Increasing women's choices in medical abortion: a study of misoprostol 400 microg swallowed immediately or held sublingually following 200 mg mifepristone.

OBJECTIVES: To assess the efficacy and acceptability of two misoprostol regimens (400 microg oral or sublingual) following mifepristone for medical abortion. METHODS: Women seeking abortion with gestations of 56 days or less since onset of their last menstrual period were offered medical abortion as an alternative to a surgical procedure. A total of 207 eligible and consenting women were given mifepristone (200 mg oral) and the option of taking 400 microg misoprostol either orally or sublingually two days later, with the option of home-use. Two weeks later, treatment success, satisfaction, and the frequency and acceptability of side effects were assessed. RESULTS: Most women (97.6%) opted for home use of misoprostol and almost three quarters selected the oral route. Overall efficacy, acceptability of side effects and satisfaction were high in both groups. The success rate was lower after sublingual than after oral administration but not significantly so (91.3% vs. 96.3%, p = 0.23, RR: 0.93, 95% CI = 0.85-1.02). The frequency and average duration of side effects in both groups were comparable except for pain/cramps and fever/chills, which were more frequently associated with the sublingual route. CONCLUSIONS: This study re-emphasises the feasibility of integrating medical abortion into health services in Turkey and the potential to increase choices for women.

Prognosticators and the role of lymphadenectomy in uterine leiomyosarcomas.

OBJECTIVE: To analyze prognostic factors, the role of lymphadenectomy and postoperative adjuvant treatments in patients with uterine leiomyosarcomas (LMS). STUDY DESIGN: Sixty-three patients with uterine LMS are retrospectively analyzed with respect to both DFS and OS. RESULTS: Multivariate DFS analysis revealed percentage necrosis to be the unique factor to be significant (median DFS was 3.31 years for <25% necrosis and 0.78 for >25% necrosis). Multivariate analysis revealed the mitotic counts to be the unique significant factor affecting the OS (median OS was 7.20 and 1.73 years, respectively, for patients with mitotic counts of 1-5 and >6; respectively). Median DFS was 2.51 years for patients who had undergone lymphadenectomy and 2.36 years for remaining who did not have a lymphadenectomy procedure (P = 0.4). With respect to OS, median values were 2.44 and 3.16 years, respectively (P = 0.7). Number of the resected lymph nodes was also not significant for both OS and DFS. CONCLUSIONS: Mitotic counts and percentage necrosis have significant effects on OS and DFS; respectively. Neither the performance nor the extent of lymphadenectomy has an effect on patient survival.

A third evaluation of tertiary cytoreduction.

OBJECTIVE: To evaluate the impact of tertiary cytoreductive surgery (TCS) on patient survival and to determine predictors of optimal TCS. METHODS: Twenty patients with recurrent epithelial ovarian carcinoma who had TCS at Hacettepe University Hospital during 1992-2004 were retrospectively reviewed. RESULTS: Tertiary cytoreductive attempt was successful (optimal defined as <2 cm residual) in 12 patients and suboptimal in the remaining eight patients. Seven patients had no macroscopic residual, five patients had <2 cm gross residual and remaining 8 patients had >or=2 cm gross residual disease. Of these alive patients, 10 patients were alive with metastatic disease and only three patients were alive without any evidence of disease. Three patients had operative morbidity (15%), all of which were mild-moderate degree. Multivariate analysis could not differentiate a unique significant factor to have a possible predictor effect of optimal TCS. Multivariate survival analysis also could not differentiate any factor to have significant effect upon patient survival, neither the outcomes of primary, secondary or tertiary cytoreductive surgeries nor the usage of preoperative or postoperative chemotherapies. CONCLUSION: TCS may not be helpful for patient survival. Neither of the clinical factors predicted an optimal TCS. Further larger series are needed for a definite conclusion.

Depth of invasion for appendiceal metastasis of ovarian cancers: does it have any clinical significance?

