The comparison of the prognostic value of scored patient generated subjective global assessment and Computed Tomography measured sarcopenia in patients with gynecological cancer.

BACKGROUND: Screening of the nutrition status is recommended for the early detection and treatment of cancer-associated malnutrition to improve the prognosis. We aimed to compare the prognostic value of Patient Generated-Subjective Global Assessment (PG-SGA) and CT measured sarcopenia in patients with gynecological cancer. METHODS: A total of 107 patients of which were 57 endometrial, 37 ovarian, and 13 cervical cancer who underwent surgery and evaluated by PG-SGA were enrolled. Skeletal muscle index (SMI) was calculated by automatic segmentation of the muscle area at the L3 level on abdominal CT scan and defined by the cut-off value of 38.9 cm2/m2. Karnofsky and Eastern Cooperative Oncology Group (ECOG) Performance Status scorings were performed. Hospitalization length (HL), overall- (OS), and progression-free- survival (PFS) were analyzed. Body muscle index (BMI) (kg/m2) was calculated. Serum CA-125 and albumin levels were obtained. RESULTS: The prevalence of malnutrition and sarcopenia were 67% and 26.2%, respectively. BMI was significantly associated with PG-SGA (p = 0.02) and SMI (p = 0.01). PG-SGA significantly correlated with CA-125 (r = 0.33, p = 0.002), ECOG (r = 0.29, p = 0.002), Karnofsky (r = -0.34, p < 0.001), and HL (r = 0.27, p = 0.004). PG-SGA showed a significant association with PFS (p = 0.007) and OS (p = 0.001). PG-SGA≥9 showed a significant relationship with prolonged HL, mortality, and progression (OR = 1.08; p = 0.03, OR = 23.09; p = 0.003, and OR = 5.39; p = 0.001, respectively). CONCLUSION: PG-SGA can identify patients at nutritional risk earlier than SMI. PG-SGA shows a higher correlation with HL and clinical performance scores than SMI. PG-SGA is a better prognostic factor for prolonged HL, OS, and PFS.

Surgical risk assessment for gynecological oncologic patients.

OBJECTIVE: Preoperative surgical risk assessment is important in terms of postoperative morbidity and mortality. Therefore, it is necessary to evaluate the efficacy and safety of these surgeries via an ideal risk assessment model, and reduce risks via applying some findings (for instance, perioperative beta-blockers). There are some risk assessment systems, but these have generally not been verified for patients with gynecologic cancer. The aim of this study was to assess the risk of surgery for gynecological oncologic patients and suggest an easy risk assessment model and risk reduction by applying our findings. MATERIALS AND METHODS: We retrospectively analyzed 258 gynecologic patients with cancer. Age, diagnosis, staging, performance scale, metoprolol use, heart, renal diabetes, Chronic Obstructive Pulmonary disease, diabetes, operation type and length, carcinoma antigen 125, ascites, albumin, surgical procedure, hospitalization length, and complications were recorded. RESULTS: Of the 258 patients, 173 patients (67.1%) had no complications, 43 patients (16.7%) had one and 42 patients (16.3%) had two or more complications. The most common complication was the acid-base imbalance (14%), followed by urinary tract infection (9.7%). Parameters associated with complications were performance status, ascites, operating length, metoprolol use, and upper abdominal surgery. In our proposed scoring model with a total score range 0-23, cut-off value points for both the presence and rate of complications was found as >5. CONCLUSION: In gynecological patients with cancer, the addition of metoprolol use and upper abdominal surgery within preoperative risk assessment evaluation parameters are significantly effective in predicting the rate and severity of complications. Moreover, we have suggested a simple, practical, and convenient scoring model for this evaluation.

Effect of using magnifying loupe glasses on lymphocele formation and surgical outcomes in gynecologic oncology.

OBJECTIVE: To investigate the effect of using magnifying loupes during surgery on surgical outcomes and lymphocele formation. MATERIALS AND METHODS: We prospectively enrolled 36 patients with gynecologic cancer who underwent pelvic and para-aortic lymphadenectomy. Age, body mass index, menopausal status, type of cancer, comorbid diseases, preoperative albumin and albumin replacement therapy, performance status, serum CA125, hemoglobin, platelets and white blood cells, surgical procedure, blood loss, blood transfusion, the count of removed lymph nodes, presence of metastatic lymph nodes, total amount of drainage, postoperative complications, operation length, and count of used hemoclips were recorded. Patients were randomized into two groups: group 1 operated using loupe glasses, and group 2, without loupes. RESULTS: In the loupe-negative group, total drainage volume was 6698 mL, whereas in the loupe-positive group, it was only 1049 mL (p<0.01). Postoperatively, the mean drainage duration was 10.6±5.1 days in loupe-negative group and 4.8±2.4 days in the loupe-positive group (p=0.0001). There were no differences between the two groups in terms of surgical site infections, fascial defects, and pulmonary thromboembolism (p=0.39, 0.33, 0.59, respectively). There was no significant difference in the number of harvested lymph nodes in patients who underwent surgery with or without loupes being used. The count of used hemoclips were 50.22±8.05 and 41.38±9.7 for the loupe-negative and positive groups, respectively (p<0.01). There was no lymphocele in the loupe-positive group, but we detected 5 (27.8%) lymphocele in the loupe-negative group (p=0.05). CONCLUSION: Gynecologic oncologic surgeons can add magnifying loupe glasses to their armament and benefit from this technical device; lymphocele development, total drainage volume, length of drainage time, and clip counts can be decreased by using loupe glasses in gynecologic cancer surgery.

