Tolga Tasci

The Factors Predicting Recurrence in Patients With Serous Borderline Ovarian Tumor.

Objective In this study, we aimed to demonstrate the characteristics, recurrence rates, survival, and factors associated with survival of patients with serous borderline ovarian tumor (BOT) who were operated on in a single institution. Our secondary goal was to evaluate the necessity of staging surgery and the importance of a comprehensive lymphadenectomy in these patients. Materials and Methods The patients who were diagnosed in our institution between January 1990 and April 2014 with a final diagnosis of serous BOT were evaluated retrospectively. Kaplan-Meier method was used for analysis of progression-free survival (PFS). Univariate Cox proportional hazards model and log rank test were used for analysis of continuous and categorical variables affecting survival, respectively. Results One hundred twenty-one (75%) patients underwent staging surgery. Stage I disease was observed in 63%, stage III was observed in 11% of the patients, and only 0.6% of patients had stage II disease. Among 162 patients, 72 patients (44%) had conservative surgery. Eight (4.9%) patients had recurrence, one of which was invasive. All recurrences were in the patients who had conservative surgery. Median follow-up of the patients was 57 months (range, 37–270 years). Five- and 10-year PFS rates were 94.9% and 92.8%, respectively. In the univariate analysis of patients with serous BOT, PFS was worse in the presence of positive para-aortic lymph nodes, positive abdominal cytology, and conservative surgery (P = 0.008, P < 0.001, P = 0.007, respectively). The patients having noninvasive implant and advanced-stage disease had a tendency to have worse PFS (P = 0.067, P = 0.069, respectively). Conclusions Staging surgery generally gives us an idea of the probability of recurrence but not an idea of overall survival. Therefore, staging surgery including lymphadenectomy could be suggested to have information about the probability of recurrence and to be able to detect patients with an invasive implant that is the only probable factor affecting overall survival.

Clinical outcomes of uterine carcinosarcoma: results of 94 patients.

Objective We aimed to determine the clinicopathologic features and identify prognostic factors of patients with uterine carcinosarcoma. Materials and Methods A total of 94 patients with uterine carcinosarcoma who were diagnosed between January 1993 and October 2013 were included. Staging surgery consisted of total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, peritoneal cytology, and omentectomy. Staging is undertaken according to the 2009 International Federation of Gynecology and Obstetrics staging system. Kaplan-Meier survival analysis was used to determine the effects of variables on disease-free survival (DFS) and overall survival (OS). Results Seventy-nine patients underwent staging surgery and none of them had residual tumor after surgery. Three-year DFS and 3-year OS were 42.7% and 59.2%, respectively. In the univariate analysis, stage, presence of para-aortic metastatic lymph nodes, uterine serosal spread, positive peritoneal cytology, and extrapelvic metastases were associated with 3-year DFS and stage, presence of para-aortic metastatic lymph nodes, uterine serosal spread, positive peritoneal cytology, adnexal involvement, and extrapelvic metastases were associated with 3-year OS. Seventy-four patients received adjuvant therapy. Adjuvant therapy did not reduce recurrence or improve survival. Any of the chemotherapy regimens was not superior to the others. In the multivariate analysis, only age was an independent prognostic factor for 3-year DFS and no parameter was statistically significant for 3-year OS. Conclusions Age was an independent prognostic factor for 3-year DFS. Older age was associated with poor survival. Extrauterine spread was associated with survival. The aims of surgery should be both staging and providing tumoral debulking. Prospective randomized trials are needed to better define the necessity and modality of the administered adjuvant therapy.

Outcomes after early or midfollicular phase LH supplementation in previous inadequate responders.

Second cycle outcomes of 75 patients who had previous inadequate ovarian response with recombinant FSH (rFSH)-only ovarian stimulation during gonadotrophin-releasing hormone analogue (GnRHa) down-regulated cycles were evaluated retrospectively. In these second cycles, both rFSH and human menopausal gonadotrophin (HMG) in GnRHa long down-regulation were given to all patients, HMG initiated either on day 1 (group A, n=37) or day 5-6 of the ovarian stimulation (group B, n=38). Total HMG dose was higher (1198+/-514 IU versus 726+/-469 IU; P<0.001), cumulative rFSH consumption was lower (1823+/-804 IU versus 2863+/-1393 IU; P=0.001) and duration of stimulation was shorter (8.94+/-1.15 days versus 10.37+/-1.80 days; P<0.001) in group A than in group B. No significant differences were found regarding fertilization, implantation or pregnancy rates and embryo quality between the groups. Further analysis by supplementary HMG dose (75 IU versus 150 IU) revealed that total gonadotrophin and HMG consumption was lower in 75 IU-supplemented subgroups. Notably, pregnancy rate was higher in patients where 75 IU HMG was supplemented on day 5-6 of ovarian stimulation, which deserves further evaluation.