AIM: Depth of appendiceal metastasis in patients with epithelial ovarian carcinoma (EOC) has not been previously analyzed for a possible relationship with clinico-pathological variables. METHODS: Sixty-nine patients with EOC treated at Hacettepe University were retrospectively analyzed. All of the patients had appendiceal metastasis. Pathological slides were re-reviewed by the same pathologist. Appendiceal metastases were defined as serosal (if tumoral spread involved only serosa of the appendix) or sero-mucosal (if tumoral spread also involved either muscular or mucosal surfaces of the appendix). Univariate and multivariate analysis did not reveal a significant difference with respect to the prognostic variables between the groups. RESULTS: Thirty-nine patients had serosal appendiceal metastasis (56.5%), while the remaining 30 patients (43.5%) had appendiceal metastasis extending toward the muscular layer (seromucosal metastasis: 16 within muscularis mucosa, 14 within the mucosa of the appendix). The mean age at the time of diagnosis was 54.58 years (range, 26-88 years), with no significant difference between the groups (P = 0.9). Comparison of the survival rates between the two groups did not reveal a significant difference. Three-year survival rates were 23.3% in the serosal metastasis and 27.9% in the seromucosal metastasis group (P = 0.9). This figure was 25% for patients with only muscular metastasis and 41.6% for patients with appendiceal metastasis extending to the mucosal layer (P = 0.2). CONCLUSION: This is the first report to analyze the metastatic pattern of EOC on the appendix with respect to depth of invasion which could not reveal a significant difference.

What is the role of office hysteroscopy in women with failed IVF cycles?

Recurrent implantation failure (RlF) may be due to unrecognized uterine pathology. Hysterosalpingography, transvaginal ultrasonography, saline infusion sonography and hysteroscopy are the tools to assess the inner architecture of the uterus. Hysteroscopy is considered to be the gold standard; however, the validity of hysteroscopy may be limited in the diagnosis of endometritis and endometrial hyperplasia. The frequencies of unrecognized uterine pathology revealed by hysteroscopy are 18-50% and 40-43% in patients undergoing IVF with or without RlF, respectively. Endometrial polyps may be associated with increased miscarriage rates. Implantation rates are decreased in patients with submucous or intramural fibroids with distorted uterine cavity. There is controversy on the impact of uterine septum less than 1 cm length on pregnancy outcome in IVF cycles. There is paucity of data on the role of hysteroscopy in failed IVF cycles. In the available two randomized controlled trials, pregnancy rates appear to be increased when hysteroscopy is performed; however within the hysteroscopy group, pregnancy rates are comparable among the normal or surgically corrected subgroups. Further studies are warranted to delineate the role of hysteroscopy in patients with failed IVF cycle(s). This review aims to evaluate the validity of office hysteroscopy in failed IVF cycles.

Metastatic lymph node number in epithelial ovarian carcinoma: does it have any clinical significance?

OBJECTIVE: To analyze the clinicopathological correlations of metastatic lymph node (LN) numbers in patients with epithelial ovarian carcinoma. METHOD: A total of 328 patients with epithelial ovarian carcinoma diagnosed and treated at Hacettepe University Hospital during 1982-2005 were retrospectively reviewed. Patients' age, number of resected lymph nodes, clinical disease stage, preoperative Ca-125 levels, peritoneal cytology, presence of ascites, tumor histology, tumor grade, maximal tumor diameter, cytoreductive success, overall and disease-free survivals were compared with respect to the number of metastatic lymph nodes (< 4 vs. > or = 4). RESULTS: The mean number of resected lymph nodes was 24.5 and mean number of metastatic lymph nodes was 6.2. About 47.3% (n=155) of the patients had < 4 metastatic lymph nodes and the remaining 52.7% of patients (n=173) had > or = 4 metastatic lymph nodes. Univariate comparison of the two groups relived preoperative Ca-125 values, peritoneal cytology and clinical disease stage to be significantly different among the two groups. However, multivariate analysis revealed a high Ca-125 level (> or = 500 IU/l) to be unique factor significantly different among the groups. Survival analysis also could not find a significant difference with respect to overall and disease-free survival among the groups. CONCLUSION: The number of metastatic lymph nodes increases as the preoperative Ca-125 values increase. Other patient characteristics do not have a significant effect on the number of metastatic lymph nodes. Metastatic LN number does not have a prognostic significance in terms of either the overall or the disease-free survival. Prospective series are needed for a definitive conclusion.

