and RT resulted in a significantly improved 5-year OS of 94.1% (HR 0.104, CI 0.013–0.809) and 62.1% (HR 0.615, CI 0.390–0.969), respectively, compared to 43.6% for OBS. CTX did not significantly improve OS leading to a 5-year OS of 56.5% (HR 0.783, CI 0.224–2.740). 5-year recurrence rate was lowest for patients treated with RCT (5.3%). 5-year RFS was 94.1% for the RCT group and proved to be significantly superior to 58.8% for RT (HR 9.034, CI 1.184–68.948), 56% for CTX (HR 12.738, CI 1.337–121.346), and 37.4% for OBS (HR 16.407, CI 2.127–126.575), respectively. In comparison with OBS, RT alone resulted in a significant improvement in RFS (HR 0.551, CI 0.354–0.856).ConclusionsOur retrospective population-based study indicates a survival benefit from treating high-grade endometrial cancer with post-operative RCT. Randomized controlled trials are needed to minimize potential confounding parameters and further clarify the subject.

Treatment Modification in Young Breast Cancer Patients.

Patients not older than 40 years are referred to as young patients. These women benefit from chemo-, endocrine and anti-HER2 therapy to a similar degree as older women. Surgery and radiation therapy also follow the same recommendations. This manuscript deals with the following topics that need special consideration in young women: endocrine therapy and ovarian suppression; fertility protection and family planning; and genetic counselling. There is an on-going debate on whether tamoxifen is sufficient as an endocrine treatment in young patients with endocrine-responsive tumours or whether suppression of ovarian function in combination with tamoxifen or aromatase inhibitor should be preferred. Recent data suggest a benefit from ovarian suppression plus exemestane in women of 35 years or younger with high-risk breast cancer. However, increased side effects bear the risk of lesser compliance, which eventually results in higher mortality. Child bearing is nowadays frequently postponed to the 4th decade of life, thereby increasing the number of women who have not yet finished their reproductive desires when diagnosed with breast cancer. These patients are in urgent need of counselling for fertility protection. Breast cancer diagnosis at young age is an indication for a possible mutation in breast cancer susceptibility genes. This has an impact on the cancer risk of the whole family, especially the offspring. Drugs that are specifically targeted to cancer cells with genetic alterations that impair DNA repair are already entering the arsenal of oncologists.

Endometrial Carcinoma Presenting as Vasculitic Sensorimotor Polyneuropathy

Paraneoplastic syndromes (PNS) are a heterogeneous group of symptoms which are indirectly caused by primary or metastatic tumor. Paraneoplastic polyneuropathy (PNP) is mostly related to small cell lung cancer (5%), prostate, gastric, and breast cancer. Only sporadic cases have been reported to be associated with endometrial cancer. We present a case of a premenopausal woman with severe vasculitic, asymmetric sensorimotor polyneuropathy that developed in conjunction with an endometrial carcinoma responding to surgical therapy of primary tumor combined to steroid therapy. Neurological symptoms such as asymmetrical sensorimotor deficits and painful paresthesias are suspicious when they occur in otherwise healthy women with no medical history. The phenomenon of a paraneoplastic syndrome can point to an underlying malignancy and can be used as marker of progression or regression of the tumor. Due to the rarity of PNP, there is no standard treatment. Recommended therapy is stage-adjusted treatment of the primary tumor.