Juvenile granulosa cell ovarian tumor: clinicopathological evaluation of ten patients.

OBJECTIVE We aimed to analyze the clinical characteristics and management of ten patients who were diagnosed with juvenile granulosa cell ovarian tumor (JGCOT). MATERIAL AND METHODS The records of 10 patients diagnosed with JGCOT between April 1995 and January 2014 in the Gynecological Oncology Clinic of our institution were retrospectively evaluated. RESULTS The median age of the patients was 21.5 years (range; 13-36). Nine patients had stage IA disease and one had stage IC disease according to the International Federation of Gynecology and Obstetrics (FIGO) criteria. Five patients underwent pelvic and para-aortic lymph node dissection. None of them had lymph node involvement. All but two patients underwent unilateral salpingo-oophorectomy. One of the other two patients had cystectomy and the other had total abdominal hysterectomy and bilateral salpingo-oophorectomy. Three patients had adjuvant therapy after surgery. Two of these patients took chemotherapy and the other took radiotherapy. Four of the five patients who desired pregnancy achieved five term pregnancies. The median follow-up time of the patients was 58 months (range; 3-113). No recurrence was observed in the follow up period. CONCLUSION JGCOT generally occurs during childhood. The primary management of JGCOT is through surgery. The role of adjuvant therapy is controversial. Because survival is long at early stages and most of the patients are young, fertility sparing surgery could be safely suggested to these patients.

Is there any predictor for residual disease after cervical conization with positive surgical margins for HSIL or microinvasive cervical cancer

Objective We aimed to identify if there is any predictor of residual disease at repeat operation after cervical conization with positive surgical margins for high-grade squamous intraepithelial lesion (HSIL) or microinvasive cervical cancer. Materials and Methods Records of patients who underwent immediate repeat conization or hysterectomy because of positive surgical margins for HSIL or microinvasive cervical cancer reported after conization were obtained. The relation between the residual disease and age, parity, menopausal status, and the factors of first conization (method, cone base area, height of cone, endocervical margin, glandular and endocervical curettage specimen involvement, and the number of quadrants with positive surgical margins) was assessed. Standard statistical tests were used. Results Seventy-four patients were included. Mean time between the 2 operations was 5.1 weeks. Thirty-four patients (45.9%) had residual disease in the second-operation specimen: 4 low-grade squamous intraepithelial lesions, 24 HSILs, 5 microinvasive lesion, and 1 invasive cervical carcinoma. The number of involved quadrants was the only predictor of residual disease (41% if ⩽2 and 80% if >2, p = .02). Conclusions Residual disease is found in nearly half of repeat operations after conization with positive margins for HSIL or microinvasive cervical cancer. Particularly, residual disease is present in 80% of the patients with more than 2 involved quadrants. This should be considered when making management decisions.

Increased monocyte chemoattractant protein-1 levels indicating early vascular damage in lean young PCOS patients

Serum levels of monocyte chemoattractant protein-1 and C-reactive protein levels, as early signs of vascular damage and cardiovascular disease, were increased in young, lean patients with polycystic ovary syndrome. Serum monocyte chemoattractant protein-1 levels were positively correlated with serum LH, T, and C-reactive protein levels.

Pulmonary recurrence in patients with endometrial cancer

Background In this article, we aimed to define the clinical, pathological, and surgical factors predicting pulmonary recurrence (PR) and determining survival after PR in patients with endometrial cancer. Methods Thirty‐six (2.7%) patients were analyzed who suffered pulmonary failure in the first recurrence out of 1345 patients who had at least extrafascial hysterectomy plus bilateral salpingo‐oophorectomy for endometrial cancer between January 1993 and May 2013. The recurrence was designated as an isolated PR in cases of the presence of recurrence only in the lung, while it was called a synchronized PR if the patient had extrapulmonary recurrence in addition to PR. Results In the multivariate analysis in the entire cohort, only International Federation of Gynecology and Obstetrics stage was an independent prognostic factor for PR. Two‐year overall survival (OS) was 52% in patients with PR. In the univariate analysis, early International Federation of Gynecology and Obstetrics stage, absence of lymphatic metastasis, negative lymphovascular space invasion, absence of cervical invasion, negative adnexal spread, negative peritoneal cytology, negative omental metastasis, adjuvant radiotherapy after initial surgery, isolated PR, and chemotherapy upon recurrence were associated with improved OS after PR. The OS was 54 months for patients with isolated PR, while it was 10 months for patients who had synchronized PR. Furthermore, OS was 43 months and 13 months for the patients who took chemotherapy and radiotherapy, respectively. Conclusion Advanced stage is associated with PR. If recurrence is only in the lung, survival is better. Systemic treatment after PR is associated with improved survival. However, multi‐center studies are required to standardize the treatment for PR.