Predictors and outcomes of recurrent disease after a negative second look laparotomy.

BACKGROUND AND OBJECTIVES: To analyze the predictors and outcomes of recurrent disease in patients with epithelial ovarian carcinoma (EOC) after a negative second look laparotomy (SLL). METHODS: One hundred nine EOC patients with a negative SLL treated at Hacettepe Hospital were retrospectively analyzed. RESULTS: Of these patients, 70 (64.2%) had no evidence of disease during follow up while remaining 39 (35.8%) had recurrence. Majority of the recurrences (82.1%) were detected within the initial 2 years of the SLL procedure. Multivariate analysis revealed stage and grade of the disease to be the significant predictors for the recurrent disease (P < 0.01 and P = 0.025, respectively). A second analysis with respect to initial metastatic sites revealed omental metastatis was significantly associated with recurrent disease (P < 0.001). Survival of patients with a recurrent disease was significantly poorer and dropped abruptly once a recurrence is developed. CONCLUSIONS: Patients with initial omental metastasis, advanced stage and high grade tumors have highest risk for developing recurrences after a (-) SLL. Most of the recurrences develop during the initial 2 years following the (-) SLL and survival drops to less than 2 years once a recurrence is found.

Occult metastasis in early ovarian cancers: risk factors and associated prognosis.

OBJECTIVE: The purpose of this study was to define risk factors associated with the occult metastasis in early stage epithelial ovarian carcinoma (EOC), and to compare the survivals in respect to occult metastasis. STUDY DESIGN: A retrospective review of 169 patients with clinically early stage EOC was performed. RESULTS: Overall, 53 patients (53/169, 31.4%) were upstaged. The most common occult metastasis was the lymphatic involvement (22/53; 41.5%). Overall, 64.1% (34/53) of these upstaged patients had unrecognized disease in the upper abdomen or retroperitoneal space. Multivariable analysis revealed 3 factors to be associated with occult metastasis: Ca-125 levels > or = 500 U/mL (P = .04), positive peritoneal cytology (P = .001), and grade III disease (P = .04). Five-year survival rates were 61.83% and 88.25%, respectively, in patients with or without occult metastasis. Among the upstaged patients, omental or peritoneal metastasis revealed the worst prognosis. CONCLUSION: Proper surgical staging is an important issue in early stage ovarian cancers, particularly in patients with high Ca-125 levels, positive cytology, and high grade tumor.

The role of secondary cytoreduction in the treatment of ovarian cancer: Hacettepe University experience.

OBJECTIVE: This study was undertaken to evaluate the role of secondary cytoreduction in patients with recurrent epithelial ovarian cancer. STUDY DESIGN: Secondarily, cytoreduced patients were retrospectively analyzed with respect to the clinicopathologic variables. RESULTS: A total of 64 patients were evaluated in this report. Multivariable analysis revealed 3 factors to be significant: optimal cytoreduction during primary (P = .003, odds ratio [OR]: 0.30; 95% CI: 0.14-0.66), secondary cytoreduction (P = .04, OR: 0.47; 95% CI: 0.22-0.99), and the endometrioid histologic type (P = .005, OR: 0.09; 95% CI: 0.02-0.48). Intrinsic factors of the tumors (grade, stage, age), size, and number of recurrent tumors were nonsignificant. CONCLUSION: Secondary cytoreductive surgery should be offered in selected recurrent epithelial ovarian cancer patients. Further prospective randomized series are needed to determine specific recommendations.