Impact of diabetes on gastrointestinal and urinary toxicity after radiotherapy for gynecologic malignancy.

OBJECTIVE: Although diabetes is a common co-morbidity in patients with gynecologic cancer, information about its impact on radiation toxicity in patients with gynecologic cancer treated with external pelvic irradiation is scarce. We aimed to investigate the relation of diabetes with acute toxicity in patients with gynecologic tumors who underwent pelvic +/- paraaortic radiotherapy. MATERIALS AND METHODS: One hundred twenty-nine patients with endometrium or cervix carcinoma were enrolled in the study. Demographic features, presence of diabetes, incidence and severity of upper gastrointestinal (UGIS), lower gastrointestinal (LGIS), and urinary symptoms were recorded from files. Correlation and logistic regression analysis was used to determine the impact of diabetes, age, chemotherapy, paraaortic irradiation on toxicities, and a prediction model was developed. RESULTS: The median age of 77 patients with endometrium cancer and 52 cervix cancer was 61 (range, 25-92) years, and 28 (21.7%) of them had diabetes. The median pelvic and tumor/tumor bed dose was 5040+247.65 cGy and 5040+222.91 cGy, respectively. Age and Gr 0 UGIS toxicity were significantly related (p=0.047). LGIS Gr 0 toxicity was found to be significantly higher in patients with diabetes (p=0.045). Gr 0 and 2 UGIS toxicities were both found to be significantly correlated with paraaortic irradiation (both p<0.001). Diabetes is also an important determinant on UGIS toxicity in patients who underwent paraaortic irradiation. CONCLUSION: The correlation we found between toxicity and diabetes, concurrent chemotherapy or paraaortic radiation necessitates special care and risk stratification for patients with diabetes. Further prospective studies with long follow-up and larger patient groups are warranted.

Incidence of suspicious axillary lymph node involvement in fluorine-18 fluoro-D-glucose positron emission tomography/computed tomography in gynecologic cancers.

OBJECTIVE: There is scarce information about axillary lymph node involvement in gynecologic cancers. We analyzed the incidence of suspicious axillary lymph nodes in gynecologic cancers. MATERIALS AND METHODS: We retrospectively analyzed the positron emission tomography/computed tomography findings of 251 patients with endometrial, cervical, and ovarian cancer. There is no cut-off value documented for axillary metastases from gynecologic cancers; therefore we adopted the cut-off standardized uptake values (SUVs) proclaimed in breast cancer. RESULTS: A total of 251 patients records were available for analysis; 40 patients (15.9%) with suspicious axillary lymph nodes were included in the study. Twenty-one and a half percent (n=20/93) of patients with endometrium cancer, 14.1% (n=14/99) of patients with ovarian cancer, and 10% (n=6/59) of those with cervical cancer had suspicious axillary lymph nodes. Patients with an maximum SUV (SUVmax) uptake higher than 3 underwent axillary lymph node biopsy. None of them was found to have axillary metastases of gynecologic cancers in the pathologic evaluation. In one patient with endometrial cancer, an obscure breast ductal carcinoma was diagnosed, another patient with endometrial cancer was found to have follicular lymphoma. The third patient with endometrial cancer had no malignancy in axillary lymph node biopsy, but had Hurthle cell neoplasia in a thyroid biopsy; the patient did not accept any surgical or medical treatment for endometrial cancer and died 23 months later. There were three (7.5%) metachronous cancers out of 40 gynecologic cancers; two patients were explained above, the third patient with endometrium cancer, who was not histopathologically evaluated although the axillary SUVmax was <3, had rectosigmoid cancer and glioblastoma metachronously. CONCLUSION: Our study shows that an important ratio (14-21%) of patients with gynecologic cancer has suspicious axillary lymph nodes. Increased SUVmax, particularly above 3, might be used as an indication for axillary biopsy and may help to identify secondary metastatic cancer.