Salvage Cytoreductive Surgery for Recurrent Endometrial Cancer.

Objective The aim of this study was to determine the effect of salvage cytoreductive surgery (SCS) on overall survival (OS) among patients with recurrent endometrial cancer and if there is any predictor for residual tumor status. Methods Between January 1993 and May 2013, data of 34 patients who had SCS for recurrent endometrial cancer were retrospectively analyzed. Overall survival was determined from SCS to last follow-up. Results The surgical procedure was local excision without laparotomy in 12 patients, and optimal cytoreduction (no visible disease) was achieved in 24 of 34 patients. There were no perioperative deaths. None of the factors was associated with achievement of optimal cytoreduction. Five-year OS rates were 37% and 27% for the entire cohort and for the laparotomy group, respectively. For the entire cohort, disease-free interval (from initial surgery to recurrence), adjuvant therapy after initial surgery, CA-125 level at recurrence, multiplicity of recurrence, surgical procedure, and optimal cytoreduction and for the laparotomy group adjuvant treatment and optimal cytoreduction were associated with OS. In the laparotomy group, OS rates were 53 and 9 months in the patients who did and did not have optimal SCS, respectively. Conclusions Significant survival benefit can be achieved with optimal resection. Prospective studies should be designed to define optimal cytoreduction and to determine the predictors of optimal cytoreduction achievement.

Early and Late Complications after Inguinofemoral Lymphadenectomy for Vulvar Cancer.

BACKGROUND We aimed to determine the frequency of early and late complications following groin surgery for vulvar cancer and analyze possible risk factors. MATERIALS AND METHODS This retrospective cohort study included 99 women who underwent for vulvar cancer. The early (≤1 month) complications were wound infection, breakdown and lymphocyst and late (>1 month) complications were lower limb lymphedema, incontinence and erysipelas. The risk factors for developing each of the complications were analyzed with regression analysis. RESULTS In the entire cohort, 29 (29.3%) women experienced early and 12 (12.1%) had late complications. Wound complications including infection and breakdown were the leading early complications (23.2%). In the multivariate analysis, both obesity (body mass index≥30 kg/m2) and advanced age (≥65 years) were found as independent predictive factors for early complications. Obese women of advanced age had 6.32 times more risk of experiencing any of the early complications, when compared to non-obese and young women (55.6% vs 8.7%). The most common late complication was lower limb lymphedema (10.1%) that was more frequently seen in young women. However, neither age nor lymph node count were significantly associated with the occurrence of lower limb lymphedema. CONCLUSIONS More than 40% of the women suffered from postoperative complications after inguinofemoral lymphadenectomy in the current study. While advanced age and obesity were the significant predictors for any of the early complications, there was no identified risk factor for lower limb lymphedema.

Lymph Node Metastasis in Patients With Endometrioid Endometrial Cancer: Overtreatment Is the Main Issue.

Objective The aim of this study was to evaluate the effectiveness of histological grade, depth of myometrial invasion, and tumor size to identify lymph node metastasis (LNM) in patients with endometrioid endometrial cancer (EC). Methods A retrospective computerized database search was performed to identify patients who underwent comprehensive surgical staging for EC between January 1993 and December 2015. The inclusion criterion was endometrioid type EC limited to the uterine corpus. The associations between LNM and surgicopathological factors were evaluated by univariate and multivariate analyses. Results In total, 368 patients were included. Fifty-five patients (14.9%) had LNM. Median tumor sizes were 4.5 cm (range, 0.7–13 cm) and 3.5 cm (range, 0.4–33.5 cm) in patients with and without LNM, respectively (P = 0.005). No LMN was detected in patients without myometrial invasion, whereas nodal spread was observed in 7.7% of patients with superficial myometrial invasion and in 22.6% of patients with deep myometrial invasion (P < 0.0001). Lymph node metastasis tended to be more frequent in patients with grade 3 disease compared with those with grade 1 or 2 disease (P = 0.131). Conclusions The risk of lymph node involvement was 30%, even in patients with the highest-risk uterine factors, that is, those who had tumors of greater than 2 cm, deep myometrial invasion, and grade 3 disease, indicating that 70% of these patients underwent unnecessary lymphatic dissection. A precise balance must be achieved between the desire to prevent unnecessary lymphadenectomy and the ability to diagnose LNM.